Variation in neoadjuvant chemotherapy utilization for epithelial ovarian cancer at high volume hospitals in the United States and associated survival.

OBJECTIVE: To estimate variation in the use of neoadjuvant chemotherapy by high volume hospitals and to determine the association between hospital utilization of neoadjuvant chemotherapy and survival. METHODS: We identified incident cases of stage IIIC or IV epithelial ovarian cancer in the National Cancer Database from 2006 to 2012. Inclusion criteria were treatment at a high volume hospital (>20 cases/year) and treatment with both chemotherapy and surgery. A logistic regression model was used to predict receipt of neoadjuvant chemotherapy based on case-mix predictors (age, comorbidities, stage etc). Hospitals were categorized by the observed-to-expected ratio for neoadjuvant chemotherapy use as low, average, or high utilization hospitals. Survival analysis was performed. RESULTS: We identified 11,574 patients treated at 55 high volume hospitals. Neoadjuvant chemotherapy was used for 21.6% (n=2494) of patients and use varied widely by hospital, from 5%-55%. High utilization hospitals (n=1910, 10 hospitals) had a median neoadjuvant chemotherapy rate of 39% (range 23-55%), while low utilization hospitals (n=2671, 14 hospitals) had a median rate of 10% (range 5-17%). For all ovarian cancer patients adjusting for clinical and socio-demographic factors, treatment at a hospital with average or high neoadjuvant chemotherapy utilization was associated with a decreased rate of death compared to treatment at a low utilization hospital (HR 0.90 95% CI 0.83-0.97 and HR 0.85 95% CI 0.75-0.95). CONCLUSIONS: Wide variation exists in the utilization of neoadjuvant chemotherapy to treat stage IIIC and IV epithelial ovarian cancer even among high volume hospitals. Patients treated at hospitals with low rates of neoadjuvant chemotherapy utilization experience decreased survival.

Etonogestrel-Releasing Contraceptive Implant for Postpartum Adolescents: A Randomized Controlled Trial.

STUDY OBJECTIVE: To compare immediate postpartum insertion of the contraceptive implant to placement at the 6-week postpartum visit among adolescent and young women. DESIGN: Non-blinded, randomized controlled trial. SETTING AND PARTICIPANTS: Postpartum adolescents and young women ages 14-24 years who delivered at an academic tertiary care hospital serving rural and urban populations in North Carolina. INTERVENTIONS: Placement of an etonogestrel-releasing contraceptive implant before leaving the hospital postpartum, or at the 4-6 week postpartum visit. MAIN OUTCOME MEASURES: Contraceptive implant use at 12 months postpartum. RESULTS: Ninety-six participants were randomized into the trial. Data regarding use at 12 months were available for 64 participants, 37 in the immediate group and 27 in the 6-week group. There was no difference in use at 12 months between the immediate group and the 6-week group (30 of 37, 81% vs 21 of 27, 78%; P = .75). At 3 months, the immediate group was more likely to have the implant in place (34 of 37, 92% vs 19 of 27, 70%; P = .02). CONCLUSION: Placing the contraceptive implant in the immediate postpartum period results in a higher rate of use at 3 months postpartum and appears to have similar use rates at 12 months compared with 6-week postpartum placement. Providing contraceptive implants to adolescents before hospital discharge takes advantage of access to care, increases the likelihood of effective contraception in the early postpartum period, appears to have no adverse effects on breastfeeding, and might lead to increased utilization at 1 year postpartum.

Predictors of Non-Attendance to the Postpartum Follow-up Visit.

Objectives This study aimed to measure the incidence and identify predictors of postpartum visit non-attendance, using medical records of women who received prenatal care and went on to deliver live births at Montefiore Hospital in 2013. Methods Pearson's Chi square tests were used to assess the association between maternal demographics, insurance status, and delivery information with non-attendance of a postpartum visit. Logistic regression and modified Poisson regression models were then used to identify statistically significant predictors of postpartum visit non-attendance. Results We found that one-third of all women who attended a prenatal visit at Montefiore Hospital did not return for a postpartum visit. Variables significantly associated with non-attendance include having Medicaid or no insurance (RR 1.4, 95 % CI 1.2-1.6), being Hispanic or Latino (RR 1.2, 95 % CI 1.1-1.3), having a vaginal delivery (RR 1.2, 95 % CI 1.1-1.4), and age <20 years (RR 0.77, 95 % CI 0.64-0.92). Conclusions for Practice We conclude that the risk of postpartum visit non-attendance disproportionately impacts socially and economically vulnerable patients who are: younger, part of a minority ethnic background, and depend on state funded health insurance. Our results highlight the disparity in access to postpartum care and the importance of identifying barriers to attendance as well as developing creative strategies of providing postpartum care outside of the traditional postpartum visit framework.

Intrauterine Device Placement During Cesarean Delivery and Continued Use 6 Months Postpartum: A Randomized Controlled Trial.

OBJECTIVE: To compare intrauterine device (IUD) use at 6 months postpartum among women who underwent intracesarean delivery (during cesarean delivery) IUD placement compared with women who planned for interval IUD placement 6 or more weeks postpartum. METHODS: In this nonblinded randomized trial, women who were undergoing a cesarean delivery and desired an IUD were randomized to intracesarean delivery or interval IUD placement. The primary outcome was IUD use at 6 months postpartum. A sample size of 112 (56 in each group) was planned to detect a 15% difference in IUD use at 6 months postpartum between groups. RESULTS: From March 2012 to June 2014, 172 women were screened and 112 women were randomized into the trial. Baseline characteristics were similar between groups. Data regarding IUD use at 6 months postpartum were available for 98 women, 48 and 50 women in the intracesarean delivery and interval groups, respectively. A larger proportion of the women in the intracesarean delivery group were using an IUD at 6 months postpartum (40/48 [83%]) compared with those in the interval group (32/50 [64%], relative risk 1.3, 95% confidence interval 1.02-1.66). Among the 56 women randomized to interval IUD insertion, 22 (39%) of them never received an IUD; 14 (25%) never returned for IUD placement, five (9%) women declined an IUD, and three (5%) had a failed IUD placement. CONCLUSION: Intrauterine device placement at the time of cesarean delivery leads to a higher proportion of IUD use at 6 months postpartum when compared with interval IUD placement. LEVEL OF EVIDENCE: I.

Mechanical bowel preparation before laparoscopic hysterectomy: a randomized controlled trial.

OBJECTIVE: To examine the influence of mechanical bowel preparation on surgical field visualization during laparoscopic hysterectomy. METHODS: The study's primary outcome was the percentage of operations rated "good" or "excellent" in terms of surgical field visualization at the outset of the case by the primary surgeon. Additional measures included assessment of visualization during the case and patient perioperative comfort. The study was powered to detect a 20% absolute difference in the proportion of cases rated as "good" or "excellent." RESULTS: Seventy-three patients were assigned to mechanical bowel preparation and 73 to no mechanical bowel preparation. The groups were comparable regarding patient and surgery characteristics. No differences were found for this rating between groups (mechanical bowel preparation, 64 of 73 patients [87.7%], compared with no mechanical bowel preparation, 60 of 73 patients [82.2%], P=.36). Surgeons guessed patient assignment correctly 59% of the time (42 of 71 patients) with mechanical bowel preparation and 55% of the time (41 of 75 patients) with no mechanical bowel preparation. CONCLUSION: Mechanical bowel preparation is well-tolerated but does not influence surgical field visualization for laparoscopic hysterectomy. CLINICAL TRIAL REGISTRATION: ClinialTrials.gov, www.clinicaltrials.gov, NCT01576965.

Effect of extreme obesity on outcomes in laparoscopic hysterectomy.

STUDY OBJECTIVE: To estimate the effect of body mass index (BMI) on several outcomes in laparoscopic hysterectomy, in particular in the extremes of obesity. DESIGN: Retrospective cohort study (Canadian Task Force classification II-3). SETTING: Tertiary-care university-based teaching hospital. PATIENTS: Eight hundred thirty-four patients who underwent laparoscopic hysterectomy from January 2007 to October 2011. INTERVENTION: Laparoscopic hysterectomy for benign indications. MEASUREMENTS AND MAIN RESULTS: Demographic, operative, and postoperative data were abstracted from medical records. The primary outcome was a composite index score that took into account operative time, nonsurgical operating room time, estimated blood loss, length of hospital stay, number of complications, and severity of complications according to the Dindo-Clavien classification. We individually examined elements of the composite index as a secondary outcome. Models were developed to assess the association of BMI with the composite index score and the components of the index, controlling for age, presence of diabetes, tobacco use, surgeon, type of hysterectomy (total vs supracervical), use of robotics, uterine weight, number of additional procedures performed, presence of adhesions requiring lysis, and deeply infiltrating endometriosis as potential confounders. Mean (SD) BMI was 31.4 (8.1). Mean (SD) uterine weight was 345 (388) g. Mean operative time was 150 (61) minutes. Increasing BMI was associated with a worse composite score (p < .01); longer operative time (p = .03), nonsurgical operating room time (p = .02), and total operating room time (p < .01); greater estimated blood loss (p < .01); and complication severity (p = .01). CONCLUSION: These data suggest that there is a significant association of BMI with surgical outcomes in laparoscopic hysterectomy, and the effect is most pronounced in the morbidly obese. These patients may stand to gain the greatest differential benefit from a laparoscopic approach to surgery. However, they should be properly counseled about the challenge that obesity poses to the operation.

A multicenter mortality prediction model for patients receiving prolonged mechanical ventilation.

OBJECTIVE: Significant deficiencies exist in the communication of prognosis for patients requiring prolonged mechanical ventilation after acute illness, in part because of clinician uncertainty about long-term outcomes. We sought to refine a mortality prediction model for patients requiring prolonged ventilation using a multicentered study design. DESIGN: Cohort study. SETTING: Five geographically diverse tertiary care medical centers in the United States (California, Colorado, North Carolina, Pennsylvania, and Washington). PATIENTS: Two hundred sixty adult patients who received at least 21 days of mechanical ventilation after acute illness. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: For the probability model, we included age, platelet count, and requirement for vasopressors and/or hemodialysis, each measured on day 21 of mechanical ventilation, in a logistic regression model with 1-yr mortality as the outcome variable. We subsequently modified a simplified prognostic scoring rule (ProVent score) by categorizing the risk variables (age 18-49, 50-64, and ≥65 yrs; platelet count 0-150 and >150; vasopressors; hemodialysis) in another logistic regression model and assigning points to variables according to ß coefficient values. Overall mortality at 1 yr was 48%. The area under the curve of the receiver operator characteristic curve for the primary ProVent probability model was 0.79 (95% confidence interval 0.75-0.81), and the p value for the Hosmer-Lemeshow goodness-of-fit statistic was .89. The area under the curve for the categorical model was 0.77, and the p value for the goodness-of-fit statistic was .34. The area under the curve for the ProVent score was 0.76, and the p value for the Hosmer-Lemeshow goodness-of-fit statistic was .60. For the 50 patients with a ProVent score >2, only one patient was able to be discharged directly home, and 1-yr mortality was 86%. CONCLUSION: The ProVent probability model is a simple and reproducible model that can accurately identify patients requiring prolonged mechanical ventilation who are at high risk of 1-yr mortality.

Second-trimester abortion for fetal anomalies or fetal death: labor induction compared with dilation and evacuation.

OBJECTIVE: To compare the safety and effectiveness of dilation and evacuation (D&E) and labor-induction abortion performed for fetal anomalies or fetal death in the second trimester. METHODS: We performed a retrospective cohort study of second-trimester abortions performed for fetal indications. We compared the frequency of complications and effectiveness of abortions performed at 13-24 weeks for these indications. We calculated proportions of patients with complications for these two methods and controlled for confounding using a log binomial model. RESULTS: Labor-induction abortions had higher complication rates and lower effectiveness than did D&E. Thirty-two of 136 women undergoing labor induction (24%) experienced one or more complications, in contrast to 9 of 263 women (3%) undergoing D&E (unadjusted relative risk 6.9 [95% confidence interval 3.4-14.0]). When controlled for confounding, the adjusted risk ratio for labor induction was 8.5 (95% confidence interval 3.7-19.8) compared with D&E. CONCLUSION: Dilation and evacuation is significantly safer and more effective than labor induction for second-trimester abortion for fetal indications. Bias and chance are unlikely explanations for these large discrepancies. Women facing this difficult decision should be offered a choice of methods and be provided information about their comparative safety and effectiveness. LEVEL OF EVIDENCE: II.

Assessing local health department performance in diabetes prevention and control--North Carolina, 2005.

INTRODUCTION: To improve the public health system's ability to prevent and control chronic diseases, we must first understand current practice and develop appropriate strategies for measuring performance. The objectives of this study were to measure capacity and performance of local health departments in diabetes prevention and control and to investigate characteristics associated with performance. METHODS: In 2005, we conducted a cross-sectional mailed survey of all 85 North Carolina local health departments to assess capacity and performance in diabetes prevention and control based on the 10 Essential Public Health Services and adapted from the Local Public Health System Performance Assessment Instrument. We linked survey responses to county-level data, including data from a national survey of local health departments. RESULTS: Local health departments reported a median of 0.05 full-time equivalent employees in diabetes prevention and 0.1 in control. Performance varied across the 10 Essential Services; activities most commonly reported included providing information to the public and to policy makers (76%), providing diabetes education (58%), and screening (74%). The mean score on a 10-point performance index was 3.5. Characteristics associated with performance were population size, health department size and accreditation status, and diabetes-specific external funding. Performance was not better in localities where the prevalence of diabetes was high or availability of primary care was low. CONCLUSION: Most North Carolina local health departments had limited capacity to conduct diabetes prevention or control programs in their communities. Diabetes is a major cause of illness and death, yet it is neglected in public health practice. These findings suggest opportunities to enhance local public health practice, particularly through targeted funding and technical assistance.

Physicians' expectations of benefit from tube feeding.

OBJECTIVE: Tube feeding is increasingly common, despite evidence for limited medical benefits. We interviewed treating physicians to describe their expectation of benefit for patients receiving a new feeding tube, and to determine whether expected benefits vary by patient characteristics. METHODS: We recruited treating physicians and surrogate decision-makers for 288 hospitalized patients in a prospective study of new feeding tube decisions. In structured interviews, physicians provided information on patients' diagnosis and whether they expected any of eight potential medical benefits for a specific patient; surrogates provided information about the patients' function, race, age, prior residence, and ability to eat by mouth. RESULTS: We completed interviews with 173 physicians about tube feeding for 280 patients (response rate, 97%). Patients commonly had acute stroke (30%), neurodegenerative disease (16%), or head and neck cancer (22%); 70% were somewhat or severely malnourished. In half or more cases, physicians expected benefits of improved nutrition (93%), hydration (60%), prolonged life (58%), ease providing medication (55%), and less aspiration risk (49%). Physicians endorsed more expected benefits for patients with stroke or those completely unable to eat by mouth (p < 0.05). CONCLUSION: Treating physicians expected multiple medical benefits for a diverse population of patients receiving feeding tubes. Physicians may be unaware of evidence, or expect more optimistic outcomes for their specific patient population. Further education and decision support may improve evidence-based decision-making about feeding tubes.

Association of psychosocial work characteristics with low back pain outcomes.

STUDY DESIGN: This is a secondary analysis of a prospective cohort of 295 patients with acute low back pain presenting to 31 primary care physicians in North Carolina. OBJECTIVE: This study examines the hypothesis that dissatisfaction with job tasks and lack of social support from coworkers and supervisor are associated with poorer low back pain outcomes. SUMMARY OF BACKGROUND DATA: Psychosocial work characteristics are thought to be associated with the occurrence, report, and development of long-term disability from low back pain, but the studies are inconclusive. METHOD.: Three psychosocial work characteristics were separately compared to these outcomes: time to functional recovery, attainment of complete recovery, and clinically relevant change on the Modified Roland Scale. RESULTS: Relative to subjects with more social support from coworkers, subjects with less social support from coworkers have 1.55 (95% CI = 1.04-2.34) times the risk of not attaining complete recovery from low back pain at 8 weeks. For all other outcomes evaluated in this study, there was not an association with the psychosocial work characteristics. Biomechanical demands were found not to modify this association. CONCLUSION: This analysis provides evidence that social support in the workplace from coworkers but not social support from a supervisor or job task satisfaction are likely targets for intervention.

Preliminary study of a school-based program to improve hypertension awareness in the community.

BACKGROUND AND OBJECTIVES: We developed a school-based program to raise community awareness about hypertension. We studied the results of the program on the outcomes of parental knowledge about high blood pressure (BP) and their reports of having seen or intending to see a health professional about their BP. METHODS: We pilot tested a prototype middle-school curriculum using a crossover design in three fifth-grade classrooms (two designated early and one designated delayed intervention) in a suburban public school. We then used McNemar's test to assess significant differences in proportions responding correctly to BP knowledge questions and proportions reporting having seen or intending to see a health care professional about BP before and after the intervention. We tested for differences at 2-month follow-up in the early intervention classrooms compared to the delayed intervention classroom using chi-square. RESULTS: Seventy-six parents (out of a potential 134) completed baseline questionnaires. Parents had high baseline knowledge about certain aspects of hypertension, but baseline knowledge that high BP could lead to kidney failure was relatively low. The percentage of parents responding correctly to a question of whether high BP could lead to kidney failure increased after the intervention from 45.5% to 64.3%. Among parents in the early intervention classrooms, the percentage who reported having seen or intending to see a health professional about their BP increased from 9.6% to 27.5%. At 2-month follow-up, 27.5% of parents in the early intervention classrooms reported being seen or intending to be seen by a health care provider about their BP compared to only 8.3% of the parents in the delayed intervention classroom. CONCLUSIONS: This program may improve parents' knowledge about hypertension and their intent to be seen about BP.

Pregnancy and STD prevention counseling using an adaptation of motivational interviewing: a randomized controlled trial.

CONTEXT: Given levels of unintended pregnancy and STDs, an effective counseling intervention is needed to improve women's consistent use of effective prevention methods. METHODS: A sample of 764 women aged 16-44 who were at risk of unintended pregnancy were enrolled in a randomized controlled trial in North Carolina in 2003-2004. Intervention participants received pregnancy and STD prevention counseling, adapted from motivational interviewing, both at enrollment and two months later; controls received only a session of general health counseling. Levels of contraceptive use (categorized as high, low or none on the basis of the effectiveness of the method and the consistency of use) and barriers to use were measured at two, eight and 12 months; chi-square tests were used to compare selected outcomes between the groups. Rates of unintended pregnancy and chlamydia infection were assessed over the study period. RESULTS: At baseline, 59% of all participants reported a high level of contraceptive use, 19% a low level and 22% nonuse. At two months, the proportions of intervention and control participants who had improved their level of use or maintained a high level (72% and 66%, respectively) were significantly larger than the proportions who had reported a high level of use at baseline (59% and 58%, respectively). No significant differences were found between the groups at 12 months, or between baseline and 12 months for either group. During the study, 10-11% of intervention and control participants became pregnant, 1-2% received a chlamydia diagnosis and 7-9% had another STD diagnosed. CONCLUSIONS: Repeated counseling sessions may be needed to improve contraceptive decision-making and to reduce the risk of unintended pregnancy and STDs.

Acceptance and use of emergency contraception with standardized counseling intervention: results of a randomized controlled trial.

OBJECTIVE: The objective of this work was to evaluate the acceptance, use and recall of an optional advance prescription for emergency contraception (EC). MATERIALS AND METHODS: This study used as randomized controlled trial evaluating contraceptive counseling intervention with women aged 16-44 years who were at risk for unintended pregnancy (N=737). Intervention participants (n=365) received contraceptive counseling with optional advance EC prescription. Control women (n=372) received no contraceptive or EC counseling. Among intervention participants, initial acceptance and use of EC in first 2 months were evaluated. Among all participants, differences were evaluated between recall of EC discussion and use of EC. RESULTS: Among 365 intervention women, 336 received EC counseling and 51% of these 336 accepted advance EC prescription. At 2 months, among the women who had accepted EC, 6% had filled and used their prescription and 8% had filled but not used their prescription. At 12 months, intervention women were significantly more likely than controls to recall talking about EC (33% vs. 5%) and obtaining a prescription (38% vs. 6%), but there were no differences in the use of EC (6% vs. 6%). CONCLUSION: When the option is available for EC counseling, approximately half of women accepted advance prescription for EC. However, few women who received information and/or an advance prescription remembered discussing EC, filled the prescription or used EC over 12 months.

The difficult doctor? Characteristics of physicians who report frustration with patients: an analysis of survey data.

BACKGROUND: Literature on difficult doctor-patient relationships has focused on the "difficult patient." Our objective was to determine physician and practice characteristics associated with greater physician-reported frustration with patients. METHODS: We conducted a secondary analysis of the Physicians Worklife Survey, which surveyed a random national sample of physicians. Participants were 1391 family medicine, general internal medicine, and medicine subspecialty physicians. The survey assessed physician and practice characteristics, including stress, depression and anxiety symptoms, practice setting, work hours, case-mix, and control over administrative and clinical practice. Physicians estimated the percentage of their patients who were "generally frustrating to deal with." We categorized physicians by quartile of reported frustrating patients and compared characteristics of physicians in the top quartile to those in the other three quartiles. We used logistic regression to model physician characteristics associated with greater frustration. RESULTS: In unadjusted analyses, physicians who reported high frustration with patients were younger (p < 0.001); worked more hours per week (p = 0.041); and had more symptoms of depression, stress, and anxiety (p < 0.004 for all). In the final model, factors independently associated with high frustration included age < 40 years, work hours > 55 per week, higher stress, practice in a medicine subspeciality, and greater number of patients with psychosocial problems or substance abuse. CONCLUSION: Personal and practice characteristics of physicians who report high frustration with patients differ from those of other physicians. Understanding factors contributing to physician frustration with patients may allow us to improve the quality of patient-physician relationships.

Adults' lack of a usual source of care: a matter of preference?

PURPOSE: We wanted to identify characteristics of adults who do not have a usual source of care and then stratify the analysis by those who prefer vs those who do not prefer to have a usual source of care. METHODS: We analyzed data from a nationally representative sample of 9,011 adults to identify characteristics of those more likely to not have a usual source of care. Based on stated reasons for lacking a usual source of care, we created 2 subpopulations of adults without a usual source of care: those who had no preference and those who did. We identified and compared characteristics of each subpopulation. RESULTS: In the year 2000, 20% of adults did not have a usual source of care. Among all adults, lack of insurance (odds ratio [OR] = 3.2; 95% confidence interval [CI], 2.6-3.9) was independently associated with lacking a usual source of care, as were male sex (OR = 2.1; 95% CI, 1.7-2.4), excellent reported health (OR = 2.0; 95% CI, 1.2-3.2), younger age (for ages 18-29 years, OR = 4.1; 95% CI, 3.1-5.4) and Hispanic ethnicity (OR = 1.5; 95% CI,1.2-1.9). Of those without a usual source of care, 72% cited reasons indicating no preference to have one. Associations among such respondents were similar to those found among adults as a whole. Among respondents who preferred to have a usual source of care, however, the sex of the respondent became less significant, lack of insurance became more significant, and reported health status became nonsignificant. CONCLUSIONS: Most adults who lack a usual source of care do so for reasons of preference, evidently placing little value on having a usual source of care. Helping these persons have a usual source of care will likely require different interventions than needed to help those who want a usual source of care but cannot get one.

Expectations and outcomes of gastric feeding tubes.

PURPOSE: To compare expected outcomes with actual outcomes from tube feeding in adult patients. SUBJECTS AND METHODS: This prospective cohort study was conducted in two North Carolina hospitals. Surrogates were interviewed shortly after feeding tube insertion and at 3- and 6-month follow-up; chart abstraction and death certificate review also were carried out. Participants were surrogate decision-makers for consecutive adult patients who received new feeding tubes. RESULTS: There were 288 patients with surrogate decision-makers enrolled. Mean age was 65 years; 30% had a primary diagnosis of stroke, 16% neurodegenerative disorder, 20% head and neck cancer, and 30% other diagnoses. At 3 months, 21% of patients had died, and 6-month mortality was 30%. At 3 months, 38% of survivors were residing in a nursing home, and 27% had the feeding tube removed. Patients were impaired in most activities of daily living (ADLs) with little change over time. Medical complications were common: 25% of patients had decubitus ulcers at 3 months, and 24% had at least one episode of pneumonia. Perceived global quality of life was poor at 4.6 (on a 0-10 scale) at baseline, and surrogates anticipated this would improve to 8.0 with tube feeding. Family surrogates' expectations for improvement from the feeding tube were very high at baseline and remained so at 3 and 6 months. CONCLUSIONS: Families' high expectations of benefit from tube feeding are in contrast to clinical outcomes. Providers and families need better information about the outcomes of this common procedure.

Surrogates' perceptions about feeding tube placement decisions.

OBJECTIVES: (1) To determine surrogates perceptions about who made the decision to place the feeding tube and who they would have preferred to have made the decision. (2) To determine surrogates' perceptions of the information they received to make this decision. METHODS: Structured interviews with 246 surrogate decision-makers. RESULTS: Fifty-five percent of surrogates felt that the decision was made primarily by the surrogate, but 75% would prefer that the decision be shared with the physician. Surrogates reported that they discussed the benefits (80%) and the risks (72%) of feeding tube placement and discussed what life would be like with the feeding tube (65%) and without the feeding tube (67%). They also reported being asked if they understood the information (85%) and their thoughts about placement (56%). Despite receiving this information, 28 to 41% reported wanting more information about these aspects. CONCLUSION: Surrogates would have preferred greater physician participation in decisions about feeding tube placement and many reported that their informational needs were not completely met. PRACTICE IMPLICATIONS: These results suggest that physicians may be justified in taking a more active role in feeding tube decisions with surrogates and that many surrogates desire more information than is required by standards of informed decision making.

Effects of sex, age, and visits on receipt of preventive healthcare services: a secondary analysis of national data.

BACKGROUND: Sex and age may exert a combined influence on receipt of preventive services with differences due to number of ambulatory care visits. METHODS: We used nationally representative data to determine weighted percentages and adjusted odds ratios of men and women stratified by age group who received selected preventive services. The presence of interaction between sex and age group was tested using adjusted models and retested after adding number of visits. RESULTS: Men were less likely than women to have received blood pressure screening (aOR 0.44;0.40-0.50), cholesterol screening (aOR 0.72;0.65-0.79), tobacco cessation counseling (aOR 0.66;0.55-0.78), and checkups (aOR 0.53;0.49-0.57). In younger age groups, men were particularly less likely than women to have received these services. In adjusted models, this observed interaction between sex and age group persisted only for blood pressure measurement (p = .016) and routine checkups (p < .001). When adjusting for number of visits, the interaction of age on receipt of blood pressure checks was mitigated but men were still overall less likely to receive the service. CONCLUSION: Men are significantly less likely than women to receive certain preventive services, and younger men even more so. Some of this discrepancy is secondary to a difference in number of ambulatory care visits.

Performance of osteoporosis risk assessment tools in postmenopausal women aged 45-64 years.

Osteoporosis risk factor assessment is of uncertain utility in women under 65 years of age. Previous comparative studies of osteoporosis risk assessment tools were not stratified by age. We compared the discriminatory ability of three previously validated osteoporosis risk assessment tools in a referral population of postmenopausal women aged 45-64 years (n=2539) and aged 65-96 years (n=1496) seen at a university-based outpatient osteoporosis center in Belgium. Risk scores for the Osteoporosis Self-assessment Tool, Osteoporosis Risk Assessment Instrument, and Simple Calculated Osteoporosis Risk Estimation were calculated for each patient. The reference standard was osteoporosis at the femoral neck, defined as a T-score < or =-2.5 based on bone mineral density measured by dual energy X-ray absorptiometry. Osteoporosis was present in 139 of 2539 (5.5%) women aged 45-64 years and 241 of 1496 (16.1%) women aged 65 years or older. The tools had similar overall discriminatory ability to identify women with osteoporosis [area under the ROC curve 0.750-0.768, P=0.23 for women aged 45-64 years; area under the ROC curve 0.745-0.762, P=0.06 for women aged 65 years or older (P>0.05 indicates no difference among tools)]. The likelihood ratios for the high-risk score categories ranged from 3.60 to 6.73 for the younger women and 3.45 to 6.99 for the older women when different score thresholds were set to maximize the performance of each tool in each age group. We conclude that the diagnostic accuracy of three osteoporosis risk assessment tools was similar in postmenopausal women aged 45-64 years and women aged 65 years or older. Use of structured risk assessment tools to identify women at high risk of osteoporosis in the early postmenopausal period warrants further study. Of the three tools evaluated, the OST is the simplest and has the best potential for use in clinical practice.