Characterizing the willingness to undergo treatment in patients with alopecia areata.

Alopecia areata is an autoimmune disease that results in partial or total balding of the scalp and/or body. Treatments available are minimally effective, have severe side effects, and are often painful. Given these burdens, patients may not feel undergoing treatment is worthwhile. The purpose of this study is to characterize the willingness of patients with alopecia areata to undergo treatment. We found that few patients are willing to undergo treatment at the risk of severe health side effects. The most acceptable form of treatment administration was topical and the least acceptable was injection at the site of hair loss. A majority of patients would only undergo treatment for hair growth that is cosmetically acceptable and the most important site of hair regrowth was the scalp. The willingness to undergo treatment differed significantly by gender, age, time since disease onset, and disease severity. This study offers insight into the preferences of patients with alopecia areata and characteristics that would make treatment widely acceptable. Institutions conducting research on treatment for alopecia areata can use the results of this study to better understand the needs of their target population.

Association between Clostridioides difficile infection and multidrug-resistant organism colonization or infection among hospitalized adults: A case-control study.

Using an ambidirectional case-control study, we found that the odds of Clostridioides difficile infection (CDI) were 3.38 (P = .01) times higher for patients with multidrug-resistant organism (MDRO) colonization compared to those without. MDRO colonization or infection 1-12 months before CDI testing significantly increased risk of positive CDI diagnosis (odds ratio 4.71, P = .02 and odds ratio = 5.03, P = .05, respectively) independent of antibiotic use, age, and comorbidity status. MDRO colonization and infection are associated with CDI, most significantly if they precede CDI.

Provider Role in Transmission of Carbapenem-Resistant Enterobacteriaceae.

OBJECTIVE We sought to evaluate the role healthcare providers play in carbapenem-resistant Enterobacteriaceae (CRE) acquisition among hospitalized patients. DESIGN A 1:4 case-control study with incidence density sampling. SETTING Academic healthcare center with regular CRE perirectal screening in high-risk units. PATIENTS We included case patients with ≥1 negative CRE test followed by positive culture with a length of stay (LOS) >9 days. For controls, we included patients with ≥2 negative CRE tests and assignment to the same unit set as case patients with a LOS >9 days. METHODS Controls were time-matched to each case patient. Case exposure was evaluated between days 2 and 9 before positive culture and control evaluation was based on maximizing overlap with the case window. Exposure sources were all CRE-colonized or -infected patients. Nonphysician providers were compared between study patients and sources during their evaluation windows. Dichotomous and continuous exposures were developed from the number of source-shared providers and were used in univariate and multivariate regression. RESULTS In total, 121 cases and 484 controls were included. Multivariate analysis showed odds of dichotomous exposure (≥1 source-shared provider) of 2.27 (95% confidence interval [CI], 1.25-4.15; P=.006) for case patients compared to controls. Multivariate continuous exposure showed odds of 1.02 (95% CI, 1.01-1.03; P=.009) for case patients compared to controls. CONCLUSIONS Patients who acquire CRE during hospitalization are more likely to receive care from a provider caring for a patient with CRE than those patients who do not acquire CRE. These data support the importance of hand hygiene and cohorting measures for CRE patients to reduce transmission risk. Infect Control Hosp Epidemiol 2017;38:1329-1334.

Do physicians' implicit views of African Americans affect clinical decision making?

BACKGROUND: Total knee replacement (TKR) is a cost-effective treatment option for severe osteoarthritis (OA). While prevalence of OA is higher among blacks than whites, TKR rates are lower among blacks. Physicians' implicit preferences might explain racial differences in TKR recommendation. The objective of this study was to evaluate whether the magnitude of implicit racial bias predicts physician recommendation of TKR for black and white patients with OA and to assess the effectiveness of a web-based instrument as an intervention to decrease the effect of implicit racial bias on physician recommendation of TKR. METHODS: In this web-based study, 543 family and internal medicine physicians were given a scenario describing either a black or white patient with severe OA refractory to medical treatment. Questionnaires evaluating the likelihood of recommending TKR, perceived medical cooperativeness, and measures of implicit racial bias were administered. The main outcome measures included TKR recommendation, implicit racial preference, and medical cooperativeness stereotypes measured with implicit association tests. RESULTS: Subjects displayed a strong implicit preference for whites over blacks (P < .0001) and associated "medically cooperative" with whites over blacks (P < .0001). Physicians reported significantly greater liking for whites over blacks (P < .0001) and reported believing whites were more medically cooperative than blacks (P < .0001). Participants reported providing similar care for white and black patients (P = .10) but agreed that subconscious biases could influence their treatment decisions (P < .0001). There was no significant difference in the rate of recommendation for TKR when the patient was black (47%) versus white (38%) (P = .439), and neither implicit nor explicit racial biases predicted differential treatment recommendations by race (all P > .06). Although participants were more likely to recommend TKR when completing the implicit association test before the decision, patient race was not significant in the association (P = .960). CONCLUSIONS: Physicians possessed explicit and implicit racial biases, but those biases did not predict treatment recommendations. Clinicians' biases about the medical cooperativeness of blacks versus whites, however, may have influenced treatment decisions.

Postoperative mortality is an inadequate quality indicator for lung cancer resection.

BACKGROUND: Postoperative mortality is the most commonly reported surgical quality measure. However, such metrics may be incapable of identifying performance outliers. The purpose of this study was to compare different measures of postoperative mortality after lung cancer resection using a large multiinstitutional database. METHODS: Data were extracted for lung cancer resection patients from the linked Surveillance Epidemiology and End Results-Medicare Registry (2006 to 2010), which provides detailed and longitudinal information about Medicare beneficiaries with cancer. Four definitions of postoperative mortality were evaluated: in-hospital, 30-day, perioperative, and 90-day. Hierarchical regression models were used to estimate mortality risk at 30 and 90 days, and provider quality was assessed by comparing observed versus expected mortality. RESULTS: We identified 11,787 lung cancer resection patients from 686 hospitals. The median age was 74 years, and 52% of patients were treated with open lobectomy. Although 30-day, perioperative, and in-hospital mortality rates were between 3% and 4%, 90-day mortality was almost double (6.89%). Clinical variables associated with 90-day mortality included sex, preexisting comorbidities, and procedure type. There were no statistically significant differences in 30-day or 90-day mortality rates among providers. CONCLUSIONS: Currently reported measures of in-hospital and 30-day postoperative mortality do not adequately represent a patient's true mortality risk as mortality almost doubles by 90 days. Because of low occurrence rate and variable provider volumes, neither 30-day nor 90-day mortality is a suitable quality indicator for lung resection.

Long-term satisfaction and medication dependence after antireflux surgery.

BACKGROUND: Antireflux surgery remains an important treatment for gastroesophageal reflux disease (GERD) refractory to medical management. However, there is a paucity of data on long-term surgical outcomes. The objectives of this study were to determine long-term patient satisfaction and medication dependence after antireflux surgery. METHODS: We identified all patients having antireflux surgery for GERD at our institution between 2000 and 2010. Medical records were reviewed and long-term outcomes were assessed using telephone surveys. Cox proportional hazards models were used to identify significant predictors of patient satisfaction and medication use 5 years and 10 years after surgery. RESULTS: We surveyed 195 patients receiving antireflux surgery with a median follow-up of 6.3 years; 191 of 195 operations (98%) were performed laparoscopically. Five years after surgery, 82% of patients were satisfied with their operation and 83% of patients were not taking any antireflux medication. At 10 years postoperatively, these rates drop to 59% and 38%, respectively. Of patients taking medication who received formal evaluation of their symptoms, only 38.5% (15 of 39) had evidence of reflux. Age, sex, year of operation, surgeon specialty, body mass index, and presenting symptom were not associated with long-term satisfaction or medication use. CONCLUSIONS: Antireflux surgery dramatically improves symptoms and provides excellent 5-year patient satisfaction and freedom from medication use. However, both of these outcomes decrease with follow-up out to 10 years.

Spatial patterns of localized-stage prostate cancer incidence among white and black men in the southeastern United States, 1999-2001.

BACKGROUND: In the United States, prostate cancer incidence is higher among black than among white males, with a higher proportion of blacks diagnosed with advanced-stage cancer. METHODS: Prostate cancer incidence (1999-2001) and census tract data were obtained for 66,468 cases in four states that account for 20% of U.S. blacks: Georgia, Florida, Alabama, and Tennessee. Spatial clusters of localized-stage prostate cancer incidence were detected by spatial scan. Clusters were examined by relative risk, population density, and socioeconomic and racial attributes. RESULTS: Overall prostate cancer incidence rates were higher in black than in white men, and a lower proportion of black cases were diagnosed with localized-stage cancer. Strong associations were seen between urban residence and high relative risk of localized-stage cancer. The highest relative risks generally occurred in clusters with a lower percent black population than the national average. Conversely, of eight nonurban clusters with significantly elevated relative risk of localized-disease, seven had a higher proportion of blacks than the national average. Furthermore, positive correlations between percent black population and relative risk of localized-stage cancer were seen in Alabama and Georgia. CONCLUSION: Association between urban residence and high relative risk of localized-stage disease (favorable prognosis) persisted after spatial clusters were stratified by percent black population. Unexpectedly, seven of eight nonurban clusters with high relative risk of localized-stage disease had a higher percentage of blacks than the U.S. population. IMPACT: Although evidence of racial disparity in prostate cancer was found, there were some encouraging findings. Studies of community-level factors that might contribute to these findings are recommended.