Surgical treatment of symptomatic subglottic stenosis during the third trimester of pregnancy.

Subglottic stenosis is a narrowing of the airway distal to the glottis. Airway narrowing can be severe and, when coupled with pregnancy, can pose a significant threat to the mother and fetus. There is sparse literature describing treatment of these critical patients, posing a challenge for management. We describe our experience with a 31-year-old woman with idiopathic subglottic stenosis who became symptomatic during her pregnancy, requiring surgical intervention early in her third trimester. The following case report describes this patient's presentation and management, in which an awake dilation technique was used. We also include a literature review on the management of subglottic stenosis in pregnancy.

Physician and Patient and Caregiver Health Attitudes and Their Effect on Medicare Resource Allocation for Patients With Advanced Cancer.

IMPORTANCE: Physicians must participate in end-of-life discussions, but they understand poorly their patients' end-of-life values and preferences. A better understanding of these preferences and the effect of baseline attitudes will improve end-of-life discussions. OBJECTIVE: To determine how baseline attitudes toward quality vs quantity of life affect end-of-life resource allocation. DESIGN, SETTING, AND PARTICIPANTS: Otolaryngology-head and neck surgery (OHNS) physicians were recruited to use a validated online tool to create a Medicare health plan for advanced cancer patients. During the exercise, participants allocated a limited pool of resources among 15 benefit categories. These data were compared with preliminary data from patients with cancer and their caregivers obtained from a separate study using the same tool. Attitudes toward quality vs quantity of life were assessed for both physicians and patients and caregivers. INTERVENTIONS: Participation in online assessment exercise. MAIN OUTCOMES AND MEASURES: Medicare resource allocation. RESULTS: Of 9120 OHNS physicians e-mailed, 767 participated. Data collected from this group were compared with data collected from 146 patients and 114 caregivers. Compared with patients and caregivers, OHNS physician allocations differed significantly in all 15 benefit categories except home care. When stratified by answers to 3 questions about baseline attitudes toward quality vs quantity of life, there were 3 categories in which allocations of patients and caregivers differed significantly from the group with the opposite attitude for at least 2 questions: other medical care (question 1, P < .001; question 2, P = .005), palliative care (question 1, P = .008; question 2, P = .006; question 3, P = .009), and treatment for cancer (questions 1 and 2, P < .001). In contrast, physician preferences showed significant differences in only 1, nonmatching category for each attitude question: cash (question 1, P = .02), drugs (question 2, P = .03), and home care (question 3, P = .048). CONCLUSIONS AND RELEVANCE: Patients with cancer and their caregivers have different preferences from physicians. These preferences are, for these patients and their caregivers, affected by their baseline health attitudes, but physician preferences are not. Understanding the effect of baseline attitudes is important for effective end-of-life discussions.

Effect of physician perspective on allocation of Medicare resources for patients with advanced cancer.

OBJECTIVES: To assess how physician perspective (perspective of patient vs perspective of physician) affects Medicare resource allocation for patients with advanced cancer and compare physician allocations with actual cancer patient and caregiver allocations. STUDY DESIGN: Cross-sectional assessment. SETTING: National assessment. SUBJECTS: Otolaryngologists. METHODS: Physicians used a validated tool to create a Medicare plan for patients with advanced cancer. Participants took the perspective of an advanced cancer patient and made resource allocations between 15 benefit categories (assessment 2, November/December 2012). Results were compared with data from a prior assessment made from a physician's perspective (assessment 1, February/March 2012) and with data from a separate study with patients with cancer and caregivers. RESULTS: In total, 767 physicians completed assessment 1 and 237 completed assessment 2. Results were compared with 146 cancer patient and 114 caregiver assessments. Assessment 1 physician responses differed significantly from patients/caregivers in 14 categories (P < .05), while assessment 2 differed in 11. When comparing physician data, assessment 2 allocations differed significantly from assessment 1 in 7 categories. When these 7 categories were compared with patient/caregiver data, assessment 2 allocations in emotional care, drug coverage, and nursing facility categories were not significantly different. Assessment 1 allocations in cosmetic care, dental, home care, and primary care categories were more similar to patient/caregiver preferences, although all but home care were still significantly different. CONCLUSIONS: Otolaryngology-head and neck surgery physician perspectives on end-of-life care differ significantly from cancer patient/caregiver perspectives, even when physicians take a patient's perspective when allocating resources. This demonstrates the challenges inherent in end-of-life discussions.

Physician allocation of Medicare resources for patients with advanced cancer.

BACKGROUND: Little is known about what patients and physicians value in end-of-life care, or how these groups would craft a health plan for those with advanced cancer. OBJECTIVE: The study objective was to assess how otolaryngology, head and neck surgery (OHNS) physicians would structure a Medicare benefit plan for patients with advanced cancer, and to compare this with cancer patient and cancer patient caregiver preferences. DESIGN: OHNS physicians used an online version of a validated tool for assessing preferences for health plans in the setting of limited resources. These data were compared to cancer patient and caregiver preferences. SETTING AND PARTICIPANTS: OHNS physicians nationwide were assessed with comparison to similar data obtained in a separate study of cancer patients and their caregivers treated at Duke University Medical Center. RESULTS: Otolaryngology physicians (n=767) completed the online assessment and this was compared with data from 146 patients and 114 caregivers. OHNS physician allocations differed significantly in 14 of the 15 benefit categories when compared with patients and caregivers. Physicians elected more coverage in the Advice, Emotional Care, Palliative Care, and Treatment for Cancer benefit categories. Patients and their caregivers elected more coverage in the Cash, Complementary Care, Cosmetic Care, Dental and Vision, Drug Coverage, Home Improvement, House Calls, Nursing Facility, Other Medical Care, and Primary Care benefit categories. CONCLUSIONS: Otolaryngology physicians have significantly different values in end-of-life care than cancer patients and their caregivers. This information is important for efficient allocation of scarce Medicare resources and for effective end-of-life discussions, both of which are key for developing appropriate health policy.