Feeling one's way in the world: Making a life.

This paper argues for the psychoanalytic relevance of the works of James Gibson and Susanne Langer in explicating the early development of the human child and makes use of this combined formulation of development to think about psychoanalytic theory and practice. From the insights of James Gibson's ecological psychology we can appreciate the embodiment and embeddedness of the child's growing mind within both her physical and social environments. Making use of Susanne Langer's concept of feeling to redefine ecological psychology's perceptual counterpart to action allows us to understand the child's seamless transition into active participation in her culture, as she learns to project her animalian capacity to feel into intersubjectively defined forms of behavior and experience with others. The paper presents a lengthy exposition of Gibson's ecological psychology, before explaining Langer's thinking and launching into the combined insights of these scholars to explicate the nature of the child's mind as she feels her way in the world and makes a life for herself within it. This is the life she will be able to remake in the embeddedness of a psychoanalytic therapeutic relationship where she can learn to feel her way in the world in a new light.

Predialysis nephrology care and dialysis-related health outcomes among older adults initiating dialysis.

BACKGROUND: Predialysis nephrology care is associated with lower mortality and rates of hospitalization following chronic dialysis initiation. Whether more frequent predialysis nephrology care is associated with other favorable outcomes for older adults is not known. METHODS: Retrospective cohort study of patients ≥66 years who initiated chronic dialysis in 2000-2001 and were eligible for VA and/or Medicare-covered services. Nephrology visits in VA and/or Medicare during the 12-month predialysis period were identified and classified by low intensity (<3 visits), moderate intensity (3-6 visits), and high intensity (>6 visits). Outcome measures included very low estimated glomerular filtration rate, severe anemia, use of peritoneal dialysis, and receipt of permanent vascular access at dialysis initiation and death and kidney transplantation within two years of initiation. Generalized linear models with propensity score weighting were used to examine the association between nephrology care and outcomes. RESULTS: Among 58,014 patients, 46 % had none, 22 % had low, 13 % had moderate, and 19 % had high intensity predialysis nephrology care. Patients with a greater intensity of predialysis nephrology care had more favorable outcomes (all p < 0.001). In adjusted models, patients with high intensity predialysis nephrology care were less likely to have severe anemia (RR = 0.70, 99 % CI: 0.65-0.74) and more likely to have permanent vascular access (RR = 3.60, 99 % CI: 3.42-3.79) at dialysis initiation, and less likely to die within two years of dialysis initiation (RR = 0.80, 99 % CI: 0.77-0.82). CONCLUSION: In a large cohort of older adults treated with chronic dialysis, greater intensity of predialysis nephrology care was associated with more favorable outcomes.

Hemoglobin levels triggering erythropoiesis-stimulating agent therapy in patients with cancer: the shift after United States Food and Drug Administration policy changes.

STUDY OBJECTIVE: To determine whether the hemoglobin level at which health care providers prescribed erythropoiesis-stimulating agent (ESA) therapy (trigger hemoglobin level) for their patients receiving chemotherapy was lower after the United States Food and Drug Administration (FDA) mandated a black-box warning in March 2007. DESIGN: Retrospective analysis. DATA SOURCE: U.S. Department of Veterans Affairs Healthcare System (VA) national databases. PATIENTS: A total of 7450 patients who were diagnosed with cancer between 2002 and 2009, were undergoing chemotherapy, and who received an ESA within 12 months after their cancer diagnosis. MEASUREMENTS AND MAIN RESULTS: Data were collected on patients' demographic, clinical, environmental, and treatment-related factors. After controlling for these factors, multivariable regression analyses were used to compare the trigger hemoglobin level before and after the FDA-mandated labeling change. The average trigger hemoglobin level was 0.73 g/dl lower after the labeling change (95% confidence interval [CI] -0.84 to -0.63). Moreover, the decline in trigger hemoglobin levels began in mid-2006, when the average trigger hemoglobin level fell from 10.50 g/dl in early 2006 (95% CI 10.36-10.63) to 9.30 g/dl by late 2009 (95% CI 9.10-9.49). CONCLUSION: Even before the 2007 FDA-mandated changes in ESA product labeling, hemoglobin levels that triggered ESA treatment began declining for patients receiving cancer care within the VA. This highlights the critical importance of dissemination of postmarketing safety data to impact shifts in ESA use for anemia management.

Comparing VA and private sector healthcare costs for end-stage renal disease.

BACKGROUND: Healthcare for end-stage renal disease (ESRD) is intensive, expensive, and provided in both the public and private sector. Using a societal perspective, we examined healthcare costs and health outcomes for Department of Veterans Affairs (VA) ESRD patients comparing those who received hemodialysis care at VA versus private sector facilities. METHODS: Dialysis patients were recruited from 8 VA medical centers from 2001 through 2003 and followed for 12 months in a prospective cohort study. Patient demographics, clinical characteristics, quality of life, healthcare use, and cost data were collected. Healthcare data included utilization (VA), claims (Medicare), and patient self-report. Costs included VA calculated costs, Medicare dialysis facility reports and reimbursement rates, and patient self-report. Multivariable regression was used to compare costs between patients receiving dialysis at VA versus private sector facilities. RESULTS: The cohort comprised 334 patients: 170 patients in the VA dialysis group and 164 patients in the private sector group. The VA dialysis group had more comorbidities at baseline, outpatient and emergency visits, prescriptions, and longer hospital stays; they also had more conservative anemia management and lower baseline urea reduction ratio (67% vs. 72%; P<0.001), although levels were consistent with guidelines (Kt/V≥1.2). In adjusted analysis, the VA dialysis group had $36,431 higher costs than those in the private sector dialysis group (P<0.001). CONCLUSIONS: Continued research addressing costs and effectiveness of care across public and private sector settings is critical in informing health policy options for patients with complex chronic illnesses such as ESRD.

Trends in anemia management in lung and colon cancer patients in the US Department of Veterans Affairs, 2002-2008.

PURPOSE: In 2007, growing concerns about adverse impacts of erythropoiesis-stimulating agents (ESAs) in cancer patients led to an FDA-mandated black box warning on product labeling, publication of revised clinical guidelines, and a Medicare coverage decision limiting ESA coverage. We examined ESA therapy in lung and colon cancer patients receiving chemotherapy in the VA from 2002 to 2008 to ascertain trends in and predictors of ESA use. METHODS: A retrospective study employed national VA databases to "observe" treatment for a 12-month period following diagnosis. Multivariable logistic regression analyses evaluated changes in ESA use following the FDA-mandated black box warning in March 2007 and examined trends in ESA administration between 2002 and 2008. RESULTS: Among 17,014 lung and 4,225 colon cancer patients, those treated after the March 2007 FDA decision had 65% (lung OR 0.35, CI(95%) 0.30-0.42) and 53% (colon OR 0.47, CI(95%) 0.36-0.63) reduced odds of ESA treatment compared to those treated before. Declines in predicted probabilities of ESA use began in 2006. The magnitude of the declines differed across age groups among colon patients (p = 0.01) and levels of hemoglobin among lung cancer patients (p = 0.04). CONCLUSIONS: Use of ESA treatment for anemia in VA cancer care declined markedly after 2005, well before the 2007 changes in product labeling and clinical guidelines. This suggests that earlier dissemination of research results had marked impacts on practice patterns with these agents.

Predialysis nephrology care and costs in elderly patients initiating dialysis.

BACKGROUND: Access to nephrology care before initiation of chronic dialysis is associated with improved outcomes after initiation. Less is known about the effect of predialysis nephrology care on healthcare costs and utilization. METHODS: We conducted retrospective analyses of elderly patients who initiated dialysis between January 1, 2000 and December 31, 2001 and were eligible for services covered by the Department of Veterans Affairs. We used multivariable generalized linear models to compare healthcare costs for patients who received no predialysis nephrology care during the year before dialysis initiation with those who received low- (1-3 nephrology visits), moderate- (4-6 visits), and high-intensity (>6 visits) nephrology care during this time period. RESULTS: There were 8022 patients meeting inclusion criteria: 37% received no predialysis nephrology care, while 24% received low, 16% moderate, and 23% high-intensity predialysis nephrology care. During the year after dialysis initiation, patients in these groups spent an average of 52, 40, 31, and 27 days in the hospital (P < 0.001), respectively, and accounted for an average of $103,772, $96,390, $93,336, and $89,961 in total healthcare costs (P < 0.001), respectively. Greater intensity of predialysis nephrology care was associated with lower costs even among patients whose first predialysis nephrology visit was ≤ 3 months before dialysis initiation. Patients with greater predialysis nephrology care also had lower mortality rates during the year after dialysis initiation (43%, 38%, 28%, and 25%, respectively, P < 0.001). CONCLUSIONS: Greater intensity of predialysis nephrology care was associated with fewer hospital days and lower total healthcare costs during the year after dialysis initiation, even though patients survived longer.

Validation of erythropoietin use data on Medicare's End-Stage Renal Disease Medical Evidence Report.

Data from Medicare's End-Stage Renal Disease Medical Evidence Report (Form 2728) suggest that underuse of erythropoiesis-stimulating agents (ESAs) may be contributing to anemia in predialysis patients. However, the data quality of Form 2728 is not known. ESA prescription records were confirmed in Department of Veterans Affairs (VA) data sets and/or ESA claims in Medicare files and compared with data collected on Form 2728 among 8,033 veterans who initiated dialysis in 2000 and 2001 and were eligible for both VA and Medicare coverage in the 12 months preceding dialysis initiation. Among the cohort, predialysis ESA use was found in 4% (n = 323) more veterans by VA/Medicare data sets (n = 2,810) than by Form 2728 (n = 2,487). With the use of VA/Medicare data sets (gold standard), the accuracy of Form 2728 for predialysis ESA use was sensitivity 57.0%, specificity 83.1%, positive predictive value 64.5%, negative predictive value 78.2%, and kappa coefficient 0.41. Sensitivity for reported predialysis ESA use on Form 2728 was lowest among veterans who were female and nonwhite, of low socioeconomic status, and with anemia or other comorbid illnesses. The poor sensitivity and specificity of predialysis ESA use data on Form 2728 raise concerns about the validity of previous reports and study findings. Investigators should recognize these shortcomings and the introduction of possible bias in future research and reports.

Predialysis nephrology care among older veterans using Department of Veterans Affairs or Medicare-covered services.

OBJECTIVE: To examine the effect of exclusive and dual use of Department of Veterans Affairs (VA) and Medicare healthcare systems on outpatient predialysis nephrology care. STUDY DESIGN: Retrospective cohort study. METHODS: Receipt, timeliness, and intensity of predialysis nephrology care were evaluated among 8033 veterans who initiated dialysis in 2000 and 2001 and were eligible for both VA and Medicare coverage in the 12 months preceding dialysis initiation. Propensity scores were incorporated into analyses to minimize potential selection bias from nonrandom veteran allocation to healthcare systems. RESULTS: Among the cohort, 17.4% were users of VA services only (VA-only users), 38.5% were users of Medicare-covered services only (Medicare-only users), and 44.1% were users of both VA and Medicare-covered services (dual users). Sixty-six percent of VA-only and dual users and 58.1% of Medicare-only users received predialysis nephrology care. Compared with Medicare-only users, dual users were more likely (risk ratio [RR], 1.12; 95% confidence interval [CI], 1.07-1.17) and VA-only users were as likely (RR, 0.98; 95% CI, 0.88-1.08) to have received predialysis nephrology care. Compared with Medicare-only use, VA-only use (RR, 0.63; 95% CI, 0.50-0.81) and dual use (RR, 0.78; 95% CI, 0.70-0.88) were associated with a lower likelihood of late nephrology care (<3 months before dialysis initiation). CONCLUSIONS: More than one-third of older veterans initiating dialysis do not receive nephrology care beforehand. Dual use of VA and Medicare-covered services was associated with greater receipt and favorable timeliness of predialysis nephrology care, while use of only Medicare-covered services was associated with late predialysis nephrology care. Further studies to identify reasons for system-level variations in access to predialysis nephrology care may assist in identifying opportunities for improvement.

Comparison of health-related quality of life measures for chronic renal failure: quality of well-being scale, short-form-6D, and the kidney disease quality of life instrument.

BACKGROUND: Studies have found that health-related quality of life (HRQOL) measurements with different conceptual bases yield widely varying results within the same study sample. Using data from a cohort of patients with chronic kidney failure, the purpose of this study was to compare the Quality of Well-Being Scale-Self-Administered (QWB-SA), the Short-Form-6D (SF-6D), and the Kidney Disease Component Summary (KDCS). METHODS: Baseline data from a multi-site prospective observational study of 322 veterans receiving hemodialysis were analyzed. Descriptive statistics were calculated. Confirmatory factor analysis was conducted to determine how closely the three HRQOL tools reflected the same underlying construct. RESULTS: Our confirmatory factor analysis offered strong evidence that the subscales of the QWB-SA, SF-6D, and 7-subscale KDCS measured more than one factor in this study sample. In the three-factor model, the SF-6D and 7-subscale KDCS correlated .911 (P < .05), indicating 83% of the variance in the 7-subscale KDCS was correlated with the SF-6D. However, a two-factor model, in which the highly correlated SF-6D and 7-subscale KDCS were combined, fit the data almost as well as the three-factor model. CONCLUSION: The three HRQOL measures addressed different underlying HRQOL constructs in this sample. The QWB-SA was significantly different from the SF-6D and KDCS.

Neuroscience and imagination: the relevance of Susanne Langer's work to psychoanalytic theory.

This paper presents the work of philosopher Susanne Langer and argues that her conceptualization of the human mind can provide psychoanalysts with a unique framework with which to theoretically combine interpretive and biological approaches to their work. Langer's earlier work in the philosophy of symbols directs her investigation into the biological sciences along the lines of sentience and imagination, which in turn become the cornerstones of her theory of mind. Langer's understanding of the continuing transformation of affect into language is a decisive contribution yet to be built upon by others.

Adherence to guidelines for ESRD anemia management.

BACKGROUND: A costly component of end-stage renal disease care is anemia management with recombinant human erythropoietin. National Kidney Foundation clinical practice guidelines recommend that erythropoietin be administered subcutaneously, rather than intravenously, given that the target hemoglobin level can be maintained with a lower subcutaneous dose. Because reimbursement for erythropoietin differs for federal versus private-sector dialysis centers, we hypothesized different use patterns by facility type. METHODS: Using data from a multisite prospective observational study of hemodialysis patients from 2001 to 2003, we examined compliance with erythropoietin administration guidelines across Veterans Affairs (VA) versus private-sector facilities and implications for erythropoietin dose, anemia management, and cost. RESULTS: Erythropoietin was administered predominantly subcutaneously for 52% of patients in VA versus 15% in private-sector facilities (P < 0.0001). Average adjusted weekly subcutaneous erythropoietin doses were 13,710 and 13,362 units at VA and private-sector facilities versus 19,453 and 21,237 units for intravenous erythropoietin (P = 0.01), with corresponding hemoglobin levels of 11.55 and 12.34 g/dL (115.5 and 123.4 g/L) for subcutaneous and 11.38 and 11.91 g/dL (113.8 and 119.1 g/L) for intravenous erythropoietin (P = 0.0002), respectively. Yearly erythropoietin costs per patient for subcutaneous administration were $7,129 and $6,948 at VA and private-sector facilities versus $10,116 and $11,043 for intravenous administration (P = 0.01), respectively. CONCLUSION: We found greater guideline adherence at VA facilities compared with the private sector, with lower erythropoietin costs, although overall adherence is low. Anemia management was similar. Future research should examine how patient preferences and financial incentives impact on the wider use of subcutaneous erythropoietin administration.