The Role of Psychologists in Pediatric Hospital Medicine.

The authors review the multiple roles of the pediatric psychologist in hospital medicine practice, which is commonly referred to as pediatric consultation-liaison (CL) psychology. A brief history of development of training of CL psychologists is discussed as well as current models of practice. The authors describe specific populations that CL psychologists assist in managing when hospitalized as well as how the CL psychologist can contribute to health care systems and public policy advocacy. Physicians are encouraged to request the services of pediatric CL psychologists to help promote psychological adjustment, coping, and well-being in hospitalized youth.

Corrigendum: What are people willing to pay for whole-genome sequencing information, and who decides what they receive?

This corrects the article DOI: 10.1038/gim.2016.61.

Patient Preferences for Device-Aided Treatments Indicated for Advanced Parkinson Disease.

BACKGROUND: Effective treatment for advanced Parkinson disease (PD) uncontrolled with oral medication includes device-aided therapies such as deep brain stimulation (DBS) and continuous levodopa-carbidopa infusion to the duodenum via a portable pump. OBJECTIVE: Our objective was to quantify patient preferences for attributes of these device-aided treatments. METHODS: We administered a Web-enabled survey to 401 patients in the United States. A discrete-choice experiment (DCE) was used to evaluate patients' willingness to accept tradeoffs among efficacy, tolerability, and convenience of alternative treatments. DCE data were analyzed using random-parameters logit. Best-worst scaling (BWS) was used to elicit the relative importance of device-specific attributes. Conditional logit was used to analyze the BWS data. We tested for differences in preferences among subgroups of patients. RESULTS: Improving ability to think clearly was twice as important as a 6-hour-per-day improvement in control of movement symptoms. After controlling for efficacy, treatment delivered via portable infusion pump was preferred over DBS, and both devices were preferred to oral therapy with poor symptom control. Patients were most concerned about device attributes relating to risk of stroke, difficulty thinking, and neurosurgery. Avoiding surgery to insert a wire in the brain was more important than avoiding surgery to insert a tube into the small intestine. Some differences in preferences among subgroups were statistically, but not qualitatively, significant. CONCLUSIONS: This study clarifies the patient perspective in therapeutic choices for advanced PD. These findings may help improve communication between patients and providers and also provide evidence on patient preferences to inform regulatory and access decisions.

Patient Preferences for Attributes of Type 2 Diabetes Mellitus Medications in Germany and Spain: An Online Discrete-Choice Experiment Survey.

INTRODUCTION: Understanding patient preferences for attributes of type 2 diabetes mellitus (T2DM) medications may help explain how the attributes differentially affect patient perceptions and behaviors. In this survey, we quantified the relative preferences among patients in Germany and Spain in separate analyses. METHODS: A stated-preference, discrete-choice experiment (DCE) survey was designed to elicit preferences for T2DM treatment attributes among patients with self-reported T2DM and who reported being prescribed T2DM medication for > 2 years. Patients recruited from an online national consumer panel completed an online survey. The survey presented choices between eight pairs of hypothetical T2DM treatments defined by seven attributes: chance of reaching target hemoglobin A1c (HbA1c) level; reduced risk of serious heart attack or stroke; frequency of hypoglycemia; risk of gastrointestinal (GI) problems; weight change; mode of administration (oral or injectable); dosing frequency. Data were analyzed using random-parameters logit. Minimum acceptable benefit (MAB) was defined as the minimum increase in the probability of reaching target HbA1c for which respondents would accept less desirable levels of other attributes. RESULTS: In Germany and Spain, 474 and 401 respondents completed the survey, respectively. DCE analysis showed that risk of GI problems was most important to German respondents. MAB analysis found that respondents would require a 56 percentage point increase in the probability of reaching their HbA1c target to offset a change from 0% to 30% risk of GI problems. For Spanish respondents, mode of administration was the most important attribute. These respondents would require a 59 percentage point increase in the probability of reaching their HbA1c target to offset moving from oral to injectable medications. CONCLUSIONS: Respondents in Germany and Spain were willing to trade efficacy for improvements in side effects and mode of administration. Given the variety of T2DM medications currently available, the results suggest that careful discussion about patient preferences could help improve patient satisfaction with T2DM treatment.

Physician and patient benefit-risk preferences from two randomized long-acting injectable antipsychotic trials.

PURPOSE: To quantify clinical trial participants' and investigators' judgments with respect to the relative importance of efficacy and safety attributes of antipsychotic treatments for schizophrenia, and to assess the impact of formulation and adherence. METHODS: Discrete-choice experiment surveys were completed by patients with schizophrenia and physician investigators participating in two phase-3 clinical trials of paliperidone palmitate 3-month long-acting injectable (LAI) antipsychotic. Respondents were asked to choose between hypothetical antipsychotic profiles defined by efficacy, safety, and mode of administration. Data were analyzed using random-parameters logit and probit models. RESULTS: Patients (N=214) and physicians (N=438) preferred complete improvement in positive symptoms (severe to none) as the most important attribute, compared with improvement in any other attribute studied. Both respondents preferred 3-month and 1-month injectables to oral formulation (P<0.05), irrespective of prior adherence to oral antipsychotic treatment, with physicians showing greater preference for a 3-month over a 1-month LAI for nonadherent patients. Physicians were willing to accept treatments with reduced efficacy for patients with prior poor adherence. The maximum decrease in efficacy (95% confidence interval [CI]) that physicians would accept for switching a patient from daily oral to 3-month injectable was as follows: adherent: 9.8% (95% CI: 7.2-12.4), 20% nonadherent: 25.4% (95% CI: 21.0-29.9), and 50% nonadherent: >30%. For patients, adherent: 10.1% (95% CI: 6.1-14.1), nonadherent: the change in efficacy studied was regarded as unimportant. CONCLUSION: Improvement in positive symptoms was the most important attribute. Patients and physicians preferred LAIs over oral antipsychotics, with physicians showing a greater preference for 3-month over 1-month LAI. Physicians and patients were willing to accept reduced efficacy in exchange for switching a patient from an oral formulation to a LAI.

Neoadjuvant Systemic Therapy for Breast Cancer: Factors Influencing Surgeons' Referrals.

BACKGROUND: This study aimed to assess the influence of disease- and patient-related factors on surgeons' decisions to refer patients with early-stage breast cancer (EBC) for neoadjuvant systemic therapy (NST). METHODS: An online survey of United States surgeons evaluated the influence of selected disease- and patient-related factors on surgeons' decisions, rated their influence (individually and in combination), and provided a relative ranking of jointly considered factors using best-worst scaling. RESULTS: The participants in this study were 100 licensed surgeons. The surgeons referred approximately 25 % of EBC patients for NST to improve surgical management. Approximately 75 % of the surgeons agreed that NST is important for EBC, if only to improve surgical management. More than half were "very likely" to refer EBC patients for NST based on anatomicopathologic factors. Less than 50 % were "very likely" to do so when considering tumor phenotype factors. Tumor size and lymph node status were ranked highest in hypothetical patient scenarios. Regarding combinations of factors, the importance of any single factor varied according to the combinations presented. Less than half of the respondents were "very familiar," and half were "somewhat familiar" with NST guidelines for breast cancer. More than half of the respondents were unaware that findings have shown achievement of pathologic complete response (pCR) after NST to be associated with improved survival. CONCLUSIONS: Surgeons' decision to refer for NST is strongly driven by surgical management goals. Anatomicopathologic factors are more influential than tumor phenotype. However, no single disease or patient factor consistently drives the decision to refer for NST. Surgeons' awareness of the association between pCR achievement and longer survival could be improved.

What are people willing to pay for whole-genome sequencing information, and who decides what they receive?

PURPOSE: Whole-genome sequencing (WGS) can be used as a powerful diagnostic tool as well as for screening, but it may lead to anxiety, unnecessary testing, and overtreatment. Current guidelines suggest reporting clinically actionable secondary findings when diagnostic testing is performed. We examined preferences for receiving WGS results. METHODS: A US nationally representative survey (n = 410 adults) was used to rank preferences for who decides (an expert panel, your doctor, you) which WGS results are reported. We estimated the value of information about variants with varying levels of clinical usefulness by using willingness to pay contingent valuation questions. RESULTS: The results were as follows: 43% preferred to decide themselves what information is included in the WGS report. 38% (95% confidence interval (CI): 33-43%) would not pay for actionable variants, and 3% (95% CI: 1-5%) would pay more than $1,000. 55% (95% CI: 50-60%) would not pay for variants for which medical treatment is currently unclear, and 7% (95% CI: 5-9%) would pay more than $400. CONCLUSION: Most people prefer to decide what WGS results are reported. Despite valuing actionable information more, some respondents perceive that genetic information could negatively impact them. Preference heterogeneity for WGS information should be considered in the development of policies, particularly to integrate patient preferences with personalized medicine and shared decision making.Genet Med 18 12, 1295-1302.

Induction of substrate specificity shifts by placement of alanine insertions within the consensus amphipathic region of the Escherichia coli GABA (gamma-aminobutyric acid) transporter encoded by gabP.

The Escherichia coli GABA (gamma-aminobutyric acid) permease GabP is a prototypical APC (amine/polyamine/choline) super-family transporter that has a CAR (consensus amphipathic region) containing multiple specificity determinants, ostensibly organized on two helical surfaces, one hydrophobic [SHS (sensitive hydrophobic surface)] and the other hydrophilic [SPS (sensitive polar surface)]. To gauge the functional effects of placing alanine insertions at close intervals across the entire GabP CAR, 64 insertion variants were constructed. Insertions, particularly those in the SHS and the SPS, were highly detrimental to steady-state [(3)H]GABA accumulation. TSR (transport specificity ratio) analysis, employing [(3)H]nipecotic acid and [(14)C]GABA, showed that certain alanine insertions were associated with a specificity shift (i.e. a change in k (cat)/ K (m)). An insertion (INS Ala-269) located N-terminal to the SHS increased specificity for [(3)H]nipecotic acid relative to [(14)C]GABA, whereas an insertion (INS Ala-321) located C-terminal to the SPS had the opposite effect. Overall, the results are consistent with a working hypothesis that the GabP CAR contains extensive functional surfaces that may be manipulated by insertion mutagenesis to alter the specificity ( k (cat)/ K (m)) phenotype. The thermodynamic basis of TSR analysis provides generality, suggesting that amino acid insertions could affect specificity in many other transporters, particularly those such as the E. coli phenylalanine permease PheP [Pi, Chow and Pittard (2002) J. Bacteriol. 184, 5842-5847] that have a functionally significant CAR-like domain.

Using Medicare claims to identify second primary cancers and recurrences in order to supplement a cancer registry.

BACKGROUND AND OBJECTIVE: The purpose of this study was to use Medicare claims to develop models to assist cancer registries in identifying cancer patients with second primaries or recurrences (an "event"). METHODS: Medicare inpatient and Part B data were merged with a cancer registry for patients first diagnosed in 1993-1994. Logistic regression was used to model the occurrence of an event at least 1 year after initial diagnosis, and to identify factors that could discriminate between recurrences and second primaries. RESULTS: Predictors of an event included an inpatient cancer diagnosis, cancer diagnosis different from the initial diagnosis from any source, and radiation or surgery claims in Part B. The ROC curve area was 0.90 with all Medicare data; 0.84 when restricted to inpatient data. A cancer diagnosis different from the initial diagnosis or having surgery predicted a second primary; regional or distant stage disease, diagnosis of secondary malignancy, or an inpatient diagnosis of primary cancer in a position other than principal predicted recurrence. CONCLUSIONS: Although Medicare claims have not been evaluated as a stand-alone system to identify second primaries and recurrences, Medicare claims may be useful tools for Cancer Registries in case ascertainment and follow-up.

Using hospital discharge files to enhance cancer surveillance.

Use of the traditional mechanism for cancer surveillance, hospital-based registries, may limit ascertainment of incident cases. In this study, the authors evaluated the ability of a statewide hospital discharge file (HDF) to enhance central cancer registry reporting. Incident cancers from a Virginia cancer registry were linked with an HDF for 1995. Medical record abstractions for over 2,000 cancers verified HDF and registry data. There were 19,740 unique cases ascertained from the two combined data sources. The registry captured approximately 83% of cases, while the HDF captured 62%. Although the HDF missed a substantial number of registry cases, the HDF positive predictive value for identifying the correct cancer site was 94%. Logistic regression was used to identify significant characteristics of cases likely to be captured only by the HDF; these characteristics included hospital cancer program certification, the position of the cancer diagnosis on the claim, and cancer surgery. This study represents the evaluation of a novel approach to enhancing registry completeness and accuracy using statewide HDFs. The results strongly suggest that neither a central cancer registry nor an HDF is a sufficient source for complete capture of cases. Using HDFs to supplement a central cancer registry may be a valuable and efficient method for improving registry completeness of reporting.