Prior studies evaluating opening pressure (OP) have mostly involved lumbar puncture (LP) for diagnosis of neurologic disease or small cohorts of healthy volunteers and therefore the normal OP is not ...well-defined.
The goal of this study was to establish the normal range of OP in a community-based population using the Mayo Clinic Study of Aging (MCSA) and to evaluate factors that contribute to OP variability.
LP OP were obtained from participants aged 32-95 years between 11/1/07 and 10/1/17, as part of routine data collection for the MCSA, a longitudinal, population-based study of residents of Olmsted County, Minnesota.
A longitudinal, population-based study of residents of Olmsted County, Minnesota.
There were 639 participants (56.8% male; 98.5% white) who underwent LP with recorded OP as part of the MCSA.
LP.
LP OP was recorded along with variables that could possibly influence its variability, including age, body mass index (BMI), and obstructive sleep apnea (OSA).
Six hundred thirty-nine participants (56.8% men) underwent LP with recorded OP; average age was 71.0 years (SD 10.9) with a mean BMI of 28.0 (SD 4.6). Mean OP was 155.4 mmH
O (SD 41.9) with a 95% reference interval of 82-242 mmH
O (range 60-314; Q1, Q3: 124, 182). Increasing age was associated with lower OP (
< 0.001), while increasing BMI was associated with higher OP (
< 0.001). Twelve (2%) participants had OP ≥ 250 mmH
O; they were younger 58.5 (SD 8.2),
< 0.001, had higher BMI 33.6 (SD 4.6),
< 0.001, and were more likely to have OSA (75%,
< 0.001). Among the 79 participants with repeat LPs within 2.5 years, the coefficient of repeatability (CR) was 64.9. Ten (12.7%) had an OP difference ≥50 mmH
O between serial LPs.
This large population-based study showed that LP OP can vary significantly among individuals. Higher OPs were associated with higher BMI and younger age.
Purpose
This study investigated factors associated with declines in emotional well-being (EWB) over time in breast cancer survivors.
Methods
Women with breast cancer (Stages I–III) residing in Los ...Angeles, CA, or Detroit, MI, and reported to the Surveillance, Epidemiology, and End Results registries between June 2005 and February 2007 completed surveys at 9 months and 4 years after diagnosis. EWB was measured by the Functional Assessment of Cancer Treatment-Breast. Using a stress coping framework, logistic regression models assessed associations between personal, social, and clinical correlates, appraisal (e.g., worry about recurrence) and coping factors (e.g., emotional support) to EWB declines.
Results
Among eligible women who completed primary breast cancer treatment, 772 completed both surveys, and 192 (24.9 %) experienced EWB declines over time. Women with past or current depression were more likely to report EWB decline (
p
< 0.01). Survivors who perceived they did not receive enough information about risk of breast cancer recurrence during primary treatment were more likely to have EWB decline (OR 0.53, 95 % CI 0.32–0.87). Greater perceived likelihood of recurrence (OR 1.95, 95 % CI 1.01–5.29) and increased worry about recurrence (OR 1.38, 95 % CI 1.10–1.72) were associated with EWB decline. Higher spirituality beliefs and practices were associated with EWB decline.
Conclusions
A considerable number of breast cancer patients report emotional well-being declines over time. Early identification of women who are vulnerable, such as women with past depression, is crucial to improve quality of care. Women would benefit from education about cancer recurrence and tailored strategies to manage worry about recurrence over time.
Implication for cancer survivors
Understanding actual risk of recurrence and managing worry about recurrence is important for cancer survivors. Emotional concerns are common for individuals with cancer so survivors should feel free to reach out and discuss such concerns with providers well into the survivorship period.
Study objective Computed tomography (CT) use has increased rapidly, raising concerns about radiation exposure and cost. The Centers for Medicare & Medicaid Services (CMS) developed an imaging ...efficiency measure (Outpatient Measure 15 OP-15) to evaluate the use of brain CT in the emergency department (ED) for atraumatic headache. We aim to determine the reliability, validity, and accuracy of OP-15. Methods This was a retrospective record review at 21 US EDs. We identified 769 patient visits that CMS labeled as including an inappropriate brain CT to identify clinical indications for CT and reviewed the 748 visits with available records. The primary outcome was the reliability of OP-15 as determined by CMS from administrative data compared with medical record review. Secondary outcomes were the measure's validity and accuracy. Outcome measures were defined according to the testing protocol of the American Medical Association's Physician Consortium for Performance Improvement. Results On record review, 489 of 748 ED brain CTs identified as inappropriate by CMS had a measure exclusion documented that was not identified by administrative data; the measure was 34.6% reliable (95% confidence interval CI 31.2% to 38.0%). Among the 259 patient visits without measure exclusions documented in the record, the measure's validity was 47.5% (95% CI 41.4% to 53.6%), according to a consensus list of indications for brain CT. Overall, 623 of the 748 ED visits had either a measure exclusion or a consensus indication for CT; the measure's accuracy was 16.7% (95% CI 14% to 19.4%). Hospital performance as reported by CMS did not correlate with the proportion of CTs with a documented clinical indication ( r =–0.11; P =.63). Conclusion The CMS imaging efficiency measure for brain CTs (OP-15) is not reliable, valid, or accurate and may produce misleading information about hospital ED performance.
Abstract Objective To identify factors associated with perceptions of care coordination in a diverse sample of breast cancer patients. Methods Breast cancer patients reported to the metropolitan SEER ...registries of Detroit or Los Angeles from 6/05 to 2/07 were surveyed after diagnosis ( N = 2268, RR = 72.4%). Outcomes were two dichotomous measures reflecting patient appraisal of care coordination during their treatment experience. Primary independent variables were race/ethnicity (white, African American, Latina-high acculturated, Latina-low acculturated) and health literacy (low, moderate, high). Logistic regression was used to evaluate factors associated with both measures of care coordination. Results 2148 subjects were included in the analytic dataset. 16.4% of women perceived low care coordination and 12.5% reported low satisfaction. Race/ethnicity was not significantly associated with care coordination. Women with low subjective health literacy were 3–4 times as likely as those with high health literacy to perceive low care coordination and low satisfaction with care coordination (OR = 3.88; 95% CI: 2.78–5.41; OR = 3.19 95% CI: 2.25–4.52, respectively). Conclusions Many breast cancer patients positively appraised their care coordination, but patients with low health literacy perceived low care coordination. Practice implications Providers should be aware of the health literacy deficits that may contribute to their patients’ attitudes towards their breast cancer care coordination.
The national obesity epidemic is contributing to an increased proportion of overweight and obese breast cancer patients. The authors' purpose was to determine whether patterns of use and outcomes of ...reconstruction differed among obese and nonobese patients.
The authors performed a 5-year follow-up survey of mastectomy-treated breast cancer patients from the Los Angeles and Detroit Surveillance, Epidemiology and End Results Cancer Registries (response rate, 59 percent). Patients were divided into three body mass index categories: normal weight (body mass index<25 kg/m), overweight (25 to 30 kg/m), and obese (>30 kg/m). Outcomes of interest were receipt of reconstruction, type and timing of reconstruction, access barriers, and satisfaction. Chi-square and t tests were used for analysis. Logistic regression was used to identify predictors of autologous reconstruction.
Of 374 mastectomy-treated patients, receipt of reconstruction did not vary by body mass index (53 percent normal weight, 48 percent overweight, and 45 percent obese; p=0.43). Receipt did vary by type of reconstruction: significantly more obese patients received transverse rectus abdominis musculocutaneous flaps compared with normal weight patients (53 percent versus 26 percent; p=0.01). No specific access barriers to reconstruction were identified. Patient satisfaction with surgical decision-making and surgical outcomes was similar across body mass index categories.
Obese compared with normal weight breast cancer patients have similar use of breast reconstruction, are more likely to receive an autologous procedure, and report similar satisfaction with surgical outcomes. Future efforts should be directed at decreasing the surgical risk in this challenging patient population.
Therapeutic, II.
To describe which providers provide breast cancer survivorship care, we conducted a longitudinal survey of nonmetastatic breast cancer patients identified by the SEER registries of Los Angeles and ...Detroit. Multinomial logistic regression examined the adjusted odds of surgeon compared with a medical oncologist follow-up or primary care provider compared with medical oncologist follow-up, adjusting for age, race/ethnicity, insurance, tumor stage, receipt of chemotherapy, endocrine therapy use, and visit to a medical oncologist at the time of diagnosis. Results were weighted to account for sample selection and nonresponse. 844 women had invasive disease and received chemotherapy or endocrine therapy. 65.2 % reported medical oncologists as their main care provider at 4 years, followed by PCP/other physicians (24.3 %) and surgeons (10.5 %). Black women were more likely to receive their follow-up care from surgeons (OR 2.47, 95 % CI 1.16–5.27) or PCP/other physicians (OR 2.62, 95 % CI 1.47–4.65) than medical oncologists. Latinas were more likely to report PCP/other physician follow-up than medical oncologists (OR 2.33, 95 % CI 1.15–4.73). Compared with privately insured women, Medicaid recipients were more likely to report PCP/other physician follow-up (OR 2.52, 95 % CI 1.24–5.15). Women taking endocrine therapy 4 years after diagnosis were less likely to report surgeons or PCP/other physicians as their primary provider of breast cancer follow-up care. Different survivorship care patterns emerge on race/ethnicity and insurance status. Interventions are needed to inform patients and providers on the recommended sources of breast cancer follow-up.
Background and Purpose
While variation in breast cancer quality indicators has been studied, to date there have been no studies examining the degree of surgeon-level variation in patient-reported ...outcomes. The purpose of this study is to examine surgeon-level variation in patient appraisals of their breast cancer care experiences.
Methods
Survey responses and clinical data from breast cancer patients reported to Detroit and Los Angeles Surveillance, Epidemiology and End Results registries from 6/2005 to 2/2007 were merged with attending surgeon surveys (1,780 patients, 291 surgeons). Primary outcomes were patient reports of access to care, care coordination, and decision satisfaction. Random-effects models examined variation due to individual surgeons for these three outcomes.
Results
Mean values on each patient-reported outcome scale were high. The amount of variation attributable to individual surgeons in the unconditional models was low to modest: 5.4 % for access to care, 3.3 % for care coordination, and 7.5 % for decision satisfaction. Few factors were independently associated with patient reports of better access to or coordination of care, but less-acculturated Latina patients had lower decision satisfaction.
Conclusions
Patients reported generally positive experiences with their breast cancer treatment, though we found disparities in decision satisfaction. Individual surgeons did not substantively explain the variation in any of the patient-reported outcomes.
Background: Concerns about the use of mastectomy and breast reconstruction for breast cancer have motivated interest in surgeon's influence on the variation in receipt of these procedures. ...Objectives: To evaluate the influence of surgeons on variations in the receipt of mastectomy and breast reconstruction for patients recently diagnosed with breast cancer. Methods: Attending surgeons (n = 419) of a population-based sample of breast cancer patients diagnosed in Detroit and Los Angeles during June 2005 to February 2007 (n = 2290) were surveyed. Respondent surgeons (n = 291) and patients (n = 1780) were linked. Random-effects models examined the amount of variation due to surgeon for surgical treatment. Covariates included patient clinical and demographic factors and surgeon demographics, breast cancer specialization, patient management process measures, and attitudes about treatment. Results: Surgeons explained a modest amount of the variation in receipt of mastectomy (4%) after controlling for patient clinical and sociodemographic factors but a greater amount for reconstruction (16%). Variation in treatment rates across surgeons for a common patient case was much wider for reconstruction (median, 29%; 5th—95th percentile, 9%–65%) then for mastectomy (median, 18%; 5th—95th percentile, 8% and 35%). Surgeon factors did not explain between-surgeon variation in receipt of treatment. For reconstruction, 1 surgeon factor (tendency to discuss treatment plans with a plastic surgeon prior to surgery) explained a substantial amount of the between-surgeon variation (31%). Conclusion: Surgeons have largely adopted a consistent approach to the initial surgery options. By contrast, the wider between-surgeon variation in receipt of breast reconstruction suggests more variation in how these decisions are made in clinical practice.
While randomized controlled trials represent the highest level of evidence we can generate in comparative effectiveness research, there are clinical scenarios where this type of study design is not ...feasible. The Comparative Effectiveness Analyses of Surgery and Radiation in localized prostate cancer (CEASAR) study is an observational study designed to compare the effectiveness and harms of different treatments for localized prostate cancer, a clinical scenario in which randomized controlled trials have been difficult to execute and, when completed, have been difficult to generalize to the population at large.
CEASAR employs a population-based, prospective cohort study design, using tumor registries as cohort inception tools. The primary outcome is quality of life after treatment, measured by validated instruments. Risk adjustment is facilitated by capture of traditional and nontraditional confounders before treatment and by propensity score analysis.
We have accrued a diverse, representative cohort of 3691 men in the USA with clinically localized prostate cancer. Half of the men invited to participate enrolled, and 86% of patients who enrolled have completed the 6-month survey.
Challenging comparative effectiveness research questions can be addressed using well-designed observational studies. The CEASAR study provides an opportunity to determine what treatments work best, for which patients, and in whose hands.
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