Secukinumab is a safe and effective treatment option for patients with moderate to severe scalp psoriasis, according to Dr. Jerry Bagel of the Psoriasis Treatment Center of Central New Jersey, and his associates.

After 12 weeks of treatment with 300 mg of secukinumab, administered subcutaneously, 52.9% of the 50 patients who received secukinumab achieved a 90% reduction in their Psoriasis Scalp Severity Index score, and 35.3% achieved complete clearance of scalp psoriasis. Only 2% of the 47 patients in the placebo group achieved PSSI 90, and no one achieved complete clearance, in the phase 3b study.

copyright eenevski/Thinkstock

[email protected]

Secukinumab is a safe and effective treatment option for patients with moderate to severe scalp psoriasis, according to Dr. Jerry Bagel of the Psoriasis Treatment Center of Central New Jersey, and his associates.

After 12 weeks of treatment with 300 mg of secukinumab, administered subcutaneously, 52.9% of the 50 patients who received secukinumab achieved a 90% reduction in their Psoriasis Scalp Severity Index score, and 35.3% achieved complete clearance of scalp psoriasis. Only 2% of the 47 patients in the placebo group achieved PSSI 90, and no one achieved complete clearance, in the phase 3b study.

copyright eenevski/Thinkstock

[email protected]

Secukinumab is a safe and effective treatment option for patients with moderate to severe scalp psoriasis, according to Dr. Jerry Bagel of the Psoriasis Treatment Center of Central New Jersey, and his associates.

After 12 weeks of treatment with 300 mg of secukinumab, administered subcutaneously, 52.9% of the 50 patients who received secukinumab achieved a 90% reduction in their Psoriasis Scalp Severity Index score, and 35.3% achieved complete clearance of scalp psoriasis. Only 2% of the 47 patients in the placebo group achieved PSSI 90, and no one achieved complete clearance, in the phase 3b study.

copyright eenevski/Thinkstock

[email protected]

Children whose ear infections involve severe bulging of the eardrum are likely to benefit from antibiotic treatment, while children with a peaked tympanogram pattern are likely to recover from the infections without the use of antibiotics, according to results from a new study.

The findings, published online Aug. 8 (Pediatrics. 2017), may help restrict pediatricians’ use of antibiotics to the patients who are most likely to benefit. For their research, Paula A. Tähtinen, MD, PhD, of Turku (Finland) University Hospital, and her colleagues, analyzed results from a previous placebo-controlled trial of 319 children in Finland with acute otitis media. Subjects were aged 6-35 months (median age 14 months; 57% boys; 99% white). The children in the cohort were evenly randomized to treatment with amoxicillin or placebo for 7 days. In the antibiotic arm, about 19% of patients failed to respond to treatment, while about 45% in the placebo arm did.

KatarzynaBialasiewicz/Thinkstock

Children whose ear infections involve severe bulging of the eardrum are likely to benefit from antibiotic treatment, while children with a peaked tympanogram pattern are likely to recover from the infections without the use of antibiotics, according to results from a new study.

The findings, published online Aug. 8 (Pediatrics. 2017), may help restrict pediatricians’ use of antibiotics to the patients who are most likely to benefit. For their research, Paula A. Tähtinen, MD, PhD, of Turku (Finland) University Hospital, and her colleagues, analyzed results from a previous placebo-controlled trial of 319 children in Finland with acute otitis media. Subjects were aged 6-35 months (median age 14 months; 57% boys; 99% white). The children in the cohort were evenly randomized to treatment with amoxicillin or placebo for 7 days. In the antibiotic arm, about 19% of patients failed to respond to treatment, while about 45% in the placebo arm did.

KatarzynaBialasiewicz/Thinkstock

Children whose ear infections involve severe bulging of the eardrum are likely to benefit from antibiotic treatment, while children with a peaked tympanogram pattern are likely to recover from the infections without the use of antibiotics, according to results from a new study.

The findings, published online Aug. 8 (Pediatrics. 2017), may help restrict pediatricians’ use of antibiotics to the patients who are most likely to benefit. For their research, Paula A. Tähtinen, MD, PhD, of Turku (Finland) University Hospital, and her colleagues, analyzed results from a previous placebo-controlled trial of 319 children in Finland with acute otitis media. Subjects were aged 6-35 months (median age 14 months; 57% boys; 99% white). The children in the cohort were evenly randomized to treatment with amoxicillin or placebo for 7 days. In the antibiotic arm, about 19% of patients failed to respond to treatment, while about 45% in the placebo arm did.

KatarzynaBialasiewicz/Thinkstock

The American Cancer Society has identified a disparity in cancer death rates, noting that persons with lower socioeconomic status have higher rates of mortality.¹ This is attributed to many factors, but it is largely owing to the higher burden of disease among lower-income individuals.¹ A component of this disease burden is measured by assessing the patient-reported outcome of cancer-related distress. The National Comprehensive Cancer Network (NCCN) Distress Management Guidelines have defined distress as “a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social and/or spiritual nature that may interfere with the ability to cope with cancer, its physical symptoms and its treatment.”²

Financial hardship related to cancer diagnosis and treatment is increasingly being recognized as an important component of disease burden and distress. The advancements in costly cancer treatments have produced burdensome direct medical costs as well as numerous indirect costs that contribute to perceived financial hardship.^3,4 These indirect costs include nonmedical expenses such as increased transportation needs or childcare, loss of earnings, or loss of household income due to caregiving needs.³ Moreover, indirect costs are often managed by patients and families through their use of savings, borrowing, reducing leisure activities, and selling possessions.³ Even though efforts to increase health coverage, such as the Affordable Care Act, have reduced the rates of individuals who are uninsured, persons with cancer who have insurance also face challenges because they cannot afford copays, monthly premiums, deductibles, and other high out-of-pocket expenses related to cancer treatment that are not covered by their insurance such as out-of-network services or providers.^5-7

Thus, financial hardship may have an impact on several areas of a patient’s life and well-being, but the effects are commonly undetected.^8-10 Research has established that financial strain can influence treatment choices and adherence to therapy.¹¹ Furthermore, the effects of financial strain have been identified across the cancer care continuum, from diagnosis through survivorship, suggesting a bidirectional relationship between financial strain and well-being.¹¹ Financial strain may reduce patient quality of life and worsen symptom burden because of the patient’s inability to access needed care, poor social supports, and/or increased stress.^11-12 These worsening outcomes may also increase the use of financial reserves and affect their ability to work.^7,11 Financial difficulties may also be associated with anxiety and depression, leading to worse quality of life and greater distress and symptom burden.¹² Identifying groups at high risk for financial strain is crucial to ensure that resources are available to assist these populations.¹³ This burden can be even more pronounced in minority and underserved patients with cancer.⁷ Patients with advanced cancer are especially vulnerable to the burden of increased costs because of the use of expensive targeted therapies; their improved survival, which extends the time of expenditure; and increased use of financial reserves.⁹ Financial hardship in patients with advanced cancer is not well understood or characterized,⁹ which is why this study aimed to better quantify distress in advanced stage cancers by describing :

▪ A cohort of patients with advanced cancer and their levels of quality of life, symptom distress, cancer-related distress and perceived financial hardship;
▪ The relationship between perceived financial hardship, quality of life, symptom distress and overall cancer-related distress; and
▪ Quality of life, symptom distress, and overall cancer-related distress according to level of perceived financial hardship.

Methods

This study is a cross-sectional, descriptive, comparative study of distress, including perceived financial hardship, among patients with advanced cancer who were receiving palliative care treatment in two outpatient medical oncology clinics in Western Pennsylvania. The data were collected during May 2013-November 2014. The study protocol was approved by the Institutional Review Board at the University of Pittsburgh. Eligible participants had to be 18 years or older and have an advanced solid tumor of any kind, with a prognosis of 1 year or less confirmed by a physician or clinic nurse practitioner/physician assistant, and be able to read and understand English at the fourth-grade level. The sample was recruited from two clinics at the University of Pittsburgh Cancer Institute, a National Cancer Institute-designated Comprehensive Cancer Program.

Measurements

Sociodemographic factors. These were measured using an investigator-derived Sociodemographic Questionnaire, a 12-item form that includes variables such as age, race, marital status, cancer type, religion and spirituality, employment status, years of education, health insurance status, and income level.

Cancer-related distress. The NCCN Distress Thermometer is a self-report visual analog scale (0, no distress; 10, great distress) formed in the shape of a thermometer combined with a problem list that is often used in outpatient cancer settings for reporting of cancer-related distress.^14-16 The sensitivity, specificity and convergent validity with the Brief Symptom Inventory and the Hospital Anxiety and Depression Scale have been established and appropriate cut-off score of the distress thermometer identified.^14-16 A score of 4 or above indicates a clinically significant level of distress.^14-16

Symptom distress. The McCorkle Symptom Distress Scale was developed in 1977 based on interviews that focused on the symptom experiences of patients. Psychometric testing among patients with cancer using the modified Symptom Distress Scale revealed high reliability (Cronbach alpha, 0.97).¹⁷ The instrument is a 13-item Likert scale (1-5) assessing the severity of distress experienced by a symptom. Total scores range from 13 to 65, where a higher score indicates greater distress. Moderate distress is indicated with a score of 25-33, and a score above 33 indicates severe distress, identifying the need for immediate intervention.¹⁷

Quality of life and spiritual well-being. The Functional Assessment of Cancer Therapy (FACT-G) is used to assess general cancer-related quality of life. It has four subscales: physical, emotional, social and family, and functional well-being, with a total score that ranges from 0-112, where higher scores show higher quality of life. The Spiritual Distress Well-Being questionnaire was used alongside the valid FACT-G assessment.^18,19 The Spiritual Well-Being Short Form was developed with an ethnically diverse population and adds 12 items to the FACT-G. The items do not necessarily assume a faith in God, allowing a wide flexibility in application and tapping into issues such as faith, meaning, and finding peace and comfort despite advanced illness. Higher scores on the Spiritual Well-Being subscore (range, 0-48) are correlated with higher scores of quality of life. The possible scores for the combined FACT-G and Spiritual Well-Being assessment range from 0-160, with higher scores showing higher quality of life.

Economic hardship. Perceived financial hardship was measured using Barrera and colleagues’ Psychological Sense of Economic Hardship Scale. ²⁰ The scale consists of 20-items broken down into 4 subscales: financial strain, inability to make ends meet, not enough money for necessities, and economic adjustments.²⁰ Economic adjustments in the 3 months before administration of the questionnaire were assessed with 9 Yes or No items, such as added another job, received government assistance, or sold possessions to increase income. The subscale of not enough money for necessities was assessed with seven 5-point scale items in which respondents noted whether they felt they had enough money for housing, clothing, home furnishings, and a car over the previous 3 months. Inability to make ends meet included two 5-point scale items that assessed the difficulty in meeting financial demands in the previous 3 months. Financial strain consisted of two 5-point scale items concerned with expecting financial hardships in the coming 3 months. Scores can range from 20-73, with a higher score indicating worse economic hardship.

Data collection and analysis

In-person data collection occurred in the clinical waiting area before the clinician visit or in the treatment room with the patient using a consecutive, convenience sample. The nursing staff checked the clinic lists daily for possible patient participants. Patients with metastatic cancer were identified and then approached for consent. After we had received the patient’s consent, the administration of the instruments took about 20 minutes to complete. The data were then entered and verified in REDCap (Research Electronic Data Capture), which is hosted at the University of Pittsburgh.²¹The levels of symptom distress, quality of life, perceived financial hardship, and cancer-related distress were described through continuously measured variables. Descriptive statistics, measures of central tendency (mean and median), and dispersion (standard deviation and range), were obtained for the subscales and total scores. Correlation analysis was used to describe the relationship between perceived financial hardship and quality of life, symptom distress, and cancer-related distress. These primary outcome variables were further explored according to the level of dichotomized perceived financial hardship using mean score as the cut point. Independent sample t tests were used to compare patients experiencing high perceived financial hardship with those experiencing low perceived financial hardship.

Results

In all, 100 patients participated in the study. Any missing data points were replaced with the mean score for that variable, although this was minimal in this study. Most of the participants were women (67%), and the average age of the participants was 63.43 years (SD, 13.05; Table 1). Of the total number of participants, 73% were white, 26% were black, and 1% were Asian. Most of the participants were either retired and not working (39%) or disabled or unable to work (34%). Almost all of the participants had some form of insurance, with 99% having either private or public health insurance. A variety of cancer types were represented in this patient population, with higher percentages of breast (25%), gynecologic (10%), lung (19%), and colon/rectal cancer (15%). Of the total number of participants, 35% had annual household incomes below $20,000, and 50% had annual household incomes of more than $20,000. On average, participants had 13.48 years (SD, 2.78) of formal education.

We conducted a bivariate correlation analysis to assess the relationship between perceived financial hardship and three other primary outcome variables (Table 3). These analyses showed significant low to moderate correlations with overall cancer-related distress (r, 0.439; P < .001), symptom distress (r, 0.409; P < .001) and overall quality of life scores (FACT-G and spiritual well-being combined score: r, -0.323; P < .001).

Discussion

Overall, this report provides data to illuminate our understanding of disparities in well-being that may be present in patients with advanced cancer. Our analysis found that patients with advanced cancer who have higher perceived financial hardship have significantly higher overall cancer-related distress, symptom distress, and poorer overall quality of life. In this study’s population of patients with advanced cancer, the most notable areas of economic hardship identified by participants were: not having enough money for necessities in the 3 months before the survey and the inability to make ends meet during the same time span, with difficulty paying bills and not having enough money left at the end of the month being most noteworthy among this study’s patient population. Financial strain and making economic adjustment were not as notable in the category of perceived financial hardship.

In regard to not having enough money, participants most commonly cited not being able to afford everyday necessities such as food, clothing, medical care, or a home, as well as leisure and recreational activities. These findings are further supported with the positive, moderate associations between perceived financial hardship and symptom distress and overall cancer-related distress found in this cohort of patients with advanced cancer and the negative, moderately associated relationship between perceived financial hardship and overall quality of life in this study’s sample.

Although these findings have been confirmed in the literature on cancer-related distress, our findings add to our knowledge on both economic and cancer-related distress exclusively in patients with advanced cancer.^9,22 The broader cancer-related distress literature has also found an association between being younger and having a lower household income as risk factors for increased financial hardship; however, the perception of financial strain and magnitude was a more significant predictor of quality of life and perception of overall well-being.^{6,8-9,12,22-23} Furthermore, patients with cancer who noted having higher financial distress typically reported decreased satisfaction with cancer care which also influenced their adherence to treatment and quality of life.²⁴

Our work now adds the important element of perceived financial hardship to the advanced cancer-related distress puzzle. We should consider integrating a financial distress assessment into routine cancer care, particularly with patients and families with advanced cancer, to proactively and routinely assess and intervene with available distress mitigating resources. Therefore, understanding the patients most likely to experience financial distress will help personalize supportive therapy.

This study’s results as well as the existing literature describing financial distress support the use of comprehensive screening instruments to capture elements of financial burden beyond out-of-pocket costs.^8,25 This screening is particularly relevant because we are increasingly recognizing that gross annual household income does not always reflect financial hardship or distress. The instrument we used for this analysis, the Psychological Sense of Economic Hardship, provides a broad view of financial toxicity including the specific components of financial strain, the inability to make ends meet, not having enough money for necessities, and economic adjustments experienced by patients with advanced cancer.²⁰ Another measure to evaluate financial toxicity among patients with cancer includes the Comprehensive Score for Financial Toxicity (COST), which is a widely used patient-reported outcome measure. It was developed with input from both patients and oncology experts.²⁵ Use of a financial toxicity assessment tool adds to our understanding of the economic financial burden experienced by patients with cancer, specifically those with advanced cancer.

Tucker-Seeley and Yabroff have identified several areas in which the research agenda for financial toxicity should focus, including: documentation of the socioeconomic context among patients across all areas of the cancer care continuum, further identification and characterization of at risk populations to address health disparities, and the inclusion of cost discussions in the health care context.²⁶ Furthermore, research is needed to identify key areas to target for interventions addressing financial toxicity, such as addressing lack of financial resources to cover the cost of cancer care, focusing on managing or preventing the distress that results from a lack of financial resources, or addressing coping behaviors used by families to manage the financial burden of cancer care.²⁶ Although cost discussions between health care providers and patients have been identified as important in reducing the financial burden of cancer care, the content, timing, and goals of those discussions still need to be better articulated for different patient populations, including patients with advanced cancer.^3,27-28 In addition, resources such as social workers, patient navigators, or financial counselors have been identified as effective in assisting patients with financial planning and accessing community resources to address financial burden and assistance.⁴

Design considerations

This study has limitations that need to be noted. Its cross-sectional design does not allow for the analysis of causal inferences. In addition, certain groups were underrepresented in this study’s sample, including uninsured patients, men, and some minority groups, which may have underestimated the amount of financial burden experienced by patients with advanced cancer. The lack of representativeness of uninsured individuals may be a result of the eligibility of persons with advanced cancer for Medicaid. However, a strength of this study is its ability to increase the representativeness of African American/black patients in the study of advanced cancer and financial hardship. In our study, just over a quarter of the participants (26 of 100; 26%) were black/African American, compared with the US Census Bureau’s national census level of 13.3% and 13.4% in Allegheny County, Pennsylvania .²⁹

The lack of employed participants in this study could be because many were not able to work because of the advanced stage of their disease. The low level of partnered status is a limitation, although one study site was a low-income hospital where one generally tends to see higher levels of unpartnered status. This study did not control for demographic information such as gender or age, thus, the relationships between the primary outcome variables and financial hardship may be overestimated. Moreover, this analysis of financial distress is limited to the context of the United States due to our lack of universal health care and unique payment system. Although we included only patients who were in the palliative phase of cancer treatment, no medical record review was conducted to determine previous cancer history and treatments, which might have provided more insight into other financial loss or cost of cancer treatment. Furthermore, we note that it can be difficult to prognosticate with accuracy and identify that some patients with advanced cancer may have been excluded from the study due to the inclusion criteria of less than 1 year of survival.

Conclusion

Perceived financial hardship is an important assessment of the burden placed on patients due to the cost of disease; and is a good start in assessing indirect costs that patients take on when coping with advanced stages of cancer and can shed light on an aspect of distress experienced by this patient population that is not commonly addressed. Subjective measures of perceived financial hardship complement objective measures that are commonly indicative of economic resources and can further our understanding of the impact of financial distress experienced by patients with cancer. Further study of financial impacts of advanced cancer as well as predictors of financial distress are essential to the early identification of financial hardship and the development of interventions to support those at high risk or experiencing financial distress.

Acknowledgments

The authors acknowledge the patients and staff at the UPMC Mercy Cancer Center in Pittsburgh, Pennsylvania, who made this study possible, and Peggy Tate for her role in data collection. They also recognize the support of the Robert Wood Johnson Foundation through the Future Nursing Scholars program. They would also like to acknowledge that permission was granted for the use of the Psychological Sense of Economic Hardship study instrument.

The American Cancer Society has identified a disparity in cancer death rates, noting that persons with lower socioeconomic status have higher rates of mortality.¹ This is attributed to many factors, but it is largely owing to the higher burden of disease among lower-income individuals.¹ A component of this disease burden is measured by assessing the patient-reported outcome of cancer-related distress. The National Comprehensive Cancer Network (NCCN) Distress Management Guidelines have defined distress as “a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social and/or spiritual nature that may interfere with the ability to cope with cancer, its physical symptoms and its treatment.”²

Financial hardship related to cancer diagnosis and treatment is increasingly being recognized as an important component of disease burden and distress. The advancements in costly cancer treatments have produced burdensome direct medical costs as well as numerous indirect costs that contribute to perceived financial hardship.^3,4 These indirect costs include nonmedical expenses such as increased transportation needs or childcare, loss of earnings, or loss of household income due to caregiving needs.³ Moreover, indirect costs are often managed by patients and families through their use of savings, borrowing, reducing leisure activities, and selling possessions.³ Even though efforts to increase health coverage, such as the Affordable Care Act, have reduced the rates of individuals who are uninsured, persons with cancer who have insurance also face challenges because they cannot afford copays, monthly premiums, deductibles, and other high out-of-pocket expenses related to cancer treatment that are not covered by their insurance such as out-of-network services or providers.^5-7

Thus, financial hardship may have an impact on several areas of a patient’s life and well-being, but the effects are commonly undetected.^8-10 Research has established that financial strain can influence treatment choices and adherence to therapy.¹¹ Furthermore, the effects of financial strain have been identified across the cancer care continuum, from diagnosis through survivorship, suggesting a bidirectional relationship between financial strain and well-being.¹¹ Financial strain may reduce patient quality of life and worsen symptom burden because of the patient’s inability to access needed care, poor social supports, and/or increased stress.^11-12 These worsening outcomes may also increase the use of financial reserves and affect their ability to work.^7,11 Financial difficulties may also be associated with anxiety and depression, leading to worse quality of life and greater distress and symptom burden.¹² Identifying groups at high risk for financial strain is crucial to ensure that resources are available to assist these populations.¹³ This burden can be even more pronounced in minority and underserved patients with cancer.⁷ Patients with advanced cancer are especially vulnerable to the burden of increased costs because of the use of expensive targeted therapies; their improved survival, which extends the time of expenditure; and increased use of financial reserves.⁹ Financial hardship in patients with advanced cancer is not well understood or characterized,⁹ which is why this study aimed to better quantify distress in advanced stage cancers by describing :

▪ A cohort of patients with advanced cancer and their levels of quality of life, symptom distress, cancer-related distress and perceived financial hardship;
▪ The relationship between perceived financial hardship, quality of life, symptom distress and overall cancer-related distress; and
▪ Quality of life, symptom distress, and overall cancer-related distress according to level of perceived financial hardship.

Methods

This study is a cross-sectional, descriptive, comparative study of distress, including perceived financial hardship, among patients with advanced cancer who were receiving palliative care treatment in two outpatient medical oncology clinics in Western Pennsylvania. The data were collected during May 2013-November 2014. The study protocol was approved by the Institutional Review Board at the University of Pittsburgh. Eligible participants had to be 18 years or older and have an advanced solid tumor of any kind, with a prognosis of 1 year or less confirmed by a physician or clinic nurse practitioner/physician assistant, and be able to read and understand English at the fourth-grade level. The sample was recruited from two clinics at the University of Pittsburgh Cancer Institute, a National Cancer Institute-designated Comprehensive Cancer Program.

Measurements

Sociodemographic factors. These were measured using an investigator-derived Sociodemographic Questionnaire, a 12-item form that includes variables such as age, race, marital status, cancer type, religion and spirituality, employment status, years of education, health insurance status, and income level.

Cancer-related distress. The NCCN Distress Thermometer is a self-report visual analog scale (0, no distress; 10, great distress) formed in the shape of a thermometer combined with a problem list that is often used in outpatient cancer settings for reporting of cancer-related distress.^14-16 The sensitivity, specificity and convergent validity with the Brief Symptom Inventory and the Hospital Anxiety and Depression Scale have been established and appropriate cut-off score of the distress thermometer identified.^14-16 A score of 4 or above indicates a clinically significant level of distress.^14-16

Symptom distress. The McCorkle Symptom Distress Scale was developed in 1977 based on interviews that focused on the symptom experiences of patients. Psychometric testing among patients with cancer using the modified Symptom Distress Scale revealed high reliability (Cronbach alpha, 0.97).¹⁷ The instrument is a 13-item Likert scale (1-5) assessing the severity of distress experienced by a symptom. Total scores range from 13 to 65, where a higher score indicates greater distress. Moderate distress is indicated with a score of 25-33, and a score above 33 indicates severe distress, identifying the need for immediate intervention.¹⁷

Quality of life and spiritual well-being. The Functional Assessment of Cancer Therapy (FACT-G) is used to assess general cancer-related quality of life. It has four subscales: physical, emotional, social and family, and functional well-being, with a total score that ranges from 0-112, where higher scores show higher quality of life. The Spiritual Distress Well-Being questionnaire was used alongside the valid FACT-G assessment.^18,19 The Spiritual Well-Being Short Form was developed with an ethnically diverse population and adds 12 items to the FACT-G. The items do not necessarily assume a faith in God, allowing a wide flexibility in application and tapping into issues such as faith, meaning, and finding peace and comfort despite advanced illness. Higher scores on the Spiritual Well-Being subscore (range, 0-48) are correlated with higher scores of quality of life. The possible scores for the combined FACT-G and Spiritual Well-Being assessment range from 0-160, with higher scores showing higher quality of life.

Economic hardship. Perceived financial hardship was measured using Barrera and colleagues’ Psychological Sense of Economic Hardship Scale. ²⁰ The scale consists of 20-items broken down into 4 subscales: financial strain, inability to make ends meet, not enough money for necessities, and economic adjustments.²⁰ Economic adjustments in the 3 months before administration of the questionnaire were assessed with 9 Yes or No items, such as added another job, received government assistance, or sold possessions to increase income. The subscale of not enough money for necessities was assessed with seven 5-point scale items in which respondents noted whether they felt they had enough money for housing, clothing, home furnishings, and a car over the previous 3 months. Inability to make ends meet included two 5-point scale items that assessed the difficulty in meeting financial demands in the previous 3 months. Financial strain consisted of two 5-point scale items concerned with expecting financial hardships in the coming 3 months. Scores can range from 20-73, with a higher score indicating worse economic hardship.

Data collection and analysis

In-person data collection occurred in the clinical waiting area before the clinician visit or in the treatment room with the patient using a consecutive, convenience sample. The nursing staff checked the clinic lists daily for possible patient participants. Patients with metastatic cancer were identified and then approached for consent. After we had received the patient’s consent, the administration of the instruments took about 20 minutes to complete. The data were then entered and verified in REDCap (Research Electronic Data Capture), which is hosted at the University of Pittsburgh.²¹The levels of symptom distress, quality of life, perceived financial hardship, and cancer-related distress were described through continuously measured variables. Descriptive statistics, measures of central tendency (mean and median), and dispersion (standard deviation and range), were obtained for the subscales and total scores. Correlation analysis was used to describe the relationship between perceived financial hardship and quality of life, symptom distress, and cancer-related distress. These primary outcome variables were further explored according to the level of dichotomized perceived financial hardship using mean score as the cut point. Independent sample t tests were used to compare patients experiencing high perceived financial hardship with those experiencing low perceived financial hardship.

Results

In all, 100 patients participated in the study. Any missing data points were replaced with the mean score for that variable, although this was minimal in this study. Most of the participants were women (67%), and the average age of the participants was 63.43 years (SD, 13.05; Table 1). Of the total number of participants, 73% were white, 26% were black, and 1% were Asian. Most of the participants were either retired and not working (39%) or disabled or unable to work (34%). Almost all of the participants had some form of insurance, with 99% having either private or public health insurance. A variety of cancer types were represented in this patient population, with higher percentages of breast (25%), gynecologic (10%), lung (19%), and colon/rectal cancer (15%). Of the total number of participants, 35% had annual household incomes below $20,000, and 50% had annual household incomes of more than $20,000. On average, participants had 13.48 years (SD, 2.78) of formal education.

We conducted a bivariate correlation analysis to assess the relationship between perceived financial hardship and three other primary outcome variables (Table 3). These analyses showed significant low to moderate correlations with overall cancer-related distress (r, 0.439; P < .001), symptom distress (r, 0.409; P < .001) and overall quality of life scores (FACT-G and spiritual well-being combined score: r, -0.323; P < .001).

Discussion

Overall, this report provides data to illuminate our understanding of disparities in well-being that may be present in patients with advanced cancer. Our analysis found that patients with advanced cancer who have higher perceived financial hardship have significantly higher overall cancer-related distress, symptom distress, and poorer overall quality of life. In this study’s population of patients with advanced cancer, the most notable areas of economic hardship identified by participants were: not having enough money for necessities in the 3 months before the survey and the inability to make ends meet during the same time span, with difficulty paying bills and not having enough money left at the end of the month being most noteworthy among this study’s patient population. Financial strain and making economic adjustment were not as notable in the category of perceived financial hardship.

In regard to not having enough money, participants most commonly cited not being able to afford everyday necessities such as food, clothing, medical care, or a home, as well as leisure and recreational activities. These findings are further supported with the positive, moderate associations between perceived financial hardship and symptom distress and overall cancer-related distress found in this cohort of patients with advanced cancer and the negative, moderately associated relationship between perceived financial hardship and overall quality of life in this study’s sample.

Although these findings have been confirmed in the literature on cancer-related distress, our findings add to our knowledge on both economic and cancer-related distress exclusively in patients with advanced cancer.^9,22 The broader cancer-related distress literature has also found an association between being younger and having a lower household income as risk factors for increased financial hardship; however, the perception of financial strain and magnitude was a more significant predictor of quality of life and perception of overall well-being.^{6,8-9,12,22-23} Furthermore, patients with cancer who noted having higher financial distress typically reported decreased satisfaction with cancer care which also influenced their adherence to treatment and quality of life.²⁴

Our work now adds the important element of perceived financial hardship to the advanced cancer-related distress puzzle. We should consider integrating a financial distress assessment into routine cancer care, particularly with patients and families with advanced cancer, to proactively and routinely assess and intervene with available distress mitigating resources. Therefore, understanding the patients most likely to experience financial distress will help personalize supportive therapy.

This study’s results as well as the existing literature describing financial distress support the use of comprehensive screening instruments to capture elements of financial burden beyond out-of-pocket costs.^8,25 This screening is particularly relevant because we are increasingly recognizing that gross annual household income does not always reflect financial hardship or distress. The instrument we used for this analysis, the Psychological Sense of Economic Hardship, provides a broad view of financial toxicity including the specific components of financial strain, the inability to make ends meet, not having enough money for necessities, and economic adjustments experienced by patients with advanced cancer.²⁰ Another measure to evaluate financial toxicity among patients with cancer includes the Comprehensive Score for Financial Toxicity (COST), which is a widely used patient-reported outcome measure. It was developed with input from both patients and oncology experts.²⁵ Use of a financial toxicity assessment tool adds to our understanding of the economic financial burden experienced by patients with cancer, specifically those with advanced cancer.

Tucker-Seeley and Yabroff have identified several areas in which the research agenda for financial toxicity should focus, including: documentation of the socioeconomic context among patients across all areas of the cancer care continuum, further identification and characterization of at risk populations to address health disparities, and the inclusion of cost discussions in the health care context.²⁶ Furthermore, research is needed to identify key areas to target for interventions addressing financial toxicity, such as addressing lack of financial resources to cover the cost of cancer care, focusing on managing or preventing the distress that results from a lack of financial resources, or addressing coping behaviors used by families to manage the financial burden of cancer care.²⁶ Although cost discussions between health care providers and patients have been identified as important in reducing the financial burden of cancer care, the content, timing, and goals of those discussions still need to be better articulated for different patient populations, including patients with advanced cancer.^3,27-28 In addition, resources such as social workers, patient navigators, or financial counselors have been identified as effective in assisting patients with financial planning and accessing community resources to address financial burden and assistance.⁴

Design considerations

This study has limitations that need to be noted. Its cross-sectional design does not allow for the analysis of causal inferences. In addition, certain groups were underrepresented in this study’s sample, including uninsured patients, men, and some minority groups, which may have underestimated the amount of financial burden experienced by patients with advanced cancer. The lack of representativeness of uninsured individuals may be a result of the eligibility of persons with advanced cancer for Medicaid. However, a strength of this study is its ability to increase the representativeness of African American/black patients in the study of advanced cancer and financial hardship. In our study, just over a quarter of the participants (26 of 100; 26%) were black/African American, compared with the US Census Bureau’s national census level of 13.3% and 13.4% in Allegheny County, Pennsylvania .²⁹

The lack of employed participants in this study could be because many were not able to work because of the advanced stage of their disease. The low level of partnered status is a limitation, although one study site was a low-income hospital where one generally tends to see higher levels of unpartnered status. This study did not control for demographic information such as gender or age, thus, the relationships between the primary outcome variables and financial hardship may be overestimated. Moreover, this analysis of financial distress is limited to the context of the United States due to our lack of universal health care and unique payment system. Although we included only patients who were in the palliative phase of cancer treatment, no medical record review was conducted to determine previous cancer history and treatments, which might have provided more insight into other financial loss or cost of cancer treatment. Furthermore, we note that it can be difficult to prognosticate with accuracy and identify that some patients with advanced cancer may have been excluded from the study due to the inclusion criteria of less than 1 year of survival.

Conclusion

Perceived financial hardship is an important assessment of the burden placed on patients due to the cost of disease; and is a good start in assessing indirect costs that patients take on when coping with advanced stages of cancer and can shed light on an aspect of distress experienced by this patient population that is not commonly addressed. Subjective measures of perceived financial hardship complement objective measures that are commonly indicative of economic resources and can further our understanding of the impact of financial distress experienced by patients with cancer. Further study of financial impacts of advanced cancer as well as predictors of financial distress are essential to the early identification of financial hardship and the development of interventions to support those at high risk or experiencing financial distress.

Acknowledgments

The authors acknowledge the patients and staff at the UPMC Mercy Cancer Center in Pittsburgh, Pennsylvania, who made this study possible, and Peggy Tate for her role in data collection. They also recognize the support of the Robert Wood Johnson Foundation through the Future Nursing Scholars program. They would also like to acknowledge that permission was granted for the use of the Psychological Sense of Economic Hardship study instrument.

The American Cancer Society has identified a disparity in cancer death rates, noting that persons with lower socioeconomic status have higher rates of mortality.¹ This is attributed to many factors, but it is largely owing to the higher burden of disease among lower-income individuals.¹ A component of this disease burden is measured by assessing the patient-reported outcome of cancer-related distress. The National Comprehensive Cancer Network (NCCN) Distress Management Guidelines have defined distress as “a multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social and/or spiritual nature that may interfere with the ability to cope with cancer, its physical symptoms and its treatment.”²

Financial hardship related to cancer diagnosis and treatment is increasingly being recognized as an important component of disease burden and distress. The advancements in costly cancer treatments have produced burdensome direct medical costs as well as numerous indirect costs that contribute to perceived financial hardship.^3,4 These indirect costs include nonmedical expenses such as increased transportation needs or childcare, loss of earnings, or loss of household income due to caregiving needs.³ Moreover, indirect costs are often managed by patients and families through their use of savings, borrowing, reducing leisure activities, and selling possessions.³ Even though efforts to increase health coverage, such as the Affordable Care Act, have reduced the rates of individuals who are uninsured, persons with cancer who have insurance also face challenges because they cannot afford copays, monthly premiums, deductibles, and other high out-of-pocket expenses related to cancer treatment that are not covered by their insurance such as out-of-network services or providers.^5-7

Thus, financial hardship may have an impact on several areas of a patient’s life and well-being, but the effects are commonly undetected.^8-10 Research has established that financial strain can influence treatment choices and adherence to therapy.¹¹ Furthermore, the effects of financial strain have been identified across the cancer care continuum, from diagnosis through survivorship, suggesting a bidirectional relationship between financial strain and well-being.¹¹ Financial strain may reduce patient quality of life and worsen symptom burden because of the patient’s inability to access needed care, poor social supports, and/or increased stress.^11-12 These worsening outcomes may also increase the use of financial reserves and affect their ability to work.^7,11 Financial difficulties may also be associated with anxiety and depression, leading to worse quality of life and greater distress and symptom burden.¹² Identifying groups at high risk for financial strain is crucial to ensure that resources are available to assist these populations.¹³ This burden can be even more pronounced in minority and underserved patients with cancer.⁷ Patients with advanced cancer are especially vulnerable to the burden of increased costs because of the use of expensive targeted therapies; their improved survival, which extends the time of expenditure; and increased use of financial reserves.⁹ Financial hardship in patients with advanced cancer is not well understood or characterized,⁹ which is why this study aimed to better quantify distress in advanced stage cancers by describing :

▪ A cohort of patients with advanced cancer and their levels of quality of life, symptom distress, cancer-related distress and perceived financial hardship;
▪ The relationship between perceived financial hardship, quality of life, symptom distress and overall cancer-related distress; and
▪ Quality of life, symptom distress, and overall cancer-related distress according to level of perceived financial hardship.

Methods

This study is a cross-sectional, descriptive, comparative study of distress, including perceived financial hardship, among patients with advanced cancer who were receiving palliative care treatment in two outpatient medical oncology clinics in Western Pennsylvania. The data were collected during May 2013-November 2014. The study protocol was approved by the Institutional Review Board at the University of Pittsburgh. Eligible participants had to be 18 years or older and have an advanced solid tumor of any kind, with a prognosis of 1 year or less confirmed by a physician or clinic nurse practitioner/physician assistant, and be able to read and understand English at the fourth-grade level. The sample was recruited from two clinics at the University of Pittsburgh Cancer Institute, a National Cancer Institute-designated Comprehensive Cancer Program.

Measurements

Sociodemographic factors. These were measured using an investigator-derived Sociodemographic Questionnaire, a 12-item form that includes variables such as age, race, marital status, cancer type, religion and spirituality, employment status, years of education, health insurance status, and income level.

Cancer-related distress. The NCCN Distress Thermometer is a self-report visual analog scale (0, no distress; 10, great distress) formed in the shape of a thermometer combined with a problem list that is often used in outpatient cancer settings for reporting of cancer-related distress.^14-16 The sensitivity, specificity and convergent validity with the Brief Symptom Inventory and the Hospital Anxiety and Depression Scale have been established and appropriate cut-off score of the distress thermometer identified.^14-16 A score of 4 or above indicates a clinically significant level of distress.^14-16

Symptom distress. The McCorkle Symptom Distress Scale was developed in 1977 based on interviews that focused on the symptom experiences of patients. Psychometric testing among patients with cancer using the modified Symptom Distress Scale revealed high reliability (Cronbach alpha, 0.97).¹⁷ The instrument is a 13-item Likert scale (1-5) assessing the severity of distress experienced by a symptom. Total scores range from 13 to 65, where a higher score indicates greater distress. Moderate distress is indicated with a score of 25-33, and a score above 33 indicates severe distress, identifying the need for immediate intervention.¹⁷

Quality of life and spiritual well-being. The Functional Assessment of Cancer Therapy (FACT-G) is used to assess general cancer-related quality of life. It has four subscales: physical, emotional, social and family, and functional well-being, with a total score that ranges from 0-112, where higher scores show higher quality of life. The Spiritual Distress Well-Being questionnaire was used alongside the valid FACT-G assessment.^18,19 The Spiritual Well-Being Short Form was developed with an ethnically diverse population and adds 12 items to the FACT-G. The items do not necessarily assume a faith in God, allowing a wide flexibility in application and tapping into issues such as faith, meaning, and finding peace and comfort despite advanced illness. Higher scores on the Spiritual Well-Being subscore (range, 0-48) are correlated with higher scores of quality of life. The possible scores for the combined FACT-G and Spiritual Well-Being assessment range from 0-160, with higher scores showing higher quality of life.

Economic hardship. Perceived financial hardship was measured using Barrera and colleagues’ Psychological Sense of Economic Hardship Scale. ²⁰ The scale consists of 20-items broken down into 4 subscales: financial strain, inability to make ends meet, not enough money for necessities, and economic adjustments.²⁰ Economic adjustments in the 3 months before administration of the questionnaire were assessed with 9 Yes or No items, such as added another job, received government assistance, or sold possessions to increase income. The subscale of not enough money for necessities was assessed with seven 5-point scale items in which respondents noted whether they felt they had enough money for housing, clothing, home furnishings, and a car over the previous 3 months. Inability to make ends meet included two 5-point scale items that assessed the difficulty in meeting financial demands in the previous 3 months. Financial strain consisted of two 5-point scale items concerned with expecting financial hardships in the coming 3 months. Scores can range from 20-73, with a higher score indicating worse economic hardship.

Data collection and analysis

In-person data collection occurred in the clinical waiting area before the clinician visit or in the treatment room with the patient using a consecutive, convenience sample. The nursing staff checked the clinic lists daily for possible patient participants. Patients with metastatic cancer were identified and then approached for consent. After we had received the patient’s consent, the administration of the instruments took about 20 minutes to complete. The data were then entered and verified in REDCap (Research Electronic Data Capture), which is hosted at the University of Pittsburgh.²¹The levels of symptom distress, quality of life, perceived financial hardship, and cancer-related distress were described through continuously measured variables. Descriptive statistics, measures of central tendency (mean and median), and dispersion (standard deviation and range), were obtained for the subscales and total scores. Correlation analysis was used to describe the relationship between perceived financial hardship and quality of life, symptom distress, and cancer-related distress. These primary outcome variables were further explored according to the level of dichotomized perceived financial hardship using mean score as the cut point. Independent sample t tests were used to compare patients experiencing high perceived financial hardship with those experiencing low perceived financial hardship.

Results

In all, 100 patients participated in the study. Any missing data points were replaced with the mean score for that variable, although this was minimal in this study. Most of the participants were women (67%), and the average age of the participants was 63.43 years (SD, 13.05; Table 1). Of the total number of participants, 73% were white, 26% were black, and 1% were Asian. Most of the participants were either retired and not working (39%) or disabled or unable to work (34%). Almost all of the participants had some form of insurance, with 99% having either private or public health insurance. A variety of cancer types were represented in this patient population, with higher percentages of breast (25%), gynecologic (10%), lung (19%), and colon/rectal cancer (15%). Of the total number of participants, 35% had annual household incomes below $20,000, and 50% had annual household incomes of more than $20,000. On average, participants had 13.48 years (SD, 2.78) of formal education.

We conducted a bivariate correlation analysis to assess the relationship between perceived financial hardship and three other primary outcome variables (Table 3). These analyses showed significant low to moderate correlations with overall cancer-related distress (r, 0.439; P < .001), symptom distress (r, 0.409; P < .001) and overall quality of life scores (FACT-G and spiritual well-being combined score: r, -0.323; P < .001).

Discussion

Overall, this report provides data to illuminate our understanding of disparities in well-being that may be present in patients with advanced cancer. Our analysis found that patients with advanced cancer who have higher perceived financial hardship have significantly higher overall cancer-related distress, symptom distress, and poorer overall quality of life. In this study’s population of patients with advanced cancer, the most notable areas of economic hardship identified by participants were: not having enough money for necessities in the 3 months before the survey and the inability to make ends meet during the same time span, with difficulty paying bills and not having enough money left at the end of the month being most noteworthy among this study’s patient population. Financial strain and making economic adjustment were not as notable in the category of perceived financial hardship.

In regard to not having enough money, participants most commonly cited not being able to afford everyday necessities such as food, clothing, medical care, or a home, as well as leisure and recreational activities. These findings are further supported with the positive, moderate associations between perceived financial hardship and symptom distress and overall cancer-related distress found in this cohort of patients with advanced cancer and the negative, moderately associated relationship between perceived financial hardship and overall quality of life in this study’s sample.

Although these findings have been confirmed in the literature on cancer-related distress, our findings add to our knowledge on both economic and cancer-related distress exclusively in patients with advanced cancer.^9,22 The broader cancer-related distress literature has also found an association between being younger and having a lower household income as risk factors for increased financial hardship; however, the perception of financial strain and magnitude was a more significant predictor of quality of life and perception of overall well-being.^{6,8-9,12,22-23} Furthermore, patients with cancer who noted having higher financial distress typically reported decreased satisfaction with cancer care which also influenced their adherence to treatment and quality of life.²⁴

Our work now adds the important element of perceived financial hardship to the advanced cancer-related distress puzzle. We should consider integrating a financial distress assessment into routine cancer care, particularly with patients and families with advanced cancer, to proactively and routinely assess and intervene with available distress mitigating resources. Therefore, understanding the patients most likely to experience financial distress will help personalize supportive therapy.

This study’s results as well as the existing literature describing financial distress support the use of comprehensive screening instruments to capture elements of financial burden beyond out-of-pocket costs.^8,25 This screening is particularly relevant because we are increasingly recognizing that gross annual household income does not always reflect financial hardship or distress. The instrument we used for this analysis, the Psychological Sense of Economic Hardship, provides a broad view of financial toxicity including the specific components of financial strain, the inability to make ends meet, not having enough money for necessities, and economic adjustments experienced by patients with advanced cancer.²⁰ Another measure to evaluate financial toxicity among patients with cancer includes the Comprehensive Score for Financial Toxicity (COST), which is a widely used patient-reported outcome measure. It was developed with input from both patients and oncology experts.²⁵ Use of a financial toxicity assessment tool adds to our understanding of the economic financial burden experienced by patients with cancer, specifically those with advanced cancer.

Tucker-Seeley and Yabroff have identified several areas in which the research agenda for financial toxicity should focus, including: documentation of the socioeconomic context among patients across all areas of the cancer care continuum, further identification and characterization of at risk populations to address health disparities, and the inclusion of cost discussions in the health care context.²⁶ Furthermore, research is needed to identify key areas to target for interventions addressing financial toxicity, such as addressing lack of financial resources to cover the cost of cancer care, focusing on managing or preventing the distress that results from a lack of financial resources, or addressing coping behaviors used by families to manage the financial burden of cancer care.²⁶ Although cost discussions between health care providers and patients have been identified as important in reducing the financial burden of cancer care, the content, timing, and goals of those discussions still need to be better articulated for different patient populations, including patients with advanced cancer.^3,27-28 In addition, resources such as social workers, patient navigators, or financial counselors have been identified as effective in assisting patients with financial planning and accessing community resources to address financial burden and assistance.⁴

Design considerations

This study has limitations that need to be noted. Its cross-sectional design does not allow for the analysis of causal inferences. In addition, certain groups were underrepresented in this study’s sample, including uninsured patients, men, and some minority groups, which may have underestimated the amount of financial burden experienced by patients with advanced cancer. The lack of representativeness of uninsured individuals may be a result of the eligibility of persons with advanced cancer for Medicaid. However, a strength of this study is its ability to increase the representativeness of African American/black patients in the study of advanced cancer and financial hardship. In our study, just over a quarter of the participants (26 of 100; 26%) were black/African American, compared with the US Census Bureau’s national census level of 13.3% and 13.4% in Allegheny County, Pennsylvania .²⁹

The lack of employed participants in this study could be because many were not able to work because of the advanced stage of their disease. The low level of partnered status is a limitation, although one study site was a low-income hospital where one generally tends to see higher levels of unpartnered status. This study did not control for demographic information such as gender or age, thus, the relationships between the primary outcome variables and financial hardship may be overestimated. Moreover, this analysis of financial distress is limited to the context of the United States due to our lack of universal health care and unique payment system. Although we included only patients who were in the palliative phase of cancer treatment, no medical record review was conducted to determine previous cancer history and treatments, which might have provided more insight into other financial loss or cost of cancer treatment. Furthermore, we note that it can be difficult to prognosticate with accuracy and identify that some patients with advanced cancer may have been excluded from the study due to the inclusion criteria of less than 1 year of survival.

Conclusion

Perceived financial hardship is an important assessment of the burden placed on patients due to the cost of disease; and is a good start in assessing indirect costs that patients take on when coping with advanced stages of cancer and can shed light on an aspect of distress experienced by this patient population that is not commonly addressed. Subjective measures of perceived financial hardship complement objective measures that are commonly indicative of economic resources and can further our understanding of the impact of financial distress experienced by patients with cancer. Further study of financial impacts of advanced cancer as well as predictors of financial distress are essential to the early identification of financial hardship and the development of interventions to support those at high risk or experiencing financial distress.

Acknowledgments

The authors acknowledge the patients and staff at the UPMC Mercy Cancer Center in Pittsburgh, Pennsylvania, who made this study possible, and Peggy Tate for her role in data collection. They also recognize the support of the Robert Wood Johnson Foundation through the Future Nursing Scholars program. They would also like to acknowledge that permission was granted for the use of the Psychological Sense of Economic Hardship study instrument.

Deck: Study finds overall high quality of care but identifies important gaps in assessment and treatment.

Active-duty service members with posttraumatic stress disorder (PTSD) or depression are frequent users of both inpatient and outpatient Military Health System (MHS) care, but there were significant variations in the quality and type of care they received, according to a recent RAND Corporation study. According to the authors, the MHS “performed well in providing initial screening for suicide and substance abuse but needs to improve at providing adequate follow-up to service members with suicide risk.”

The Quality of Care for PTSD and Depression in the Military Health System study is the third in a series of reports on the quality of depression and PTSD care for active-duty service members. The study examined data for 2013-2014 and included 14,654 service members with PTSD and 30,496 with depression; 6,322 service members were in both groups. The goal of the report was to determine whether the service members with PTSD or depression receive evidence-based care and whether there were disparities in care quality by branch of service, geographic region, and other characteristics, such as gender, age, pay grade, race/ethnicity, or deployment history.

Related: New Center of Excellence to Lead Research of “Signature Wounds”

In both the PTSD and depression cohorts, the majority of active-component service members were enlisted soldiers and had 1 or more deployments. A large number of patients were in both the PTSD and depression cohorts. The study noted that more than half of patients in the PTSD cohort had a diagnosis of depression, and more than one-fourth of those in the depression cohort received a PTSD diagnosis during the 12-month observation period.

Service members with PTSD or depression were willing to engage the health system with medians of 40 and 31 visits for PTSD and depression, respectively, during the 1-year observation period. Most of these visits were for unrelated conditions. Importantly, more than half of patients received their care from primary care providers. Social workers, psychiatrists, and clinical psychologists provided care for slightly less than half of the PTSD cohort. These mental health provider groups saw between 33% and 40% of the depression cohort. The majority of patients in both the PTSD and depression cohorts received care for their cohort diagnosis solely at military treatment facilities

Related: Posttraumatic Stress Disorder, Depression, and Other Comorbidities: Clinical and Systems Approaches to Diagnostic Uncertainties

“The high utilization for both medical and psychological conditions combined with the high number of different providers raise questions about the extent of coordination vs fragmentation of care for all the care these service members received,” the study reported. “The high number of psychotherapy visits received by members of these cohorts suggests that the MHS may be more successful than the civilian sector in engaging patients with PTSD or depression in psychosocial interventions.”

The study also highlighted the following important gaps in treatment, assessment, and follow-up:

• Assessment of baseline symptom severity of PTSD for a new treatment episode with the PCL (PTSD Checklist) was not as frequent, though current efforts are under way within the MHS to increase the regular use of the PCL to monitor PTSD patient symptoms.
• Standardized tools were used in less than half of the assessments for depression, suicide risk, and recent substance use and almost never used for assessment of function.
• Appropriate minimal care for patients with suicidal ideation was less than optimal (54%), primarily due to a lack of documentation regarding addressing access to lethal means. A Safety Plan Worksheet has recently been added to the clinical guideline for assessment and management of suicide risk which may improve this performance in the future.
• Most service members with PTSD or depression received at least some psychotherapy, but the MHS could increase delivery of evidence-based psychotherapy.
• Improvements are still needed in rates of outcome monitoring and performance on outcome measures.
• Multiple “statistically significant and clinically meaningful differences” were found in measure scores by service branch, TRICARE region, and service member.

Related: Following the Trajectory of PTSD

Deck: Study finds overall high quality of care but identifies important gaps in assessment and treatment.

Active-duty service members with posttraumatic stress disorder (PTSD) or depression are frequent users of both inpatient and outpatient Military Health System (MHS) care, but there were significant variations in the quality and type of care they received, according to a recent RAND Corporation study. According to the authors, the MHS “performed well in providing initial screening for suicide and substance abuse but needs to improve at providing adequate follow-up to service members with suicide risk.”

The Quality of Care for PTSD and Depression in the Military Health System study is the third in a series of reports on the quality of depression and PTSD care for active-duty service members. The study examined data for 2013-2014 and included 14,654 service members with PTSD and 30,496 with depression; 6,322 service members were in both groups. The goal of the report was to determine whether the service members with PTSD or depression receive evidence-based care and whether there were disparities in care quality by branch of service, geographic region, and other characteristics, such as gender, age, pay grade, race/ethnicity, or deployment history.

Related: New Center of Excellence to Lead Research of “Signature Wounds”

In both the PTSD and depression cohorts, the majority of active-component service members were enlisted soldiers and had 1 or more deployments. A large number of patients were in both the PTSD and depression cohorts. The study noted that more than half of patients in the PTSD cohort had a diagnosis of depression, and more than one-fourth of those in the depression cohort received a PTSD diagnosis during the 12-month observation period.

Service members with PTSD or depression were willing to engage the health system with medians of 40 and 31 visits for PTSD and depression, respectively, during the 1-year observation period. Most of these visits were for unrelated conditions. Importantly, more than half of patients received their care from primary care providers. Social workers, psychiatrists, and clinical psychologists provided care for slightly less than half of the PTSD cohort. These mental health provider groups saw between 33% and 40% of the depression cohort. The majority of patients in both the PTSD and depression cohorts received care for their cohort diagnosis solely at military treatment facilities

Related: Posttraumatic Stress Disorder, Depression, and Other Comorbidities: Clinical and Systems Approaches to Diagnostic Uncertainties

“The high utilization for both medical and psychological conditions combined with the high number of different providers raise questions about the extent of coordination vs fragmentation of care for all the care these service members received,” the study reported. “The high number of psychotherapy visits received by members of these cohorts suggests that the MHS may be more successful than the civilian sector in engaging patients with PTSD or depression in psychosocial interventions.”

The study also highlighted the following important gaps in treatment, assessment, and follow-up:

• Assessment of baseline symptom severity of PTSD for a new treatment episode with the PCL (PTSD Checklist) was not as frequent, though current efforts are under way within the MHS to increase the regular use of the PCL to monitor PTSD patient symptoms.
• Standardized tools were used in less than half of the assessments for depression, suicide risk, and recent substance use and almost never used for assessment of function.
• Appropriate minimal care for patients with suicidal ideation was less than optimal (54%), primarily due to a lack of documentation regarding addressing access to lethal means. A Safety Plan Worksheet has recently been added to the clinical guideline for assessment and management of suicide risk which may improve this performance in the future.
• Most service members with PTSD or depression received at least some psychotherapy, but the MHS could increase delivery of evidence-based psychotherapy.
• Improvements are still needed in rates of outcome monitoring and performance on outcome measures.
• Multiple “statistically significant and clinically meaningful differences” were found in measure scores by service branch, TRICARE region, and service member.

Related: Following the Trajectory of PTSD

Deck: Study finds overall high quality of care but identifies important gaps in assessment and treatment.

Active-duty service members with posttraumatic stress disorder (PTSD) or depression are frequent users of both inpatient and outpatient Military Health System (MHS) care, but there were significant variations in the quality and type of care they received, according to a recent RAND Corporation study. According to the authors, the MHS “performed well in providing initial screening for suicide and substance abuse but needs to improve at providing adequate follow-up to service members with suicide risk.”

The Quality of Care for PTSD and Depression in the Military Health System study is the third in a series of reports on the quality of depression and PTSD care for active-duty service members. The study examined data for 2013-2014 and included 14,654 service members with PTSD and 30,496 with depression; 6,322 service members were in both groups. The goal of the report was to determine whether the service members with PTSD or depression receive evidence-based care and whether there were disparities in care quality by branch of service, geographic region, and other characteristics, such as gender, age, pay grade, race/ethnicity, or deployment history.

Related: New Center of Excellence to Lead Research of “Signature Wounds”

In both the PTSD and depression cohorts, the majority of active-component service members were enlisted soldiers and had 1 or more deployments. A large number of patients were in both the PTSD and depression cohorts. The study noted that more than half of patients in the PTSD cohort had a diagnosis of depression, and more than one-fourth of those in the depression cohort received a PTSD diagnosis during the 12-month observation period.

Service members with PTSD or depression were willing to engage the health system with medians of 40 and 31 visits for PTSD and depression, respectively, during the 1-year observation period. Most of these visits were for unrelated conditions. Importantly, more than half of patients received their care from primary care providers. Social workers, psychiatrists, and clinical psychologists provided care for slightly less than half of the PTSD cohort. These mental health provider groups saw between 33% and 40% of the depression cohort. The majority of patients in both the PTSD and depression cohorts received care for their cohort diagnosis solely at military treatment facilities

Related: Posttraumatic Stress Disorder, Depression, and Other Comorbidities: Clinical and Systems Approaches to Diagnostic Uncertainties

“The high utilization for both medical and psychological conditions combined with the high number of different providers raise questions about the extent of coordination vs fragmentation of care for all the care these service members received,” the study reported. “The high number of psychotherapy visits received by members of these cohorts suggests that the MHS may be more successful than the civilian sector in engaging patients with PTSD or depression in psychosocial interventions.”

The study also highlighted the following important gaps in treatment, assessment, and follow-up:

• Assessment of baseline symptom severity of PTSD for a new treatment episode with the PCL (PTSD Checklist) was not as frequent, though current efforts are under way within the MHS to increase the regular use of the PCL to monitor PTSD patient symptoms.
• Standardized tools were used in less than half of the assessments for depression, suicide risk, and recent substance use and almost never used for assessment of function.
• Appropriate minimal care for patients with suicidal ideation was less than optimal (54%), primarily due to a lack of documentation regarding addressing access to lethal means. A Safety Plan Worksheet has recently been added to the clinical guideline for assessment and management of suicide risk which may improve this performance in the future.
• Most service members with PTSD or depression received at least some psychotherapy, but the MHS could increase delivery of evidence-based psychotherapy.
• Improvements are still needed in rates of outcome monitoring and performance on outcome measures.
• Multiple “statistically significant and clinically meaningful differences” were found in measure scores by service branch, TRICARE region, and service member.

Related: Following the Trajectory of PTSD

“You must be the change you wish to see in the world.” This famous quote from Mahatma Gandhi has inspired many to transform their work and personal space into an eternal quest for improvement. We hospitalists are now well-recognized agents of change in our work environment, improving the quality and safety of inpatient care, striving to create increased value, and promoting the delivery of cost-effective care.

What does the “Core Competencies” represent and who should use it?

It comprises a set of competency-based learning objectives that present a shared understanding of the knowledge, skills, and attitudes expected of physicians practicing hospital medicine in the United States.

A common misconception is that every hospitalist can be expected to demonstrate proficiency in all topics in the Core Competencies. While every item in the compendium is highly relevant to the field as a whole, its significance for individual hospitalists will vary depending on their practice pattern, leadership role, and local culture.

It also is noteworthy to indicate that it is not a set of practice guidelines that provide recommendations based on the latest scientific evidence, nor does it represent any legal standard of care. Rather, the Core Competencies offers an agenda for curricular training and to broadly influence the direction of the field. It also is important to realize that the Core Competencies is not an all-inclusive list that restricts a hospitalist’s scope of practice. Instead, hospitalists should use the Core Competencies as an educational and professional benchmark with the ultimate goal of providing safe, efficient, and high-value care using interdisciplinary collaboration when necessary.

As a core set of attributes, all hospitalists can use it to reflect on their knowledge, skills, and attitudes, as well as those of their group or practice collectively. The Core Competencies highlights areas within the field that are prime for further research and quality improvement initiatives on a national, regional, and local level. Thus, they also should be of interest to health care administrators and a variety of stakeholders looking to support and fund such efforts in enhancing health care value and quality for all.

It is also a framework for the development of curricula for both education and professional development purposes for use by hospitalists, hospital medicine programs, and health care institutions. Course Directors of Continuing Medical Education programs can use the Core Competencies to identify learning objectives that fulfill the goal of the educational program. Similarly, residency and fellowship program directors and medical school clerkship directors can use it to develop course syllabi targeted to the needs of their learner groups.

The structure and format of the Core Competencies in Hospital Medicine

The 53 chapters in the 2017 revision are divided into three sections – Clinical Conditions, Procedures, and Healthcare Systems, all integral to the practice of hospital medicine. Each chapter starts with an introductory paragraph that discusses the relevance and importance of the subject. Each competency-based learning objective describes a particular concept coupled with an action verb that specifies an expected level of proficiency.

For example, the action verb “explain” that requires a mere description of a subject denotes a lower competency level, compared with the verb “evaluate,” which implies not only an understanding of the matter but also the ability to assess its value for a particular purpose. These learning objectives are further categorized into knowledge, skills, and attitudes subsections to reflect the cognitive, psychomotor, and affective domains of learning.

Because hospitalists are the experts in complex hospital systems, the clinical and procedural sections have an additional subsection, “System Organization and Improvement.” The objectives in this paragraph emphasize the critical role that hospitalists can play as leaders of multidisciplinary teams to improve the quality of care of all patients with a similar condition or undergoing the same procedure.

Examples of everyday use of the Core Competencies for practicing hospitalists

A hospitalist looking to improve her performance of bedside thoracentesis reviews the chapter on Thoracentesis. She then decides to enhance her skills by attending an educational workshop on the use of point-of-care ultrasonography.

A hospital medicine group interested in improving the rate of common hospital-acquired infections reviews the Urinary Tract Infection, Hospital-Acquired and Healthcare-Associated Pneumonia, and Prevention of Healthcare-Associated Infections and Antimicrobial Resistance chapters to identify possible gaps in practice patterns. The group also goes through the chapters on Quality Improvement, Practice-based Learning and Improvement, and Hospitalist as Educator, to further reflect upon the characteristics of their practice environment. The group then adopts a separate strategy to address identified gaps by finding suitable evidence-based content in a format that best fits their need.

An attending physician leading a team of medical residents and students reviews the chapter on Syncope to identify the teaching objectives for each learner. He decides that the medical student should be able to “define syncope” and “explain the physiologic mechanisms that lead to reflex or neurally mediated syncope.” He determines that the intern on the team should be able to “differentiate syncope from other causes of loss of consciousness,” and the senior resident should be able to “formulate a logical diagnostic plan to determine the cause of syncope while avoiding rarely indicated diagnostic tests … ”

New chapters in the 2017 revision

SHM’s Core Competencies Task Force (CCTF) considered several topics as potential new chapters for the 2017 Revision. The SHM Education Committee judged each for its value as a “core” subject by its relevance, intersection with other specialties, and its scope as a stand-alone chapter.

There are two new clinical conditions – hyponatremia and syncope – mainly chosen because of their clinical importance, the risk of complications, and management inconsistencies that offer hospitalists great opportunities for quality improvement initiatives. The CCTF also identified the use of point-of-care ultrasonography as a notable advancement in the field. A separate task force is working to evaluate best practices and develop a practice guideline that hospitalists can use. The CCTF expects to add more chapters as the field of hospital medicine continues to advance and transform the delivery of health care globally.

The 2017 Revision of the Core Competencies in Hospital Medicine is located online at www.journalofhospitalmedicine.com or using the URL shortener bit.ly/corecomp17.

Dr. Nichani is assistant professor of medicine and director of education for the division of hospital medicine at Michigan Medicine, University of Michigan, Ann Arbor. He serves as the chair of the SHM Education Committee.

“You must be the change you wish to see in the world.” This famous quote from Mahatma Gandhi has inspired many to transform their work and personal space into an eternal quest for improvement. We hospitalists are now well-recognized agents of change in our work environment, improving the quality and safety of inpatient care, striving to create increased value, and promoting the delivery of cost-effective care.

What does the “Core Competencies” represent and who should use it?

It comprises a set of competency-based learning objectives that present a shared understanding of the knowledge, skills, and attitudes expected of physicians practicing hospital medicine in the United States.

A common misconception is that every hospitalist can be expected to demonstrate proficiency in all topics in the Core Competencies. While every item in the compendium is highly relevant to the field as a whole, its significance for individual hospitalists will vary depending on their practice pattern, leadership role, and local culture.

It also is noteworthy to indicate that it is not a set of practice guidelines that provide recommendations based on the latest scientific evidence, nor does it represent any legal standard of care. Rather, the Core Competencies offers an agenda for curricular training and to broadly influence the direction of the field. It also is important to realize that the Core Competencies is not an all-inclusive list that restricts a hospitalist’s scope of practice. Instead, hospitalists should use the Core Competencies as an educational and professional benchmark with the ultimate goal of providing safe, efficient, and high-value care using interdisciplinary collaboration when necessary.

As a core set of attributes, all hospitalists can use it to reflect on their knowledge, skills, and attitudes, as well as those of their group or practice collectively. The Core Competencies highlights areas within the field that are prime for further research and quality improvement initiatives on a national, regional, and local level. Thus, they also should be of interest to health care administrators and a variety of stakeholders looking to support and fund such efforts in enhancing health care value and quality for all.

It is also a framework for the development of curricula for both education and professional development purposes for use by hospitalists, hospital medicine programs, and health care institutions. Course Directors of Continuing Medical Education programs can use the Core Competencies to identify learning objectives that fulfill the goal of the educational program. Similarly, residency and fellowship program directors and medical school clerkship directors can use it to develop course syllabi targeted to the needs of their learner groups.

The structure and format of the Core Competencies in Hospital Medicine

The 53 chapters in the 2017 revision are divided into three sections – Clinical Conditions, Procedures, and Healthcare Systems, all integral to the practice of hospital medicine. Each chapter starts with an introductory paragraph that discusses the relevance and importance of the subject. Each competency-based learning objective describes a particular concept coupled with an action verb that specifies an expected level of proficiency.

For example, the action verb “explain” that requires a mere description of a subject denotes a lower competency level, compared with the verb “evaluate,” which implies not only an understanding of the matter but also the ability to assess its value for a particular purpose. These learning objectives are further categorized into knowledge, skills, and attitudes subsections to reflect the cognitive, psychomotor, and affective domains of learning.

Because hospitalists are the experts in complex hospital systems, the clinical and procedural sections have an additional subsection, “System Organization and Improvement.” The objectives in this paragraph emphasize the critical role that hospitalists can play as leaders of multidisciplinary teams to improve the quality of care of all patients with a similar condition or undergoing the same procedure.

Examples of everyday use of the Core Competencies for practicing hospitalists

A hospitalist looking to improve her performance of bedside thoracentesis reviews the chapter on Thoracentesis. She then decides to enhance her skills by attending an educational workshop on the use of point-of-care ultrasonography.

A hospital medicine group interested in improving the rate of common hospital-acquired infections reviews the Urinary Tract Infection, Hospital-Acquired and Healthcare-Associated Pneumonia, and Prevention of Healthcare-Associated Infections and Antimicrobial Resistance chapters to identify possible gaps in practice patterns. The group also goes through the chapters on Quality Improvement, Practice-based Learning and Improvement, and Hospitalist as Educator, to further reflect upon the characteristics of their practice environment. The group then adopts a separate strategy to address identified gaps by finding suitable evidence-based content in a format that best fits their need.

An attending physician leading a team of medical residents and students reviews the chapter on Syncope to identify the teaching objectives for each learner. He decides that the medical student should be able to “define syncope” and “explain the physiologic mechanisms that lead to reflex or neurally mediated syncope.” He determines that the intern on the team should be able to “differentiate syncope from other causes of loss of consciousness,” and the senior resident should be able to “formulate a logical diagnostic plan to determine the cause of syncope while avoiding rarely indicated diagnostic tests … ”

New chapters in the 2017 revision

SHM’s Core Competencies Task Force (CCTF) considered several topics as potential new chapters for the 2017 Revision. The SHM Education Committee judged each for its value as a “core” subject by its relevance, intersection with other specialties, and its scope as a stand-alone chapter.

There are two new clinical conditions – hyponatremia and syncope – mainly chosen because of their clinical importance, the risk of complications, and management inconsistencies that offer hospitalists great opportunities for quality improvement initiatives. The CCTF also identified the use of point-of-care ultrasonography as a notable advancement in the field. A separate task force is working to evaluate best practices and develop a practice guideline that hospitalists can use. The CCTF expects to add more chapters as the field of hospital medicine continues to advance and transform the delivery of health care globally.

The 2017 Revision of the Core Competencies in Hospital Medicine is located online at www.journalofhospitalmedicine.com or using the URL shortener bit.ly/corecomp17.

Dr. Nichani is assistant professor of medicine and director of education for the division of hospital medicine at Michigan Medicine, University of Michigan, Ann Arbor. He serves as the chair of the SHM Education Committee.

“You must be the change you wish to see in the world.” This famous quote from Mahatma Gandhi has inspired many to transform their work and personal space into an eternal quest for improvement. We hospitalists are now well-recognized agents of change in our work environment, improving the quality and safety of inpatient care, striving to create increased value, and promoting the delivery of cost-effective care.

What does the “Core Competencies” represent and who should use it?

It comprises a set of competency-based learning objectives that present a shared understanding of the knowledge, skills, and attitudes expected of physicians practicing hospital medicine in the United States.

A common misconception is that every hospitalist can be expected to demonstrate proficiency in all topics in the Core Competencies. While every item in the compendium is highly relevant to the field as a whole, its significance for individual hospitalists will vary depending on their practice pattern, leadership role, and local culture.

It also is noteworthy to indicate that it is not a set of practice guidelines that provide recommendations based on the latest scientific evidence, nor does it represent any legal standard of care. Rather, the Core Competencies offers an agenda for curricular training and to broadly influence the direction of the field. It also is important to realize that the Core Competencies is not an all-inclusive list that restricts a hospitalist’s scope of practice. Instead, hospitalists should use the Core Competencies as an educational and professional benchmark with the ultimate goal of providing safe, efficient, and high-value care using interdisciplinary collaboration when necessary.

As a core set of attributes, all hospitalists can use it to reflect on their knowledge, skills, and attitudes, as well as those of their group or practice collectively. The Core Competencies highlights areas within the field that are prime for further research and quality improvement initiatives on a national, regional, and local level. Thus, they also should be of interest to health care administrators and a variety of stakeholders looking to support and fund such efforts in enhancing health care value and quality for all.

It is also a framework for the development of curricula for both education and professional development purposes for use by hospitalists, hospital medicine programs, and health care institutions. Course Directors of Continuing Medical Education programs can use the Core Competencies to identify learning objectives that fulfill the goal of the educational program. Similarly, residency and fellowship program directors and medical school clerkship directors can use it to develop course syllabi targeted to the needs of their learner groups.

The structure and format of the Core Competencies in Hospital Medicine

The 53 chapters in the 2017 revision are divided into three sections – Clinical Conditions, Procedures, and Healthcare Systems, all integral to the practice of hospital medicine. Each chapter starts with an introductory paragraph that discusses the relevance and importance of the subject. Each competency-based learning objective describes a particular concept coupled with an action verb that specifies an expected level of proficiency.

For example, the action verb “explain” that requires a mere description of a subject denotes a lower competency level, compared with the verb “evaluate,” which implies not only an understanding of the matter but also the ability to assess its value for a particular purpose. These learning objectives are further categorized into knowledge, skills, and attitudes subsections to reflect the cognitive, psychomotor, and affective domains of learning.

Because hospitalists are the experts in complex hospital systems, the clinical and procedural sections have an additional subsection, “System Organization and Improvement.” The objectives in this paragraph emphasize the critical role that hospitalists can play as leaders of multidisciplinary teams to improve the quality of care of all patients with a similar condition or undergoing the same procedure.

Examples of everyday use of the Core Competencies for practicing hospitalists

A hospitalist looking to improve her performance of bedside thoracentesis reviews the chapter on Thoracentesis. She then decides to enhance her skills by attending an educational workshop on the use of point-of-care ultrasonography.

A hospital medicine group interested in improving the rate of common hospital-acquired infections reviews the Urinary Tract Infection, Hospital-Acquired and Healthcare-Associated Pneumonia, and Prevention of Healthcare-Associated Infections and Antimicrobial Resistance chapters to identify possible gaps in practice patterns. The group also goes through the chapters on Quality Improvement, Practice-based Learning and Improvement, and Hospitalist as Educator, to further reflect upon the characteristics of their practice environment. The group then adopts a separate strategy to address identified gaps by finding suitable evidence-based content in a format that best fits their need.

An attending physician leading a team of medical residents and students reviews the chapter on Syncope to identify the teaching objectives for each learner. He decides that the medical student should be able to “define syncope” and “explain the physiologic mechanisms that lead to reflex or neurally mediated syncope.” He determines that the intern on the team should be able to “differentiate syncope from other causes of loss of consciousness,” and the senior resident should be able to “formulate a logical diagnostic plan to determine the cause of syncope while avoiding rarely indicated diagnostic tests … ”

New chapters in the 2017 revision

SHM’s Core Competencies Task Force (CCTF) considered several topics as potential new chapters for the 2017 Revision. The SHM Education Committee judged each for its value as a “core” subject by its relevance, intersection with other specialties, and its scope as a stand-alone chapter.

There are two new clinical conditions – hyponatremia and syncope – mainly chosen because of their clinical importance, the risk of complications, and management inconsistencies that offer hospitalists great opportunities for quality improvement initiatives. The CCTF also identified the use of point-of-care ultrasonography as a notable advancement in the field. A separate task force is working to evaluate best practices and develop a practice guideline that hospitalists can use. The CCTF expects to add more chapters as the field of hospital medicine continues to advance and transform the delivery of health care globally.

The 2017 Revision of the Core Competencies in Hospital Medicine is located online at www.journalofhospitalmedicine.com or using the URL shortener bit.ly/corecomp17.

Dr. Nichani is assistant professor of medicine and director of education for the division of hospital medicine at Michigan Medicine, University of Michigan, Ann Arbor. He serves as the chair of the SHM Education Committee.

NEW YORK – All dermatologists, including those who are office based, should know how to recognize and treat infectious diseases and infections from all over the world.

That was the unifying message put forth by dermatologists who spoke at the American Academy of Dermatology summer meeting during a session on infectious diseases and infestations in returned travelers.

Key to recognizing such diseases is knowing what questions to ask, said Vikash S. Oza, MD, director of pediatric dermatology at New York University.“It’s important to know where the patient went to understand the endemic issues,” as well as the purpose of the patient’s visit, said Dr. Oza. “Patients who travel to be with family come back with a higher burden of illness,” possibly because they are less likely to seek medical advice prior to travel and more likely to mingle with local populations, drink from local water supplies, and come into contact with livestock during travel, he added.

Watch out for children

Children are at particular risk: One analysis found that 25% of children suffer at least one skin disorder after international travel, he said.

Prevention

The best defense is to prevent tick bites, and liberal use of DEET has proved to be effective as has permethrin-impregnated clothing, which kills the tick.

Ticks tend to be found on long blades of grass or in leaf debris. They neither jump nor fly, “but reach out in desperation,” said Dr. Oza, who urges hikers to take a shower after hiking, check the scalp and behind the ears, and place all clothing in a hot dryer for 10 minutes, which will kill any deer ticks.

Pets, too, should be checked – even on their eyelids, he added. If a tick is found and removed within 48 hours, it has little chance of infecting its host, he said.

Aedes aegypti mosquitoes pose multiple threats

Common causes of rash and fever in travelers include malaria, dengue, spotted fever, rickettsia, yellow fever, chikungunya, and Zika, said Jose Dario Martinez, MD, of the departments of internal medicine and dermatology, University Hospital, Monterrey, Mexico.

The latter has proved to be a major challenge. In just a few months, the Zika virus has swept across all of the Americas, with the exception of Canada and Chile. It is spread by Aedes aegypti, which thrives and breeds close to homes and is a difficult vector to eradicate, he said. The same mosquito also transmits yellow fever, dengue, and chikungunya.

This year, the Aedes aegypti mosquito has been disrupting tropical vacations because of its ability to transmit not only Zika but dengue, chikungunya, and yellow fever.

Again, the 60-year-old product DEET plays a major defensive role. It lasts the longest of any such products, repels a broad array of insects, and is recommended by the Centers for Disease Control and Prevention and the American Academy of Pediatrics, but it is not recommended for children younger than 2 months of age.

Picaridin, which has been available in the United States since 2005, is also recommended by AAP. It is odorless and does not irritate the skin. Oil of lemon eucalyptus is commonly used in China, but has not been tested for children under aged 3 years.

“If you’re going camping, probably the best thing you can do is wear permethrin-treated clothing and shoes,” Dr. Oza said.

Bedbugs

No discussion of infections among travelers would be complete without a discussion of bedbugs, whose numbers have rebounded since the 1950s, when DDT nearly wiped them out, said Theodore Rosen, MD, professor of dermatology, Baylor College of Medicine, Houston.

NEW YORK – All dermatologists, including those who are office based, should know how to recognize and treat infectious diseases and infections from all over the world.

That was the unifying message put forth by dermatologists who spoke at the American Academy of Dermatology summer meeting during a session on infectious diseases and infestations in returned travelers.

Key to recognizing such diseases is knowing what questions to ask, said Vikash S. Oza, MD, director of pediatric dermatology at New York University.“It’s important to know where the patient went to understand the endemic issues,” as well as the purpose of the patient’s visit, said Dr. Oza. “Patients who travel to be with family come back with a higher burden of illness,” possibly because they are less likely to seek medical advice prior to travel and more likely to mingle with local populations, drink from local water supplies, and come into contact with livestock during travel, he added.

Watch out for children

Children are at particular risk: One analysis found that 25% of children suffer at least one skin disorder after international travel, he said.

Prevention

The best defense is to prevent tick bites, and liberal use of DEET has proved to be effective as has permethrin-impregnated clothing, which kills the tick.

Ticks tend to be found on long blades of grass or in leaf debris. They neither jump nor fly, “but reach out in desperation,” said Dr. Oza, who urges hikers to take a shower after hiking, check the scalp and behind the ears, and place all clothing in a hot dryer for 10 minutes, which will kill any deer ticks.

Pets, too, should be checked – even on their eyelids, he added. If a tick is found and removed within 48 hours, it has little chance of infecting its host, he said.

Aedes aegypti mosquitoes pose multiple threats

Common causes of rash and fever in travelers include malaria, dengue, spotted fever, rickettsia, yellow fever, chikungunya, and Zika, said Jose Dario Martinez, MD, of the departments of internal medicine and dermatology, University Hospital, Monterrey, Mexico.

The latter has proved to be a major challenge. In just a few months, the Zika virus has swept across all of the Americas, with the exception of Canada and Chile. It is spread by Aedes aegypti, which thrives and breeds close to homes and is a difficult vector to eradicate, he said. The same mosquito also transmits yellow fever, dengue, and chikungunya.

This year, the Aedes aegypti mosquito has been disrupting tropical vacations because of its ability to transmit not only Zika but dengue, chikungunya, and yellow fever.

Again, the 60-year-old product DEET plays a major defensive role. It lasts the longest of any such products, repels a broad array of insects, and is recommended by the Centers for Disease Control and Prevention and the American Academy of Pediatrics, but it is not recommended for children younger than 2 months of age.

Picaridin, which has been available in the United States since 2005, is also recommended by AAP. It is odorless and does not irritate the skin. Oil of lemon eucalyptus is commonly used in China, but has not been tested for children under aged 3 years.

“If you’re going camping, probably the best thing you can do is wear permethrin-treated clothing and shoes,” Dr. Oza said.

Bedbugs

No discussion of infections among travelers would be complete without a discussion of bedbugs, whose numbers have rebounded since the 1950s, when DDT nearly wiped them out, said Theodore Rosen, MD, professor of dermatology, Baylor College of Medicine, Houston.

NEW YORK – All dermatologists, including those who are office based, should know how to recognize and treat infectious diseases and infections from all over the world.

That was the unifying message put forth by dermatologists who spoke at the American Academy of Dermatology summer meeting during a session on infectious diseases and infestations in returned travelers.

Key to recognizing such diseases is knowing what questions to ask, said Vikash S. Oza, MD, director of pediatric dermatology at New York University.“It’s important to know where the patient went to understand the endemic issues,” as well as the purpose of the patient’s visit, said Dr. Oza. “Patients who travel to be with family come back with a higher burden of illness,” possibly because they are less likely to seek medical advice prior to travel and more likely to mingle with local populations, drink from local water supplies, and come into contact with livestock during travel, he added.

Watch out for children

Children are at particular risk: One analysis found that 25% of children suffer at least one skin disorder after international travel, he said.

Prevention

The best defense is to prevent tick bites, and liberal use of DEET has proved to be effective as has permethrin-impregnated clothing, which kills the tick.

Ticks tend to be found on long blades of grass or in leaf debris. They neither jump nor fly, “but reach out in desperation,” said Dr. Oza, who urges hikers to take a shower after hiking, check the scalp and behind the ears, and place all clothing in a hot dryer for 10 minutes, which will kill any deer ticks.

Pets, too, should be checked – even on their eyelids, he added. If a tick is found and removed within 48 hours, it has little chance of infecting its host, he said.

Aedes aegypti mosquitoes pose multiple threats

Common causes of rash and fever in travelers include malaria, dengue, spotted fever, rickettsia, yellow fever, chikungunya, and Zika, said Jose Dario Martinez, MD, of the departments of internal medicine and dermatology, University Hospital, Monterrey, Mexico.

The latter has proved to be a major challenge. In just a few months, the Zika virus has swept across all of the Americas, with the exception of Canada and Chile. It is spread by Aedes aegypti, which thrives and breeds close to homes and is a difficult vector to eradicate, he said. The same mosquito also transmits yellow fever, dengue, and chikungunya.

This year, the Aedes aegypti mosquito has been disrupting tropical vacations because of its ability to transmit not only Zika but dengue, chikungunya, and yellow fever.

Again, the 60-year-old product DEET plays a major defensive role. It lasts the longest of any such products, repels a broad array of insects, and is recommended by the Centers for Disease Control and Prevention and the American Academy of Pediatrics, but it is not recommended for children younger than 2 months of age.

Picaridin, which has been available in the United States since 2005, is also recommended by AAP. It is odorless and does not irritate the skin. Oil of lemon eucalyptus is commonly used in China, but has not been tested for children under aged 3 years.

“If you’re going camping, probably the best thing you can do is wear permethrin-treated clothing and shoes,” Dr. Oza said.

Bedbugs

No discussion of infections among travelers would be complete without a discussion of bedbugs, whose numbers have rebounded since the 1950s, when DDT nearly wiped them out, said Theodore Rosen, MD, professor of dermatology, Baylor College of Medicine, Houston.

For many black women, big is beautiful, and size is not only a cultural norm, but also an asset, say researchers from University of North Texas in Fort Worth. But African American women are nearly twice as likely to develop diabetes and more than twice as likely to develop end-stage kidney disease or die of complications of diabetes than are white women. They also have a higher prevalence of being overweight or obese.

Related: Genomic Variation May Reveal ‘Biological Pathway’ to Obesity

However, focusing on weight loss to reduce rates of chronic disease, disability, and premature death may be the wrong tack, the researchers say; weight-loss programs often don’t work well for black women. Even those programs that may have been tailored to the black woman through culturally appropriate artwork and language, African American media outlets, and “meaningful themes” (such as family and spirituality) tend not to produce sustainable results. Most programs aim for participants to lose 5% to 10% of body mass (or roughly 9 to 18 lb for a 185-lb woman) to reduce cardiovascular risk. On average, the researchers say, black women lose 4 to 10 lb—and they typically regain as much as 33% of the weight lost within the year.  

The answer, the researchers say, is to not use body mass index (BMI) as a guide. Body mass index is a poor proxy, they say, for general health and health behaviors because it fails to account for differences in body composition, fitness levels, and nutritional differences that predict health and longevity. “BMI itself,” the researchers note, “as a measure of health is of limited value.” According to an analysis of National Health and Nutrition Examination Surveys data, using BMI to predict cardiometabolic risk misclassifies nearly 75 million U.S. adults.

Related: Some Patients With Diabetes Aren’t Getting Needed Weight Advice

The researchers suggest a collaborative approach may help: community-based participatory research. A key feature is bringing in the women as partners in research so that their subjective experiences inform the programs. The researchers cite a study in which the collaborative team ultimately “shifted its focus” from using weight loss alone as a metric to what they labeled as “a common-sense approach” more focused on physical activity and nutritional goals perceived by participants as relevant and valuable.

For many black women, big is beautiful, and size is not only a cultural norm, but also an asset, say researchers from University of North Texas in Fort Worth. But African American women are nearly twice as likely to develop diabetes and more than twice as likely to develop end-stage kidney disease or die of complications of diabetes than are white women. They also have a higher prevalence of being overweight or obese.

Related: Genomic Variation May Reveal ‘Biological Pathway’ to Obesity

However, focusing on weight loss to reduce rates of chronic disease, disability, and premature death may be the wrong tack, the researchers say; weight-loss programs often don’t work well for black women. Even those programs that may have been tailored to the black woman through culturally appropriate artwork and language, African American media outlets, and “meaningful themes” (such as family and spirituality) tend not to produce sustainable results. Most programs aim for participants to lose 5% to 10% of body mass (or roughly 9 to 18 lb for a 185-lb woman) to reduce cardiovascular risk. On average, the researchers say, black women lose 4 to 10 lb—and they typically regain as much as 33% of the weight lost within the year.  

The answer, the researchers say, is to not use body mass index (BMI) as a guide. Body mass index is a poor proxy, they say, for general health and health behaviors because it fails to account for differences in body composition, fitness levels, and nutritional differences that predict health and longevity. “BMI itself,” the researchers note, “as a measure of health is of limited value.” According to an analysis of National Health and Nutrition Examination Surveys data, using BMI to predict cardiometabolic risk misclassifies nearly 75 million U.S. adults.

Related: Some Patients With Diabetes Aren’t Getting Needed Weight Advice

The researchers suggest a collaborative approach may help: community-based participatory research. A key feature is bringing in the women as partners in research so that their subjective experiences inform the programs. The researchers cite a study in which the collaborative team ultimately “shifted its focus” from using weight loss alone as a metric to what they labeled as “a common-sense approach” more focused on physical activity and nutritional goals perceived by participants as relevant and valuable.

For many black women, big is beautiful, and size is not only a cultural norm, but also an asset, say researchers from University of North Texas in Fort Worth. But African American women are nearly twice as likely to develop diabetes and more than twice as likely to develop end-stage kidney disease or die of complications of diabetes than are white women. They also have a higher prevalence of being overweight or obese.

Related: Genomic Variation May Reveal ‘Biological Pathway’ to Obesity

However, focusing on weight loss to reduce rates of chronic disease, disability, and premature death may be the wrong tack, the researchers say; weight-loss programs often don’t work well for black women. Even those programs that may have been tailored to the black woman through culturally appropriate artwork and language, African American media outlets, and “meaningful themes” (such as family and spirituality) tend not to produce sustainable results. Most programs aim for participants to lose 5% to 10% of body mass (or roughly 9 to 18 lb for a 185-lb woman) to reduce cardiovascular risk. On average, the researchers say, black women lose 4 to 10 lb—and they typically regain as much as 33% of the weight lost within the year.  

The answer, the researchers say, is to not use body mass index (BMI) as a guide. Body mass index is a poor proxy, they say, for general health and health behaviors because it fails to account for differences in body composition, fitness levels, and nutritional differences that predict health and longevity. “BMI itself,” the researchers note, “as a measure of health is of limited value.” According to an analysis of National Health and Nutrition Examination Surveys data, using BMI to predict cardiometabolic risk misclassifies nearly 75 million U.S. adults.

Related: Some Patients With Diabetes Aren’t Getting Needed Weight Advice

The researchers suggest a collaborative approach may help: community-based participatory research. A key feature is bringing in the women as partners in research so that their subjective experiences inform the programs. The researchers cite a study in which the collaborative team ultimately “shifted its focus” from using weight loss alone as a metric to what they labeled as “a common-sense approach” more focused on physical activity and nutritional goals perceived by participants as relevant and valuable.

Henrique Orlandi Mourao

Researchers have found evidence to suggest that a type of acute myeloid leukemia (AML) depends on the production of heme.

The group’s work has revealed 2 ways to target heme synthesis that might be used to treat this type of AML, which is driven by the oncogene MYCN.

John Schuetz, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee, and his colleague described this research in JCI Insight.

Previous research had suggested that heme production was affected in leukemia.

However, Dr Schuetz said, “Absolutely nothing was known about the role of heme biosynthesis [in AML] before our work.”

The researchers’ first clue regarding heme’s role in AML arose from a computer search. The team searched a genomic database for other genes that were abnormally switched on in MYCN-driven AML.

They found that UROD was highly activated and noted that UROD is part of the molecular machinery that synthesizes heme.

Especially significant, Dr Schuetz said, was the finding that MYCN-driven AML with the most over-activated UROD was far more lethal than other AMLs.

The researchers found that cells with over-activated MYCN consumed more oxygen and depended on the production of heme for self-renewal and oncogenic transformation. But the team was able to block cancer cell self-renewal in the MYCN cells by blocking heme synthesis.

The researchers also found they could suppress self-renewal by blocking ABCG2, a “relief-valve” molecule that rids the cells of porphyrin, a building-block molecule of heme.

Blocking ABCG2 caused the buildup of porphyrin, which is toxic to the leukemia cells. However, blocking ABCG2 in normal cells produced no ill effects.

In mouse models of MYCN leukemia, the researchers tested a strategy of knocking out ABCG2. These knockout mice had significantly slower disease progression and longer survival.

What’s more, the team found they could cure leukemia in these mice by inhibiting ABCG2 and ramping up the heme machinery.

“Our findings suggest 2 drug strategies to treat AML,” Dr Schuetz said. “One would be to target UROD, which would reduce heme biosynthesis. Such drugs would selectively affect leukemia cells because they are so dependent on heme.”

“The other strategy would be to use drugs to inhibit the relief-valve protein and, at the same time, administer a chemical that is a precursor of heme. This would cause a buildup of toxic molecules that are part of the heme synthesis pathway.”

Dr Schuetz said other cancers with an over-activated heme pathway might also be vulnerable to such a treatment strategy.

He and his colleagues plan to extend their understanding of the heme machinery in AML with further studies. For example, they don’t know whether heme’s role in cell respiration is the only important one in supporting AML progression, since heme plays a wide range of roles in cells.

The researchers are also planning to test whether drugs that suppress UROD function in the heme-production machinery can effectively battle AML.

Henrique Orlandi Mourao

Researchers have found evidence to suggest that a type of acute myeloid leukemia (AML) depends on the production of heme.

The group’s work has revealed 2 ways to target heme synthesis that might be used to treat this type of AML, which is driven by the oncogene MYCN.

John Schuetz, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee, and his colleague described this research in JCI Insight.

Previous research had suggested that heme production was affected in leukemia.

However, Dr Schuetz said, “Absolutely nothing was known about the role of heme biosynthesis [in AML] before our work.”

The researchers’ first clue regarding heme’s role in AML arose from a computer search. The team searched a genomic database for other genes that were abnormally switched on in MYCN-driven AML.

They found that UROD was highly activated and noted that UROD is part of the molecular machinery that synthesizes heme.

Especially significant, Dr Schuetz said, was the finding that MYCN-driven AML with the most over-activated UROD was far more lethal than other AMLs.

The researchers found that cells with over-activated MYCN consumed more oxygen and depended on the production of heme for self-renewal and oncogenic transformation. But the team was able to block cancer cell self-renewal in the MYCN cells by blocking heme synthesis.

The researchers also found they could suppress self-renewal by blocking ABCG2, a “relief-valve” molecule that rids the cells of porphyrin, a building-block molecule of heme.

Blocking ABCG2 caused the buildup of porphyrin, which is toxic to the leukemia cells. However, blocking ABCG2 in normal cells produced no ill effects.

In mouse models of MYCN leukemia, the researchers tested a strategy of knocking out ABCG2. These knockout mice had significantly slower disease progression and longer survival.

What’s more, the team found they could cure leukemia in these mice by inhibiting ABCG2 and ramping up the heme machinery.

“Our findings suggest 2 drug strategies to treat AML,” Dr Schuetz said. “One would be to target UROD, which would reduce heme biosynthesis. Such drugs would selectively affect leukemia cells because they are so dependent on heme.”

“The other strategy would be to use drugs to inhibit the relief-valve protein and, at the same time, administer a chemical that is a precursor of heme. This would cause a buildup of toxic molecules that are part of the heme synthesis pathway.”

Dr Schuetz said other cancers with an over-activated heme pathway might also be vulnerable to such a treatment strategy.

He and his colleagues plan to extend their understanding of the heme machinery in AML with further studies. For example, they don’t know whether heme’s role in cell respiration is the only important one in supporting AML progression, since heme plays a wide range of roles in cells.

The researchers are also planning to test whether drugs that suppress UROD function in the heme-production machinery can effectively battle AML.

Henrique Orlandi Mourao

Researchers have found evidence to suggest that a type of acute myeloid leukemia (AML) depends on the production of heme.

The group’s work has revealed 2 ways to target heme synthesis that might be used to treat this type of AML, which is driven by the oncogene MYCN.

John Schuetz, PhD, of St. Jude Children’s Research Hospital in Memphis, Tennessee, and his colleague described this research in JCI Insight.

Previous research had suggested that heme production was affected in leukemia.

However, Dr Schuetz said, “Absolutely nothing was known about the role of heme biosynthesis [in AML] before our work.”

The researchers’ first clue regarding heme’s role in AML arose from a computer search. The team searched a genomic database for other genes that were abnormally switched on in MYCN-driven AML.

They found that UROD was highly activated and noted that UROD is part of the molecular machinery that synthesizes heme.

Especially significant, Dr Schuetz said, was the finding that MYCN-driven AML with the most over-activated UROD was far more lethal than other AMLs.

The researchers found that cells with over-activated MYCN consumed more oxygen and depended on the production of heme for self-renewal and oncogenic transformation. But the team was able to block cancer cell self-renewal in the MYCN cells by blocking heme synthesis.

The researchers also found they could suppress self-renewal by blocking ABCG2, a “relief-valve” molecule that rids the cells of porphyrin, a building-block molecule of heme.

Blocking ABCG2 caused the buildup of porphyrin, which is toxic to the leukemia cells. However, blocking ABCG2 in normal cells produced no ill effects.

In mouse models of MYCN leukemia, the researchers tested a strategy of knocking out ABCG2. These knockout mice had significantly slower disease progression and longer survival.

What’s more, the team found they could cure leukemia in these mice by inhibiting ABCG2 and ramping up the heme machinery.

“Our findings suggest 2 drug strategies to treat AML,” Dr Schuetz said. “One would be to target UROD, which would reduce heme biosynthesis. Such drugs would selectively affect leukemia cells because they are so dependent on heme.”

“The other strategy would be to use drugs to inhibit the relief-valve protein and, at the same time, administer a chemical that is a precursor of heme. This would cause a buildup of toxic molecules that are part of the heme synthesis pathway.”

Dr Schuetz said other cancers with an over-activated heme pathway might also be vulnerable to such a treatment strategy.

He and his colleagues plan to extend their understanding of the heme machinery in AML with further studies. For example, they don’t know whether heme’s role in cell respiration is the only important one in supporting AML progression, since heme plays a wide range of roles in cells.

The researchers are also planning to test whether drugs that suppress UROD function in the heme-production machinery can effectively battle AML.

Photo by Diane Reid

A new study suggests patients with advanced cancer who suffer cardiac arrest in the hospital have a survival rate of less than 10%, which is about half the rate of patients without cancer who suffer cardiac arrest.

This finding helps to clear up some myths about cardiac arrest survival and can be used as a guidepost when hospitalized cancer patients and their families consider do-not-resuscitate (DNR) orders, said Jeffrey T. Bruckel, MD, of the University of Rochester Medical Center in New York.

“We’re hopeful that our study, in some way, will help doctors and cancer patients make more informed decisions about the end of life,” Dr Bruckel said. “It’s very important to have early, frank discussions around the goals of care.”

Dr Bruckel and his colleagues published their study in the Journal of Oncology Practice.

The researchers used a US-wide resuscitation registry to evaluate survival after cardiac arrest in patients treated at 369 hospitals.

The study excluded patients with implantable defibrillators and those who were admitted for surgery, emergency room treatment, rehabilitation, or treatment from cardiac catheterization labs or interventional radiology.

Of the 47,157 eligible patients who experienced cardiac arrest, 14% (n=6585) had advanced cancer, including hematologic malignancies.

After cardiac arrest, 57.5% of the advanced cancer patients were resuscitated successfully, as were 63% of non-cancer patients (P<0.001).

After resuscitation, 9.6% of the cancer patients survived to be discharged, compared to 19.2% of non-cancer patients (P<0.001).

When the researchers adjusted their analysis for potential confounders, results were similar. The rate of successful resuscitation was 52.3% in advanced cancer patients and 56.6% in non-cancer patients (P<0.001). The rate of survival to discharge was 7.4% and 13.4%, respectively (P<0.001).

Dr Bruckel said there was no evidence to suggest that patients with advanced cancer received less aggressive resuscitation care.

However, there was a significant difference in the mean duration of resuscitation time among non-survivors with cancer—22.5 minutes—and non-survivors without cancer—24.2 minutes (P<0.001). After adjustment, the mean duration of resuscitation was 22.5 minutes and 24.1 minutes, respectively (P<0.001).

Cancer patients were more likely than those without cancer to sign DNR orders after resuscitation—55.6% and 43%, respectively (P<0.001). Results were similar after adjustment—50.4% and 41.6%, respectively (P<0.001).

Dr Bruckel and his colleagues said there were several limitations to this study, including a lack of detailed data on the types of advanced cancer and cancer treatments being given at the time of cardiac arrest.

Therefore, the next step in advancing this work is to gather data on the types of cancer diagnosis and treatment plans of patients who undergo in-hospital cardiac arrest.

Dr Bruckel also believes it is important to know how patients feel about this data and how both patients and physicians are using this data in decision-making.

“A large component of end-of-life care involves patient and family care decision-making, and a lot of that is driven by the routine discussions that we have,” Dr Bruckel said. “Not every patient is going to want detailed information, but for those that do, it’s important to have it. It’s important to tell them what we know.” 

Photo by Diane Reid

A new study suggests patients with advanced cancer who suffer cardiac arrest in the hospital have a survival rate of less than 10%, which is about half the rate of patients without cancer who suffer cardiac arrest.

This finding helps to clear up some myths about cardiac arrest survival and can be used as a guidepost when hospitalized cancer patients and their families consider do-not-resuscitate (DNR) orders, said Jeffrey T. Bruckel, MD, of the University of Rochester Medical Center in New York.

“We’re hopeful that our study, in some way, will help doctors and cancer patients make more informed decisions about the end of life,” Dr Bruckel said. “It’s very important to have early, frank discussions around the goals of care.”

Dr Bruckel and his colleagues published their study in the Journal of Oncology Practice.

The researchers used a US-wide resuscitation registry to evaluate survival after cardiac arrest in patients treated at 369 hospitals.

The study excluded patients with implantable defibrillators and those who were admitted for surgery, emergency room treatment, rehabilitation, or treatment from cardiac catheterization labs or interventional radiology.

Of the 47,157 eligible patients who experienced cardiac arrest, 14% (n=6585) had advanced cancer, including hematologic malignancies.

After cardiac arrest, 57.5% of the advanced cancer patients were resuscitated successfully, as were 63% of non-cancer patients (P<0.001).

After resuscitation, 9.6% of the cancer patients survived to be discharged, compared to 19.2% of non-cancer patients (P<0.001).

When the researchers adjusted their analysis for potential confounders, results were similar. The rate of successful resuscitation was 52.3% in advanced cancer patients and 56.6% in non-cancer patients (P<0.001). The rate of survival to discharge was 7.4% and 13.4%, respectively (P<0.001).

Dr Bruckel said there was no evidence to suggest that patients with advanced cancer received less aggressive resuscitation care.

However, there was a significant difference in the mean duration of resuscitation time among non-survivors with cancer—22.5 minutes—and non-survivors without cancer—24.2 minutes (P<0.001). After adjustment, the mean duration of resuscitation was 22.5 minutes and 24.1 minutes, respectively (P<0.001).

Cancer patients were more likely than those without cancer to sign DNR orders after resuscitation—55.6% and 43%, respectively (P<0.001). Results were similar after adjustment—50.4% and 41.6%, respectively (P<0.001).

Dr Bruckel and his colleagues said there were several limitations to this study, including a lack of detailed data on the types of advanced cancer and cancer treatments being given at the time of cardiac arrest.

Therefore, the next step in advancing this work is to gather data on the types of cancer diagnosis and treatment plans of patients who undergo in-hospital cardiac arrest.

Dr Bruckel also believes it is important to know how patients feel about this data and how both patients and physicians are using this data in decision-making.

“A large component of end-of-life care involves patient and family care decision-making, and a lot of that is driven by the routine discussions that we have,” Dr Bruckel said. “Not every patient is going to want detailed information, but for those that do, it’s important to have it. It’s important to tell them what we know.” 

Photo by Diane Reid

A new study suggests patients with advanced cancer who suffer cardiac arrest in the hospital have a survival rate of less than 10%, which is about half the rate of patients without cancer who suffer cardiac arrest.

This finding helps to clear up some myths about cardiac arrest survival and can be used as a guidepost when hospitalized cancer patients and their families consider do-not-resuscitate (DNR) orders, said Jeffrey T. Bruckel, MD, of the University of Rochester Medical Center in New York.

“We’re hopeful that our study, in some way, will help doctors and cancer patients make more informed decisions about the end of life,” Dr Bruckel said. “It’s very important to have early, frank discussions around the goals of care.”

Dr Bruckel and his colleagues published their study in the Journal of Oncology Practice.

The researchers used a US-wide resuscitation registry to evaluate survival after cardiac arrest in patients treated at 369 hospitals.

The study excluded patients with implantable defibrillators and those who were admitted for surgery, emergency room treatment, rehabilitation, or treatment from cardiac catheterization labs or interventional radiology.

Of the 47,157 eligible patients who experienced cardiac arrest, 14% (n=6585) had advanced cancer, including hematologic malignancies.

After cardiac arrest, 57.5% of the advanced cancer patients were resuscitated successfully, as were 63% of non-cancer patients (P<0.001).

After resuscitation, 9.6% of the cancer patients survived to be discharged, compared to 19.2% of non-cancer patients (P<0.001).

When the researchers adjusted their analysis for potential confounders, results were similar. The rate of successful resuscitation was 52.3% in advanced cancer patients and 56.6% in non-cancer patients (P<0.001). The rate of survival to discharge was 7.4% and 13.4%, respectively (P<0.001).

Dr Bruckel said there was no evidence to suggest that patients with advanced cancer received less aggressive resuscitation care.

However, there was a significant difference in the mean duration of resuscitation time among non-survivors with cancer—22.5 minutes—and non-survivors without cancer—24.2 minutes (P<0.001). After adjustment, the mean duration of resuscitation was 22.5 minutes and 24.1 minutes, respectively (P<0.001).

Cancer patients were more likely than those without cancer to sign DNR orders after resuscitation—55.6% and 43%, respectively (P<0.001). Results were similar after adjustment—50.4% and 41.6%, respectively (P<0.001).

Dr Bruckel and his colleagues said there were several limitations to this study, including a lack of detailed data on the types of advanced cancer and cancer treatments being given at the time of cardiac arrest.

Therefore, the next step in advancing this work is to gather data on the types of cancer diagnosis and treatment plans of patients who undergo in-hospital cardiac arrest.

Dr Bruckel also believes it is important to know how patients feel about this data and how both patients and physicians are using this data in decision-making.

“A large component of end-of-life care involves patient and family care decision-making, and a lot of that is driven by the routine discussions that we have,” Dr Bruckel said. “Not every patient is going to want detailed information, but for those that do, it’s important to have it. It’s important to tell them what we know.”