bluuebunny/crossref_metadata_2025_split huggingface dataset:
Communication and Decision‐Making in Seriously Ill Patients: Findings of the SUPPORT Project
Authors: Covinsky Kenneth E. , Fuller Jon D. , Yaffe Kristine , Johnston C. Bree , Hamel Mary Beth , Lynn Joanne , Teno Joan M. , Phillips Russell S. 
Published: April 2015

OBJECTIVES: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) represents one of the largest and most comprehensive efforts to describe patient preferences in seriously ill patients, and to evaluate how effectively patient preferences are communicated. Our objective was to review findings from SUPPORT describing the communication of seriously ill patients' preferences for end‐of‐life care.METHODS: We identified published reports from SUPPORT describing patient preferences and the communication of those preferences. We abstracted findings that addressed each of the following questions: What patient characteristics predict patient preferences for end of life care? How well do physicians, nurses, and surrogates understand their patients' preferences, and what variables are correlated with this understanding? Does increasing the documentation of existing advance directives result in care more consistent with patients' preferences?RESULTS: Patients who are older, have cancer, are women, believe their prognoses are poor, and are more dependent in ADL function are less likely to want CPR. However, there is considerable variability and geographic variation in these preferences. Physician, nurse, and surrogate understanding of their patient's preferences is only moderately better than chance. Most patients do not discuss their preferences with their physicians, and only about half of patients who do not wish to receive CPR receive DNR orders. Factors other than the patients' preferences and prognoses, including the patient's age, the physician's specialty, and the geographic site of care were strong determinants of whether DNR orders were written. In SUPPORT patients, there was no evidence that increasing the rates of documentation of advance directives results in care that is more consistent with patients' preferences.CONCLUSIONS: SUPPORT documents that physicians and surrogates are often unaware of seriously ill patients' preferences. The care provided to patients is often not consistent with their preferences and is often associated with factors other than preferences or prognoses. Improving these deficiencies in end‐of‐life care may require systematic change rather than simple interventions.
The Effects of Patient Race on Outcomes in Seriously Ill Patients in SUPPORT: An Overview of Economic Impact, Medical Intervention, and End‐Of‐Life Decisions
Authors: Borum Marie L. , Lynn Joanne , Zhong Zhenshao 
Published: April 2015

BACKGROUND: Black Americans have significantly lower life expectancy than white Americans. Racial differences in medical access, management, and DNR orders have been documented.OBJECTIVE: To review the effects of patient race on intervention and end‐of‐life decisions in seriously ill patients in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).DESIGN: Review of published analyses from SUPPORT.SETTING: Five teaching hospitalsPARTICIPANTS: A total of 9105 patients aged 18 years or older (15% black race) meeting diagnostic and illness severity criteria.MEASUREMENT: Analysis of data collected by chart abstraction and interviews.RESULTS: Blacks reported significant loss in savings, although adjusting for diagnosis and disease severity did not demonstrate significant racial differences. Economic hardship was associated with a preference for comfort care, except in black patients (OR 0.71; CI 95%, 0.57‐0.88). Blacks received less intervention with no significant difference in survival. Pain level and control were not affected by race. Blacks were more likely to want CPR, although adjustment for self‐pay or Medicaid eliminated racial differences. Blacks were more likely to continue to prefer CPR 2 months after hospitalization (28% vs 17%) and were more likely to change a DNR order to preferring CPR (40 vs 27%). Blacks also more frequently wished to discuss CPR preferences with their physicians but were less likely to have this type of communication (OR 1.53; CI 95%, 1.11‐2.11).CONCLUSIONS: Patient race may impact on medical intervention and preferences in seriously ill patients. However, in this population, the differences are of modest clinical importance.
Insights About Dying from the SUPPORT Project
Authors: Freeborne Nancy , Lynn Joanne , Desbiens Norman A. 
Published: April 2015

OBJECTIVES: The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) project was a study of 9105 seriously ill patients, 4274 of whom died within 6 months. HELP, the Hospitalized Elderly Longitudinal Project, was an ancillary study, in four of the five SUPPORT hospitals, of 1286 persons aged 80 years and older, 321 of whom died within 6 months. This paper reviews the SUPPORT and HELP literature to bring together insights concerning the time near death of seriously ill patients.METHODS: We reviewed published reports from SUPPORT and HELP, specifically, demographics of dying; characteristics of a prognostic model to estimate survival; patient symptoms near death; patient preferences and decision‐making near death; ineffectiveness of the SUPPORT intervention; costs of dying while seriously ill; and the impact of serious illness on the family. We also compared and contrasted the experience of patients with different conditions.RESULTS: Patients in SUPPORT who died were typically younger than age 75. Most SUPPORT patients who died were male and most had an income of less than $11,000, although the older patients in HELP were even more likely to have had such low incomes. Patients with cirrhosis were much younger than most decedents, and patients with cancer were less often poor. Most had serious symptoms close to death. The place of death was more closely related to hospital bed supply than to decisions made by healthcare providers or individual patient preferences or characteristics. Prognosis near death was quite uncertain, especially in patients with heart and lung failure.CONCLUSIONS: Although SUPPORT aimed to describe and compare decision‐making affecting seriously ill patients, it also illuminated many other aspects of their course near death.
Age Differences in Care Practices and Outcomes for Hospitalised Patients with Cancer
Authors: Rose Julia Hunnum , O'Toole Elizabeth E. , Dawson Neal V. , Thomas Charles , Connors Alfred F. , Wenger Neil S. , Phillips Russell S. , Hamel Mary Beth , Cohen Harvey J. , Lynn Joanne 
Published: April 2015

OBJECTIVE:To identify age group differences in care practices and outcomes for seriously ill hospitalized patients with malignancy.DESIGN:Prospective cohort study (SUPPORT project).SETTING:Five United States teaching hospitals; data was gathered between 1989 and 1994.SUBJECTS:Nine hundred twenty five older (age ≥ 65 years), 983 middle aged (age = 45–64 years), and 274 younger (age = 18–44 years) hospitalized patients receiving care for non‐small cell lung cancer, colon cancer metastasized to the liver, or multi‐organ system failure associated with malignancy.MEASUREMENTS:Care practices and patient outcomes were determined from hospital records. Length of survival was identified using the National Death Index. After adjusting for important variables, including severity of illness (i.e., SUPPORT model estimate for 2‐month survival, cancer condition), hospital site, selection to intervention and sociodemographic variables, age group differences in care practices and outcomes were identified using general linear models.RESULTS:Older patients with cancer had lower resource utilization during hospitalization (P< .04) and were less likely to receive cancer‐related treatments (i.e., chemotherapy, platelet infusions, scheduled intravenous medications) than middle‐aged and young‐adult patients in the first week of hospitalization (P≤ .01). More care topics were discussed with older patients and their families then with younger patients and their families (P< .001). Length of stay and total hospital costs were lower for older and middle‐aged patients than for younger patients. Although more older patients had discussions about transfer to hospice (P< .001), older patients were no more likely to be discharged with supportive care (inpatient hospice or home with home/hospice care). Older patients died sooner than middle‐aged patients (P< .01).CONCLUSIONS:Patient age influenced care decisions and outcomes. Older patients (age ≥ 65 years) received less aggressive care, had more discussions about care decisions, and died sooner than younger patients with cancer. Younger patients had longer stays, higher hospital costs, and greater probability of rehospitalization. Although well over half of patients died within 6 months of hospitalization, few patients in any age group were discharged with supportive care. Future studies should examine age differences in palliation, as well as acute care of cancer patients across inpatient and ambulatory care settings and should assess quality of care at the end of life.
Physician Understanding Of Patient Resuscitation Preferences: Insights and Clinical Implications
Authors: Wenger Neil S. , Phillips Russell S. , Teno Joan M. , Oye Robert K. , Dawson Neal V. , Liu Honghu , Califf Robert , Layde Peter , Hakim Rosemarie , Lynn Joanne 
Published: April 2015

OBJECTIVE: To describe physician understanding of patient preferences concerning cardiopulmonary resuscitation (CPR) and to assess the relationship of physician understanding of patient preferences with do not resuscitate (DNR) orders and in‐hospital CPR.DESIGN: We evaluated physician understanding of patient CPR preference and the association of patient characteristics and physician‐patient communication with physician understanding of patient CPR preferences. Among patients preferring to forgo CPR, we compared attempted resuscitations and time to receive a DNR order between patients whose preference was understood or misunderstood by their physician.PATIENTS/SETTING: Seriously ill hospitalized adult patients were enrolled in the Study to Understand Prognoses and Preferences for the Outcomes of Treatments.GENERAL RESULTS: Physicians understood 86% of patient preferences for CPR, but only 46% of patient preferences to forgo CPR. Younger patient age, higher physician‐estimated quality of life, and higher physician prediction of 6‐month survival were independently associated with both physician understanding when a patient preferred to receive CPR and physician misunderstanding when a patient preferred to forgo CPR. Physicians who spoke with patients about resuscitation and had longer physician‐patient relationships understood patients' preferences to forgo CPR more often. Patients whose physicians understood their preference to forgo CPR more often received DNR orders, received them earlier, and were significantly less likely to undergo resuscitation.CONCLUSIONS: Physicians often misunderstand seriously ill, hospitalized patients' resuscitation preferences, especially preferences to forgo CPR. Factors associated with misunderstanding suggest that physicians infer patients' preferences without asking the patient. Patients who prefer to forgo CPR but whose wishes are not understood by their physician may receive unwanted treatment.
Living and Dying with Chronic Obstructive Pulmonary Disease
Authors: Lynn Joanne , Ely E. Wesley , Zhong Zhenshao , McNiff Kristin Landrum , Dawson Neal V. , Connors Al , Desbiens Norman A. , Claessens Michael , McCarthy Ellen P. 
Published: April 2015

OBJECTIVE: To characterize chronic obstructive pulmonary disease (COPD) over patients' last 6 months of life.STUDY DESIGN: A retrospective analysis of a prospective cohort from the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).SETTING: Hospitalization for exacerbation of COPD at five US teaching hospitals.PARTICIPANTS: COPD patients who died within 1 year (n = 416) among 1016 enrolled.METHODS: Interview and medical record data were organized into time windows beginning with death and ending 6 months earlier.OUTCOME MEASURES: Days in hospital, prognosis, illness severity, function, symptoms, patients' preferences, and impacts on families.RESULTS: One‐year survival was 59%, 39% had ≥3 comorbidities, and 15 to 25% of the patients' last 6 months were in hospitals. Exacerbation etiologies included respiratory infection (47%) and cardiac problems (30%). Better quality of life predicted longer survival (ARR: 0.36; 95% CI, 0.19‐ 0.87) as did heart failure etiology of exacerbation (ARR: 0.57; CI, 0.40, 0.82). Estimates of survival by physicians and by prognostic model were well calibrated, although patients with the worst prognoses survived longer than predicted. Patients' estimates of prognosis were poorly calibrated.One‐quarter of patients had serious pain throughout, and two‐thirds had serious dyspnea. Patients' illnesses had a major impact on more than 25% of families. Patients' preferences for Do‐Not‐Resuscitate orders increased from 40% at 3 to 6 months before death to 77% within 1 month of death; their decisions not to use mechanical ventilation increased from 12 to 31%, and their preferences for resuscitation decreased from 52 to 23%.CONCLUSIONS: Patients with advanced COPD often die within 1 year and have substantial comorbidities and symptoms. Adequate description anchors improved care.
A Randomized Controlled Trial of Exercise to Improve Outcomes of Acute Hospitalization in Older Adults
Authors: Siebens Hilary , Aronow Harriet , Edwards Diane , Ghasemi Zahra 
Published: April 2015

OBJECTIVE: Older adults hospitalized for nondisabling diagnoses can lose functional ability. Lack of exercise or physical activity during the acute illness and recovery may be contributory. This study evaluated whether increased exercise in hospital and afterward would shorten length of stay and improve physical function at 1 month.DESIGN: A randomized controlled trial.SETTING: A 700‐bed community‐based hospital with academic and teaching programs.PARTICIPANTS: Three hundred patients (mean age 78.2 years ± 5.6) with nondisabling medical and surgical diagnoses who were admitted to an acute care hospital between December 1990 and April 1992. All patients had an expected length of stay 5 or more days, were ambulatory before admission, and were not expected to die within 12 months.INTERVENTION: A hospital‐based general exercise program was administered to intervention patients along with encouragement to continue the program, self‐administered, at home.MEASUREMENTS: The primary outcome was hospital length of stay. Secondary outcomes at 1 month post‐discharge included measures of physical function and other general health indicators.RESULTS: There was no significant difference in length of stay between treatment and control groups controlling for baseline characteristics and diagnoses. The intervention was associated with better function in instrumental activities of daily living (β = .433 (95% CI, 0.044–0.842)) at 1 month but no change in perceived general health status and other measures of physical function.CONCLUSIONS: An exercise program started during hospitalization and continued for 1 month did not shorten length of stay but did improve functional outcome at 1 month.
Comparison of Informal Caregiving by Black and White Older Adults in a Community Population
Authors: McCann Judith J. , Hebert Liesi E. , Beckett Laurel A. , Morris Martha Clare , Scherr Paul A. , Evans Denis A. 
Published: April 2015

OBJECTIVES: To examine the prevalence of informal caregiving and demographic factors associated with caregiving time in older community residents and compare caregiving prevalence and time spent providing care by black and white residents.DESIGN: A cross‐sectional, population‐based study.SETTING: The study was conducted as part of the Chicago Health and Aging Project (CHAP) in a geographically defined community of black and white residents aged 65 and older.PARTICIPANTS: Participants were 5924 community residents (61.4% black; 38.6% white) who answered questions about informal caregiving responsibilities during a structured interview about a broad range of health and social factors.METHODS: Data were collected during an in‐home interview. Multiple logistic and linear regression models were used to examine the association between caregiving and race, gender, age, marital status, and education.RESULTS: More than 16% of residents had provided care to others during the previous 12 months, and 10.3% were currently providing care. Compared with whites, blacks were 30% more likely to be caregivers, spent almost 13 more hours each week in caregiving activities, and were more likely to assist friends. The probability of caregiving increased significantly with age for married persons, decreased with age for unmarried persons, and was lower for men compared with women. The time spent providing care each week increased significantly with age for married persons and did not differ between men and women.CONCLUSIONS: Although physicians and other healthcare providers typically view older people as the recipients of informal care, individuals older than age 65 provide a substantial amount of care to others with health problems and disability. Most research has focused on the needs of young and middle‐aged caregivers, and little is known about the needs of these older caregivers. Future research should use sampling strategies that provide adequate numbers of white and non‐white participants for meaningful comparisons. This will permit identification of racial and cultural differences in caregiving so that interventions can be tailored to specific groups.
Subsystems Contributing to the Decline in Ability to Walk: Bridging the Gap Between Epidemiology and Geriatric Practice in the InCHIANTI Study
Authors: Ferrucci Luigi , Bandinelli Stefania , Benvenuti Enrico , Di Iorio Angelo , Macchi Claudio , Harris Tamara B. , Guralnik Jack M 
Published: April 2015

BACKGROUND: Older patients are often referred to geriatricians because of complaints of progressive difficulties in walking. The diagnostic and therapeutic approach to these patients is complex. Multiple physiologic subsystems may influence the ability to walk, and no standard criteria are currently available to establish whether these subsystems are functioning within the normal range. To address this lack of knowledge we conducted the InCHIANTI study.OBJECTIVE: To identify measures that clinicians can use to understand the causes of walking difficulties in older persons.DESIGN: A population‐based study of persons living in the Chianti geographic area (Tuscany, Italy).PARTICIPANTS: 1453 persons (age‐range 20–102 years; 91.6% of the eligible) selected from city registry of Greve in Chianti and Bagno a Ripoli (Tuscany, Italy), using a multistage sampling method.MEASUREMENTS: Factors that influence walking ability were classified into six main physiologic subsystems: central nervous system, perceptual system, peripheral nervous system, muscles, bone/joints, and energy production/delivery. Measures of the integrity and functioning of each of these proposed subsystems were identified and administered to all participants.CONCLUSIONS: Data collected in InCHIANTI will be used to identify the main risk factors that influence loss of the ability to walk in older persons, to define physiologic subsystems that are critical for walking, to select the best measures of their integrity, and to establish critical ranges in these measures that are compatible with “normal” walking ability. The final goal is to translate epidemiological research into a geriatric clinical tool that makes possible more precise diagnosis and more effective treatment in patients with walking dysfunction.
Returning to the Bedside: Using the History and Physical Examination To Identify Rotator Cuff Tears
Authors: Litaker David , Pioro Mathilde , Bilbeisi Hazem El , Brems John 
Published: April 2015

OBJECTIVES: To determine the value of elements of the bedside history and physical examination in predicting arthrography results in older patients with suspected rotator cuff tear (RCT).DESIGN: Retrospective chart reviewSETTING: Orthopedic practice limited to disorders of the shoulderPARTICIPANTS: 448 consecutive patients with suspected RCT referred for arthrography over a 4‐year periodMAIN OUTCOME MEASURE: Presence of partial or complete RCT on arthrogramRESULTS: 301 patients (67.2%) had evidence of complete or partial RCT. Clinical findings in the univariate analysis most closely associated with rotator cuff tear included infra‐ and supraspinatus atrophy (P < .001), weakness with either elevation (P < .001) or external rotation (P < .001), arc of pain (P = .004), and impingement sign (P = .01). Stepwise logistic regression based on a derivation dataset (n = 191) showed that weakness with external rotation (Adjusted Odds Ratio (AOR) 6.96 (3.09, 13.03)), age ≥ 65 (AOR 4.05 (2.47, 16.07)), and night pain (AOR 2.61 (1.004, 7.39)) best predicted the presence of RCT. A five‐point scoring system developed from this model was applied in the remaining patient sample (n = 216) to test validity. No significant differences in performance were noted using ROC curve comparison. Using likelihood ratios, a clinical score = 4 was superior in predicting RCT to the diagnostic prediction of an expert clinician. This score had specificity equivalent to magnetic resonance imaging or ultrasonography in diagnosis of RCT.CONCLUSIONS: The presence of three simple features in the history and physical examination of the shoulder can identify RCT efficiently. This approach offers a valuable strategy to diagnosis at the bedside without compromising sensitivity or specificity.
Misclassification of High‐Risk Older Subjects Using Waist Action Levels Established for Young and Middle‐Aged Adults—Results from the Rotterdam Study
Authors: Molarius Anu , Seidell Jacob C. , Visscher Tommy L.S. , Hofman Albert 
Published: April 2015

OBJECTIVES: In the literature, cutoff points based on waist circumference (waist action levels) have been suggested to replace cutoff points based on body mass index (BMI) and waist‐hip ratio (WHR) in identifying subjects who are overweight or obese and/or with central fat distribution. These cutoff points have been based on analysis in mainly middle‐aged and younger adults. In this article, we examine the applicability of the suggested waist action levels in an older population.PARTICIPANTS: A total of 6423 men and women aged 55 or over participating in the Rotterdam Study, a population‐based cohort study.MEASUREMENTS: Sensitivities and specificities of the proposed waist action levels in relation to the cutoff points for BMI and WHR were calculated. Also, cardiovascular risk factor levels at baseline examination in the different categories defined by high/low waist circumference, BMI and WHR were investigated.RESULTS: At waist action level 1 (waist circumference ≥94 cm in men, ≥80 cm in women), sensitivity was 71% in men and 86% in women for detecting those with high BMI (≥25 kg/m2) and/or WHR (≥0.95 in men, ≥0.80 in women). At waist action level 2 (waist circumference ≥102 cm in men, ≥88 cm in women in comparison with BMI ≥30 kg/m2 and/or WHR ≥0.95 in men, ≥0.80 in women), sensitivity was considerably lower: 35% in men and 59% in women. This was mainly due to a large proportion of subjects with low waist and BMI but high WHR. Specificity was high (>90%) at both action levels. Cardiovascular disease risk factors, except smoking, tended to increase with increasing waist circumference, WHR, and BMI.CONCLUSIONS: The suggested cutoff points for waist circumference are only to a limited degree useful in identifying subjects with overweight and obesity and/or central fat distribution in an older population. This concerns especially the upper cutoff point (waist action level 2) and is mainly due to the increased central distribution of fat with advancing age.