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September 28, 2009JAMA news releases are made available to the public after 3 pm US Central time on the first 4 Tuesdays of each month. The Archives of Journals news releases are made available to the public after 3 pm Central time on Mondays. We also provide a list of previous news releases. THIS WEEK'S CONTENTS
ARCHIVES OF INTERNAL MEDICINE NEWS RELEASES
(Embargoed Until: 3 P.M. (CT), Monday, September 28, 2009)
INFORMATION CONTAINED IN THESE NEWS RELEASES IS PROTECTED BY COPYRIGHT. JOURNAL ATTRIBUTION IS REQUIRED. JOURNALISTS CAN NOW ACCESS EMBARGOED JAMA/ARCHIVES STUDIES ON-LINE. Go to www.jamamedia.org for more information and to apply for access. Please Note: The FOR THE MEDIA website now has a search feature to enable media to find previous JAMA/Archives news releases on specific medical topics. This search feature link is located on the home page at www.jamamedia.org EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, September 28, 2009
Survey: Men May Not Be Adequately Involved in Decisions About Prostate Cancer Screening
Second Study Attempts to Quantify Benefits, Risks CHICAGO—Men largely make decisions about prostate cancer screening based on conversations with their clinicians, but these discussions often do not include information about the risks of testing in addition to the benefits, according to a report in the September 28 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. A second report in the same issue uses statistical modeling to estimate the benefits and risks of prostate-specific antigen (PSA) screening in men of various ages and risk levels. The majority of American men older than 50 have been screened with the PSA blood test, according to background information in one of the articles. However, the practice is controversial because there is no convincing evidence that screening prevents deaths from the disease, and treating early-stage cancers detected by screenings may lead to important complications. "Given the uncertain benefit for screening and known treatment risks, prostate cancer screening decisions should be guided by patient preferences," the authors write. "Indeed, most professional organizations recommend that the first step in screening should be a discussion between health care providers and patients about the risks and benefits of early detection and treatment so that patients can make informed decisions about whether to be screened." Richard M. Hoffman, M.D., M.P.H., of New Mexico VA Health Care System and University of New Mexico School of Medicine, Albuquerque, and colleagues conducted a telephone survey of 3,010 randomly selected English-speaking adults age 40 and older in 2006 and 2007. The sample included 375 men who had either undergone or discussed PSA testing with their clinicians in the previous two years. These men were asked what they knew about prostate cancer, what their discussions with clinicians were like and what factors and sources of information influenced their screening decisions. Overall, 69.9 percent of the men had discussed screening with their clinician before making a decision, including 14.4 percent who chose not to undergo testing. Most often, clinicians raised the idea of screening (64.6 percent), and 73.4 percent recommended it. Recommendation from a clinician was the only characteristic of the discussion associated with testing. "Although respondents generally endorsed shared decision-making process and felt informed, only 69.9 percent actually discussed screening before making a testing decision, few subjects [32 percent] reported having discussed the cons of screening, 45.2 percent said they were not asked for their preference about PSA testing and performance on knowledge testing was poor," with only 47.8 percent of men correctly answering any of three questions about prostate cancer risk and screening accuracy, the authors write. "Therefore, these discussions-when held-did not meet criteria for shared decision making. Our findings suggest that patients need a greater level of involvement in screening discussions and to be better informed about prostate cancer screening issues." In a second study, Kirsten Howard, B.Sc., M.App.Sc., M.P.H., M.Health.Econ., Ph.D., of the University of Sydney, Australia, and colleagues constructed a statistical model to provide information for men age 40, 50, 60 and 70 years at low, moderate and high risk for prostate cancer based on family history. Using Australian prostate cancer incidence rates before PSA screening began in 1989 and cancer death rates in 2005, along with data from the European Randomized Study of Screening for Prostate Cancer and the Australian Bureau of Statistics, the authors examined two hypothetical cohorts of men who either participated in or declined annual PSA screening. The model predicts that benefits and harms of annual PSA screening vary with age and risk level. For example, for every 1,000 60-year-old men at low risk, 53 of those who were screened yearly would be diagnosed with prostate cancer and 3.5 would die of the disease during a 10-year period, compared with 23 diagnoses and 4.4 deaths in unscreened men. "For 1,000 men screened from 40 to 69 years of age, there will be 27.9 prostate cancer deaths and 639.5 deaths overall by age 85 years compared with 29.9 prostate cancer deaths and 640.4 deaths overall in unscreened men," the authors write. "Higher-risk men have more prostate cancer deaths averted but also more prostate cancers diagnosed and related harms." In the model, screened men are two to four times more likely to be diagnosed with prostate cancer than unscreened men, but death rates from prostate cancer and from all causes are not significantly different. This implies that many men whose cancer is detected by PSA screening may be undergoing treatment for clinically insignificant cancers, the authors note.
"In conclusion, before undergoing PSA screening, men should be aware of the possible benefits and harms and of their chances of these benefits and harms occurring," they write. "Even under optimistic assumptions, the net mortality benefit is small, even when prostate cancer deaths are cumulated to 85 years of age. These quantitative estimates can be used to support the goal of individual informed choices about PSA screening."
Editor's Note: Please see the articles for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Study Helps Highlight Difficulties of Shared Decision Making
Virtually every professional organizations' PSA screening guidelines urge clinicians to engage patients in shared decision making before performing PSA testing, write Steven H. Woolf, M.D., M.P.H., of Virginia Commonwealth University, Richmond, and Alex Krist, M.D., M.P.H., in an accompanying editorial. "Definitions of shared decision making vary, but the term generally refers to the effort to help patients understand the benefits, harms and uncertainties of available options and to apply personal preferences to determine the best choice. Both parties share information, jointly participate in decision making and agree on a course of action that incorporates personal preferences."
"Today's practice environment presents few incentives or support tools for those clinicians and patients who prefer a discussion rather than simply marking a checkbox for PSA on a laboratory requisition form," they continue. "In the United States, where medical technologies are often adopted long before their effectiveness and safety are confirmed, the difficulties of implementing shared decision making for prostate cancer screening will likely recur with other modalities of care. What is ultimately required is a deeper change in culture among providers and consumers of health care to delay dissemination, resist the assumption that newer is better, wait for evidence, tolerate observation over intervention and accept uncertainty."
Editor's Note: Please see the article for additional information, including author contributions and affiliations, financial disclosures, funding and support, etc. Editorial: Information Can Aid Discussion of PSA Screening
"Data from the National Survey of Medical Decisions reported in this issue of the Archives suggest that many patients have not had an opportunity to discuss the full range of issues related to the PSA screening decision," writes Michael Pignone, M.D., M.P.H., of University of North Carolina-Chapel Hill, in an accompanying editorial. "Because of the complexity of factors that need to be considered in such discussions, tools have been developed to help guide providers and patients in considering the benefits and downsides of screening and in reaching a value-concordant decision," he continues. "One type of tool, patient decision aids, has been shown to increase patient knowledge, participation and confidence."
"To inform the development of future decision aids, Howard and colleagues present a balance sheet of the consequences of PSA screening in Australian men from different age groups and with different levels of underlying risk," Dr. Pignone continues. "The work by Howard and colleagues is an important step in providing information to patients and providers to facilitate discussion about this trade-off."
Editor's Note: Dr. Pignone is supported by an Established Investigator Award from the National Cancer Institute and by the Foundation for Informed Medical Decision Making. Please see the article for additional information, including author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, September 28, 2009
Electronic Alerts About Abnormal Imaging Test Results Do Not Always Result in Timely Follow-Up
CHICAGO—Abnormal results on outpatient imaging tests sometimes may not receive timely follow-up even when clinicians receive and read results in an advanced, integrated electronic medical record system, according to a report in the September 28 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. "Communication breakdown is consistently identified as a preventable factor in studies of adverse events and a significant contributor to outpatient diagnostic errors from a lack of follow-up of abnormal test results," the authors write as background information in the article. The high volume and number of transitions between clinicians in outpatient care makes timely communication particularly challenging. For instance, a primary care physician may refer a patient with respiratory symptoms to undergo several laboratory and imaging tests and a pulmonary consultation. Any abnormal findings, such as a lung mass, would need to be communicated quickly and effectively to all clinicians involved in treating the patient. Some health care systems, including the Department of Veterans Affairs, use electronic communication with alerts to notify clinicians who order imaging tests about critical abnormal results-an approach that may have advantages over a paper-based reporting system. "However, effective communication involves more than just information transfer-it requires a response from the recipient, such as taking follow-up action and acknowledging receipt of the information to the sender," the authors write. Hardeep Singh, M.D., M.P.H., of Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, studied critical imaging alert notifications in the outpatient setting of one Department of Veterans Affairs facility between November 2007 and June 2008. The researchers used tracking software to determine whether alerts about abnormal test results were read within two weeks, then reviewed medical records and contacted health care practitioners to determine whether timely follow-up actions (such as ordering a follow-up test or consultation) were taken within four weeks of the alert transmission. Of 123,638 imaging tests (including X-rays, computer tomographic [CT] scans, magnetic resonance imaging [MRI] and mammograms) performed during the study period, results from 1,196 (0.97 percent) generated alerts to the ordering clinician. Of these alerts, 217 (18.1 percent) were not read or acknowledged. Alerts were more likely to be unacknowledged if the ordering clinician was a trainee or if an alert was sent to more than one clinician (for example, when the ordering clinician was not the patient's primary care physician, and alerts were sent to both the specialist and the patient's regular physician). Timely follow-up of abnormal results did not occur following 92 (7.7 percent) of all alerts, including 7.3 percent of alerts that were acknowledged and 9.7 percent of alerts that were unacknowledged. This follow-up was also less likely to occur when more than one clinician received the alert, but more likely to occur when a radiologist also communicated concerns about the results verbally, either by phone or in person. "Nearly all abnormal test results lacking timely follow-up at four weeks were eventually found to have measurable clinical impact in terms of further diagnostic testing or treatment," the authors write.
"Our findings suggest that an electronic medical record that facilitates transmission and availability of critical imaging results to the health care provider through either automated notification or direct access of primary report does not eliminate the problem of missed test results even when one or more health care providers read the results," they conclude. "Therefore, even in the best of information systems that contain advanced notification features, patients with abnormal imaging results are vulnerable to 'falling through the cracks.' This underscores the need for a multidisciplinary approach involving human-computer interaction and informatics to complement the benefits achieved by automated notification and the need for continuous monitoring procedures to ensure follow-up even when health care providers 'acknowledge,' i.e., read abnormal results."
Editor's Note: This study was supported by an NIH career development award to Dr. Singh, the VA National Center of Patient Safety, Agency for Health Care Research and Quality, and in part by the Houston VA HSR&D Center of Excellence. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. EMBARGOED FOR RELEASE UNTIL 3 P.M. (CT), MONDAY, September 28, 2009
At-Home Care May Be An Alternative to Hospital Care for Elderly Patients With Chronic Heart Failure
CHICAGO—Hospital-at-home care may be a practical alternative to traditional hospital inpatient care for patients with acutely decompensated (suddenly worsening) chronic heart failure, according to a report in the September 28 issue of Archives of Internal Medicine, one of the JAMA/Archives journals. Nearly 7 million Europeans and 5 million North Americans are affected by chronic heart failure, a progressive and disabling syndrome, according to background information in the article. Hospitalization for chronic heart failure for older patients has increased and occurs in 2 percent to 3 percent of patients over age 85 every year. In the United States, decompensation (worsening) of chronic heart failure leads to more than 1 million hospital admissions per year and a 50 percent risk of subsequent hospitalization within six months of discharge. "Although the hospital is the standard venue for providing acute medical care, it may be hazardous for older persons, who commonly experience iatrogenic illness [complications due to treatment], functional decline and other adverse events." Vittoria Tibaldi, M.D., Ph.D., and colleagues at the University of Torino, San Giovanni Battista Hospital, Torino, Italy, compared the effectiveness of a physician-led hospital-at-home service for elderly patients with acute decompensation of chronic heart failure with traditional hospital inpatient care. Patients age 75 or older with decompensation of chronic heart failure were randomly assigned to either a general medical ward (53 patients) or to the Geriatric Home Hospitalization Service (48 patients) between April 2004 and April 2005. The Geriatric Home Hospitalization Service provided diagnostic and therapeutic treatments by hospital health care professionals in the home of the patient. At six months, 15 percent of all patients had died, with no significant differences between the two groups. "The number of subsequent hospital admissions was not statistically different in the two groups, but the mean [average] time to first additional admission was longer for the Geriatric Home Hospitalization Service patients (84.3 days vs. 69.8 days). Only the Geriatric Home Hospitalization Service patients experienced improvements in depression, nutritional status and quality-of-life scores," the authors write.
"Recent trends in health care favor alternatives to traditional acute care in hospitals. These trends include advancement in telehealth technologies and increased demand for treatment at home," the authors conclude. "Further development of hospital-at-home care will require additional research and dedicated resources to support dissemination."
Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc. For more information, contact JAMA/Archives media relations at 312/464-JAMA (5262) or e-mail mediarelations{at}jama-archives.org. |
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