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News Article | April 24, 2017
Site: www.futurity.org

Patients are far more willing to disclose their sexual orientation to health care providers than those providers believe, new research suggests. More than three-quarters of hospital emergency room doctors and nurses thought patients would refuse to discuss their sexual orientation, while only 10.3 percent of patients said they would balk at the question, the study shows. Closing that disclosure gap, the investigators say, has the potential to improve the care of lesbian, gay, and bisexual patients, a population with historically poorer overall health and less access to health care and insurance than the straight population. About 8 million American adults identify as lesbian, gay, or bisexual, according to government estimates. The research, published in JAMA Internal Medicine, is part of the EQUALITY Study, a collaboration among researchers at the Johns Hopkins University School of Medicine, Brigham and Women’s Hospital, and Harvard Medical School. “Unlike racial/ethnic and age data, information about sexual orientation and gender identity has not been collected routinely in health care settings, which limits the ability of researchers and clinicians to determine the unique needs of the lesbian, gay and bisexual communities,” says Brandyn Lau, assistant professor of surgery at Johns Hopkins and the study’s senior author. “Health care providers haven’t collected these data, at least in part due to fear of offending patients, but this study shows that most patients actually would not be offended,” he says. Researchers aren’t taking to LGB teens of color The study focused on emergency departments, which get more than 130 million patient visits annually in the United States. EDs are the source of nearly half of US inpatient hospital admissions and the primary point of entry for uninsured and underinsured patients. The research team first interviewed 53 adult patients and 26 health care professionals from three community hospitals and two academic medical centers. Although clinicians recognized the importance of knowing a patient’s sexual orientation when medically relevant, most patients believed that sexual orientation was always relevant. Many felt health care professionals needed to know sexual orientation not just to enable them to provide relevant care, but also to help them recognize the lesbian, gay, and bisexual population. “Our patients are telling us,” says lead author Adil Haider, director of the Center for Surgery and Public Health at Brigham and Women’s Hospital, “that routinely asking all patients who come to the ED about this information creates a sense of normalcy toward people of all sexual orientations and signals that each patient is equally welcome here, including the 3 to 10 percent of Americans who identify as lesbian, gay, or bisexual.” Being rude to your doctor makes them mess up The second phase of the research was an online survey of 1,516 potential adult patients (244 lesbian, 289 gay, 179 bisexual, and 804 straight) and 429 ED health care professionals (209 physicians and 220 nurses). Just under 78 percent of the clinicians said patients would refuse to provide their sexual orientation if asked, but only 10.3 percent of patients said they would decline. Specifically, only about 10 percent of straight patients, 4.8 percent of lesbians, 12 percent of gay men, and 16.4 percent of bisexual patients said they would refuse to answer a question in the ED about sexual orientation. “We need to make collecting sexual orientation information a regular part of our practice, similar to how other demographic information such as age and race is collected,” Lau says. “Because I don’t think providers will start consistently collecting these data on their own, clinics and hospitals need to mandate it.” The Patient-Centered Outcomes Research Institute funded the work. Source: Johns Hopkins University The post Doctors don’t think we’ll answer this identity question appeared first on Futurity.


A study that surveyed a national sample of emergency department health care providers and adult patients suggests that patients are substantially more willing to disclose their sexual orientation than health care workers believe. In a report on the study, published in JAMA Internal Medicine on April 24, the researchers found that nearly 80 percent of health care professionals believed patients would refuse to provide sexual orientation information, while only 10.3 percent of patients reported they would refuse. Closing that disclosure gap, the investigators say, has the potential to improve the care of lesbian, gay and bisexual patients, a population with historically poorer overall health and less access to health care and insurance compared to the straight population. An estimated 8 million American adults identify as lesbian, gay or bisexual, according to government sources. The new research, part of the EQUALITY Study, is a collaborative effort among researchers at the Johns Hopkins University School of Medicine, Brigham and Women's Hospital and Harvard Medical School. "Unlike racial/ethnic and age data, information about sexual orientation and gender identity has not been collected routinely in health care settings, which limits the ability of researchers and clinicians to determine the unique needs of the lesbian, gay and bisexual communities," says Brandyn Lau, M.P.H., C.P.H., assistant professor of surgery at the Johns Hopkins University School of Medicine and the report's senior author. "Health care providers haven't collected these data, at least in part due to fear of offending patients, but this study shows that most patients actually would not be offended," he says. For the study, which the researchers believe is the first to compare patients' and clinicians' views about routine collection of sexual identity data, the scientists focused on emergency departments (EDs), which see more than 130 million visits annually in the U.S. EDs are the source of nearly half of inpatient hospital admissions in the U.S. and the primary point of entry for uninsured and underinsured patients, making them ideal locations for collecting sexual orientation information. In the study's first phase, the research team recruited 53 adult patients and 26 health care professionals from three community hospitals and two academic medical centers for qualitative interviews that lasted an average of one hour. The interviews took place between August 2014 and January 2015, and one of two researchers had a guided conversation with each participant about sexual orientation collection in the ED, barriers and facilitators to collection, and preferred methods of collection. The interviews revealed that although clinicians recognized the importance of disclosure of sexual orientation when medically relevant, most patients believed that sexual orientation was always relevant. Similarly, many patients stated that sexual orientation was something health care professionals needed to know, not only for the sake of patients' health care, but also for recognizing and normalizing the lesbian, gay and bisexual population. "Our patients are telling us that routinely asking all patients who come to the ED about this information creates a sense of normalcy toward people of all sexual orientations and signals that each patient is equally welcome here, including the three to 10 percent of Americans who identify as lesbian, gay or bisexual," says Adil Haider, M.D., M.P.H., Kessler Director of the Center for Surgery and Public Health at Brigham and Women's Hospital and the paper's first author. In the next phase of the study, the research team conducted an online survey using a nationally representative sample from GfK's KnowledgePanel and GfK's Physician Consulting Network. GfK is a marketing research company with survey tools tailored to a variety of interests. Surveys were sent to 1,516 potential adult patients (244 lesbian, 289 gay, 179 bisexual and 804 straight) and 429 ED health care professionals (209 physicians and 220 nurses) between March and April 2015. The 53-question survey for patients and 45-question survey for health care professionals consisted of multiple-choice responses, Likert scale choices (agree/strongly agree, neutral, and disagree/strongly disagree) and open-ended questions. 333 (77.8 percent) of all surveyed clinicians said patients would refuse to provide their sexual orientation if asked, but only 154 patients (10.3 percent) reported they would refuse to do so, indicating a significant discrepancy between what physicians and patients believe, the researchers said. In the population-weighted results, 143 straight patients (10.1 percent of the total), one lesbian (4.8 percent), three gay (12.0 percent) and five bisexual (16.4 percent) patients would refuse to share their sexual orientation in the ED. Bisexual patients were almost twice as likely to refuse to provide their sexual orientation as were straight patients. Both patients and clinicians indicated nonverbal self-report as the preferred method of sexual orientation information collection. "We need to make collecting sexual orientation information a regular part of our practice, similar to how other demographic information such as age and race is collected, and because I don't think providers will start consistently collecting these data on their own, clinics and hospitals need to mandate it," says Lau. As a next step, the research team will test different approaches to data collection, also as part of the EQUALITY Study. Other authors on this paper include Lisa M. Kodadek, Claire Snyder, Laura Vail, Danielle German and Susan Peterson of the Johns Hopkins University; Eric B. Schneider, Rachel R. Adler and Anju Ranjit of Harvard Medical School; Maya Torain of Duke University School of Medicine; Ryan Y. Shields of Yale School of Medicine; and Jeremiah D. Schuur of Brigham & Women's Hospital. This study was funded by PCORI (contract AD-1306-03980). Brandyn Lau is supported by the Institute for Excellence in Education Berkheimer Faculty Education Scholar Grant contract CE-12-11-4489 from the Patient Centered Outcomes Research Institute (PCORI) and grant 1R01HS024547 from the Agency for Healthcare Research and Quality.


Zogg C.K.,Center for Surgery and Public Health
Journal of Oncology | Year: 2014

Exemplified by cancer cells' preference for glycolysis, for example, the Warburg effect, altered metabolism in tumorigenesis has emerged as an important aspect of cancer in the past 10-20 years. Whether due to changes in regulatory tumor suppressors/oncogenes or by acting as metabolic oncogenes themselves, enzymes involved in the complex network of metabolic pathways are being studied to understand their role and assess their utility as therapeutic targets. Conversion of glycolytic intermediate 3-phosphoglycerate into phosphohydroxypyruvate by the enzyme phosphoglycerate dehydrogenase (PHGDH) - a rate-limiting step in the conversion of 3-phosphoglycerate to serine - represents one such mechanism. Forgotten since classic animal studies in the 1980s, the role of PHGDH as a potential therapeutic target and putative metabolic oncogene has recently reemerged following publication of two prominent papers near-simultaneously in 2011. Since that time, numerous studies and a host of metabolic explanations have been put forward in an attempt to understand the results observed. In this paper, I review the historic progression of our understanding of the role of PHGDH in cancer from the early work by Snell through its reemergence and rise to prominence, culminating in an assessment of subsequent work and what it means for the future of PHGDH. © 2014 Cheryl K. Zogg.


Owens C.D.,University of California at San Francisco | Kim J.M.,University of California at San Francisco | Hevelone N.D.,Center for Surgery and Public Health | Hevelone N.D.,Brigham and Women's Hospital | And 4 more authors.
Journal of Vascular Surgery | Year: 2012

Patients with advanced peripheral artery disease (PAD) have a high prevalence of cardiovascular (CV) risk factors and shortened life expectancy. However, CV risk factors poorly predict midterm (<5 years) mortality in this population. This study tested the hypothesis that baseline biochemical parameters would add clinically meaningful predictive information in patients undergoing lower extremity bypass operations. This was a prospective cohort study of patients with clinically advanced PAD undergoing lower extremity bypass surgery. The Cox proportional hazard model was used to assess the main outcome of all-cause mortality. A clinical model was constructed with known CV risk factors, and the incremental value of the addition of clinical chemistry, lipid assessment, and a panel of 11 inflammatory parameters was investigated using the C statistic, the integrated discrimination improvement index, and Akaike information criterion. The study monitored 225 patients for a median of 893 days (interquartile range, 539-1315 days). In this study, 50 patients (22.22%) died during the follow-up period. By life-table analysis (expressed as percent surviving ± standard error), survival at 1, 2, 3, 4, and 5 years, respectively, was 90.5% ± 1.9%, 83.4% ± 2.5%, 77.5% ± 3.1%, 71.0% ± 3.8%, and 65.3% ± 6.5%. Compared with survivors, decedents were older, diabetic, had extant coronary artery disease, and were more likely to present with critical limb ischemia as their indication for bypass surgery (P < .05). After adjustment for the above, clinical chemistry and inflammatory parameters significant (hazard ratio [95% confidence interval]) for all-cause mortality were albumin (0.43 [0.26-0.71]; P = .001), estimated glomerular filtration rate (0.98 [0.97-0.99]; P = .023), high-sensitivity C-reactive protein (hsCRP; 3.21 [1.21-8.55]; P = .019), and soluble vascular cell adhesion molecule (1.74 [1.04-2.91]; P = .034). Of the inflammatory molecules investigated, hsCRP proved most robust and representative of the integrated inflammatory response. Albumin, eGFR, and hsCRP improved the C statistic and integrated discrimination improvement index beyond that of the clinical model and produced a final C statistic of 0.82. A risk prediction model including traditional risk factors and parameters of inflammation, renal function, and nutrition had excellent discriminatory ability in predicting all-cause mortality in patients with clinically advanced PAD undergoing bypass surgery. © 2012 Society for Vascular Surgery.


Nguyen P.L.,Dana-Farber Cancer Institute | Je Y.,Harvard University | Schutz F.A.B.,Harvard University | Hoffman K.E.,University of Houston | And 4 more authors.
JAMA - Journal of the American Medical Association | Year: 2011

Context: Whether androgen deprivation therapy (ADT) causes excess cardiovascular deaths in men with prostate cancer is highly controversial and was the subject of a joint statement by multiple medical societies and a US Food and Drug Administration safety warning. Objective: To perform a systematic review and meta-analysis of randomized trials to determine whether ADT is associated with cardiovascular mortality, prostate cancer-specific mortality (PCSM), and all-cause mortality in men with unfavorable-risk, nonmetastatic prostate cancer. Data Sources: A search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases for relevant randomized controlled trials in English between January 1, 1966, and April 11, 2011. Study Selection: Inclusion required nonmetastatic disease, intervention group with gonadotropin-releasing hormone agonist-based ADT, control group with no immediate ADT, complete information on cardiovascular deaths, and median follow-up of more than 1 year. Data Extraction: Extraction was by 2 independent reviewers. Summary incidence, relative risk (RR), and CIs were calculated using random-effects or fixed-effects models. Results: Among 4141 patients from 8 randomized trials, cardiovascular death in patients receiving ADT vs control was not significantly different (255/2200 vs 252/ 1941 events; incidence, 11.0%; 95% CI, 8.3%-14.5%; vs 11.2%; 95% CI, 8.3%- 15.0%; RR, 0.93; 95% CI, 0.79-1.10; P=.41). ADT was not associated with excess cardiovascular death in trials of at least 3 years (long duration) of ADT (11.5%; 95% CI, 8.1%-16.0%; vs 11.5%; 95% CI, 7.5%-17.3%; RR, 0.91; 95% CI, 0.75-1.10; P=.34) or in trials of 6 months or less (short duration) of ADT (10.5%; 95% CI, 6.3%- 17.0%; vs 10.3%; 95% CI, 8.2%-13.0%; RR, 1.00; 95% CI, 0.73-1.37; P=.99). Among 4805 patients from 11 trials with overall death data, ADT was associated with lower PCSM (443/2527 vs 552/2278 events; 13.5%; 95% CI, 8.8%-20.3%; vs 22.1%; 95% CI, 15.1%-31.1%; RR, 0.69; 95% CI, 0.56-0.84; P≲λτ∀.001) and lower all-cause mortality (1140/2527 vs 1213/2278 events; 37.7%; 95% CI, 27.3%-49.4%; vs 44.4%; 95% CI, 32.5%-57.0%; RR, 0.86; 95% CI, 0.80-0.93; P≲λτ∀. 001). Conclusion: In a pooled analysis of randomized trials in unfavorable-risk prostate cancer, ADT use was not associated with an increased risk of cardiovascular death but was associated with a lower risk of PCSM and all-cause mortality. ©2011 American Medical Association. All rights reserved.


Perry D.C.,University of Liverpool | Metcalfe D.,Center for Surgery and Public Health | Griffin X.L.,University of Oxford | Costa M.L.,University of Oxford
BMJ (Online) | Year: 2016

Objectives: To determine whether the use of total hip arthroplasty (THA) among individuals with a displaced intracapsular fracture of the femoral neck is based on national guidelines or if there are systematic inequalities. Design: Observational cohort study using the National Hip Fracture Database (NHFD). Setting: All hospitals that treat adults with hip fractures in England, Wales, and Northern Ireland. Participants: Patients within the national database (all aged ≥60) who received operative treatment for a nonpathological displaced intracapsular hip fracture from 1 July 2011 to 31 April 2015. Main outcom e measures: Provision of THA to patients considered eligible under criteria published by the National Institute for Health and Care Excellence (NICE). Results: 114 119 patients with hip fracture were included, 11 683 (10.2%) of whom underwent THA. Of those who satisfied the NICE criteria, 32% (6780) received a THA. Of patients who underwent THA, 42% (4903) did not satisfy the NICE criteria. A recursive partitioning algorithm found that the NICE eligibility criteria did not optimally explain which patients underwent THA. A model with superior explanatory power drew distinctions that are not supported by NICE, which were an age cut off at 76 and a different ambulation cut off. Among patients who satisfied the NICE eligibility, the use of THA was less likely with higher age (odds ratio 0.88, 95% confidence interval 0.87 to 0.88), worsening abbreviated mental test scores (0.49 (0.41 to 0.58) for normal cognition v borderline cognitive impairment)), worsening American Society of Anesthesiologists score (0.74, 0.66 to 0.84), male sex (0.85, 0.77 to 0.93), worsening ambulatory status (0.32, 0.28 to 0.35 for walking with a stick v independent ambulation), and fifths of worsening socioeconomic area deprivation (0.76 (0.66 to 0.88) for least v most deprived fifth). Patients receiving treatment during the working week were more likely to receive THA than at the weekend (0.90, 0.83 to 0.98). Conclusions: There are wide disparities in the use of THA among individuals with hip fractures, and compliance with NICE guidance is poor. Patients with higher levels of socioeconomic deprivation and those who require surgery at the weekend were less likely to receive THA. Inconsistent compliance with NICE recommendations means that the optimal treatment for older adults with hip fractures can depend on where and when they present to hospital. © BMJ Publishing Group Ltd 2016.


Sacks G.D.,Center for Surgery and Public Health | Hill C.,Harvard University | Rogers S.O.,Brigham and Women's Hospital
Journal of Trauma - Injury, Infection and Critical Care | Year: 2011

Background: Postacute care is an essential component of medical care aimed at returning trauma patients to their preinjury functional status. Rehabilitation services, skilled nursing facilities, and home care all play a role in facilitating the healing process. Access to such care may be limited based on insurance status, leaving the uninsured with limited resources to reach full recovery. We hypothesized that access to specialized postacute care is less available to patients who lack health insurance. Methods: A retrospective cohort of trauma patients in the National Trauma Databank from 2002 to 2006 was assessed to determine whether insurance status was a predictor of discharge to a specialized postacute care facility (rehabilitation, skilled nursing facilities, and home health). Using multivariate logistic regression, we assessed the likelihood of discharge to such facilities on the basis of insurance status, controlling for patient demographics and injury severity. Results: Adjusting for variation in age, race/ethicity, gender, and injury type and severity, uninsured patients had the lowest odds of being discharged to a skilled nursing facility (odds ratio [OR], 0.76; 95% confidence interval [CI] 0.73-0.80; p < 0.001), home health (OR, 0.51; 95% CI 0.49-0.53; p < 0.001), and rehabilitation (OR, 0.45; 95% CI 0.44-0.46; p < 0.001). Uninsured patients had the highest odds, however, of being discharged directly home (OR, 1.32; 95% CI 1.30-1.34; p < 0.001). Conclusion: Insurance status is an important predictor of hospital disposition and access to specialized posthospital care. Uninsured patients are less likely to have access to the full range of medical care available to ensure complete recovery from traumatic injuries. Copyright © 2011 by Lippincott Williams & Wilkins.


Billmeier S.E.,Brigham and Women's Hospital | Billmeier S.E.,Center for Surgery and Public Health | Ayanian J.Z.,Center for Surgery and Public Health | Ayanian J.Z.,Harvard University | And 6 more authors.
Journal of the National Cancer Institute | Year: 2011

Background Lobectomy is considered the standard treatment for early-stage non-small cell lung cancer (NSCLC); however, more limited resections are commonly performed. We examined patient and surgeon factors associated with limited resection and compared postoperative and long-term outcomes between sublobar and lobar resections. Methods A population-and health system-based sample of patients newly diagnosed with stage I or II NSCLC between 2003 and 2005 in five geographically defined regions, five integrated health-care delivery systems, and 15 Veterans Affairs hospitals was observed for a median of 55 months, through May 31, 2010. Predictors of limited resection and postoperative outcomes were compared using unadjusted and propensity score-weighted analyses. All P values are from two-sided tests. Results One hundred fifty-five (23%) patients underwent limited resection and 524 (77%) underwent lobectomy. In adjusted analyses of patient-specific factors, smaller tumor size (P =. 004), coverage by Medicare or Medicaid, no insurance or unknown insurance (P =. 02), more severe lung disease (P <. 001), and a history of stroke (P =. 049) were associated with receipt of limited resection. In adjusted analyses of surgeon characteristics, thoracic surgery specialty (P =. 02), non-fee-for-service compensation (P =. 008), and National Cancer Institute cancer center designation (P =. 006) were associated with higher odds of limited resection. Unadjusted 30-day mortality was higher with limited resection than with lobectomy (7.1% vs 1.9%, difference = 5.2%, 95% confidence interval [CI] = 1.5% to 10.8%, P =. 003), and the adjusted difference was not statistically significant (6.5% vs 2.9%, difference = 3.6%, 95% CI =-.1% to 9.2%, P =. 09). Postoperative complications did not differ by type of surgery (all P >. 05). Over the course of the study, a non-statistically significant trend toward improved long-term survival was evident for lobectomy, compared with limited resection, in adjusted analyses (hazard ratio of death = 1.35 for limited resection, 95% CI = 0.99 to 1.84, P =. 05). Conclusions Evidence is statistically inconclusive but suggestive that lobectomy, compared with limited resection, is associated with increased long-term survival for early-stage lung cancer. Clinical, socioeconomic, and surgeon factors appear to be associated with the choice of surgical resection. © 2011 The Author.


McClure R.S.,Brigham and Women's Hospital | Narayanasamy N.,Brigham and Women's Hospital | Wiegerinck E.,Brigham and Women's Hospital | Lipsitz S.,Center for Surgery and Public Health | And 5 more authors.
Annals of Thoracic Surgery | Year: 2010

Background: This study reviews a single institution experience with the Carpentier-Edwards pericardial aortic valve bioprosthesis, concentrating on late outcomes. Methods: From December 1991 to June 2002, 1,000 patients underwent aortic valve replacement with the Carpentier-Edwards pericardial valve (mean follow-up 6.01 ± 3.56 years). The institutional database was reviewed. Follow-up data were acquired through telephone interviews and mail-in questionnaires. Time-to-event analyses were performed by the Kaplan-Meier method. Mean age was 74.1 years; 545 patients (54.5%) were male. Mean preoperative ejection fraction was 52.5%. Isolated aortic valve replacement occurred in 372 cases (37.2%). Combined aortic valve replacement with coronary artery bypass grafting occurred in 443 cases (44.3%). The remaining 185 patients (18.5%) underwent complex procedures with concomitant mitral, tricuspid, or arch repair. One hundred forty patients (14.0%) had prior aortic valve surgery. Follow-up was 99.4% complete. Results: Overall operative mortality was 7.2% (72 of 1,000). There were 503 late deaths (50.3%). Age-stratified survival at 15 years was 43.7% for patients less than 65 years of age; 18.2% for patients aged 65 to 75; and 9.4% for patients aged more than 75 years. There were 26 failed bioprostheses (2.6%) requiring reoperation. Structural valve deterioration was the cause in 13 of 26 cases (50%), endocarditis in 11 of 26 (42%), and perivalvular leak in 2 of 26 (7.6%). Age-stratified freedom from reoperation due to structural valve deterioration at 15 years was 34.7% for patients less than 65 years of age; 89.4% for patients aged 65 to 75; and 99.5% for patients aged more than 75 years. Conclusions: The Carpentier-Edwards pericardial bioprosthesis shows long-term durability with low rates of structural failure. © 2010 The Society of Thoracic Surgeons.


Billmeier S.E.,Brigham and Women's Hospital | Billmeier S.E.,Center for Surgery and Public Health | Ayanian J.Z.,Center for Surgery and Public Health | Ayanian J.Z.,Harvard University | And 5 more authors.
Annals of Surgery | Year: 2013

Objective:: To assess factors associated with nursing home admission, severe functional impairment, or death 1 year after surgery for stage I-IIIa non-small cell lung cancer. Background:: Patients perceive long-term disability to be one of the most undesirable complications of lung cancer treatment. METHODS:: A multiregional cohort was surveyed 12 months after surgery. Logistic regression was used to determine adjusted predictors of long-term disability. Recursive partitioning was used to create a risk index based on preoperative factors. RESULTS:: Of the 1007 patients, 146 (15%) were admitted to a nursing home or died by 1 year after surgery, with higher risk among patients 80 years or older, those with severe comorbidities, and those with stage II-IIIa disease (all Ps ≤ 0.01). Among 759 survivors who completed the follow-up survey, 51 (7%) were admitted to a nursing home or reported inability to get out of bed, dress or wash themselves, or perform usual activities. Patients with moderate comorbidities (P < 0.001) or lack of high school diploma (P = 0.03) were more likely to experience nursing home admission or severe functional impairment. The risk of nursing home admission, severe functional impairment, or death was low (16%) for patients younger than 75 years and for those 75 years or older with stage I disease, intermediate (33%) for patients 75 years or older with stage II-IIIa disease and no or mild comorbidities, and high (60%) for those 75 years or older with stage II-IIIa disease and moderate or severe comorbidities. CONCLUSIONS:: PatientsE' risk of long-term disability should be incorporated in preoperative counseling. © 2013 by Lippincott Williams & Wilkins.

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