The utility of home sleep apnea tests in patients with low versus high pre-test probability for moderate to severe OSA

Purpose

Home sleep apnea tests (HSATs) are an alternative to attended polysomnograms (PSGs) when the pre-test probability for moderate to severe OSA is high. However, insurers often mandate use anytime OSA is suspected regardless of the pre-test probability. Our objective was to determine the ability of HSATs to rule in OSA when the pre-test probability of an apnea hypopnea index (AHI) in the moderate to severe range is low.

Methods

Patients who underwent HSATs were characterized as low or high pre-test probability based on the presence of two symptoms of the STOP instrument plus either BMI >?35 or male gender. The odds of HSAT diagnostic for OSA dependent on pre-test probability was calculated. Stepwise selection determined predictors of non-diagnostic HSAT. As PSG is performed after HSATs that do not confirm OSA, false negative results were assessed.

Results

Among 196 individuals, pre-test probability was low in 74 (38%) and high in 122 (62%). A lower percentage of individuals with a low versus high pre-test probability for moderate to severe OSA had HSAT results that confirmed OSA (61 versus 84%, p?=?0.0002) resulting in an odds ratio (OR) of 0.29 for confirmatory HSAT in the low pre-test probability group (95% CI [0.146, 0.563]). Multivariate logistic regression demonstrated that age ≤?50 (OR 3.10 [1.24–7.73]), female gender (OR 3.58[1.50–8.66]), non-enlarged neck circumference (OR 11.50 [2.50–52.93]), and the absence of loud snoring (OR 3.47 [1.30–9.25]) best predicted non-diagnostic HSAT. OSA was diagnosed by PSG in 54% of individuals with negative HSAT which was similar in both pre-test probability groups.

Conclusion

HSATs should be reserved for individuals with high pre-test probability for moderate to severe disease as opposed to any individual with suspected OSA.

     

Diagnostic accuracy of level IV portable sleep monitors versus polysomnography for obstructive sleep apnea: a systematic review and meta-analysis

Purpose

Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder. In-laboratory, overnight type I polysomnography (PSG) is the current “gold standard” for diagnosing OSA. Home sleep apnea testing (HSAT) using portable monitors (PMs) is an alternative testing method offering better comfort and lower costs. We aimed to systematically review the evidence on diagnostic ability of type IV PMs compared to PSG in diagnosing OSA.

Methods

Participants: patients ≥16 years old with symptoms suggestive of OSA;intervention: type IV PMs (devices with <?2 respiratory channels); comparator: in-laboratory PSG; outcomes: diagnostic accuracy measures;studies: cross-sectional, prospective observational/experimental/quasi-experimental studies; information sources: MEDLINE and Cochrane Library from January 1, 2010 to May 10, 2016. All stages of review were conducted independently by two investigators.

Results

We screened 6054 abstracts and 117 full-text articles to select 24 full-text articles for final review. These 24 studies enrolled a total of 2068 patients with suspected OSA and evaluated 10 different PMs with one to six channels. Only seven (29%) studies tested PMs in the home setting. The mean difference (bias) between PSG-measured and PM-measured apnea-hypopnea index (AHI) ranged from ??14.8 to 10.6 events/h. At AHI ≥?5 events/h, the sensitivity of type IV PMs ranged from 67.5–100% and specificity ranged from 25 to 100%.

Conclusion

While current evidence is not very strong for the stand-alone use of level IV PMs in clinical practice, they can potentially widen access to diagnosis and treatment of OSA. Policy recommendations regarding HSAT use should also consider the health and broader social implications of false positive and false negative diagnoses.

     

Cancer Risk Communication with Low Health Literacy Patients: A Continuing Medical Education Program

BACKGROUND

Low health literacy (HL) is an important risk factor for cancer health disparities.

OBJECTIVE

Describe a continuing medical education (CME) program to teach primary care physicians (PCP) cancer risk communication and shared decision-making (SDM) with low HL patients and baseline skills assessment.

DESIGN

Cluster randomized controlled trial in five primary care clinics in New Orleans, LA.

PARTICIPANTS

Eighteen PCPs and 73 low HL patients overdue for cancer screening.

INTERVENTION

Primary care physicians completed unannounced standardized patient (SP) encounters at baseline. Intervention physicians received SP verbal feedback; academic detailing to review cancer screening guidelines, red flags for identifying low HL, and strategies for effective counseling; and web-based tutorial of SP comments and checklist items hyperlinked to reference articles/websites.

MAIN MEASURES

Baseline PCP self-rated proficiency, SP ratings of physician general cancer risk communication and SDM skills, patient perceived involvement in care.

RESULTS

Baseline assessments show physicians rated their proficiency in discussing cancer risks and eliciting patient preference for treatment/decision-making as “very good”. SPs rated physician exploration of perceived cancer susceptibility, screening barriers/motivators, checking understanding, explaining screening options and associated risks/benefits, and eliciting preferences for screening as “satisfactory”. Clinic patients rated their doctor’s facilitation of involvement in care and information exchange as “good”. However, they rated their participation in decision-making as “poor”.

DISCUSSION

The baseline skills assessment suggests a need for physician training in cancer risk communication and shared decision making for patients with low HL. We are determining the effectiveness of teaching methods, required resources and long-term feasibility for a CME program.

     

Patient-predicted sleep position vs. HST data: a tendency to underestimate supine sleep

Purpose

The purpose of this study is to measure people’s accuracy when they estimate what proportion of their nightly sleep at home is supine vs. non-supine.

Methods

A series of patients referred for obstructive sleep apnea (OSA) evaluation were asked if they “knew with confidence” how they slept with regard to their body position. “Yes” responders were then asked to estimate what percentage of their sleep was supine vs. non-supine. This value was compared with the actual proportion of supine vs. non-supine sleep that they exhibited in a home sleep test (HST) that followed.

Results

We obtained data from 49 subjects who expressed that they “knew with confidence” how they sleep in terms of body position. Subjects in aggregate underestimated their proportion of supine sleep by 21.6% (p < .001). Thirty-nine subjects (80%) slept supine more in the HST whereas 8 (16%) slept supine less compared to their pre-test estimates. Using a common classification of OSA severity, 9 subjects (18%) demonstrated a more severe degree of OSA than would have occurred had they slept as they had predicted.

Conclusions

Subjects in this study frequently underestimated their proportion of supine sleep compared to values measured in an HST. Because of the increased supine sleep they exhibited, the severity of their OSA was often greater in the test than it would have been had the subjects slept as they predicted. Sleep physicians should take into account the tendency of people to underestimate supine sleep. If patients with positional sleep apnea assert that they “always sleep laterally” when at home, they may be underestimating their true night-by-night OSA disease burden.

     

Joy and Challenges in Improving Chronic Illness Care: Capturing Daily Experiences of Academic Primary Care Teams

BACKGROUND

Two chronic care collaboratives (The National Collaborative and the California Collaborative) were convened to facilitate implementing the chronic care model (CCM) in academic medical centers and into post-graduate medical education.

OBJECTIVE

We developed and implemented an electronic team survey (ETS) to elicit, in real-time, team member’s experiences in caring for people with chronic illness and the effect of the Collaborative on teams and teamwork.

DESIGN

The ETS is a qualitative survey based on Electronic Event Sampling Methodology. It is designed to collect meaningful information about daily experience and any event that might influence team members’ daily work and subsequent outcomes.

PARTICIPANTS

Forty-one residency programs from 37 teaching hospitals participated in the collaboratives and comprised faculty and resident physicians, nurses, and administrative staff.

APPROACH

Each team member participating in the collaboratives received an e-mail with directions to complete the ETS for four weeks during 2006 (the National Collaborative) and 2007 (the California Collaborative).

KEY RESULTS

At the team level, the response rate to the ETS was 87% with team members submitting 1,145 narrative entries. Six key themes emerged from the analysis, which were consistent across all sites. Among teams that achieved better clinical outcomes on Collaborative clinical indicators, an additional key theme emerged: professional work satisfaction, or “Joy in Work”. In contrast, among teams that performed lower in collaborative measures, two key themes emerged that reflected the effect of providing care in difficult institutional environments—“lack of professional satisfaction” and awareness of “system failures”.

CONCLUSIONS

The ETS provided a unique perspective into team performance and the day-to-day challenges and opportunities in chronic illness care. Further research is needed to explore systematic approaches to integrating the results from this study into the design of improvement efforts for clinical teams.

     

Sleep quality of mother-caregivers of Duchenne muscular dystrophy patients

Background

Sleep disturbance is a common problem for caregivers. In general, patients with Duchenne muscular dystrophy (DMD) use noninvasive ventilation to maintain quality of life and improve survival.

Objective

The aim of this study was to evaluate the sleep quality of caregiver-mothers of sons with DMD and factors that are associated with their sleep quality.

Methods

We evaluated 32 caregiver-mothers of sons with DMD and 32 mothers of sons without any neuromuscular or chronic disease (control—CTRL group). The evaluation of quality of sleep was made using the Pittsburgh Sleep Quality Index (PSQI).

Results

Caregiver-mothers had poor sleep quality, specifically longer sleep latency and reduced sleep efficiency. The impaired sleep quality of the caregiver-mothers was associated with the length of time of noninvasive ventilation used by their sons.

Conclusions

Our results suggest that caregiver-mothers of sons with DMD have poor quality of sleep, and the length of use of noninvasive ventilation of their sons is associated with better sleep of caregiver-mothers.

     

The Challenges of Multimorbidity from the Patient Perspective

Background

Although multiple co-occurring chronic illnesses within the same individual are increasingly common, few studies have examined the challenges of multimorbidity from the patient perspective.

Objective

The aim of this study is to examine the self-management learning needs and willingness to see non-physician providers of patients with multimorbidity compared to patients with single chronic illnesses.

Design

This research is designed as a cross-sectional survey.

Participants

Based upon ICD-9 codes, patients from a single VHA healthcare system were stratified into multimorbidity clusters or groups with a single chronic illness from the corresponding cluster. Nonproportional sampling was used to randomly select 720 patients.

Measurements

Demographic characteristics, functional status, number of contacts with healthcare providers, components of primary care, self-management learning needs, and willingness to see nonphysician providers.

Results

Four hundred twenty-two patients returned surveys. A higher percentage of multimorbidity patients compared to single morbidity patients were “definitely” willing to learn all 22 self-management skills, of these only 2 were not significant. Compared to patients with single morbidity, a significantly higher percentage of patients with multimorbidity also reported that they were “definitely” willing to see 6 of 11 non-physician healthcare providers.

Conclusions

Self-management learning needs of multimorbidity patients are extensive, and their preferences are consistent with team-based primary care. Alternative methods of providing support and chronic illness care may be needed to meet the needs of these complex patients.

     

Firing a loaded gun during sleep in an elderly man with a “perfect storm” of risk factors including severe obstructive sleep apnea

Purpose

We report a case of firing a loaded gun during sleep in a geriatric patient with undiagnosed major sleep disorders and multiple risk factors for sleep violence. Polysomnographic findings, diagnostic challenges, and forensic implications in this unprecedented geriatric case are discussed.

Methods

A 75-year-old employed man, married for 32 years, presented to a sleep center reporting to having fired a shot in his bedroom during sleep while his wife was away, without memory of hearing the gunshot. The day before the event, the patient had a normal life, apart from serious worries about recent nearby burglaries that prompted his sleeping with a loaded gun placed behind his bed. The patient underwent a sleep medicine workup, including nocturnal video polysomnography (vPSG).

Results

The patient and his wife were unaware of any sleep problems. Upon careful questioning, only mild daytime sleepiness and rare episodes of minor abnormal motor behavior were reported. At vPSG, sleep structure was markedly disrupted with only one clear sleep cycle with REM sleep that had preserved REM-atonia; severe obstructive sleep apnea and moderately severe periodic limb movement activity were documented. Brief abnormal movements from REM sleep without apparent precipitant were recorded. CPAP therapy was effective.

Conclusions

In this case, there was a “perfect storm” of sleep and psychological risk factors that converged to strongly promote precipitous arousals with sleep-related violence in a patient with documented sleep motor dyscontrol. Primary care physicians, including geriatric specialists, should question patients and their spouses about any symptoms of sleep disorders.

     

Reducing Patients’ Unmet Concerns in Primary Care: the Difference One Word Can Make

Context

In primary, acute-care visits, patients frequently present with more than 1 concern. Various visit factors prevent additional concerns from being articulated and addressed.

Objective

To test an intervention to reduce patients’ unmet concerns.

Design

Cross-sectional comparison of 2 experimental questions, with videotaping of office visits and pre and postvisit surveys.

Setting

Twenty outpatient offices of community-based physicians equally divided between Los Angeles County and a midsized town in Pennsylvania.

Participants

A volunteer sample of 20 family physicians (participation rate?=?80%) and 224 patients approached consecutively within physicians (participation rate?=?73%; approximately 11 participating for each enrolled physician) seeking care for an acute condition.

Intervention

After seeing 4 nonintervention patients, physicians were randomly assigned to solicit additional concerns by asking 1 of the following 2 questions after patients presented their chief concern: “Is there anything else you want to address in the visit today?” (ANY condition) and “Is there something else you want to address in the visit today?” (SOME condition).

Main Outcome Measures

Patients’ unmet concerns: concerns listed on previsit surveys but not addressed during visits, visit time, unanticipated concerns: concerns that were addressed during the visit but not listed on previsit surveys.

Results

Relative to nonintervention cases, the implemented SOME intervention eliminated 78% of unmet concerns (odds ratio (OR)?=?.154, p?=?.001). The ANY intervention could not be significantly distinguished from the control condition (p?=?.122). Neither intervention affected visit length, or patients’; expression of unanticipated concerns not listed in previsit surveys.

Conclusions

Patients’ unmet concerns can be dramatically reduced by a simple inquiry framed in the SOME form. Both the learning and implementation of the intervention require very little time.

     

The Relationship between Body Mass Index and Mental Health Among Iraq and Afghanistan Veterans

BACKGROUND

Obesity is a growing public health concern and is becoming an epidemic among veterans in the post-deployment period.

OBJECTIVE

To explore the relationship between body mass index (BMI) and posttraumatic stress disorder (PTSD) in a large cohort of Iraq and Afghanistan veterans, and to evaluate trajectories of change in BMI over 3 years.

DESIGN

Retrospective, longitudinal cohort analysis of veterans’ health records

PARTICIPANTS

A total of 496,722 veterans (59,790 female and 436,932 male veterans) whose height and weight were recorded at the Department of Veterans Affairs (VA) healthcare system at least once after the end of their last deployment and whose first post-deployment outpatient encounter at the VA was at least 1 year prior to the end of the study period (December 31, 2011).

MAIN MEASURES

BMI, mental health diagnoses.

KEY RESULTS

Seventy-five percent of Iraq and Afghanistan veterans were either overweight or obese at baseline. Four trajectories were observed: “stable overweight” represented the largest class; followed by “stable obese;” “overweight/obese gaining;” and “obese losing.” During the 3-year ascertainment period, those with PTSD and depression in particular were at the greatest risk of being either obese without weight loss or overweight or obese and continuing to gain weight. Adjustment for demographics and antipsychotic medication attenuated the relationship between BMI and certain mental health diagnoses. Although BMI trajectories were similar in men and women, some gender differences were observed. For example, the risk of being in the persistently obese class in men was highest for those with PTSD, whereas for women, the risk was highest among those with depression.

CONCLUSIONS

The growing number of overweight or obese returning veterans is a concerning problem for clinicians who work with these patients. Successful intervention to reduce the prevalence of obesity will require integrated efforts from primary care and mental health to treat underlying mental health causes and assist with engagement in weight loss programs.

     

Ethical Issues in Patients with Cirrhosis

Purpose of Review

To briefly summarize topical ethical issues in patients with cirrhosis.

Recent Findings

The “four quadrants” framework is ideally suited to address ethical issues in patients with cirrhosis. The presence of hepatic encephalopathy complicates any ethical analysis and stresses the importance of advanced directives and end of life planning, both of which appear to be poorly applied. Organ allocation in liver transplantation (LT) based on survival benefit, a “not unreasonable standard” to assess live donor LT (LDLT) in patients removed from the wait list, LT in patients with acute alcoholic hepatitis, and LT in undocumented immigrants are supported by sound ethical principles.

Summary

Significant ethical issues remain challenging and unresolved for patients with cirrhosis. Further research must be done to assess how frequently ethical problems occur in individual patients. Clear, detailed policies, based on strong ethical platforms, must be developed to further address these significant ethical challenges.

     

Barriers to and Facilitators of Alcohol Use Disorder Pharmacotherapy in Primary Care: A Qualitative Study in Five VA Clinics

Background

Three medications are FDA-approved and recommended for treating alcohol use disorders (AUD) but they are not offered to most patients with AUD. Primary care (PC) may be an optimal setting in which to offer and prescribe AUD medications, but multiple barriers are likely.

Objective

This qualitative study used social marketing theory, a behavior change approach that employs business marketing techniques including “segmenting the market,” to describe (1) barriers and facilitators to prescribing AUD medications in PC, and (2) beliefs of PC providers after they were segmented into groups more and less willing to prescribe AUD medications.

Design

Qualitative, interview-based study.

Participants

Twenty-four providers from five VA PC clinics.

Approach

Providers completed in-person semi-structured interviews, which were recorded, transcribed, and analyzed using social marketing theory and thematic analysis. Providers were divided into two groups based on consensus review.

Key Results

Barriers included lack of knowledge and experience, beliefs that medications cannot replace specialty addiction treatment, and alcohol-related stigma. Facilitators included training, support for prescribing, and behavioral staff to support follow-up. Providers more willing to prescribe viewed prescribing for AUD as part of their role as a PC provider, framed medications as a potentially effective “tool” or “foot in the door” for treating AUD, and believed that providing AUD medications in PC might catalyze change while reducing stigma and addressing other barriers to specialty treatment. Those less willing believed that medications could not effectively treat AUD, and that treating AUD was the role of specialty addiction treatment providers, not PC providers, and would require time and expertise they do not have.

Conclusions

We identified barriers to and facilitators of prescribing AUD medications in PC, which, if addressed and/or capitalized on, may increase provision of AUD medications. Providers more willing to prescribe may be the optimal target of a customized implementation intervention to promote changes in prescribing.

     

Outcomes after rectosigmoid resection for endometriosis: a systematic literature review

Purpose

“Endometriosis” is defined such as the presence of endometrial glands and stroma outside the uterine cavity. This ectopic condition may develop as deeply infiltrating endometriosis (DIE) when a solid mass is located deeper than 5 mm underneath the peritoneum including the intestinal wall. The ideal surgical treatment is still under search, and treatment may range from simple shaving to rectal resection. The aim of the present systematic review is to report and analyze the postoperative outcomes after rectosigmoid resection for endometriosis.

Methods

We performed a systematic review according to Meta-analysis of Observational Studies in Epidemiology guidelines. The search was carried out in the PubMed database, using the keywords: “rectal resection” AND “endometriosis” and “rectosigmoid resection” AND “endometriosis.” The search revealed 380 papers of which 78 were fully analyzed.

Results

Thirty-eight articles published between 1998 and 2017 were included. Three thousand seventy-nine patients (mean age 34.28?±?2.46) were included. Laparoscopic approach was the most employed (90.3%) followed by the open one (7.9%) and the robotic one (1.7%). Overall operative time was 238.47?±?66.82. Conversion rate was 2.7%. In more than 80% of cases, associated procedures were performed. Intraoperative complications were observed in 1% of cases. The overall postoperative complications rate was 18.5% (571 patients), and the most frequent complication was recto-vaginal fistula (74 patients, 2.4%). Postoperative mortality rate was 0.03% and mean hospital stay was 8.88?±?3.71 days.

Conclusions

Despite the large and extremely various number of associated procedures, rectosigmoid resection is a feasible and safe technique to treat endometriosis.

     

Barriers Beyond Words: Cancer,Culture, and Translation in a Community of Russian Speakers

BACKGROUND

Language and culture relate in complex ways. Addressing this complexity in the context of language translation is a challenge when caring for patients with limited English proficiency (LEP).

OBJECTIVE

To examine processes of care related to language, culture and translation in an LEP population is the objective of this study.

DESIGN

We used community based participatory research to examine the experiences of Russian-speaking cancer patients in San Francisco, California. A Russian Cancer Information Taskforce (RCIT), including community-based organizations, local government, and clinics, participated in all phases of the study.

PARTICIPANTS

A purposeful sample of 74 individuals were the participants of the study.

APPROACH

The RCIT shaped research themes and facilitated access to participants. Methods were focus groups, individual interviews, and participant observation. RCIT reviewed data and provided guidance in interpreting results.

RESULTS

Four themes emerged. (1) Local Russian-language resources were seen as inadequate and relatively unavailable compared to other non-English languages; (2) a taboo about the word “cancer” led to language “games” surrounding disclosure; (3) this taboo, and other dynamics of care, reflected expectations that Russian speakers derived from experiences in their countries of origin; (4) using interpreters as cultural brokers or establishing support groups for Russian speakers could help address barriers.

CONCLUSIONS

The language barriers experienced by this LEP population reflect cultural and linguistic issues. Providers should consider partnering with trained interpreters to address the intertwining of language and culture.

     

“Getting by” in a Swiss Tertiary Hospital: the Inconspicuous Complexity of Decision-making Around Patients’ Limited Language Proficiency

Background

While the need to address language barriers to provide quality care for all is generally accepted, little is known about the complexities of decision-making around patients’ limited language proficiency in everyday clinical encounters.

Objective

To understand how linguistic complexities shape cross-cultural encounters by incorporating the perspective of both, patients and physicians.

Design

A qualitative hospital study with semi-structured interviews and participant-observation in a Swiss University Hospital. Thirty-two encounters were observed and 94 interviews conducted.

Participants

Sixteen patients of Turkish and 16 of Albanian origin and all actors (administration, nurses, physicians, if required, interpreters) involved in the patients’ entire process.

Main Approach

Interviews were audio-recorded and transcribed verbatim. A thematic content analysis was conducted using MAXQDA. For reporting, the COREQ guidelines were used.

Key Results

Three themes were relevant to patients and physicians alike: Assessment of the language situation, the use of interpreters, and dealing with conversational limits. Physicians tend to assess patients’ language proficiency by their body language, individual demeanor, or adequacy of responses to questions. Physicians use professional interpreters for “high-stakes” conversations, and “get by” through “low-stakes” topics by resorting to bilingual family members, for example. Patients are driven by factors like fearing costs or the wish to manage on their own. High acceptance of conversational limits by patients and physicians alike stands in stark contrast to the availability of interpreters.

Conclusions

The decision for or against interpreter use in the “real world” of clinical care is complex and shaped by small, frequently inconspicuous decisions with potential for suboptimal health care. Physicians occupy a key position in the decision-making to initiate the process of medical interpreting. The development and testing of a conceptual framework close to practice is crucial for guiding physicians’ assessment of patients’ language proficiency and their decision-making on the use of interpreting services.

     

Robotik-assistierte kolorektale Chirurgie

Background

Robotics-assisted colorectal resections are well-established and standardized procedures. The penetrance of this technique shows an exponential increase worldwide. This development will be further enhanced through the implemetation of other innovative robotics systems in the near future.

Objective

Meaningful indications, set-up, operative strategy and techniques are presented and discussed.

Methods

Presentation of our experiences with nearly 400 colorectal resections with the Da Vinci® SI system. Discussion of the available data and studies.

Results

The features of robotic assistance are particularly helpful in technically challenging situations and complex operative procedures. Robotic assistance improves outcome after these minimally invasive operations. Oncological rectal resection, right sided hemicolectomy and anterior rectopexy are reasonable and meaningful indications for the Da Vinci® SI system. The Da Vinci® XI system and the forthcoming alternative systems from other manufacurers make complete colectomy and restorative coloproctectomy ideal interventions for robotic assistance.

Conclusion

Robotics-assisted colorectal resections are well-established and standardized procedures. They improve outcome after complex procedures and will help to increase the penetrance of minimally invasive approaches in colorectal surgery. The continuous ongoing technical innovations, such as immunfluorescence, “smart” clamping (already available), navigation, in vivo microscopy, large data managment and cognitive systems (upcoming) will further change the operating theater working place. There is only one negative argument against active participation in this important development – the high costs.

     

Teamlet Structure and Early Experiences of Medical Home Implementation for Veterans

BACKGROUND

High functioning interdisciplinary primary care teams are a critical component of the patient-centered medical home. In 2010, the Veterans Administration (VA) implemented a medical home model termed the Patient Aligned Care Teams (PACT), with reorganization of staff into small teams (“teamlets”) as a core feature.

OBJECTIVE

To examine the early experiences of primary care personnel as they assumed new roles through reorganization into teamlets.

DESIGN

Convergent mixed methods study design involving semi-structured interviews and a survey; data were collected in 2011 and 2012.

PARTICIPANTS

We interviewed 41 frontline teamlet members (i.e., primary care physicians and staff) from three practices that were part of a PACT demonstration laboratory and examined clinician and staff survey data from 22 practices.

MAIN MEASURES

Semi-structured interview guide and clinician and staff survey questions covering the following domains: teamlet formation and structure, within-teamlet communication, cross-coverage, role changes, teamlet training, impact on Veterans, and leadership facilitation and support.

KEY RESULTS

Respondents had limited input into teamlet structure and indicated limited training on the PACT initiative. Guidelines delineating each teamlet member’s roles and responsibilities were emphasized as important needs. Chronic understaffing also contributed to implementation challenges and territorial attitudes surfaced when cross-coverage was not clear. In addition, several core features of VA’s medical home transformation were not fully implemented by teamlet members. Most also reported limited guidance and feedback from leadership. Despite these challenges, teamlet-based care was perceived to have a positive impact on Veterans’ experiences of primary care and also resulted in improved communication among staff.

CONCLUSIONS

The PACT teamlet model holds much promise for improving primary care at the VA. However, more comprehensive training, improving the stability of teamlets, developing clear cross-coverage policies, and better defined teamlet member responsibilities are important areas in need of attention by VA leadership.

     

Strategies for Effective Discontinuation of Proton Pump Inhibitors

Purpose of Review

Proton pump inhibitors (PPIs) are effective for many conditions but are often overprescribed. Recent concerns about long-term risks have made patients re-evaluate their need to take PPIs chronically, though these population-based studies have methodological weaknesses. The goal of this review is to provide evidenced-based strategies for discontinuation of PPI therapy.

Recent Findings

Given that some patients experience rebound symptoms when abruptly stopping continuous PPI therapy due to its effect on hypergastrinemia, strategies focus on avoiding rebound. Tapering the PPI and then initiating a “step-down” approach with the use of alternative medications may be effective. “On-demand therapy” provides patients with the option to take intermittent PPI courses, reducing overall use and cost while preserving patient satisfaction. It is important for providers to consider ambulatory pH or pH/impedance testing to rule out diagnoses that may require alternative medications like neuromodulators.

Summary

A number of studies reviewed here can provide guidance in counseling patients on PPI discontinuation. It is important for the provider to obtain a baseline needs assessment for PPI therapy and to elucidate predictors of difficulty in discontinuation prior to initiating a strategy.

     

Self-identity After Cancer: “Survivor”, “Victim”, “Patient”, and “Person with Cancer”

Background

Living through cancer often involves developing new identities which may strongly influence well-being and relationships with care providers, yet little is currently known about these post-cancer identities.

Objectives

To examine (1) the extent to which four post-cancer identities (patient, person who has had cancer, victim, and survivor) are adopted, (2) relations between each identity and involvement in cancer-related activities and mental and physical well-being, and (3) correlates of these identities.

Design

Cross-sectional questionnaire-based study.

Participants

168 young to middle-aged adults who had previously experienced cancer.

Measurements

Cancer identifications, background variables, psychological functioning, cancer risk appraisals and coping, cancer-related activities, and mental and physical well-being.

Results

At least somewhat, 83% endorsed survivor identity, 81% identity of “person who has had cancer”, 58% “patient”, and 18% “victim”. Identities were minimally correlated with one another and differentially associated with involvement in cancer-related activities. Survivor and person who has had cancer identities correlated with involvement in most cancer-related activities such as wearing cancer-related items and talking about prevention (ps?<? 0.5). Survivor identity correlated with better psychological well-being and post-traumatic growth, victim identity with poorer well-being (ps?<? 0.5); neither identifying as a patient nor a person with cancer was related to well-being. Through regression analyses, identities were shown to be explained by unique combination of background, functioning, appraisal and coping variables.

Conclusions

Survivor identity appears most common and most associated with active involvement and better psychological well-being, but other identifications are also common and simultaneously held. Adoption of specific cancer identities is likely to impact interactions with health care providers, including those in general internal medicine, and health behavior changes.