Letters
in 5.6% and 0.36%, respectively, only marginally less than the prevalence in those with symptomatic GERD.7 The difficulty in identifying the right patients with GERD to endoscope is demonstrated in the study by Kramer et al,8 published in this issue. In an impressive audit of nearly 500 000 cases of GERD identified in Veteran Health Administration records, the authors found that those patients more likely to receive an EGD in the first year after diagnosis were actually less likely to have either BE or esophageal cancer.8 Men older than 65 years, for example, were nearly 7-fold more likely to have BE or esophageal cancer compared with a cohort of women younger than 50 years as the reference group, but these men were also significantly less likely to undergo EGD (odds ratio, 0.77).8 We still miss most patients with BE despite the widespread use of EGD; up to 95% of cases of adenocarcinoma occur in the setting of no prior diagnosis of BE.9 The data from Kramer et al8 suggest that this may in part be due to underutilization of EGD in high-risk cases. On the other hand, the mortality of symptomatic reflux is not increased over the background population,10 and there is still no convincing evidence that endoscopic screening of symptomatic GERD will reduce esophageal adenocarcinoma rates (stopping smoking and losing weight would probably be more valuable).3 Until noninvasive biomarkers to identify BE are available, judicious application of EGD to those with alarm signals or other high-risk cases (eg, those with chronic heartburn, who are older white men, or those with chronic reflux who are obese) seems reasonable but is unlikely to save many lives. Nicholas J. Talley, MD, PhD, FRACP Kate E. Napthali, FRACP Author Affiliations: University of Newcastle, Newcastle, New South Wales, Australia (Talley); John Hunter Hospital, Newcastle, New South Wales, Australia (Napthali); Mayo Clinic, Rochester, Minnesota (Talley). Corresponding Author: Nicholas J. Talley, MD, PhD, FRACP, University of Newcastle, Callaghan, NSW 2308, Australia ([email protected]). Published Online: January 27, 2014. doi:10.1001/jamainternmed.2013.12992. Conflict of Interest Disclosures: None reported. 1. Evans JA, Early DS, Fukami N, et al; ASGE Standards of Practice Committee; Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. The role of endoscopy in Barrett’s esophagus and other premalignant conditions of the esophagus. Gastrointest Endosc. 2012;76(6):1087-1094. 2. Solaymani-Dodaran M, Logan RF, West J, Card T, Coupland C. Risk of oesophageal cancer in Barrett’s oesophagus and gastro-oesophageal reflux. Gut. 2004;53(8):1070-1074. 3. Kahrilas PJ, Shaheen NJ, Vaezi MF; American Gastroenterological Association Institute; Clinical Practice and Quality Management Committee. American Gastroenterological Association Institute technical review on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135(4):1392-1413. 4. Shaheen NJ, Weinberg DS, Denberg TD, Chou R, Qaseem A, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Upper endoscopy for gastroesophageal reflux disease: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med. 2012;157(11):808-816. 5. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308-328. 466
6. Vakil N, Moayyedi P, Fennerty MB, Talley NJ. Limited value of alarm features in the diagnosis of upper gastrointestinal malignancy: systematic review and meta-analysis. Gastroenterology. 2006;131(2):390-401. 7. Rex DK, Cummings OW, Shaw M, et al. Screening for Barrett’s esophagus in colonoscopy patients with and without heartburn. Gastroenterology. 2003;125(6):1670-1677. 8. Kramer JR, Shakhatreh MH, Naik AD, Duan Z, El-Serag HB. Use and yield of endoscopy in patients with uncomplicated gastroesophageal reflux disorder [published online January 27, 2014]. JAMA Intern Med. doi:10.1001/ jamainternmed.2013.12756. 9. Dulai GS, Guha S, Kahn KL, Gornbein J, Weinstein WM. Preoperative prevalence of Barrett’s esophagus in esophageal adenocarcinoma: a systematic review. Gastroenterology. 2002;122(1):26-33. 10. Chang JY, Locke GR III, McNally MA, et al. Impact of functional gastrointestinal disorders on survival in the community. Am J Gastroenterol. 2010;105(4):822-832.
Physicians’ Preferences for Hospice if They Were Terminally Ill and the Timing of Hospice Discussions With Their Patients Physicians often delay hospice discussions with their terminally ill patients despite guidelines recommending such discussions for patients expected to die within 1 year,1,2 but reasons for this are not well understood. Evidence suggests that physicians “practice what they preach” when counseling about health behaviors,3 although their treatment recommendations may not necessarily reflect their own preferences, with one study suggesting they recommend more conservative treatments than they might choose for themselves.4 As physicians may prefer less aggressive endof-life care than their patients generally receive,5 physicians’ personal preferences for hospice may influence their approach to hospice discussions with their terminally ill patients. We examined physicians’ reported preferences for hospice enrollment if they were terminally ill. We also assessed whether physicians who would enroll in hospice if terminally ill differed from others in the timing of hospice discussions with their patients. Methods | This study was approved by the institutional review boards at all participating institutions. We surveyed physicians caring for patients with cancer enrolled in the multiregional population-based Cancer Care Outcomes Research and Surveillance (CanCORS) study.1 Informed consent was implied by physicians’ participation in the survey. Physicians indicated on a 5-point Likert scale how strongly they agreed or disagreed with the statement “If I were terminally ill with cancer, I would enroll in hospice.” They were also asked to assume that they were caring for an asymptomatic patient with advanced cancer, who they believed had 4 to 6 months to live and report whether they would discuss hospice with the patient “now,” “when the patient first develops symptoms,” “when there are no more nonpalliative treatments to offer,” “only if the patient is admitted to the hospital,” or “only if the patient and/or family bring it up.”1 Among 4488 respondents (response rate 61%), we excluded 105 who did not answer the hospice self-preference
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Letters
Table. Physician Willingness to Enroll in Hospice: Personal and Practice Characteristicsa
Physician Characteristics
Total, No. (%)
Unadjusted Proportion Who Strongly Agree They Would Enroll in Hospice if Terminally Ill With Cancer, %
Total
4368 (100)
64.5
Strongly Agreeing They Would Enroll in Hospice, Adjusted OR (95% CI)b
Age, y ≤39
959 (22)
65.4
1 [Reference]
40-49
1264 (29)
65.5
1.08 (0.89-1.31)
50-54
767 (18)
67.1
1.18 (0.95-1.47)
55-59
702 (16)
65.4
1.20 (0.96-1.50)
≥60
676 (15)
57.7
1.00 (0.79-1.25)
3453 (80)
61.9
1 [Reference]
837 (20)
76.1
1.80 (1.49-2.18)
Sex
Abbreviation: OR, odds ratio.
Male Female
a
Percentages include only reported, nonimputed values and may not sum to 100% because of rounding or missing values. Missing values were present for the following variables: sex (n = 78), specialty (n = 77), proportion of patients in managed care (n = 374), and number of terminally ill patients cared for in the past year (n = 62). Adjusted analyses used imputed data.
b
Adjusting for all variables in the table, as well as type of practice. Board certification, US medical school graduate status, and level of teaching involvement were not associated in adjusted analyses and were not included in the model.
Specialty Primary care physician
1743 (41)
69.5
1 [Reference]
Surgery
923 (22)
56.6
0.65 (0.55-0.78)
Medical oncology
600 (14)
70.3
0.93 (0.74-1.17)
Radiation oncology
257 (6)
57.6
0.57 (0.42-0.76)
Other specialty
768 (18)
61.2
0.75 (0.62-0.90)
≤50
2330 (58)
60.8
1 [Reference]
≥51
1664 (42)
69.8
1.30 (1.12-1.51)
≤12
2308 (54)
62.5
1 [Reference]
≥13
1998 (46)
67.1
1.29 (1.12-1.50)
Patients in managed care, %
No. of terminally-ill patients in the last year
Figure. Physician Willingness to Enroll in Hospice and Report of Early Hospice Discussions With Terminally Ill Patients With Cancer
Adjusted Proportion Who Would Discuss Hospice “Now,” %
35 30 25 20 15 10 5 0
Strongly agree
Other responses
Personal Preferences for Hospice Enrollment if Terminally Ill
question and 15 likely trainees who graduated after 2004. Multiple imputation was used to address item nonresponse in the adjusted analyses.6 We used multivariable logistic regression to examine physician and practice factors associated with physicians’ strong agreement that they would enroll in hospice if terminally ill with cancer. In a second model, we assessed if physicians who strongly agreed they would enroll in hospice were more likely than other physicians to report discussing jamainternalmedicine.com
hospice “now” with their terminally ill patients. We omitted variables with adjusted P values >.10. Results | Respondents’ characteristics are given in the Table. Most respondents strongly (64.5%) or somewhat (21.4%) agreed they would enroll in hospice if terminally ill. In adjusted analyses, physicians who were female, cared for more terminally ill patients, and worked in managed-care settings were more likely than others to strongly agree they would enroll in hospice. Surgeons and radiation oncologists were less likely than primary care physicians to strongly agree they would enroll in hospice. Overall, 26.5% reported they would discuss hospice “now” with a patient who had 4 to 6 months to live. Other physicians reported they would wait until the patient has symptoms (16.4%), there were no more treatments to offer (48.7%), the patient and/or family brings it up (4.3%), or the patient is hospitalized (4.1%). After adjustment, physicians who strongly agreed they would enroll in hospice themselves were more likely than other physicians to report discussing hospice “now” (odds ratio, 1.7; 95% CI, 1.5-2.0) (Figure). Discussion | Most physicians reported they would enroll in hospice if they were terminally ill with cancer, particularly women, primary care physicians, and those in managed-care settings and with more terminally ill patients. Physicians with strong JAMA Internal Medicine March 2014 Volume 174, Number 3
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467
Letters
Garrett M. Chinn, MD, MS Pang-Hsiang Liu, MD, PhD Carrie N. Klabunde, PhD, MHS, MBA Katherine L. Kahn, MD Nancy L. Keating, MD, MPH Author Affiliations: Division of General Medicine, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston (Chinn); Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (Liu, Keating); Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (Klabunde); RAND, Santa Monica, California (Kahn); Division of General Internal Medicine, Department of Medicine, David Geffen School of Medicine, Los Angeles, California (Kahn); Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (Keating). Corresponding Author: Nancy L. Keating, MD, MPH, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115-5899 ([email protected]). Published Online: December 16, 2013. doi:10.1001/jamainternmed.2013.12825. Author Contributions: Drs Liu and Keating had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Chinn, Liu, Keating. Acquisition of data: Klabunde, Kahn, Keating. Analysis and interpretation of data: Chinn, Liu, Klabunde, Kahn, Keating. Drafting of the manuscript: Chinn, Liu, Keating. Critical revision of the manuscript for important intellectual content: Chinn, Liu, Klabunde, Kahn, Keating. Statistical analysis: Chinn, Liu, Keating. Obtained funding: Kahn, Keating. Administrative, technical, or material support: Klabunde. Study supervision: Kahn, Keating. Conflict of Interest Disclosures: None reported. Funding/Support: This work of the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium was supported by grants from the National Cancer Institute (NCI) to the Statistical Coordinating Center (U01 CA093344) and the NCI-supported Primary Data Collection and Research Centers (Dana Farber Cancer Institute/Cancer Research Network [U01 CA093332], Harvard Medical School/Northern California Cancer Center [U01 CA093324], RAND/UCLA [U01 CA093348], University of Alabama at Birmingham [U01 CA093329], University of Iowa [U01 CA093339], University of North Carolina [U01 CA093326]) and by a Department of Veterans Affairs grant to the Durham VA Medical Center [CRS 02-164]. Dr Keating’s effort was also funded by grant 1R01CA164021-01A1 from the NCI. Role of the Sponsors: Dr Klabunde is an employee of the NCI. Aside from her contributions, the funding agencies had no role in design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript Previous Presentation: Portions of this work were presented in abstract form at the Society of General Internal Medicine’s 36th Annual Meeting; April 25, 2013; Denver, Colorado.
1. Keating NL, Landrum MB, Rogers SO Jr, et al. Physician factors associated with discussions about end-of-life care. Cancer. 2010;116(4):998-1006. 2. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: palliative care: version 1. 2013. http://www.nccn.org/professionals /physician_gls/pdf/palliative.pdf. Accessed May 21, 2013. 3. Wells KB, Lewis CE, Leake B, Ware JE Jr. Do physicians preach what they practice? A study of physicians’ health habits and counseling practices. JAMA. 1984;252(20):2846-2848. 4. Ubel PA, Angott AM, Zikmund-Fisher BJ. Physicians recommend different treatments for patients than they would choose for themselves. Arch Intern Med. 2011;171(7):630-634. 5. Gramelspacher GP, Zhou X-H, Hanna MP, Tierney WM. Preferences of physicians and their patients for end-of-life care. J Gen Intern Med. 1997;12(6):346-351. 6. He Y, Zaslavsky AM, Landrum MB, Harrington DP, Catalano P. Multiple imputation in a large-scale complex survey: a practical guide. Stat Methods Med Res. 2010;19(6):653-670.
Posttraumatic Stress Disorder and Medication Nonadherence in Patients With Uncontrolled Hypertension Posttraumatic stress disorder (PTSD) is common in primary care patients1 and is associated with psychological distress, suicide risk, and disability. Posttraumatic stress disorder also increases risk of incident and recurrent cardiovascular events,2 possibly by reducing medication adherence.3 Prior studies showing an association between PTSD and medication nonadherence3 are limited by their use of self-report to measure adherence as PTSD can bias reporting of negative behaviors.4 We evaluated the association between PTSD and antihypertensive medication adherence using electronic monitoring in primary care patients with uncontrolled hypertension. Methods | The institutional review board of Columbia University Medical Center, New York, New York, approved the protocol. All patients provided written informed consent. We enrolled a convenience sample of patients with uncontrolled hypertension from an academic hospital-based primary care Figure. Posttraumatic Stress Disorder (PTSD) Symptoms and Nonadherence to Antihypertensive Medications 100
% of Nonadherence to Blood Pressure Medication
personal preferences for hospice were more likely than others to report discussing hospice with their patients earlier. Physicians should consider their personal preferences for hospice as a factor as they care for terminally ill patients with cancer. Physicians with negative views of hospice may consider pursuing additional education about how hospice may help their patients.
80
60
40
20
0 0
Additional Contributions: Robert Fletcher, MD, MSc, Harvard Medical School, provided helpful comments on an earlier version of the manuscript. Correction: This article was corrected on January 8, 2014, to fix the value of the number of respondents reported in the Methods section. 468
1-2
3-4
PTSD Symptom Score
Nonadherence was defined as taking less than 80% of the antihypertensive regimen. Error bars represent 95% CIs.
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in 5.6% and 0.36%, respectively, only marginally less than the prevalence in those with symptomatic GERD.7 The difficulty in identifying the right patients with GERD to endoscope is demonstrated in the study by Kramer et al,8 published in this issue. In an impressive audit of nearly 500 000 cases of GERD identified in Veteran Health Administration records, the authors found that those patients more likely to receive an EGD in the first year after diagnosis were actually less likely to have either BE or esophageal cancer.8 Men older than 65 years, for example, were nearly 7-fold more likely to have BE or esophageal cancer compared with a cohort of women younger than 50 years as the reference group, but these men were also significantly less likely to undergo EGD (odds ratio, 0.77).8 We still miss most patients with BE despite the widespread use of EGD; up to 95% of cases of adenocarcinoma occur in the setting of no prior diagnosis of BE.9 The data from Kramer et al8 suggest that this may in part be due to underutilization of EGD in high-risk cases. On the other hand, the mortality of symptomatic reflux is not increased over the background population,10 and there is still no convincing evidence that endoscopic screening of symptomatic GERD will reduce esophageal adenocarcinoma rates (stopping smoking and losing weight would probably be more valuable).3 Until noninvasive biomarkers to identify BE are available, judicious application of EGD to those with alarm signals or other high-risk cases (eg, those with chronic heartburn, who are older white men, or those with chronic reflux who are obese) seems reasonable but is unlikely to save many lives. Nicholas J. Talley, MD, PhD, FRACP Kate E. Napthali, FRACP Author Affiliations: University of Newcastle, Newcastle, New South Wales, Australia (Talley); John Hunter Hospital, Newcastle, New South Wales, Australia (Napthali); Mayo Clinic, Rochester, Minnesota (Talley). Corresponding Author: Nicholas J. Talley, MD, PhD, FRACP, University of Newcastle, Callaghan, NSW 2308, Australia ([email protected]). Published Online: January 27, 2014. doi:10.1001/jamainternmed.2013.12992. Conflict of Interest Disclosures: None reported. 1. Evans JA, Early DS, Fukami N, et al; ASGE Standards of Practice Committee; Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. The role of endoscopy in Barrett’s esophagus and other premalignant conditions of the esophagus. Gastrointest Endosc. 2012;76(6):1087-1094. 2. Solaymani-Dodaran M, Logan RF, West J, Card T, Coupland C. Risk of oesophageal cancer in Barrett’s oesophagus and gastro-oesophageal reflux. Gut. 2004;53(8):1070-1074. 3. Kahrilas PJ, Shaheen NJ, Vaezi MF; American Gastroenterological Association Institute; Clinical Practice and Quality Management Committee. American Gastroenterological Association Institute technical review on the management of gastroesophageal reflux disease. Gastroenterology. 2008;135(4):1392-1413. 4. Shaheen NJ, Weinberg DS, Denberg TD, Chou R, Qaseem A, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Upper endoscopy for gastroesophageal reflux disease: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med. 2012;157(11):808-816. 5. Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308-328. 466
6. Vakil N, Moayyedi P, Fennerty MB, Talley NJ. Limited value of alarm features in the diagnosis of upper gastrointestinal malignancy: systematic review and meta-analysis. Gastroenterology. 2006;131(2):390-401. 7. Rex DK, Cummings OW, Shaw M, et al. Screening for Barrett’s esophagus in colonoscopy patients with and without heartburn. Gastroenterology. 2003;125(6):1670-1677. 8. Kramer JR, Shakhatreh MH, Naik AD, Duan Z, El-Serag HB. Use and yield of endoscopy in patients with uncomplicated gastroesophageal reflux disorder [published online January 27, 2014]. JAMA Intern Med. doi:10.1001/ jamainternmed.2013.12756. 9. Dulai GS, Guha S, Kahn KL, Gornbein J, Weinstein WM. Preoperative prevalence of Barrett’s esophagus in esophageal adenocarcinoma: a systematic review. Gastroenterology. 2002;122(1):26-33. 10. Chang JY, Locke GR III, McNally MA, et al. Impact of functional gastrointestinal disorders on survival in the community. Am J Gastroenterol. 2010;105(4):822-832.
Physicians’ Preferences for Hospice if They Were Terminally Ill and the Timing of Hospice Discussions With Their Patients Physicians often delay hospice discussions with their terminally ill patients despite guidelines recommending such discussions for patients expected to die within 1 year,1,2 but reasons for this are not well understood. Evidence suggests that physicians “practice what they preach” when counseling about health behaviors,3 although their treatment recommendations may not necessarily reflect their own preferences, with one study suggesting they recommend more conservative treatments than they might choose for themselves.4 As physicians may prefer less aggressive endof-life care than their patients generally receive,5 physicians’ personal preferences for hospice may influence their approach to hospice discussions with their terminally ill patients. We examined physicians’ reported preferences for hospice enrollment if they were terminally ill. We also assessed whether physicians who would enroll in hospice if terminally ill differed from others in the timing of hospice discussions with their patients. Methods | This study was approved by the institutional review boards at all participating institutions. We surveyed physicians caring for patients with cancer enrolled in the multiregional population-based Cancer Care Outcomes Research and Surveillance (CanCORS) study.1 Informed consent was implied by physicians’ participation in the survey. Physicians indicated on a 5-point Likert scale how strongly they agreed or disagreed with the statement “If I were terminally ill with cancer, I would enroll in hospice.” They were also asked to assume that they were caring for an asymptomatic patient with advanced cancer, who they believed had 4 to 6 months to live and report whether they would discuss hospice with the patient “now,” “when the patient first develops symptoms,” “when there are no more nonpalliative treatments to offer,” “only if the patient is admitted to the hospital,” or “only if the patient and/or family bring it up.”1 Among 4488 respondents (response rate 61%), we excluded 105 who did not answer the hospice self-preference
JAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Monash University Library User on 11/24/2015
jamainternalmedicine.com
Letters
Table. Physician Willingness to Enroll in Hospice: Personal and Practice Characteristicsa
Physician Characteristics
Total, No. (%)
Unadjusted Proportion Who Strongly Agree They Would Enroll in Hospice if Terminally Ill With Cancer, %
Total
4368 (100)
64.5
Strongly Agreeing They Would Enroll in Hospice, Adjusted OR (95% CI)b
Age, y ≤39
959 (22)
65.4
1 [Reference]
40-49
1264 (29)
65.5
1.08 (0.89-1.31)
50-54
767 (18)
67.1
1.18 (0.95-1.47)
55-59
702 (16)
65.4
1.20 (0.96-1.50)
≥60
676 (15)
57.7
1.00 (0.79-1.25)
3453 (80)
61.9
1 [Reference]
837 (20)
76.1
1.80 (1.49-2.18)
Sex
Abbreviation: OR, odds ratio.
Male Female
a
Percentages include only reported, nonimputed values and may not sum to 100% because of rounding or missing values. Missing values were present for the following variables: sex (n = 78), specialty (n = 77), proportion of patients in managed care (n = 374), and number of terminally ill patients cared for in the past year (n = 62). Adjusted analyses used imputed data.
b
Adjusting for all variables in the table, as well as type of practice. Board certification, US medical school graduate status, and level of teaching involvement were not associated in adjusted analyses and were not included in the model.
Specialty Primary care physician
1743 (41)
69.5
1 [Reference]
Surgery
923 (22)
56.6
0.65 (0.55-0.78)
Medical oncology
600 (14)
70.3
0.93 (0.74-1.17)
Radiation oncology
257 (6)
57.6
0.57 (0.42-0.76)
Other specialty
768 (18)
61.2
0.75 (0.62-0.90)
≤50
2330 (58)
60.8
1 [Reference]
≥51
1664 (42)
69.8
1.30 (1.12-1.51)
≤12
2308 (54)
62.5
1 [Reference]
≥13
1998 (46)
67.1
1.29 (1.12-1.50)
Patients in managed care, %
No. of terminally-ill patients in the last year
Figure. Physician Willingness to Enroll in Hospice and Report of Early Hospice Discussions With Terminally Ill Patients With Cancer
Adjusted Proportion Who Would Discuss Hospice “Now,” %
35 30 25 20 15 10 5 0
Strongly agree
Other responses
Personal Preferences for Hospice Enrollment if Terminally Ill
question and 15 likely trainees who graduated after 2004. Multiple imputation was used to address item nonresponse in the adjusted analyses.6 We used multivariable logistic regression to examine physician and practice factors associated with physicians’ strong agreement that they would enroll in hospice if terminally ill with cancer. In a second model, we assessed if physicians who strongly agreed they would enroll in hospice were more likely than other physicians to report discussing jamainternalmedicine.com
hospice “now” with their terminally ill patients. We omitted variables with adjusted P values >.10. Results | Respondents’ characteristics are given in the Table. Most respondents strongly (64.5%) or somewhat (21.4%) agreed they would enroll in hospice if terminally ill. In adjusted analyses, physicians who were female, cared for more terminally ill patients, and worked in managed-care settings were more likely than others to strongly agree they would enroll in hospice. Surgeons and radiation oncologists were less likely than primary care physicians to strongly agree they would enroll in hospice. Overall, 26.5% reported they would discuss hospice “now” with a patient who had 4 to 6 months to live. Other physicians reported they would wait until the patient has symptoms (16.4%), there were no more treatments to offer (48.7%), the patient and/or family brings it up (4.3%), or the patient is hospitalized (4.1%). After adjustment, physicians who strongly agreed they would enroll in hospice themselves were more likely than other physicians to report discussing hospice “now” (odds ratio, 1.7; 95% CI, 1.5-2.0) (Figure). Discussion | Most physicians reported they would enroll in hospice if they were terminally ill with cancer, particularly women, primary care physicians, and those in managed-care settings and with more terminally ill patients. Physicians with strong JAMA Internal Medicine March 2014 Volume 174, Number 3
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a Monash University Library User on 11/24/2015
467
Letters
Garrett M. Chinn, MD, MS Pang-Hsiang Liu, MD, PhD Carrie N. Klabunde, PhD, MHS, MBA Katherine L. Kahn, MD Nancy L. Keating, MD, MPH Author Affiliations: Division of General Medicine, Department of Medicine, Massachusetts General Hospital, and Harvard Medical School, Boston (Chinn); Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts (Liu, Keating); Division of Cancer Control and Population Sciences, National Cancer Institute, Bethesda, Maryland (Klabunde); RAND, Santa Monica, California (Kahn); Division of General Internal Medicine, Department of Medicine, David Geffen School of Medicine, Los Angeles, California (Kahn); Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts (Keating). Corresponding Author: Nancy L. Keating, MD, MPH, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115-5899 ([email protected]). Published Online: December 16, 2013. doi:10.1001/jamainternmed.2013.12825. Author Contributions: Drs Liu and Keating had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Chinn, Liu, Keating. Acquisition of data: Klabunde, Kahn, Keating. Analysis and interpretation of data: Chinn, Liu, Klabunde, Kahn, Keating. Drafting of the manuscript: Chinn, Liu, Keating. Critical revision of the manuscript for important intellectual content: Chinn, Liu, Klabunde, Kahn, Keating. Statistical analysis: Chinn, Liu, Keating. Obtained funding: Kahn, Keating. Administrative, technical, or material support: Klabunde. Study supervision: Kahn, Keating. Conflict of Interest Disclosures: None reported. Funding/Support: This work of the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium was supported by grants from the National Cancer Institute (NCI) to the Statistical Coordinating Center (U01 CA093344) and the NCI-supported Primary Data Collection and Research Centers (Dana Farber Cancer Institute/Cancer Research Network [U01 CA093332], Harvard Medical School/Northern California Cancer Center [U01 CA093324], RAND/UCLA [U01 CA093348], University of Alabama at Birmingham [U01 CA093329], University of Iowa [U01 CA093339], University of North Carolina [U01 CA093326]) and by a Department of Veterans Affairs grant to the Durham VA Medical Center [CRS 02-164]. Dr Keating’s effort was also funded by grant 1R01CA164021-01A1 from the NCI. Role of the Sponsors: Dr Klabunde is an employee of the NCI. Aside from her contributions, the funding agencies had no role in design and conduct of the study; in the collection, analysis, and interpretation of the data; or in the preparation, review, or approval of the manuscript Previous Presentation: Portions of this work were presented in abstract form at the Society of General Internal Medicine’s 36th Annual Meeting; April 25, 2013; Denver, Colorado.
1. Keating NL, Landrum MB, Rogers SO Jr, et al. Physician factors associated with discussions about end-of-life care. Cancer. 2010;116(4):998-1006. 2. National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: palliative care: version 1. 2013. http://www.nccn.org/professionals /physician_gls/pdf/palliative.pdf. Accessed May 21, 2013. 3. Wells KB, Lewis CE, Leake B, Ware JE Jr. Do physicians preach what they practice? A study of physicians’ health habits and counseling practices. JAMA. 1984;252(20):2846-2848. 4. Ubel PA, Angott AM, Zikmund-Fisher BJ. Physicians recommend different treatments for patients than they would choose for themselves. Arch Intern Med. 2011;171(7):630-634. 5. Gramelspacher GP, Zhou X-H, Hanna MP, Tierney WM. Preferences of physicians and their patients for end-of-life care. J Gen Intern Med. 1997;12(6):346-351. 6. He Y, Zaslavsky AM, Landrum MB, Harrington DP, Catalano P. Multiple imputation in a large-scale complex survey: a practical guide. Stat Methods Med Res. 2010;19(6):653-670.
Posttraumatic Stress Disorder and Medication Nonadherence in Patients With Uncontrolled Hypertension Posttraumatic stress disorder (PTSD) is common in primary care patients1 and is associated with psychological distress, suicide risk, and disability. Posttraumatic stress disorder also increases risk of incident and recurrent cardiovascular events,2 possibly by reducing medication adherence.3 Prior studies showing an association between PTSD and medication nonadherence3 are limited by their use of self-report to measure adherence as PTSD can bias reporting of negative behaviors.4 We evaluated the association between PTSD and antihypertensive medication adherence using electronic monitoring in primary care patients with uncontrolled hypertension. Methods | The institutional review board of Columbia University Medical Center, New York, New York, approved the protocol. All patients provided written informed consent. We enrolled a convenience sample of patients with uncontrolled hypertension from an academic hospital-based primary care Figure. Posttraumatic Stress Disorder (PTSD) Symptoms and Nonadherence to Antihypertensive Medications 100
% of Nonadherence to Blood Pressure Medication
personal preferences for hospice were more likely than others to report discussing hospice with their patients earlier. Physicians should consider their personal preferences for hospice as a factor as they care for terminally ill patients with cancer. Physicians with negative views of hospice may consider pursuing additional education about how hospice may help their patients.
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Additional Contributions: Robert Fletcher, MD, MSc, Harvard Medical School, provided helpful comments on an earlier version of the manuscript. Correction: This article was corrected on January 8, 2014, to fix the value of the number of respondents reported in the Methods section. 468
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PTSD Symptom Score
Nonadherence was defined as taking less than 80% of the antihypertensive regimen. Error bars represent 95% CIs.
JAMA Internal Medicine March 2014 Volume 174, Number 3
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