By Joshua Smith, MD
Faculty Peer Reviewed
As I am sure many of my fellow interns can attest, choosing to begin one’s year on the wards and as a night float at Bellevue Hospital has resulted in two predictable outcomes: an unbelievable appreciation for free time and an utter lack of knowledge regarding anything occurring outside the 10 block radius of NYU’s three hospitals. Therefore, it is with great enthusiasm that, thanks to an elective block, I have once again been able to open my mind to the rest of New York City and the world at large.
In world news, the devastating floods in Pakistan have now left an estimated 4.6 million people homeless and have claimed the lives of as many as 1600. Despite the US pledging 60 million dollars in aid, Pakistan continues to struggle due to the lack of additional monetary aid from around the world. Unfortunately , many countries are facing economic hardships of their own as a result of the seemingly endless stream of disasters that have occurred this year [1].
Closer to home, in a blow to civil rights activists in California on Monday, an order from the 9th Circuit Court of Appeals set aside a federal judge’s decision earlier this month that would have permitted same-sex marriages to resume in California as early as Wednesday [2]. It appears that the battle for civil rights in California and the country at large continues to take two steps forward and one step back.
In popular medical news this week, a massive egg recall began after cases of Salmonella were linked to consumption of eggs from a particular egg producer in Iowa. There have been no reported deaths but estimates for the number affected are now in the thousands [3].
Turning to the medical literature, several themes have emerged this week including end-of-life care, doctor-patient communication, as well as several new studies investigating renal transplantation.
Palliative Care
Major media outlets including the NY Times this week reported the results of a study on palliative care that was published in the New England Journal of Medicine [4][5]. This randomized, controlled study was performed on a group of individuals with newly diagnosed metastatic small-cell-lung cancer, a group that typically has a substantial symptom burden and in whom aggressive measures are often taken near the end of life. The participants in the study were randomly assigned to either early palliative care (as adapted from the National Consensus Project for Quality Palliative Care) along with standard oncologic therapy or to oncologic therapy alone. Quality of life and mood were assessed using the Functional Assessment of Cancer Therapy-Lung (FACT-L) and the Hospital Anxiety and Depression Scale, respectively, at the onset of therapy and again after 12 weeks. The primary outcome was change in quality of life at 12 weeks. The results of the study showed that patients assigned to early palliative care had a better quality of life than did patients assigned to standard care (FACT-L score of 98 vs. 91.5, p=0.03) and fewer patients in the palliative care group than in the standard group had depressive symptoms (16% vs. 38%, P=0.01). Furthermore, though patients in the early palliative care group received less aggressive end-of-life care, their median survival was significantly longer than in the group receiving standard care (11.6 months vs. 8.9 months, P=0.02). Though this study had several important limitations including the fact that it was performed at a single tertiary center with limited patient diversity and was not blinded, I think that the findings in this study are extremely important to take note of in our current medical culture where we pursue futile aggressive measures regardless of cost abd palliative care is not begun until the very end of life.
Doctor-Patient Communication
Two articles this week focused on the importance of communication between doctors and their patients and the outcome of that communication (or lack thereof).
The Archives of Internal Medicine reports the results of a study by Olsen, et al. aimed at identifying communication discrepancies between physicians and hospitalized patients [6]. The participants in the study included a wide variety of hospitalized patients and the house staff that cared for them. Patients were given two standardized questionnaires. The study produced some very interesting findings including a significant discrepancy between the percentage of patients who appropriately reported their diagnosis (43%), named the physician in charge of their care (18%), and were informed of side effects of new medications (10%) versus what the physician felt that they had communicated to the patient. Though this study is rife with limitations including being performed at a single institution with a limited amount of patient diversity, the results are striking. Physicians should be reminded of the rift that exists between what we perceive that our patients understand and what they actually understand about their conditions.
Though it is generally accepted that it is in our patients’ best interest that we disclose medical errors surrounding their care , the fear of legal repercussion has often stood in the way of this becoming a standard practice. Kachalia, et al looks at the question of these types of communications in the most recent Annals of Internal Medicine [7]. The study was designed to compare liability claims and costs before and after implementation of a disclosure-with-offer program. It was performed using data from the University of Michigan Health System (UMHS), a system which has fully disclosed and offered compensation to its patients for medical errors since 2001. The patients enrolled in the study were those inpatients and outpatients involved in claims made to UMHS. The results showed a significant decrease in new legal claims, number of lawsuits per month, time to claim resolution, and costs after implementation of the program of disclosure with offer of compensation. The results of this study should be analyzed with caution as malpractice claims declined throughout Michigan during the study period in general and UMHS’s unique approach to offering compensation may lead to lack of generalizability. However, despite these limitations, this study does suggest that a medical center can implement a disclosure-with-offer program without increasing its malpractice costs. As this is undoubtedly in our patients’ best interest, it would be a shame for other hospital systems to not follow suit.
Renal Transplantation
For reasons unbeknownst to this writer, renal transplantation was a hot topic in the medical literature this week…
Historically, the data regarding medical outcomes in living kidney donors has been obtained almost exclusively from white patient populations. To address this racial discrepancy, Lentine, et al. performed a study analyzing racial variation in medical outcomes among living kidney donors. The results were published in this week’s New England Journal of Medicine [8]. The individuals included in the study were chosen by linking identifiers from the Organ Procurement and Transplantation Network (OPTN) with administrative data of a private U.S. health insurer. This resulted in a database of 4650 individuals who were living kidney donors that had also been patients under the given health insurance. The data were then compared with prevalence patterns for the general population. The patient demographics in this study were much more diverse than in previous studies (76.3% white, 13.1% black, 8.2% Hispanic, and 2.4% another race or ethnic group). The results showed that black and Hispanic donors had a significantly increased risk of hypertension, diabetes mellitus requiring drug therapy, and chronic kidney disease which could not be explained by socioeconomic factors. Most of these results were in line with the racial disparities seen in medical conditions in the general population and were not unique to living kidney donors. The limitations of this study including the limited available data and sampling approach using data from an insurance plan do decrease its applicability, however the results support long-standing data that indicate that non-white populations in the U.S. tend to suffer worse health outcomes in general and the living kidney donor population is no exception. Therefore, increased attention to health outcomes in these populations is warranted.
Also in renal transplant news, a cohort study by Summers, et al. published in The Lancet investigated factors that affect outcome after transplantation of kidneys donated after controlled cardiac death in the UK [9]. The study was undertaken due to the fact that 1/3 of all kidneys from deceased donors in the UK are donated after cardiac death, but concerns had been raised as to the outcome of such transplants as compared to donors who suffered brain death. The study included a large number of kidney transplants (9134), 8289 which were donated after brain death and 845 after controlled cardiac death. The results showed no significant difference in graft survival or eGFR up to 5 years after transplant in the two groups. The results from this well-designed, large, multi-center study indicate that kidneys from controlled cardiac-death donors demonstrate equivalent graft survival and function when compared with kidneys donated from brain-death donors for at least 5 years post-transplant.
To conclude our busy week in renal transplantation research, a study by Kainz, et al. published in The Annals of Internal Medicine looked into steroid pretreatment of organ donors to prevent post-ischemic renal allograft failure [10]. Post-transplantation acute renal failure (ARF) occurs in an estimated 25% of recipients of organs from deceased donors, and inflammation in the donor organ is associated with an increased risk for ARF. Therefore, this prospective, randomized controlled multi-center trial was designed to determine whether administering corticosteroids to donors reduces the incidence and duration of ARF in organ recipients. Incidence of ARF, defined as greater than 1 dialysis session in the first week after transplantation, was the primary end point. The results of the study showed no significant difference in incidence of ARF between the steroid-treated donors and the placebo-treated donors. Though the study may lack generalizability due to its mainly-white patient population and the limited geographic diversity of its centers, these findings suggest that pre-treatment of donors with steroids is not indicated in renal transplantation.
Dr. Smith is a first year resident at NYU Langone Medical Center
Peer reviewed by Neil Shapiro, MD, Editor-In-Chief, Clinical Correlations
Image of Bellevue Ambulatory Care Center courtesy of Wikimedia Commons
References:
[1] http://www.nytimes.com/2010/08/20/world/asia/20pstan.html?_r=1&ref=world
[2] http://www.cnn.com/2010/US/08/17/same.sex.marriage/index.html?npt=NP1
[3] http://www.nytimes.com/2010/08/19/business/19eggs.html?ref=health
[4] http://www.nytimes.com/2010/08/19/health/19care.html?ref=health
[5] Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non–small-cell lung cancer. N Engl J Med 2010;363:733-42. http://www.nejm.org/doi/full/10.1056/NEJMoa1000678
[6] Olson DP, Windish DM. Communication discrepancies between physicians and hospitalized patients. Arch Intern Med 2010;170(15):1302-1307. http://archinte.ama-assn.org/cgi/content/short/170/15/1302
[7] Kachalia AK, Kaufman SR, Boothman R, et al. Liability claims and costs before and after implementation of a medical error disclosure program. Ann Intern Med 2010;153(4):213-221. http://www.annals.org/content/153/4/213.abstract?aimhp
[8] Lentine KL, Schnitzler MA, Xiao H, et al. Racial variation in medical outcomes among living kidney donors. N Engl J Med 2010;363:724-732 http://www.nejm.org/doi/full/10.1056/NEJMoa1000950
[9] Summers DM, Johnson RJ, Allen J, et al. Analysis of factors that affect outcome after transplantation of kidneys donated after cardiac death in the UK. Lancet 2010, early online publication, doi:10.1016/S0140-6736(10)60827-6 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2810%2960827-6/abstract
[10] Kainz A, Wilflingseder J, Mitterbauer C, et al. Steroid pretreatment of organ donors to prevent postischemic renal allograft failure. Ann Intern Med 2010;153(4):222-230 http://www.annals.org/content/153/4/222.abstract