Publications

Importance

The Second Universal Definition of Myocardial Infarction (MI) divides MIs into different types. Type 1 MIs result spontaneously from instability of atherosclerotic plaque, whereas type 2 MIs occur in the setting of a mismatch between oxygen demand and supply, as with severe hypotension. Type 2 MIs are uncommon in the general population, but their frequency in human immunodeficiency virus (HIV)-infected individuals is unknown.

Objectives

To characterize MIs, including type; identify causes of type 2 MIs; and compare demographic and clinical characteristics among HIV-infected individuals with type 1 vs type 2 MIs.

Design, Setting, and Participants

This longitudinal study identified potential MIs among patients with HIV receiving clinical care at 6 US sites from January 1, 1996, to March 1, 2014, using diagnoses and cardiac biomarkers recorded in the centralized data repository. Sites assembled deidentified packets, including physician notes and electrocardiograms, procedures, and clinical laboratory tests. Two physician experts adjudicated each event, categorizing each definite or probable MI as type 1 or type 2 and identifying the causes of type 2 MI.

Main Outcomes and Measures

The number and proportion of type 1 vs type 2 MIs, demographic and clinical characteristics among those with type 1 vs type 2 MIs, and the causes of type 2 MIs.

Results

Among 571 patients (median age, 49 years [interquartile range, 43-55 years]; 430 men and 141 women) with definite or probable MIs, 288 MIs (50.4%) were type 2 and 283 (49.6%) were type 1. In analyses of type 1 MIs, 79 patients who underwent cardiac interventions, such as coronary artery bypass graft surgery, were also included, totaling 362 patients. Sepsis or bacteremia (100 [34.7%]) and recent use of cocaine or other illicit drugs (39 [13.5%]) were the most common causes of type 2 MIs. A higher proportion of patients with type 2 MIs were younger than 40 years (47 of 288 [16.3%] vs 32 of 362 [8.8%]) and had lower current CD4 cell counts (median, 230 vs 383 cells/µL), lipid levels (mean [SD] total cholesterol level, 167 [63] vs 190 [54] mg/dL, and mean (SD) Framingham risk scores (8% [7%] vs 10% [8%]) than those with type 1 MIs or who underwent cardiac interventions.

Conclusions and Relevance

Approximately half of all MIs among HIV-infected individuals were type 2 MIs caused by heterogeneous clinical conditions, including sepsis or bacteremia and recent use of cocaine or other illicit drugs. Demographic characteristics and cardiovascular risk factors among those with type 1 and type 2 MIs differed, suggesting the need to specifically consider type among HIV-infected individuals to further understand MI outcomes and to guide prevention and treatment.

The number of older prisoners is increasing exponentially. For example, the number of geriatric female prisoners in California has increased 350% in the past decade. Despite an increasing population of geriatric female prisoners, the degree of functional impairment in this population is unknown. Therefore, the goals of this study were to describe the prevalence and nature of functional impairment in geriatric female prisoners in California and to identify aspects of the prison environment that may exacerbate functional impairments. Questionnaires were analyzed from 120 geriatric women in California state prisons. Functional impairment was defined as impairment in activities of daily living (ADLs) or in prison ADLs (PADLs), including dropping to the floor for alarms, standing for count, getting to meals, hearing orders, and climbing onto the top bunk. The mean age of participants was 62; 16% were dependent in one ADL, and 69% reported one PADL impairment. Increasing severity of functional impairment was associated with worse health status and more adverse prison experiences. For example, fall rates ranged from 33% in women without impairment to 57% with PADL impairment to 63% with ADL dependence (P=.02). Several prison environmental stressors were identified that likely exacerbate functional impairment. For example, 29% of geriatric women were assigned to a top bunk. Geriatric female prisoners report high rates of functional impairment. ADL and PADL impairment were associated with worse health status and adverse prison experiences. Therefore, the evaluation of functional impairment in geriatric female prisoners needs to consider the unique demands of the prison environment.

BACKGROUND

Little is known about patient characteristics associated with comprehension of consent information, and whether modifications to the consent process can promote understanding.

OBJECTIVE

To describe a modified research consent process, and determine whether literacy and demographic characteristics are associated with understanding consent information.

DESIGN

Descriptive study of a modified consent process: consent form (written at a sixth-grade level) read to participants, combined with 7 comprehension questions and targeted education, repeated until comprehension achieved (teach-to-goal).

PARTICIPANTS

Two hundred and four ethnically diverse subjects, aged > or = 50, consenting for a trial to improve the forms used for advance directives.

MEASUREMENTS

Number of passes through the consent process required to achieve complete comprehension. Literacy assessed in English and Spanish with the Short Form Test of Functional Health Literacy in Adults (scores 0 to 36).

RESULTS

Participants had a mean age of 61 years and 40% had limited literacy (s-TOHFLA<23). Only 28% of subjects answered all comprehension questions correctly on the first pass. After adjustment, lower literacy (P=.04) and being black (P=.03) were associated with requiring more passes through the consent process. Not speaking English as a primary language was associated with requiring more passes through the consent process in bivariate analyses (P<.01), but not in multivariable analyses (P>.05). After the second pass, most subjects (80%) answered all questions correctly. With a teach-to-goal strategy, 98% of participants who engaged in the consent process achieved complete comprehension.

CONCLUSIONS

Lower literacy and minority status are important determinants of understanding consent information. Using a modified consent process, little additional education was required to achieve complete comprehension, regardless of literacy or language barriers.

OBJECTIVE

To determine whether an advance directive redesigned to meet most adults' literacy needs (fifth grade reading level with graphics) was more useful for advance care planning than a standard form (>12th grade level).

METHODS

We enrolled 205 English and Spanish-speaking patients, aged >/=50 years from an urban, general medicine clinic. We randomized participants to review either form. Main outcomes included acceptability and usefulness in advance care planning. Participants then reviewed the alternate form; we assessed form preference and six-month completion rates.

RESULTS

Forty percent of enrolled participants had limited literacy. Compared to the standard form, the redesigned form was rated higher for acceptability and usefulness in care planning, P

CONCLUSIONS

The redesigned advance directive was rated more acceptable and useful for advance care planning and was preferred over a standard form. It also resulted in higher six-month completion rates.

PRACTICE IMPLICATIONS

An advance directive redesigned to meet most adults' literacy needs may better enable patients to engage in advance care planning.

BACKGROUND

Wealthy women have higher rates of screening mammography than poor women do. Screening mammography is beneficial for women with substantial life expectancies, but women with limited life expectancies are unlikely to benefit. It is unknown whether higher screening rates in wealthy women are due to increased screening in women with substantial life expectancies, limited life expectancies, or both. This study examines the relationship between wealth and screening mammography use in older women according to life expectancy.

METHODS

A cohort study was performed of 4222 women 65 years or older with Medicare participating in the 2002 and 2004 Health and Retirement Survey. Women were categorized according to wealth and life expectancy (based on 5-year prognosis from a validated prognostic index). The outcome was self-reported receipt of screening mammography within 2 years.

RESULTS

Overall, within 2 years, 68% of women (2871 of 4222) received a screening mammogram. Screening was associated with wealth (net worth, > $100 000) and good prognosis (< or = 10% probability of dying in 5 years). Screening mammography was more common among wealthy women than among poor women (net worth, < $10 000) both for women with good prognosis (82% vs 68%; P < .001) and for women with limited prognoses (> or = 50% probability of dying in 5 years) (48% vs 32%; P = .02). These associations remained after multivariate analysis accounting for age, race, education, proxy report, and rural residence.

CONCLUSIONS

Poorer older women with favorable prognoses are at risk of not receiving screening mammography when they are likely to benefit. Wealthier older women with limited prognoses are often screened when they are unlikely to benefit.

OBJECTIVES

To assess engagement in multiple steps of the advance care planning (ACP) process 6 months after exposure to an advance directive. In this study, ACP is conceptualized similarly to the behavior change model.

DESIGN

Descriptive study.

SETTINGS

County general medicine clinic in San Francisco.

PARTICIPANTS

One hundred seventy-three English or Spanish speakers, aged 50 and older (mean 61) given a standard (12th-grade reading level) and an easy-to-read (5th-grade reading level) advance directive.

MEASUREMENTS

Six months after exposure to two advance directives, self-reported ACP contemplation; discussions with family, friends discussions with clinicians; and documentation were measured. Associations were examined between ACP steps and between subject characteristics ACP engagement.

RESULTS

Most participants (73%) were nonwhite and 31% had less than a high school education. Sixty-one percent contemplated ACP, 56% discussed ACP with family or friends, 22% discussed ACP with clinicians, and 13% documented ACP wishes. Subjects who had discussed ACP with their family or friends were more likely to discuss ACP with their clinicians (36% vs 2%, P<.001) and document ACP wishes (18% vs 4%, P=.009) than those who had not. Latinos and subjects with less than a high school education discussed ACP more often with family or friends (P<.06) and clinicians (P<.03) than other ethnic groups and subjects with more education.

CONCLUSIONS

ACP involves distinct steps including contemplation, discussions, and documentation. The ACP paradigm should be broadened to include contemplation and discussions. Promoting discussions with family and friends may be one of the most important targets for ACP interventions, and literacy- and language-appropriate advance directives may help reverse patterns of sociodemographic disparities in ACP.

OBJECTIVES

To explore barriers to multiple advance care planning (ACP) steps and identify common barrier themes that impede older adults from engaging in the process as a whole.

DESIGN

Descriptive study.

SETTING

General medicine clinic. San Francisco County.

PARTICIPANTS

One hundred forty-three English and Spanish speakers aged 50 and older (mean 61) enrolled in an advance directive preference study.

MEASUREMENT

Six months after reviewing two advance directives, self-reported ACP engagement and barriers to each ACP step were measured with open- and closedended questions using quantitative and qualitative (thematic content) analyses.

RESULTS

Forty percent of participants did not contemplate ACP, 46% did not discuss with family or friends, 80% did not discuss with their doctor, and 90% did not document ACP wishes. Six barrier themes emerged: perceiving ACP as irrelevant (84%), personal barriers (53%), relationship concerns (46%), information needs (36%), health encounter time constraints (29%), and problems with advance directives (29%). Some barriers were endorsed at all steps (e.g., perceiving ACP as irrelevant). Others were endorsed at individual steps (e.g., relationship concerns for family or friend discussions, time constraints for doctor discussion, and problems with advance directives for documentation).

DISCUSSION

Perceiving ACP to be irrelevant was the barrier theme most often endorsed at every ACP step. Other barriers were endorsed at specific steps. Understanding ACP barriers may help clinicians prioritize and address them and may also provide a framework for tailoring interventions to improve ACP engagement.

OBJECTIVES

To determine whether the survival benefit associated with moderate alcohol use remains after accounting for nontraditional risk factors such as socioeconomic status (SES) and functional limitations.

DESIGN

Prospective cohort.

SETTING

The Health and Retirement Study (HRS), a nationally representative study of U.S. adults aged 55 and older.

PARTICIPANTS

Twelve thousand five hundred nineteen participants were enrolled in the 2002 wave of the HRS.

MEASUREMENTS

Participants were asked about their alcohol use, functional limitations (activities of daily living, instrumental activities of daily living, and mobility), SES (education, income, and wealth), psychosocial factors (depressive symptoms, social support, and the importance of religion), age, sex, race and ethnicity, smoking, obesity, and comorbidities. Death by December 31, 2006, was the outcome measure.

RESULTS

Moderate drinkers (1 drink/d) had a markedly more-favorable risk factor profile, with higher SES and fewer functional limitations. After adjusting for demographic factors, moderate drinking (vs no drinking) was strongly associated with less mortality (odds ratio (OR)=0.50, 95% confidence interval (CI)=0.40-0.62). When traditional risk factors (smoking, obesity, and comorbidities) were also adjusted for, the protective effect was slightly attenuated (OR=0.57, 95% CI=0.46-0.72). When all risk factors including functional status and SES were adjusted for, the protective effect was markedly attenuated but still statistically significant (OR=0.72, 95% CI=0.57-0.91).

CONCLUSION

Moderate drinkers have better risk factor profiles than nondrinkers, including higher SES and fewer functional limitations. Although these factors explain much of the survival advantage associated with moderate alcohol use, moderate drinkers maintain their survival advantage even after adjustment for these factors.

OBJECTIVE

To examine whether the effect of health literacy (HL) on patient-physician communication varies with patient-physician language concordance and communication type.

METHODS

771 outpatients rated three types of patient-physician communication: receptive communication (physician to patient); proactive communication (patient to physician); and interactive, bidirectional communication. We assessed HL and language categories including: English-speakers, Spanish-speakers with Spanish-speaking physicians (Spanish-concordant), and Spanish-speakers without Spanish-speaking physicians (Spanish-discordant).

RESULTS

Overall, the mean age of participants was 56 years, 58% were women, 53% were English-speakers, 23% Spanish-concordant, 24% Spanish-discordant, and 51% had limited HL. Thirty percent reported poor receptive, 28% poor proactive, and 56% poor interactive communication. In multivariable analyses, limited HL was associated with poor receptive and proactive communication. Spanish-concordance and discordance was associated with poor interactive communication. In stratified analyses, among English-speakers, limited HL was associated with poor receptive and proactive, but not interactive communication. Among Spanish-concordant participants, limited HL was associated with poor proactive and interactive, but not receptive communication. Spanish-discordant participants reported the worst communication for all types, independent of HL.

CONCLUSION

Limited health literacy impedes patient-physician communication, but its effects vary with language concordance and communication type. For language discordant dyads, language barriers may supersede limited HL in impeding interactive communication.

PRACTICE IMPLICATIONS

Patient-physician communication interventions for diverse populations need to consider HL, language concordance, and communication type.

BACKGROUND

Advance directive law may compromise the clinical effectiveness of advance directives.

PURPOSE

To identify unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences.

DATA SOURCES

Advance directive legal statutes for all 50 U.S. states and the District of Columbia and English-language searches of LexisNexis, Westlaw, and MEDLINE from 1966 to August 2010.

STUDY SELECTION

Two independent reviewers selected 51 advance directive statutes and 20 articles. Three independent legal reviewers selected 105 legal proceedings.

DATA EXTRACTION

Two reviewers independently assessed data sources and used critical content analysis to determine legal barriers to the clinical effectiveness of advance directives. Disagreements were resolved by consensus.

DATA SYNTHESIS

Legal and content-related barriers included poor readability (that is, laws in all states were written above a 12th-grade reading level), health care agent or surrogate restrictions (for example, 40 states did not include same-sex or domestic partners as default surrogates), and execution requirements needed to make forms legally valid (for example, 35 states did not allow oral advance directives, and 48 states required witness signatures, a notary public, or both). Vulnerable populations most likely to be affected by these barriers included patients with limited literacy, limited English proficiency, or both who cannot read or execute advance directives; same-sex or domestic partners who may be without legally valid and trusted surrogates; and unbefriended, institutionalized, or homeless patients who may be without witnesses and suitable surrogates.

LIMITATION

Only appellate-level legal cases were available, which may have excluded relevant cases.

CONCLUSION

Unintended negative consequences of advance directive legal restrictions may prevent all patients, and particularly vulnerable patients, from making and communicating their end-of-life wishes and having them honored. These restrictions have rendered advance directives less clinically useful. Recommendations include improving readability, allowing oral advance directives, and eliminating witness or notary requirements.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs and the Pfizer Foundation.