Accuracy of Predictions of Survival in Later Stages of Cancer

Though 83% of 168 cancer patients admitted for “terminal care” died within 12 weeks of admission predictions of the probable length of survival showed little relation to the actual length of survival. A total of 83% of all “errors” were in an “optimistic” direction, the patient being expected to survive longer than he actually did.No significant differences were found between the accuracy of predictions made at referral by general practitioners, by doctors at other hospitals, by hospice physicians on the day of admission, or by ward sisters and senior nurses at the same time. A week after admission predicted and actual survival correlated more closely but predictions were still optimistic.It is concluded that predictions of the length of time which a cancer patient who is at the end of active treatment can be expected to survive should be made and interpreted with the greatest caution.     

Care of the dying in general practice.

The hospice movement has improved the care for the dying patient. But can the hospice experience be easily applied to general practice? In one year in this practice 10 patients were terminally ill, and three of these died at home. The clinical problems encountered over four years are described to illustrate the factors that affect prescribing, which makes caring for a dying patient at home different from that in hospital or even in a hospice.     

Family physicians' attitudes toward advance directives.

OBJECTIVE: To examine the attitudes toward, the experience with and the knowledge of advance directives of family physicians in Ontario. DESIGN: Cross-sectional survey. PARTICIPANTS: A questionnaire was mailed to 1000 family physicians, representing a random sample of one-third of the active members of the Ontario College of Family Physicians; 643 (64%) responded. RESULTS: In all, 86% of the physicians favoured the use of advance directives, but only 19% had ever discussed them with more than 10 patients. Most of the physicians agreed with statements supporting the use of advance directives and disagreed with statements opposing their use. Of the respondents 80% reported that they had never used a directive in managing an incompetent patient. Of the physicians who responded that they had such experience, over half said that they had not always followed the directions contained in the directive. The proportions of physicians who responded that certain patient groups should be offered the opportunity to complete an advance directive were 96% for terminally ill patients, 95% for chronically ill patients, 85% for people with human immunodeficiency virus infection, 77% for people over 65 years of age, 43% for all adults, 40% for people admitted to hospital on an elective basis and 33% for people admitted on an emergency basis. The proportions of physicians who felt that the following strategies would encourage them to offer advance directives to their patients were 92% for public education, 90% for professional education, 89% for legislation protecting physicians against liability when following a directive, 80% for legislation supporting the use of directives, 79% for hospital policy supporting the use of directives, 73% for reimbursement for time spent discussing directives with patients and 64% for hospital policy requiring that all patients be routinely offered the opportunity to complete a directive at the time of admission. CONCLUSIONS: Family physicians favour advance directives but use them infrequently. Most physicians support offering them to terminally or chronically ill patients but not to all patients at the time of admission to hospital. Although governments emphasize legislation, most physicians believe that public and professional education programs would be at least as likely as legislation to encourage them to offer advance directives to their patients.     

Death certification in general practice: review of records.

The records of death that had been certified by general practitioners in one practice over 18 years were assessed in the light of the recent joint publications of the Royal College of Physicians and the Royal College of Pathologists. Over this period roughly 30% of the deaths in the practice population occurred outside hospital and a total of 262 certificates were issued. A review of 262 counterfoils of records of death certification showed that 12 counterfoils (4.6%) had no age and sex mentioned, and three counterfoils did not describe the place of death. The average age at death outside hospital was 71.6 years--the age of women being 75.1 years compared with that of men of 68.2 years. Only 2% of patients had had a necropsy. The common causes of death stated in the certificates were: cardiovascular 41%, carcinoma 35%, respiratory 15%, and stroke 8%. All contributory causes are also mentioned. Ninety seven per cent of the patients were seen after death by the doctors in the practice and 68% had been seen in the two days preceding death. We emphasise the importance of keeping accurate records of deaths in general practice for audit and research as well as for planning services for terminally ill and recently bereaved patients.     

Terminal cancer care and patients' preference for place of death: a prospective study.

OBJECTIVE--To assess the preference of terminally ill patients with cancer for their place of final care. DESIGN--Prospective study of randomly selected patients with cancer from hospital and the community who were expected to die within a year. Patients expected to live less than two months were interviewed at two week intervals; otherwise patients were interviewed monthly. Their main carer was interviewed three months after the patient''s death. SETTING--District general hospital, hospices, and patients'' homes. MAIN OUTCOME MEASURE--Stated preferred place of final care; actual place of death; reason for final hospital admission for those in hospital; community care provision required for home care. RESULTS--Of 98 patients approached, 84 (86%) agreed to be interviewed, of whom 70 (83%) died during the study and 59 (84%) stated a preferred place of final care: 34 (58%) wished to die at home given existing circumstances, 12 (20%) in hospital, 12 (20%) in a hospice, and one (2%) elsewhere. Their own home was the preferred place of care for 17 (94%) of the patients who died there, whereas of the 32 patients who died in hospital 22 (69%) had stated a preference to die elsewhere. Had circumstances been more favourable 67% (41) of patients would have preferred to die at home, 16% (10) in hospital, and 15% (9) in hospice. CONCLUSION--With a limited increase in community care 50% more patients with cancer could be supported to die at home, as they and their carers would prefer.     

Predicting 7-Day Survival Using Heart Rate Variability in Hospice Patients with Non-Lung Cancers

Background

A simple and accurate survival prediction tool can facilitate decision making processes for hospice patients with advanced cancers. The objectives of this study were to explore the association of cardiac autonomic functions and survival in patients with advanced cancer and to evaluate the prognostic value of heart rate variability (HRV) in 7-day survival prediction.

Methods

A prospective study was conducted on 138 patients with advanced cancer recruited from the hospice ward of a regional hospital in southern Taiwan. Information on functional status and symptom burden of the patients was recorded. Frequency-domain HRV was obtained for the evaluation of cardiac autonomic functions at admission. The end point of the study was defined as the survival status at day 7 after admission to the hospice ward. Multivariate logistic regression analyses were performed to evaluate the independent associations between HRV indices and survival of 7 days or less.

Results

The median survival time of the patients was 20 days (95% CI, 17–28 days). Results from the multivariate logistic regression analysis indicated that the natural logarithm-transformed high-frequency power (lnHFP) of a value less than 2 (OR = 3.8, p = 0.008) and ECOG performance status of 3 or 4 (OR = 3.4, p = 0.023) were significantly associated with a higher risk of survival of 7 days or less. Receiver operating characteristic (ROC) curve analysis revealed that the area under the curve was 0.71 (95% CI, 0.61–0.81).

Conclusions

In hospice patients with non-lung cancers, an lnHPF value below 2 at hospice admission was significantly associated with survival of 7 days or less. HRV might be used as a non-invasive and objective tool to facilitate medical decision making by improving the accuracy in survival prediction.     

Long-term prognosis of duodenal ulcer: follow-up study and survey of doctors' estimates.

In 1976 we reviewed a randomly selected cohort of 227 patients with duodenal ulcer first diagnosed in 1963. The cohort comprised cases diagnosed in both hospitals and general practice. Fifty patients had died, 12 had emigrated, and 154 (93%) of the remaining patients were interviewed. Fifty-seven medically treated patients had no symptoms, 44 had mild symptoms, and 19 had more severe symptoms. The remaining 34 patients had been treated surgically. Cases diagnosed in hospital had a more severe prognosis than those diagnosed in general practice. A random sample of 65 general practitioners and 78 medical and surgical gastroenterologists tried to predict the results of this study. The range of the predictions was very wide showing that individual prognostic estimates were highly unreliable. The mean prediction by all doctors differed little from the actual result, suggesting that the collective experience of the medical profession is more reliable. The predictions of general practitioners, physicians, and surgeons showed small systematic differences, presumably reflecting the different types of patients they treat.     

Effects of residency training in family medicine v. internship training on professional attitudes and practice patterns.

OBJECTIVES: To determine whether the professional attitudes and practice patterns of physicians with residency training in family medicine differ from those of generalists with internship training. DESIGN: Mail survey conducted in 1985-86. SETTING: Province of Quebec. PARTICIPANTS: A stratified random sample of French-speaking family and general practitioners who graduated after 1972 (325 physicians with residency training and 304 with internship training) (response rate 82%). MAIN RESULTS: Physicians with residency training were 3 years younger on average than those with internship training, were more likely to be female (38% v. 18%, p less than 0.001) and were more likely to work on a salaried basis in CLSCs (public community health centres) (36% v. 14%, p less than 0.001). Even after these confounding factors were controlled for, physicians with residency training seemed to be more sensitive to the psychosocial aspects of patient care and tended to attach more importance to informing patients about useful materials and resources concerning their health problems. They were not, however, more likely to value health counselling or integrate it in medical practice. CONCLUSION: Our findings provide some evidence that the new requirement that physicians complete a residency in family medicine to obtain medical licensure in general practice in Quebec may foster a more patient-centred approach to health care.     

Understanding of elderly patients' resuscitation preferences by physicians and nurses.

We compared the understanding by family physicians and nurses of their elderly outpatients'' preferences for cardiopulmonary resuscitation and mechanical ventilation under 3 scenarios reflecting varying qualities of life. Physicians and nurses correctly predicted patients'' treatment preferences in from 59% to 84% and 53% to 78% of cases, respectively, for the various decisions. For most decisions, neither physicians nor nurses were significantly more accurate in their predictions than expected by chance alone. Moreover, nurses and physicians did not significantly agree with one another in their predictions of patients'' preferences for any of these decisions. These results suggest that while nurses'' and physicians'' perceptions of patients'' preferences for life-sustaining treatment are not necessarily similar, neither nurses nor physicians systematically understand their elderly patients'' resuscitation preferences.     

Impact of physician BMI on obesity care and beliefs

Using a national cross-sectional survey of 500 primary care physicians conducted between 9 February and 1 March 2011, the objective of this study was to assess the impact of physician BMI on obesity care, physician self-efficacy, perceptions of role-modeling weight-related health behaviors, and perceptions of patient trust in weight loss advice. We found that physicians with normal BMI were more likely to engage their obese patients in weight loss discussions as compared to overweight/obese physicians (30% vs. 18%, P = 0.010). Physicians with normal BMI had greater confidence in their ability to provide diet (53% vs. 37%, P = 0.002) and exercise counseling (56% vs. 38%, P = 0.001) to their obese patients. A higher percentage of normal BMI physicians believed that overweight/obese patients would be less likely to trust weight loss advice from overweight/obese doctors (80% vs. 69%, P = 0.02). Physicians in the normal BMI category were more likely to believe that physicians should model healthy weight-related behaviors-maintaining a healthy weight (72% vs. 56%, P = 0.002) and exercising regularly (73% vs. 57%, P = 0.001). The probability of a physician recording an obesity diagnosis (93% vs. 7%, P < 0.001) or initiating a weight loss conversation (89% vs. 11%, P ≤ 0.001) with their obese patients was higher when the physicians' perception of the patients' body weight met or exceeded their own personal body weight. These results suggest that more normal weight physicians provided recommended obesity care to their patients and felt confident doing so.     

Nomograms-based prediction of overall and cancer-specific survivals for patients with chromophobe renal cell carcinoma

This study built and tested two effective nomograms for the purpose of predicting cancer-specific survival and overall survival of chromophobe renal cell carcinoma (chRCC) patients. Multivariate Cox regression analysis was employed to filter independent prognostic factors predictive of cancer-specific survival and overall survival, and the nomograms were built based on a training set incorporating 2901 chRCC patients in a retrospective study (from 2004 to 2015) downloaded from the surveillance, epidemiology, and end results (SEER) database. The nomograms were verified on a validation cohort of 1934 patients, subsequently the performances of the nomograms were examined according to the receiver operating characteristic curve, calibration curves, the concordance (C-index), and decision curve analysis. The results showed that tumor grade, AJCC and N stages, race, marital status, age, histories of chemotherapy, radiotherapy and surgery were the individual prognostic factors for overall survival, and that AJCC, N and SEER stages, histories of surgery, radiotherapy and chemotherapy, age, tumor grade were individual prognostic factors for cancer-specific survival. According to C-indexes, receiver operating characteristic curves, and decision curve analysis outcomes, the nomograms showed a higher accuracy in predicting overall survival and OSS when compared with TNM stage and SEER stage. All the calibration curves were significantly consistent between predictive and validation sets. In this study, the nomograms, which were validated to be highly accurate and applicable, were built to facilitate individualized predictions of the cancer-specific survival and overall survival to patients diagnosed with chRCC between 2004 and 2015.     

Global climate change and accuracy of prediction of species' geographical ranges: establishment success of introduced ladybirds (Coccinellidae, Chilocorus spp.) worldwide

AimPredictions of how the geographical ranges of species change implicitly assume that range can be determined without invoking climate change. The aim here was to determine how accurate predictions of range change might be before entertaining global climatic change. LocationWorldwide. MethodsAll the documented global biological control translocations of ladybirds (Coccinellidae: Chilocorus spp.) were analysed with the ecoclimatic program, CLIMEX. This program determines species distributions in relation to climate, and can be used to express the favourableness of different localities for a species. CLIMEX is also a useful exploratory tool for determining the likelihood of establishment of species introduced from one area to another. ResultsPredictive models were developed based on the likelihood of establishment of fifteen Chilocorus spp. relative to their physiological characteristics and climatic tolerances. This likelihood was compared with actual establishment with a resultant range of 0% accuracy to 100% accuracy. Only four (26.7%) species climatic tolerances could the predicted with 100% certainty. The general lack of accurate prediction was because climate is not always the overriding feature determining whether a species will establish or not. Other determinants, such as localized response to microclimate, phenology, host type and availability, presence of natural enemies and hibernation sites play a varying role over and above climate in determining whether a species will establish at a new locality. Main conclusionsThis study shows that even in the absence of climate change, range cannot always be determined, which means that most predictions of range change with climate change are likely to be wrong.     

A Flexible Alternative to the Cox Proportional Hazards Model for Assessing the Prognostic Accuracy of Hospice Patient Survival

Prognostic models are often used to estimate the length of patient survival. The Cox proportional hazards model has traditionally been applied to assess the accuracy of prognostic models. However, it may be suboptimal due to the inflexibility to model the baseline survival function and when the proportional hazards assumption is violated. The aim of this study was to use internal validation to compare the predictive power of a flexible Royston-Parmar family of survival functions with the Cox proportional hazards model. We applied the Palliative Performance Scale on a dataset of 590 hospice patients at the time of hospice admission. The retrospective data were obtained from the Lifepath Hospice and Palliative Care center in Hillsborough County, Florida, USA. The criteria used to evaluate and compare the models'' predictive performance were the explained variation statistic R², scaled Brier score, and the discrimination slope. The explained variation statistic demonstrated that overall the Royston-Parmar family of survival functions provided a better fit (R² = 0.298; 95% CI: 0.236–0.358) than the Cox model (R² = 0.156; 95% CI: 0.111–0.203). The scaled Brier scores and discrimination slopes were consistently higher under the Royston-Parmar model. Researchers involved in prognosticating patient survival are encouraged to consider the Royston-Parmar model as an alternative to Cox.     

Weight Loss and Gender: An Examination of Physician Attitudes

Objective: The purpose of this study was to investigate physician attitudes toward the treatment of overweight and obese individuals and to evaluate potential gender differences in treatment recommendations. Research Methods and Procedures: A survey describing several hypothetical patients was sent to 700 randomly selected physicians; 209 (29.9%) returned the survey. Two versions of the questionnaire (one for men and one for women) described three hypothetical patients at three levels of body mass index (BMI) (32, 28, and 25 kg/m²). One‐half of the physicians received a version of the questionnaire describing the patients as women, and one‐half received a version describing the patients as men. Respondents answered questions about attitudes toward treatment and specific interventions and referrals they would view as appropriate. Results: Physicians were more likely to encourage women with a BMI of 25 kg/m² to lose weight than men with the same BMI, and indicated that they would suggest more treatment referrals for women than men. Men with a BMI of 32 kg/m² were more likely to be encouraged to lose weight than women with the identical BMI. Physicians were more likely to encourage weight loss and see treatment referrals as appropriate for patients with higher BMIs. Discussion: This study indicates that physicians treat male and female patients differently, with physicians more likely to encourage weight loss and provide referrals for women with a BMI of 25 kg/m² than for men with an identical BMI and less likely to encourage weight loss for women than men with a BMI of 32 kg/m².     

Five-year results of the peer assessment program of the College of Physicians and Surgeons of Ontario.

The office practices of 918 physicians selected through stratified random sampling from the College of Physicians and Surgeons of Ontario (CPSO) registry were assessed by peers and the Peer Assessment Committee of the CPSO from 1981 to 1985. The sample comprised 662 general practitioners (GPs) and family physicians (FPs) and 256 specialists in 11 fields. Of the physicians 749 (82%) had neither deficient records nor an unsatisfactory level of patient care. Of the GPs and FPs 97 (15%) had serious deficiencies in one or both areas, as compared with 4 (2%) of the specialists (p2 less than 0.00001). The proportions of certificants of the Royal College of Physicians and Surgeons of Canada and of the College of Family Physicians of Canada (CFPC) with serious deficiencies were low (2% and 3% respectively). Three statistically significant predictors of physician performance were found among the GPs and FPs: age, CFPC membership status and type of practice. Of the 56 physicians who were reassessed 6 to 12 months later 29 (52%) had made the improvements recommended by the committee. Our findings demonstrate the need, feasibility and acceptance of a peer assessment program of office practices in Ontario.     

Physicians' beliefs and behaviour during a randomized controlled trial of episiotomy: consequences for women in their care.

OBJECTIVE: To evaluate whether physicians'' beliefs concerning episiotomy are related to their use of procedures and to differential outcomes in childbirth. DESIGN: Post-hoc cohort analysis of physicians and patients involved in a randomized controlled trial of episiotomy. SETTING: Two tertiary care hospitals and one community hospital in Montreal. PARTICIPANTS: Of the 703 women at low risk of medical or obstetric problems enrolled in the trial we studied 447 women (226 primiparous and 221 multiparous) attended by 43 physicians. Subjects attended by residents or nurses were excluded. MAIN OUTCOME MEASURES: Patients: intact perineum v. perineal trauma, length of labour, procedures used (instrumental delivery, oxytocin augmentation of labour, cesarean section and episiotomy), position for birth, rate of and reasons for not assigning women to a study arm, postpartum perineal pain and satisfaction with the birth experience, physicians: beliefs concerning episiotomy. RESULTS: Women attended by physicians who viewed episiotomy very unfavorably were more likely than women attended by the other physicians to have an intact perineum (23% v. 11% to 13%, p < 0.05) and to experience less perineal trauma. The first stage of labour was 2.3 to 3.5 hours shorter for women attended by physicians who viewed episiotomy favourably than for women attended by physicians who viewed episiotomy very unfavorably (p < 0.05 to < 0.01), and the former physicians were more likely to use oxytocin augmentation of labour. Physicians who viewed episiotomy more favourably failed more often than those who viewed the procedure very unfavourably to assign patients to a study arm late in labour (odds ratio [OR] 1.88, p < 0.05), both overall and because they felt that "fetal distress" or cesarean section necessitated exclusion of the subject. They used the lithotomy position for birth more often (OR 3.94 to 4.55, p < 0.001), had difficulty limiting episiotomy in the restricted-use arm of the trial and diagnosed fetal distress and perineal inadequacy more often than the comparison groups. The patients of physicians who viewed episiotomy very favourably experienced more perineal pain (p < 0.01), and of those who viewed episiotomy favourably and very favourably experienced less satisfaction with the birth experience (p < 0.01) than the patients of physicians who viewed the procedure very unfavourably. CONCLUSIONS: Physicians with favourably views of episiotomy were more likely to use techniques to expedite labour, and their patients were more likely to have perineal trauma and to be less satisfied with the birth experience. This evidence that physician beliefs can influence patient outcomes has both clinical and research implications.     

Management of Obesity in Primary Care

SIMKIN-SILVERMAN, LAUREY R, RENA R WING. Management of obesity in primary care. Obesity is one of the most common presenting chronic medical conditions in primary care, yet it is not adequately treated. Physicians are often reluctant to counsel patients because of their limited training in treating chronic weight problems and negative attitudes toward obese patients. This study evaluated the feasibility of training physicians to provide weight control counseling to their patients. Eleven physicians were randomly assigned to either an obesity-counseling skills training group or to a control group. Physicians in the counseling skills group received training in behavioral and motivational weight control techniques using a five-step patient-centered model; they were also given patient materials for use in their practice. To evaluate pretraining to posttraining changes in physician counseling behavior, independent samples of patients with obesity were surveyed immediately after their visit to the physician's office. Physicians in both the counseling skills training and the control groups discussed weight with 42% to 47% of their patients at baseline. This increased to 89% in physicians who received training, whereas it remained at 42% in control physicians. Scores on a counseling measure also significantly increased from a mean of 2. 7 to 9. 9 in the counseling group, whereas scores in the control group remained low and stable (2. 3 and 1. 9, respectively). The training program was effective in improving the frequency and quality of counseling that physicians delivered to their patients with obesity. Future research is needed to evaluate the effect of physician counseling on the weight and physical activity level of their patients.     

Effects of One-Hour Training Course and Spirometry on the Ability of Physicians to Diagnose and Treat Chronic Obstructive Pulmonary Disease

BackgroundsIn China, the prevalence of chronic obstructive pulmonary disease (COPD) in persons 40 years of age or older is estimated at 8.2%, but this is likely a substantial underestimate.MethodsEight secondary hospitals which didn’t have spirometries were chosen randomly in Hunan province of central south China. Physician subjects at these hospitals underwent a one-hour training course on the Chinese COPD guidelines. Physicians answered questionnaires assessing their knowledge of the guidelines before and after the training session. The mean correct scores of questionnaires were compared before and after training. Four out of the eight hospitals were given access to spirometry. Eligible patient subjects underwent spirometry testing prior to the physician visit. After seeing the patient, physicians were asked to answer a questionnaire relating to the diagnosis and severity of COPD. Physicians were then given the results of the spirometry, and asked to answer the same questionnaire. Physicians’ responses before and after receiving the spirometry results were compared.Results225 physicians participated in the training session. 207 questionnaires were completed. Mean scores (out of 100) before and after the training were 53.1 ± 21.7 and 93.3 ± 9.8, respectively. 18 physicians and 307 patient subjects participated in the spirometry intervention. Based on spirometric results, the prevalence of COPD was 38.8%. Physicians correctly identified the presence of COPD without spirometric data in 85 cases (76.6%); this increased to 117 cases (97.4%) once spirometric data were available. Without spirometric data, physicians incorrectly diagnosed COPD in 38 patients; this decreased to 6 patients once spirometric data were available. Spirometric data also improved the ability of physicians to correctly grade COPD severity.ConclusionsSimple educational training can substantially improve physicians’ knowledge relating to COPD. Spirometry combined with education improves the ability of physicians to diagnose COPD and to assess its severity.     

Assessing the Validity of Using Serious Game Technology to Analyze Physician Decision Making

Background

Physician non-compliance with clinical practice guidelines remains a critical barrier to high quality care. Serious games (using gaming technology for serious purposes) have emerged as a method of studying physician decision making. However, little is known about their validity.

Methods

We created a serious game and evaluated its construct validity. We used the decision context of trauma triage in the Emergency Department of non-trauma centers, given widely accepted guidelines that recommend the transfer of severely injured patients to trauma centers. We designed cases with the premise that the representativeness heuristic influences triage (i.e. physicians make transfer decisions based on archetypes of severely injured patients rather than guidelines). We randomized a convenience sample of emergency medicine physicians to a control or cognitive load arm, and compared performance (disposition decisions, number of orders entered, time spent per case). We hypothesized that cognitive load would increase the use of heuristics, increasing the transfer of representative cases and decreasing the transfer of non-representative cases.

Findings

We recruited 209 physicians, of whom 168 (79%) began and 142 (68%) completed the task. Physicians transferred 31% of severely injured patients during the game, consistent with rates of transfer for severely injured patients in practice. They entered the same average number of orders in both arms (control (C): 10.9 [SD 4.8] vs. cognitive load (CL):10.7 [SD 5.6], p = 0.74), despite spending less time per case in the control arm (C: 9.7 [SD 7.1] vs. CL: 11.7 [SD 6.7] minutes, p<0.01). Physicians were equally likely to transfer representative cases in the two arms (C: 45% vs. CL: 34%, p = 0.20), but were more likely to transfer non-representative cases in the control arm (C: 38% vs. CL: 26%, p = 0.03).

Conclusions

We found that physicians made decisions consistent with actual practice, that we could manipulate cognitive load, and that load increased the use of heuristics, as predicted by cognitive theory.