Browsing by Subject "Discordance"

Now showing 1 - 3 of 3
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    Assessment of Discordance Between Surrogate Care Goals and Medical Treatment Provided to Older Adults With Serious Illness
    (JAMA Network, 2020-05) Comer, Amber R.; Hickman, Susan E.; Slaven, James E.; Monahan, Patrick O.; Sachs, Greg A.; Wocial, Lucia D.; Burke, Emily S.; Torke, Alexia M.; Health Sciences, School of Health and Human Sciences
    Importance: An important aspect of high-quality care is ensuring that treatments are in alignment with patient or surrogate decision-maker goals. Treatment discordant with patient goals has been shown to increase medical costs and prolong end-of-life difficulties. Objectives: To evaluate discordance between surrogate decision-maker goals of care and medical orders and treatments provided to hospitalized, incapacitated older patients. Design, setting, and participants: This prospective cohort study included 363 patient-surrogate dyads. Patients were 65 years or older and faced at least 1 major medical decision in the medical and medical intensive care unit services in 3 tertiary care hospitals in an urban Midwestern area. Data were collected from April 27, 2012, through July 10, 2015, and analyzed from October 5, 2018, to December 5, 2019. Main outcomes and measures: Each surrogate's preferred goal of care was determined via interview during initial hospitalization and 6 to 8 weeks after discharge. Surrogates were asked to select the goal of care for the patient from 3 options: comfort-focused care, life-sustaining treatment, or an intermediate option. To assess discordance, the preferred goal of care as determined by the surrogate was compared with data from medical record review outlining the medical treatment received during the target hospitalization. Results: A total of 363 dyads consisting of patients (223 women [61.4%]; mean [SD] age, 81.8 [8.3] years) and their surrogates (257 women [70.8%]; mean [SD] age, 58.3 [11.2] years) were included in the analysis. One hundred sixty-nine patients (46.6%) received at least 1 medical treatment discordant from their surrogate's identified goals of care. The most common type of discordance involved full-code orders for patients with a goal of comfort (n = 41) or an intermediate option (n = 93). More frequent in-person contact between surrogate and patient (adjusted odds ratio [AOR], 0.43; 95% CI, 0.23-0.82), patient residence in an institution (AOR, 0.44; 95% CI, 0.23-0.82), and surrogate-rated quality of communication (AOR, 0.98; 95% CI, 0.96-0.99) were associated with lower discordance. Surrogate marital status (AOR for single vs married, 1.92; 95% CI, 1.01-3.66), number of family members involved in decisions (AOR for ≥2 vs 0-1, 1.84; 95% CI, 1.05-3.21), and religious affiliation (AOR for none vs any, 4.87; 95% CI, 1.12-21.09) were associated with higher discordance. Conclusions and relevance: This study found that discordance between surrogate goals of care and medical treatments for hospitalized, incapacitated patients was common. Communication quality is a modifiable factor associated with discordance that may be an avenue for future interventions.
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    The mythical concept and untoward consequences of a diagnosis of dysplastic nevus: an overdue tribute to A. Bernard Ackerman, MD
    (Derm101, 2015-01-30) Hurwitz, Robert M.; Tavel, Morton E.; Department of Medicine, IU School of Medicine
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    Variability in stone composition and metabolic correlation between kidneys in patients with bilateral nephrolithiasis
    (Elsevier, 2019-12-20) Rivera, Marcelino E.; Nottingham, Charles U.; Borofsky, Michael S.; Kissel, Suzanne M.; Maniar, Viraj; Dauw, Casey A.; York, Nadya E.; Krambeck, Amy E.; Lingeman, James E.; Urology, School of Medicine
    Introduction: To evaluate the clinical significance of discordant stone analyses in patients undergoing bilateral ureteroscopy. Methods: A retrospective chart review was performed for all patients undergoing stone extraction with bilateral ureteroscopy at our institution in an aim to identify patients who had bilateral stone analysis and 24-hour urine chemistry data available. Stones were then classified based upon the dominant present (>50%). Twenty-four hour urinalysis results were reviewed and statistical analysis performed comparing discordant and concordant patient populations, assessing significant differences that would potentially influence clinical management. Results: We identified 79 patients (158 renal units) who had bilateral stones removed at the time of ureteroscopy. The majority of stones were classified as calcium oxalate (CaOx) (60.1%) followed by calcium phosphate (CaP) (27.8%), brushite (5.1%), uric acid (UA) (4.4%) and cystine (2.5%). Discrepancies in stone classifications were present 24% of the time. Evaluation of 24-hour urinalysis results demonstrated that patients with CaOx:CaP stone discordance compared to CaOx:CaOx concordant stone formers were more likely to have an elevated pH (p=0.02) and lower uric acid supersaturation (p=0.01). Conclusions: Discrepancies in stone mineral content are common in patients with bilateral stone disease. A single stone analysis from one side in the setting of bilateral stone disease is insufficient for management of patients with bilateral renal stones, and may lead to mismanagement when this misrepresented information is utilized in addition to 24-hour urinalysis results. At least one stone analysis should be performed from both sides during a bilateral stone extraction procedure.