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BACKGROUND: Limited data are available on the use of complementary and alternative medicine (CAM) and factors associated with use among the pediatric population in the United States. METHODS: Using the 2007 National Health Interview Survey data among individuals <18 years of age (n = 9417), we compared CAM users (excluding those using vitamins and minerals) and non-CAM users. Using bivariable and multivariable logistic regression models, we examined independent associations of CAM use with sociodemographic factors, prescription medication use, delays in health care caused by access difficulties, and common medical conditions/symptoms. RESULTS: In an adjusted multivariable logistic model, CAM users were more likely than non-CAM users to be adolescents rather than infants or toddlers (adjusted odds ratio [aOR]: 1.61 [95% confidence interval (CI): 1.11-2.34]); live in the West (aOR: 2.05 [95% CI: 1.62-2.59]), Northeast (aOR: 1.36 [95% CI: 1.02-1.80]), or Midwest (aOR: 1.35 [95% CI: 1.04-1.74]) compared with those in the South; more likely to have a parent with a college education (aOR: 4.33 [95% CI: 2.92-6.42]); and more likely to use prescription medication (aOR: 1.51 [95% CI: 1.19-1.92]). Pediatric CAM users were more likely to have anxiety or stress (aOR: 2.54 [95% CI: 1.89-3.42]), dermatologic conditions (aOR: 1.35 [95% CI: 1.03-1.78]), musculoskeletal conditions (aOR: 1.94 [95% CI: 1.31-2.87]), and sinusitis (aOR: 1.54 [95% CI: 1.11-2.14]). Use of CAM by a parent was strongly associated with the child's use of CAM (aOR: 3.83 [95% CI: 3.04-4.84]). CONCLUSIONS: In 2007, pediatric CAM users were more likely to take prescription medications, have a parent who used CAM, and have chronic conditions such as anxiety or stress, musculoskeletal conditions, dermatologic conditions, or sinusitis. Research is required to guide pediatricians in making recommendations on CAM modalities for children including potential risks and/or benefits and interactions with conventional therapies. [ABSTRACT FROM AUTHOR]

This pilot study describes a randomized controlled trial of an audio CD-based interactive guided imagery program for smoking cessation for adults versus a wait-listed control. Feasibility, process measures, and biochemically validated abstinence were assessed at end of treatment (6 weeks) and 12 weeks, as well as at 52 weeks for intervention participants. Fifty-nine percent of intervention participants attended four of six guided imagery sessions, and 94% found the technique helpful for smoking cessation. Intervention participants had greater readiness to quit (Readiness to Quit Ladder, 8.3 vs. 7.2, p < .05) and lower state anxiety (Spielberger Index, 32 vs. 38, p < .05) at end of treatment than the control group. Abstinence rates in the intervention versus control groups were 36% versus 18% (p = .43) at 6 weeks and 30% versus 12% (p = .40) at 12 weeks, respectively. At 1 year, 24% of intervention participants remained abstinent. A guided imagery program for smoking cessation was feasible, perceived to be helpful, improved intermediate measures, and resulted in a trend toward smoking cessation. [ABSTRACT FROM AUTHOR]

BACKGROUND: Although many adults in the United States use herbs, little is known about the personal use of herbs by health care professionals (HCPs) and factors associated with use. METHODS: We performed a cross-sectional study of HCPs prior to their enrollment in an online course about herbs and dietary supplements between September 2004 and May 2005. We used multivariable logistic regression to analyze demographic and practice factors associated with herb use. RESULTS: Of the 1249 health care professionals surveyed, 51% reported using an herb in the last week. The rates of use were highest among physician assistants or nurse practitioners (PA or NP) (63%), clinical nurses (59%), and HCP students (52%), while physicians (48%), dietitians (40%), and pharmacists (37%) had lower rates. Among health care professionals who reported herb use, the most common herbs taken were green tea (24%), flax seed (18%), chamomile (11%), and aloe vera (8%). Factors associated with herb use included older age, being a nurse, a HCP student, an NP or PA compared with being a physician, being non-Caucasian, living outside of North Carolina and having increased knowledge of herbs and dietary supplements. [ABSTRACT FROM AUTHOR]

OBJECTIVE: We examined the use of complementary and alternative medical (CAM) therapies among Chinese and Vietnamese Americans who had limited proficiency with the English language and explore the association between patient-clinician discussions about CAM therapy use and patient assessments of quality of care. METHODS: We surveyed Chinese and Vietnamese Americans who visited 11 community health centers in 8 major cities throughout the United States. RESULTS: Of the 4410 patients surveyed, 3258 (74%) returned completed questionnaires. Two thirds of respondents reported they had 'ever used' some form of CAM therapy; however, only 7.6% of these patients had discussed their use of CAM therapies with clinicians. Among patients who had used CAM therapies during the week before their most recent visits, clinician-patient discussions about CAM therapy use were associated with better overall patient ratings of quality of care. CONCLUSION: Use of CAM therapies was common among Chinese and Vietnamese Americans who had limited proficiency with the English language. Although discussions about CAM therapy use with clinicians were uncommon, these discussions were associated with better ratings of quality of care. [ABSTRACT FROM AUTHOR]

Over-the-counter dietary supplements to treat obesity appeal to many patients who desire a 'magic bullet' for weight loss. Asking overweight patients about their use of weight-loss supplements and understanding the evidence for the efficacy, safety, and quality of these supplements are critical when counseling patients regarding weight loss. A schema for whether physicians should recommend, caution, or discourage use of a particular weight-loss supplement is presented in this article. More than 50 individual dietary supplements and more than 125 commercial combination products are available for weight loss. Currently, no weight-loss supplements meet criteria for recommended use. Although evidence of modest weight loss secondary to ephedra-caffeine ingestion exists, potentially serious adverse effects have led the U.S. Food and Drug Administration to ban the sale of these products. Chromium is a popular weight-loss supplement, but its efficacy and long-term safety are uncertain. Guar gum and chitosan appear to be ineffective; therefore, use of these products should be discouraged. Because of insufficient or conflicting evidence regarding the efficacy of conjugated linoleic acid, ginseng, glucomannan, green tea, hydroxycitric acid, L-carnitine, psyllium, pyruvate, and St. John's wort in weight loss, physicians should caution patients about the use of these supplements and closely monitor those who choose to use these products. [ABSTRACT FROM AUTHOR]

Context: Visit length is an important component of physician payment systems. As use and insurance coverage of complementary and alternative medicine (CAM) increases, equitable reimbursement strategies for CAM providers will be needed. Little information is available about the time CAM providers spend with patients.Objective: To describe the length of visit and determinants of visit time to chiropractors and acupuncturists.Design: Survey of CAM practitioners that collected information on providers (e.g., socio-demographics, practice patterns, training) and professional visit encounters (e.g., patient demographics, payment source, problem acuity, visit length, procedures performed).Subjects: Random sample of 130 licensed chiropractors and 133 licensed acupuncturists surveyed in 1998-1999, each from one Western and one Northeastern US state.Measures: Patient, provider, and visit factors associated with visit duration were analyzed using weighted linear regression.Results: Data were available on 2550 chiropractic and 2561 acupuncture visits. Mean chiropractic visit length was 21.5 minutes (SE = 0.8). Mean acupuncture visit length was 56.6 minutes (SE = 0.7) In both professions, new patient visits took longer, while visits for wellness or chronic problems were shorter. Preventive counseling by the chiropractor increased visit time, as did use of manual (vs. instrument) spinal manipulation, soft tissue techniques and physiotherapeutics. Acupuncture visits were shorter when specialized needling techniques (e.g. auricular or scalp acupuncture) were used, and longer with other adjunctive Asian therapies (e.g., cupping or magnets). Self-paid acupuncture visits were longer, as were visits with acupuncturists who had less practice experience or fewer years of training.Conclusions: For both chiropractic and acupuncture, certain visit factors, provider characteristics, and procedures increase visit length, many of which parallel those observed in conventional medical settings. Thus, a similar time-based payment scheme may be a reasonable starting point for developing methods for reimbursing CAM providers. [ABSTRACT FROM AUTHOR]

Background: Rheumatic fever has become uncommon in the United States while rapid diagnostic test technology for streptococcal antigens has improved. However, little is known about the effectiveness or cost-effectiveness of various strategies for managing pharyngitis caused by group A beta-hemolytic streptococcus (GAS) in U.S. adults.Objective: To examine the cost-effectiveness of several diagnostic and management strategies for patients with suspected GAS pharyngitis.Design: Cost-effectiveness analysis.Data Sources: Published literature, including systematic reviews where possible. When costs were not available in the literature, we estimated them from our institution and Medicare charges.Target Population: Adults in the general U.S. population.Time Horizon: 1 year.Perspective: Societal.Interventions: Five strategies for the management of adult patients with pharyngitis: 1) observation without testing or treatment, 2) empirical treatment with penicillin, 3) throat culture using a two-plate selective culture technique, 4) optical immunoassay (OIA) followed by culture to confirm negative OIA test results, or 5) OIA alone.Outcome Measures: Cost per lost quality-adjusted life-days (converted to life-years where appropriate) and incremental cost-effectiveness.Results Of Base-case Analysis: Empirical treatment was the least effective strategy at a GAS pharyngitis prevalence of 10% (resulting in 0.41 lost quality-adjusted life-day). Although the other four strategies had similar effectiveness (all resulted in about 0.27 lost quality-adjusted life-day), culture was the least expensive strategy.Results Of Sensitivity Analyses: Results were sensitive to the prevalence of GAS pharyngitis: OIA followed by culture was most effective when GAS pharyngitis prevalence was greater than 20%. Observation was least expensive when prevalence was less than 6%, and empirical treatment was least expensive when prevalence was greater than 71%. The effectiveness of strategies was also very sensitive to the probability of anaphylaxis: When the probability of anaphylaxis was about half the baseline probability, OIA/culture was most effective; when the probability was 1.6 times that of baseline, observation was most effective. Only at an OIA cost less than half of baseline did the OIA alone strategy become less expensive than culture. Results were not sensitive to other variations in probabilities or costs of diagnosis or treatment of GAS pharyngitis.Conclusions: Observation, culture, and two rapid antigen test strategies for diagnostic testing and treatment of suspected GAS pharyngitis in adults have very similar effectiveness and costs, although culture is the least expensive and most effective strategy when the GAS pharyngitis prevalence is 10%. Empirical treatment was not the most effective or least expensive strategy at any prevalence of GAS pharyngitis in adults, although it may be reasonable for individual patients at very high risk for GAS pharyngitis as assessed by a clinical decision rule. [ABSTRACT FROM AUTHOR]

Depression is common among HIV-infected patients, but little is known about risk factors for depression in this population. Several studies before protease inhibitors became available have reported inconsistent associations between depression and disease severity. Delivering high quality HIV care includes adequate detection and treatment of depression. The objective of this study was to describe the prevalence and correlates of depression among a contemporary group of HIV-infected patients. The setting and design for the study was a chart abstraction for HIV-infected patients in a primary care practice in Boston, Mass, in June 1997. Among 275 HIV-infected patients, depression was documented in 147 patient charts (53%), half of whom (n = 73, 27%) also received antidepressant medications. We used multivariable logistic regression to identify risk factors for depression among patients with both a chart diagnosis of depression and current antidepressant medication use. We observed increased risk of depression among patients with a history of substance use (odds ratio 2.7, 95% confidence interval 1.5-4.7), recent medical hospitalization (2.6, 1.4-5.0), and homosexual risk behavior (2.1, 1.1-4.2). Depression remains a common problem for HIV-infected patients, particularly among those with history of substance abuse, medical hospitalization, or homosexual risk behavior. Routine screening for depression in this population with special attention to those at higher risk may offer opportunities for earlier diagnosis and treatment. [ABSTRACT FROM AUTHOR]

Background: Older age is associated with less aggressive treatment and higher short-term mortality due to serious illness. It is not known whether less aggressive care contributes to this survival disadvantage in elderly persons.Objective: To determine the effect of age on short-term survival, independent of baseline patient characteristics and aggressiveness of care.Design: Secondary analysis of data from a prospective cohort study.Setting: Five academic medical centers participating in SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments).Patients: 9105 adults hospitalized with one of nine serious illnesses associated with an average 6-month mortality rate of 50%.Measurements: Survival through 180 days of follow-up. In Cox proportional hazards modeling, adjustment was made for patient sex; ethnicity; income; baseline physical function; severity of illness; intensity of hospital resource use; presence of do-not-resuscitate orders on study day 1; and presence and timing of decisions to withhold transfer to the intensive care unit, major surgery, dialysis, blood transfusion, vasopressors, and tube feeding.Results: The mean (+/- SD) patient age was 63 +/- 16 years, 44% of patients were female, and 16% were black. Overall survival to 6 months was 53%. In analyses that adjusted for sex, ethnicity, income, baseline functional status, severity of illness, and aggressiveness of care, each additional year of age increased the hazard of death by 1.0% (hazard ratio, 1.010 [95% CI, 1.007 to 1.013]) for patients 18 to 70 years of age and by 2.0% (hazard ratio, 1.020 [CI, 1.013 to 1.026]) for patients older than 70 years of age. Adjusted estimates of age-specific 6-month mortality rates were 44% for 55-year-old patients, 48% for 65-year-old patients, 53% for 75-year-old patients, and 60% for 85-year-old patients. Similar results were obtained in analyses that did not adjust for aggressiveness of care. Acute physiology and diagnosis had much larger relative contributions to prognosis than age.Conclusions: We found a modest independent association between patient age and short-term survival of serious illness. This age effect was not explained by the current practice of providing less aggressive care to elderly patients. [ABSTRACT FROM AUTHOR]

Background: Because uncontrolled echocardiographic surveys suggested that up to 30% to 38% of users of fenfluramine and dexfenfluramine had valvular disease, these drugs were withdrawn from the market.Objective: To determine the risk for new or worsening valvular abnormalities among users of fenfluramine or dexfenfluramine who underwent echocardiography before they began to take these medications.Design: Cohort study.Setting: Academic primary care practices.Patients: 46 patients who used fenfluramine or dexfenfluramine for 14 days or more and had echocardiograms obtained before therapy.Measurements: Follow-up echocardiography. The primary outcome was new or worsening valvulopathy, defined as progression of either aortic or mitral regurgitation by at least one degree of severity and disease that met U.S. Food and Drug Administration criteria (at least mild aortic regurgitation or moderate mitral regurgitation).Results: Two patients (4.3% [95% CI, 0.6% to 14.8%]) receiving fenfluramine-phentermine developed valvular heart disease. One had baseline bicuspid aortic valve and mild aortic regurgitation that progressed to moderate regurgitation. The second patient developed new moderate aortic insufficiency.Conclusion: Users of diet medications are at risk for valvular heart disease. However, the incidence may be lower than that reported previously. [ABSTRACT FROM AUTHOR]

Background: Renal failure requiring dialysis in the setting of hospitalization for serious illness is a poor prognostic sign, and dialysis and aggressive care are sometimes withheld.Objective: To evaluate the clinical outcomes and cost-effectiveness of initiating dialysis and continuing aggressive care for seriously ill hospitalized patients.Design: Prospective cohort study and cost-effectiveness analysis.Setting: Five geographically diverse teaching hospitals.Patients: 490 patients (median age, 61 years; 58% women) enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) in whom dialysis was initiated.Measurements: Survival, functional status, quality of life, and health care costs. Life expectancy was estimated by extrapolating survival data (up to 4.4 years of follow-up) using a declining exponential function. Utilities (quality-of-life weights) were estimated by using time-tradeoff questions. Costs were based on data from SUPPORT and published Medicare data.Results: Median duration of survival was 32 days, and only 27% of patients were alive after 5 months. Survivors reported a median of one dependency in activities of daily living, and 62% rated their quality of life as "good" or better. Overall, the estimated cost per quality-adjusted life-year saved by initiating dialysis and continuing aggressive care rather than withholding dialysis and allowing death to occur was $128,200. For the 103 patients in the worst prognostic category, the estimated cost per quality-adjusted life-year was $274,100; for the 94 patients in the best prognostic category, the cost per quality-adjusted life-year was $61,900.Conclusions: For the few patients who survived, clinical outcomes were fairly good. With the exception of patients with the best prognoses, however, the cost-effectiveness of initiating dialysis and continuing aggressive care far exceeded $50,000 per quality-adjusted life-year, a commonly cited threshold for cost-effective care. [ABSTRACT FROM AUTHOR]

Objective: To examine the impact of illness on the families of seriously ill adults and to determine the correlates of adverse economic impact.Design: Data were collected during the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT), a prospective cohort study of outcomes, preferences, and decision making in seriously ill hospitalized adults and their families.Setting: Five tertiary care hospitals in the United States.Participants: The 2661 seriously ill patients in nine diagnostic categories who survived their index hospitalization and were discharged home were eligible for this analysis. Surrogate and/or patient interviews about the impact of illness on the family were obtained for 2129 (80%) of these patients (mean age, 62 years; 43% women; 6-month survival, 75%).Outcome Measures: Surrogates and patients were surveyed to determine the frequency of adverse caregiving and economic burdens. Multivariable analyses were performed to determine correlates of loss of family savings.Results: One third (34%) of patients required considerable caregiving assistance from a family member. In 20% of cases, a family member had to quit work or make another major life change to provide care for the patient. Loss of most or all of the family savings was reported by 31% of families, whereas 29% reported loss of the major source of income. Patient factors independently associated with loss of the family's savings on multivariable analysis included poor functional status (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.10 to 1.78 for patients needing assistance with three or more activities of daily living), lower family income (OR, 1.74; 95% CI, 1.37 to 2.21 for those with annual incomes below $25,000), and young age (OR, 2.85; 95% CI, 2.13 to 3.82 for those younger than 45 years compared with those 65 years or older).Conclusions: Many families of seriously ill patients experience severe caregiving and financial burdens. Families of younger, poorer, and more functionally dependent patients are most likely to report loss of most or all of the family's savings. [ABSTRACT FROM AUTHOR]

Context: Health values (utilities or preferences for health states) are often incorporated into clinical decisions and health care policy when issues of quality vs length of life arise, but little is known about health values of the very old.Objective: To assess health values of older hospitalized patients, compare their values with those of their surrogate decision makers, investigate possible determinants of health values, and determine whether health values change over time.Design: A prospective, longitudinal, multicenter cohort study.Setting: Four academic medical centers.Participants: Four hundred fourteen hospitalized patients aged 80 years or older and their surrogate decision makers who were interviewed and understood the task.Main Outcome Measures: Time-trade-off utilities, reflecting preferences for current health relative to a shorter but healthy life.Results: On average, patients equated living 1 year in their current state of health with living 9.7 months in excellent health (mean [SD] utility, 0.81 [0.28]). Although only 126 patients (30.7%) rated their current quality of life as excellent or very good, 284 (68.6%) were willing to give up at most 1 month of 12 in exchange for excellent health (utility > or =0.92). At the other extreme, 25 (6.0%) were willing to live 2 weeks or less in excellent health rather than 1 year in their current state of health (utility < or =0.04). Patients were willing to trade significantly less time for a healthy life than their surrogates assumed they would (mean difference, 0.05; P=.007); 61 surrogates (20.3%) underestimated the patient's time-trade-off score by 0.25 (3 months of 12) or more. Patients willing to trade less time for better health were more likely to want resuscitation and other measures to extend life. Time-trade-off score correlated only modestly with quality-of-life rating (r=0.28) and inversely with depression score (r=-0.27), but there were few other clinical or demographic predictors of health values. When patients who survived were asked the time-trade-off question again at 1 year, they were willing to trade less time for better health than at baseline (mean difference, 0.04; P=.04).Conclusion: Very old hospitalized patients who could be interviewed were able, in most cases, to have their health values assessed using the time-trade-off technique. Most patients were unwilling to trade much time for excellent health, but preferences varied greatly. Because proxies and multivariable analyses cannot gauge health values of elderly hospitalized patients accurately, health values of the very old should be elicited directly from the patient. [ABSTRACT FROM AUTHOR]

BACKGROUND: Serious illness often causes economic hardship for patients' families. However, it is not known whether this hardship is associated with a preference for the goal of care to focus on maximizing comfort instead of maximizing life expectancy or whether economic hardship might give rise to disagreement between patients and surrogates over the goal of care. METHODS: We performed a cross-sectional study of 3158 seriously ill patients (median age, 63 years; 44% women) at 5 tertiary medical centers with 1 of 9 diagnoses associated with a high risk of mortality. Two months after their index hospitalization, patients and surrogates were surveyed about patients' preferences for the primary goal of care: either care focused on extending life or care focused on maximizing comfort. Patients and surrogates were also surveyed about the financial impact of the illness on the patient's family. RESULTS: A report of economic hardship on the family as a result of the illness was associated with a preference for comfort care over life-extending care (odds ratio, 1.26; 95% confidence interval, 1.07-1.48) in an age-stratified bivariate analysis. Similarly, in a multivariable analysis controlling for patient demographics, illness severity, functional dependency, depression, anxiety, and pain, economic hardship on the family remained associated with a preference for comfort care over life-extending care (odds ratio, 1.31; 95% confidence interval, 1.10-1.57). Economic hardship on the family did not affect either the frequency or direction of patient-surrogate disagreements about the goal of care. CONCLUSIONS: In patients with serious illness, economic hardship on the family is associated with preferences for comfort care over life-extending care. However, economic hardship on the family does not appear to be a factor in patient-surrogate disagreements about the goal of care. [ABSTRACT FROM AUTHOR]

Objective: To assess 1) the health values and health ratings of seriously ill hospitalized patients, their surrogate decision makers, and their physicians; 2) the determinants of health values; and 3) whether health values change over time.Design: Prospective, longitudinal, multicenter study.Setting: 5 academic medical centers.Participants: 1438 seriously ill patients with at least one of nine diseases who had a projected overall 6-month mortality rate of 50%; their surrogates; and their physicians.Measurements: Time-tradeoff utilities (reflecting preferences for a shorter but healthy life) and health ratings.Results: At study day 3, patients had a mean time-tradeoff utility of 0.73 +/- 0.32 (median [25th, 75th percentile], 0.92 [0.63, 1.0]), indicating that they equated living 1 year in their current state of health with living 8.8 months in excellent health. However, scores varied widely; 34.8% of patients were unwilling to exchange any time in their current state of health for a shorter life in excellent health (utility, 1.0), and 9.0% were willing to live 2 weeks or less in excellent health rather than 1 year in their current state of health (utility, 0.04). Health rating scores averaged 57.8 +/- 24.0 (median [25th percentile, 75th percentile], 60 [50, 75]) on a scale of 0 (death) to 100 (perfect health). The patients' mean time-tradeoff score exceeded that of their paired surrogates (n = 1041) by 0.08 (P < 0.0001). Time-tradeoff scores were related to psychosocial well-being; health ratings; desire for resuscitation and extension of life rather than relief of pain and discomfort; degree of willingness to live with constant pain; and perceived prognosis for survival and independent functioning. Scores of surviving patients increased by an average of 0.06 after 2 months (P < 0.0001) and 0.08 after 6 months (P < 0.0001).Conclusions: Health values of seriously ill patients vary widely, are higher than patients' surrogates believe, are related to few other preference and health status measures, and increase over time. [ABSTRACT FROM AUTHOR]

Background: Patient age may influence decisions to withhold life-sustaining treatments, independent of patients' preferences for or ability to benefit from such treatments. Controversy exists about the appropriateness of using age as a criterion for making treatment decisions.Objective: To determine the effect of age on decisions to withhold life-sustaining therapies.Design: Prospective cohort study.Setting: Five medical centers participating in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT).Patients: 9105 hospitalized adults who had one of nine illnesses associated with an average 6-month mortality rate of 50%.Measurements: Outcomes were the presence and timing of decisions to withhold ventilator support, surgery, and dialysis. Adjustment was made for sociodemographic characteristics, prognoses, baseline function, patients' preferences for life-extending care, and physicians' understanding of patients' preferences for life-extending care.Results: The median patient age was 63 years; 44% of patients were women, and 53% survived to 180 days. In adjusted analyses, older age was associated with higher rates of withholding each of the three life-sustaining treatments studied. For ventilator support, the rate of decisions to withhold therapy increased 15% with each decade of age (hazard ratio, 1.15 [95% CI, 1.12 to 1.19]); for surgery, the increase per decade was 19% (hazard ratio, 1.19 [CI, 1.12 to 1.27]); and for dialysis, the increase per decade was 12% (hazard ratio, 1.12 [CI, 1.06 to 1.19]). Physicians underestimated older patients' preferences for life-extending care; adjustment for this underestimation resulted in an attenuation of the association between age and decisions to withhold treatments.Conclusion: Even after adjustment for differences in patients' prognoses and preferences, older age was associated with higher rates of decisions to withhold ventilator support, surgery, and dialysis. [ABSTRACT FROM AUTHOR]

Background: Physicians are frequently unaware of patient preferences for end-of-life care. Identifying and exploring barriers to patient-physician communication about end-of-life issues may help guide physicians and their patients toward more effective discussions.Objective: To examine correlates and associated outcomes of patient communication and patient preferences for communication with physicians about cardiopulmonary resuscitation and prolonged mechanical ventilation.Design: Prospective cohort study.Setting: Five tertiary care hospitals.Patients: 1832 (85%) of 2162 eligible patients completed interviews.Measurements: Surveys of patient characteristics and preferences for end-of-life care; perceptions of prognosis, decision making, and quality of life; and patient preferences for communication with physicians about end-of-life decisions.Results: Fewer than one fourth (23%) of seriously ill patients had discussed preferences for cardiopulmonary resuscitation with their physicians. Of patients who had not discussed their preferences for resuscitation, 58% were not interested in doing so. Of patients who had not discussed and did not want to discuss their preferences, 25% did not want resuscitation. In multivariable analyses, patient factors independently associated with not wanting to discuss preferences for cardiopulmonary resuscitation included being of an ethnicity other than black (adjusted odds ratio [OR], 1.48 [95% CI, 1.10 to 1.99), not having an advance directive (OR, 1.35 [CI, 1.04 to 1.76]), estimating an excellent prognosis (OR, 1.72 [CI, 1.32 to 2.59]), reporting fair to excellent quality of life (OR, 1.36 [CI, 1.05 to 1.76]), and not desiring active involvement in medical decisions (OR, 1.33 [CI, 1.07 to 1.65]). Factors independently associated with wanting to discuss preferences for resuscitation but not doing so included being black (OR, 1.53 [CI, 1.11 to 2.11]) and being younger (OR, 1.14 per 10-year interval younger [CI, 1.04 to 1.25]).Conclusions: Among seriously ill hospitalized adults, communication about preferences for cardiopulmonary resuscitation is uncommon. A majority of patients who have not discussed preferences for end-of-life care do not want to do so. For patients who do not want to discuss their preferences, as well as patients with an unmet need for such discussions, failure to discuss preferences for cardiopulmonary resuscitation and mechanical ventilation may result in unwanted interventions. [ABSTRACT FROM AUTHOR]

Background: Alleviating the problems faced by dying persons and their families has drawn substantial public attention, but little is known about the experience of dying.Objective: To characterize the experience of dying from the perspective of surrogate decision makers, usually close family members (89%).Design: Prospective cohort study.Setting: Five teaching hospitals.Patients: Persons who had one of nine serious medical conditions or were 80 years of age or older who died and for whom a surrogate decision maker completed an interview about the death.Measurements: Medical records were reviewed and surrogate decision makers were interviewed.Results: 4124 of 9105 seriously ill patients died (46%); 408 of 1176 elderly patients died (35%). The patients' family members were interviewed after 3357 persons (73%) had died. Of 1541 patients who survived the enrollment hospitalization, 46% died during a later hospitalization. In the last 3 days of life, 55% of patients were conscious. Among these patients, pain, dyspnea, and fatigue were prevalent. Four in 10 patients had severe pain most of the time. Severe fatigue affected almost 8 in 10 patients. More than 1 in 4 patients had moderate dysphoria. Sixty-three percent of patients had difficulty tolerating physical or emotional symptoms. Overall, 11% of patients had a final resuscitation attempt. A ventilator was used in one fourth of patients, and a feeding tube was used in four tenths of patients. Most patients (59%) were reported to prefer a treatment plan that focused on comfort, but care was reported to be contrary to the preferred approach in 10% of cases.Conclusions: Most elderly and seriously ill patients died in acute care hospitals. Pain and other symptoms were commonplace and troubling to patients. Family members believed that patients preferred comfort, but life-sustaining treatments were often used. These findings indicate important opportunities to improve the care of dying patients. [ABSTRACT FROM AUTHOR]

Background: Medical treatment decisions should be based on the preferences of informed patients or their proxies and on the expected outcomes of treatment. Because seriously ill patients are at risk for cardiac arrest, examination of do-not-resuscitate (DNR) practices affecting them provides useful insights into the associations between various factors and medical decision making.Objective: To examine the association between patients' preferences for resuscitation (along with other patient and physician characteristics) and the frequency and timing of DNR orders.Design: Prospective cohort study.Setting: 5 teaching hospitals.Patients: 6802 seriously ill hospitalized patients enrolled in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT) between 1989 and 1994.Measurements: Patients and their surrogates were interviewed about patients' cardiopulmonary resuscitation preferences, medical records were reviewed to determine disease severity, and a multivariable regression model was constructed to predict the time to the first DNR order.Results: The patients' preference for cardiopulmonary resuscitation was the most important predictor of the timing of DNR orders, but only 52% of patients who preferred not to be resuscitated actually had DNR orders written. The probability of surviving for 2 months was the next most important predictor of the timing of DNR orders. Although DNR orders were not linearly related to the probability of surviving for 2 months, they were written earlier and more frequently for patients with a 50% or lower probability of surviving for 2 months. Orders were written more quickly for patients older than 75 years of age, regardless of prognosis. After adjustment for these and other influential patient characteristics, the use and timing of DNR orders varied significantly among physician specialties and among hospitals.Conclusions: Patients' preferences and short-term prognoses are associated with the timing of DNR orders. However, the substantial variation seen among hospital sites and among physician specialties suggests that there is room for improvement. In this study, DNR orders were written earlier for patients older than 75 years of age, regardless of prognosis. This finding suggests that physicians may be using age in a way that is inconsistent with the reported association between age and survival. The process for making decisions about DNR orders needs to be improved if such orders are to routinely and accurately reflect patients' preferences and probable outcomes. [ABSTRACT FROM AUTHOR]

BACKGROUND: Variations in hospital policies and practices regarding the use of vitamins, minerals, herbs, and other dietary supplements could compromise patient safety and quality of care. We undertook this study to describe pediatric hospital policies regarding dietary supplements. METHODS: We administered a cross-sectional survey of a sample of National Association of Children Hospitals and Related Institutions members. Pharmacy personnel were asked about the following: written policies addressing dietary supplements; how such policies are made; and responsibilities for storage, administration, documentation, and checking for potential interactions. We created a 10-point hospital policy and practices quality score to assess the quality of each policy. RESULTS: Of the 186 eligible National Association of Children Hospitals and Related Institutions hospitals, 109 responded (59%). Forty-four percent reported having written policies on vitamins and minerals, herbs, and other dietary supplements. Few hospitals had herbs (2%) or other dietary supplements (38%) on formulary. However, most (81%) allowed patients to use their home supply of dietary supplements under defined circumstances, and 64% allowed staff to make recommendations about dietary supplement use. In 70% of hospitals, nurses stored and administered the home supply of dietary supplements. Less than half (46%) required documentation of a check for drug or dietary supplements interactions. One third (32%) had surgical preoperative recommendations regarding dietary supplements. Only 11% of 109 hospitals satisfied the 10 criteria necessary for a perfect hospital policy and practices quality score indicative of quality practices regarding patient use of dietary supplements. CONCLUSION: Even among those hospitals that have written policies about dietary supplements, there is a wide range in policy quality, which may compromise the safety of patients. [ABSTRACT FROM AUTHOR]

BACKGROUND: Little is known about the prevalence of dietary supplement (DS) use in American adolescents. We conducted this study to analyze the prevalence of DS use and factors associated with this use in a national population-based sample. METHODS: We used data from the 1999 - 2002 National Health and Nutrition Examination Surveys (NHANES) for adolescents age 11 to 19. Using weighted logistic regression, we identified demographic and clinical factors associated with the use of any DS, vitamins or minerals, herbs and other DS. RESULTS: Among the 5,306 responses representing approximately 36 million Americans 11-19 years old, 27% reported use of one or more DS in the prior month. The most commonly used DS were: multivitamins (16%) and vitamin C (6%). In the multivariable analysis, African American [adjusted odds ratio 0.40 (0.31-0.50) 95% CI] and Mexican American [0.55 (0.44-0.69)] adolescents were less likely to use DS compared with non-Hispanic whites. DS use was more common in those who used prescription medications [1.37 (1.10-1.72)] and among those who had a diagnosis of chronic headaches [1.25 (1.04-1.50)]. DS use was less common among those reporting fair or poor health status [0.59 (0.40-0.88)]. CONCLUSION: Twenty seven percent of American adolescents use DS. DS use is higher among teens that use prescription medications; physicians and pharmacists should be aware of this, ask patients, and check for potential interactions. [ABSTRACT FROM AUTHOR]

Objective: Mind-body therapies (MBT) are used by 16.6% of adults in the United States. Little is known about the patterns of and reasons for use of MBT by adults with common medical conditions.Methods: We analyzed data on MBT use from the 2002 National Health Interview Survey Alternative Medicine Supplement (n=31,044). MBT included relaxation techniques (deep breathing exercises, guided imagery, meditation, and progressive muscle relaxation), yoga, tai chi, and qigong. To identify medical conditions associated with use of MBT overall and of individual MBT, we used multivariable models adjusted for sociodemographic factors, insurance status, and health habits. Among users of MBT (n=5170), we assessed which medical conditions were most frequently treated with MBT, additional rationale for using MBT, and perceived helpfulness.Results: We found a positive association between MBT use and several medical conditions including various pain syndromes and anxiety/depression. Among adults using MBT to treat specific medical conditions, MBT was most commonly used for anxiety/depression and musculoskeletal pain syndromes. More than 50% of respondents used MBT in conjunction with conventional medical care, and 20% used MBT for conditions they thought conventional medicine would not help. Overall, we found high rates (68-90%) of perceived helpfulness of MBT for specific medical conditions.Discussion: MBT is commonly used by patients with prevalent medical conditions. Further research is needed to determine the reasons for widespread use of MBT for treatment of specific medical conditions and to evaluate the efficacy of MBT. [ABSTRACT FROM AUTHOR]

Context: Complementary and alternative medicine (CAM) use by US adults increased substantially between 1990 and 1997, yet little is known about more recent trends.Objective: Compare CAM therapy use by US adults in 2002 and 1997.Design: Comparison of two national surveys of CAM use by US adults: (1) the Alternative Health/Complementary and Alternative Medicine supplement to the 2002 National Health Interview Survey (NHIS, N = 31,044) and (2) a 1997 national survey (N = 2055), each containing questions about 15 common CAM therapies.Main Outcome Measures: Prevalence, sociodemographic correlates, and insurance coverage of CAM use.Results: The most commonly used CAM modalities in 2002 were herbal therapy (18.6%, representing over 38 million US adults) followed by relaxation techniques (14.2%, representing 29 million US adults) and chiropractic (7.4%, representing 15 million US adults). Among CAM users, 41% used two or more CAM therapies during the prior year. Factors associated with highest rates of CAM use were ages 40-64, female gender, non-black/non-Hispanic race, and annual income of dollar 65,000 or higher. Overall CAM use for the 15 therapies common to both surveys was similar between 1997 and 2002 (36.5%, vs. 35.0%, respectively, each representing about 72 million US adults). The greatest relative increase in CAM use between 1997 and 2002 was seen for herbal medicine (12.1% vs.18.6%, respectively), and yoga (3.7% vs. 5.1%, respectively),while the largest relative decrease occurred for chiropractic (9.9% to 7.4%, respectively).Conclusions: The prevalence of CAM use has remained stable from 1997 to 2002. Over one in three respondents used CAM in the past year, representing about 72 million US adults. [ABSTRACT FROM AUTHOR]

Background: Several studies suggest yoga may be effective for chronic low back pain; however, trials targeting minorities have not been conducted. PRIMARY STUDY OBJECTIVES: Assess the feasibility of studying yoga in a predominantly minority population with chronic low back pain. Collect preliminary data to plan a larger powered study.Study Design: Pilot randomized controlled trial.Setting: Two community health centers in a racially diverse neighborhood of Boston, Massachusetts.Participants: Thirty English-speaking adults (mean age 44 years, 83% female, 83% racial/ethnic minorities; 48% with incomes < or = $30,000) with moderate-to-severe chronic low back pain.Interventions: Standardized series of weekly hatha yoga classes for 12 weeks compared to a waitlist usual care control.Outcome Measures: Feasibility measured by time to complete enrollment, proportion of racial/ethnic minorities enrolled, retention rates, and adverse events. Primary efficacy outcomes were changes from baseline to 12 weeks in pain score (0=no pain to 10=worst possible pain) and back-related function using the modified Roland-Morris Disability Questionnaire (0-23 point scale, higher scores reflect poorer function). Secondary efficacy outcomes were analgesic use, global improvement, and quality of life (SF-36).Results: Recruitment took 2 months. Retention rates were 97% at 12 weeks and 77% at 26 weeks. Mean pain scores for yoga decreased from baseline to 12 weeks (6.7 to 4.4) compared to usual care, which decreased from 7.5 to 7.1 (P=.02). Mean Roland scores for yoga decreased from 14.5 to 8.2 compared to usual care, which decreased from 16.1 to 12.5 (P=.28). At 12 weeks, yoga compared to usual care participants reported less analgesic use (13% vs 73%, P=.003), less opiate use (0% vs 33%, P=.04), and greater overall improvement (73% vs 27%, P=.03). There were no differences in SF-36 scores and no serious adverse events.Conclusion: A yoga study intervention in a predominantly minority population with chronic low back pain was moderately feasible and may be more effective than usual care for reducing pain and pain medication use. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To examine the patterns of herbal therapy use among adults in the United States and to describe factors associated with herb use. DESIGN: We examined the use of natural herbs from the 2002 National Health Interview Survey (NHIS). We analyzed factors associated with herb use and reasons for herb use with logistic regression. RESULTS: Factors associated with herb use include the following: age (45-64 years old), being uninsured, being female, having a higher education, living in the West, using prescription medications or over-the-counter (OTC) medications, and self-identified as 'non-Hispanic other.' Factors associated with no herb use include being non-Hispanic black and living in the South or Midwest. Seventy-two percent of those who used herbs used prescription medications, and 84% of those who used herbs also used an OTC medication in the prior 12 months. Among adults who used herbs, the most commonly mentioned were echinacea (41%), ginseng (25%), gingko (22%), and garlic (20%). The most frequent conditions for herb use were head or chest cold (30%), musculoskeletal conditions (16%), and stomach or intestinal illness (11%). Among those who used herbs in the prior year, factors associated with using herbs because conventional medical treatments were too expensive included being uninsured, having poor health, and being 25-44 years old. CONCLUSIONS: Nearly 1 in 5 people in the US population report using an herb for treatment of health conditions and/or health promotion. More than half did not disclose this information to a conventional medical professional. [ABSTRACT FROM AUTHOR]