Dataset Information

Age, comorbidity, life expectancy, and pulmonary nodule follow-up in older veterans.

ABSTRACT:

Background

Pulmonary nodule guidelines do not indicate how to individualize follow-up according to comorbidity or life expectancy.

Objectives

To characterize comorbidity and life expectancy in older veterans with incidental, symptom-detected, or screen-detected nodules in 2008-09 compared to 2013-14. To determine the impact of these patient factors on four-year nodule follow-up among the 2008-09 subgroup.

Design

Retrospective cohort study.

Setting

Urban Veterans Affairs Medical Center.

Participants

243 veterans age ?65 with newly diagnosed pulmonary nodules in 2008-09 (followed for four years through 2012 or 2013) and 446 older veterans diagnosed in 2013-14.

Measurements

The primary outcome was receipt of any follow-up nodule imaging and/or biopsy within four years after nodule diagnosis. Primary predictor variables included age, Charlson-Deyo Comorbidity Index (CCI), and life expectancy. Favorable life expectancy was defined as age 65-74 with CCI 0 while limited life expectancy was defined as age ?85 with CCI ?1 or age ?65 with CCI ?4. Interaction by nodule size was also examined.

Results

From 2008-09 to 2013-14, the number of older veterans diagnosed with new pulmonary nodules almost doubled, including among those with severe comorbidity and limited life expectancy. Overall among the 2008-09 subgroup, receipt of nodule follow-up decreased with increasing comorbidity (CCI ?4 versus 0: adjusted RR 0.61, 95% CI 0.39-0.95) with a trend towards decreased follow-up among those with limited life expectancy (adjusted RR 0.69, 95% CI 0.48-1.01). However, we detected an interaction effect with nodule size such that comorbidity and life expectancy were associated with decreased follow-up only among those with nodules ?6 mm.

Conclusions

We found some individualization of pulmonary nodule follow-up according to comorbidity and life expectancy in older veterans with smaller nodules only. As increased imaging detects nodules in sicker patients, guidelines need to be more explicit about how to best incorporate comorbidity and life expectancy to maximize benefits and minimize harms for patients with nodules of all sizes.

SUBMITTER: Wong ML

PROVIDER: S-EPMC6059441 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Publications

Age, comorbidity, life expectancy, and pulmonary nodule follow-up in older veterans.

Wong Melisa L ML Shi Ying Y Fung Kathy Z KZ Ngo Sarah S Elicker Brett M BM Brown James K JK Hiatt Robert A RA Tang Victoria L VL Walter Louise C LC

PloS one 20180725 7

<h4>Background</h4>Pulmonary nodule guidelines do not indicate how to individualize follow-up according to comorbidity or life expectancy.<h4>Objectives</h4>To characterize comorbidity and life expectancy in older veterans with incidental, symptom-detected, or screen-detected nodules in 2008-09 compared to 2013-14. To determine the impact of these patient factors on four-year nodule follow-up among the 2008-09 subgroup.<h4>Design</h4>Retrospective cohort study.<h4>Setting</h4>Urban Veterans Affa ...[more]

PMID: 30044854

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Project description:ImportanceDespite guidelines recommending against prostate-specific antigen (PSA) screening in elderly men with limited life expectancy, PSA screening remains common.ObjectiveTo identify clinician characteristics associated with PSA screening rates in older veterans stratified by life expectancy.Design, setting, and participantsCross-sectional study of 826 286 veterans 65 years or older eligible for PSA screening who had VA laboratory tests performed in 2011 in the VA health care system.Main outcomes and measuresThe primary outcome was the percentage of men with a screening PSA test in 2011. Limited life expectancy was defined as age of at least 85 years with Charlson comorbidity score of 1 or greater or age of at least 65 years with Charlson comorbidity score of 4 or greater. Primary predictors were clinician characteristics including degree-training level, specialty, age, and sex. We performed log-linear Poisson regression models for the association between each clinician characteristic and PSA screening stratified by patient life expectancy and adjusted for patient demographics and clinician clustering.ResultsIn 2011, 466 017 (56%) of older veterans received PSA screening, including 39% of the 203 717 men with limited life expectancy. After adjusting for patient demographics, higher PSA screening rates in patients with limited life expectancy was associated with having a clinician who was an older man and was no longer in training. The PSA screening rates ranged from 27% for men with a physician trainee to 42% for men with an attending physician (P < .001); 22% for men with a geriatrician to 82% for men with a urologist as their clinician (P < .001); 29% for men with a clinician 35 years or younger to 41% for those with a clinician 56 years or older (P < .001); and 38% for men with a female clinician older than 55 years vs 43% for men with a male clinician older than 55 years (P < .001).Conclusions and relevanceMore than one-third of men with limited life expectancy received PSA screening. Men whose clinician was a physician trainee had substantially lower PSA screening rates than those with an attending physician, nurse practitioner, or physician assistant. Interventions to reduce PSA screening rates in older men with limited life expectancy should be designed and targeted to high-screening clinicians- older male, nontrainee clinicians-for greatest impact.

Dataset Information

Age, comorbidity, life expectancy, and pulmonary nodule follow-up in older veterans.

Background

Objectives

Design

Setting

Participants

Measurements

Results

Conclusions

Publications

Age, comorbidity, life expectancy, and pulmonary nodule follow-up in older veterans.

Similar Datasets

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