Publications by authors named "Shehzad K Niazi"

21 Publications

  • Page 1 of 1

Choosing and Using Patient-Reported Outcome Measures in Clinical Practice.

Arch Phys Med Rehabil 2021 Mar 10. Epub 2021 Mar 10.

Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.

The increasing use of patient-reported outcome (PRO) measures is forcing clinicians and health care systems to decide which to select and how to incorporate them into their records and clinical workflows. This overview addresses three topics related to these concerns. First, a literature review summarizes key psychometric and practical factors (such as reliability, responsiveness, computer adaptive testing, and interpretability) in choosing PROs for clinical practice. Second, three clinical decision support (CDS) issues are highlighted: gathering PROs, electronic health record impact on providers, and incorporating PROs into CDS design and implementation. Lastly, the salience of cross-cutting domains as well as nine key pragmatic decisions are reviewed. Cross-cutting domains are those that are relevant across most medical and mental health conditions, such as the SPADE symptom pentad (sleep problems, pain, anxiety, depression, and low energy/fatigue) and physical functioning. The nine pragmatic decisions include: 1) generic vs. disease-specific scales; 2) single- vs. multi-domain scales; 3) universal scales vs. user-choice selection; 4) number of domains to measure; 5) prioritization of domains when multiple domains are assessed; 6) action thresholds; 7) clinical purpose (screening vs. monitoring); as well as the 8) frequency and 9) logistical aspects of PRO administration.
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http://dx.doi.org/10.1016/j.apmr.2020.12.033DOI Listing
March 2021

Mental Health and Chemical Dependency Services at US Cancer Centers.

J Natl Compr Canc Netw 2021 Mar 4:1-10. Epub 2021 Mar 4.

1Department of Psychiatry & Psychology.

Background: It is standard of care and an accreditation requirement to screen for and address distress and psychosocial needs in patients with cancer. This study assessed the availability of mental health (MH) and chemical dependency (CD) services at US cancer centers.

Methods: The 2017-2018 American Hospital Association (AHA) survey, Area Health Resource File, and Centers for Medicare & Medicaid Services Hospital Compare databases were used to assess availability of services and associations with hospital-level and health services area (HSA)-level characteristics.

Results: Of 1,144 cancer centers surveyed, 85.4% offered MH services and 45.5% offered CD services; only 44.1% provided both. Factors associated with increased adjusted odds of offering MH services were teaching status (odds ratio [OR], 1.76; 95% CI, 1.18-2.62), being a member of a hospital system (OR, 2.00; 95% CI, 1.31-3.07), and having more beds (OR, 1.04 per 10-bed increase; 95% CI, 1.02-1.05). Higher population estimate (OR, 0.98; 95% CI, 0.97-0.99), higher percentage uninsured (OR, 0.90; 95% CI, 0.86-0.95), and higher Mental Health Professional Shortage Area level in the HSA (OR, 0.99; 95% CI, 0.98-1.00) were associated with decreased odds of offering MH services. Government-run (OR, 2.85; 95% CI, 1.30-6.22) and nonprofit centers (OR, 3.48; 95% CI, 1.78-6.79) showed increased odds of offering CD services compared with for-profit centers. Those that were members of hospital systems (OR, 1.61; 95% CI, 1.14-2.29) and had more beds (OR, 1.02; 95% CI, 1.01-1.03) also showed increased odds of offering these services. A higher percentage of uninsured patients in the HSA (OR, 0.92; 95% CI, 0.88-0.97) was associated with decreased odds of offering CD services.

Conclusions: Patients' ability to pay, membership in a hospital system, and organization size may be drivers of decisions to co-locate services within cancer centers. Larger organizations may be better able to financially support offering these services despite poor reimbursement rates. Innovations in specialty payment models highlight opportunities to drive transformation in delivering MH and CD services for high-need patients with cancer.
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http://dx.doi.org/10.6004/jnccn.2020.7657DOI Listing
March 2021

Impact of County Health Rankings on Nationwide Liver Transplant Outcomes.

Transplantation 2020 Nov 24. Epub 2020 Nov 24.

Department of Psychiatry & Psychology, Mayo Clinic, Jacksonville, Florida Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, Florida Department of Health Sciences Research, Mayo Clinic, Jacksonville, Florida Department of Transplantation, Mayo Clinic, Jacksonville, Florida Department of Psychiatry & Psychology, Mayo Clinic, Rochester, Minnesota.

Background: There is limited information concerning whether social determinants of health affect postliver transplant (LT) outcomes. This study aims to understand to what extent the health of LT recipients' counties of residence influence long-term LT outcomes.

Methods: We used the United Network for Organ Sharing data to identify adult LT recipients transplanted between January 2010 and June 2018. Patient-level data were matched to county-level County Health Ranking data using transplant recipient zip code, and nationwide County Health Rankings were created. Mixed-effects Cox proportional hazards models were used to examine associations between County Health Rankings and graft and patient survival post-LT.

Results: Health Outcomes rank was significantly associated with posttransplant graft and patient survival, with worst tertile counties showing a 13% increased hazard of both graft failure and patient mortality compared to best tertile counties.

Conclusions: Although county health is associated with LT outcomes, it also appears that LT recipient selection is effective at mitigating major disparities based on county of residence and helps yield equitable outcomes in this respect.
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http://dx.doi.org/10.1097/TP.0000000000003557DOI Listing
November 2020

Intensive Multicomponent Fibromyalgia Treatment: A Translational Study to Evaluate Effectiveness in Routine Care Delivery.

J Clin Rheumatol 2020 Sep 4. Epub 2020 Sep 4.

Division of Rheumatology.

Objective: The current study was designed to evaluate the translation of clinical trial outcomes and clinical guidelines for the treatment of fibromyalgia (FM) into an intensive multicomponent clinical program embedded in routine care delivery. The study aimed to assess the adaptation of these recommended strategies into routine clinical care while evaluating their effectiveness and durability in improving functional status and level of distress in a large clinical sample of FM patients.

Methods: Four hundred eighty-nine patients with FM completed a 2-day program that incorporated best practice recommendations for the treatment of FM. Patients completed the Fibromyalgia Impact Questionnaire-Revised, the Center for Epidemiologic Studies Depression Scale, and the Pain Catastrophizing Scale at admission to the program and at follow-up on average 5 months posttreatment.

Results: Significant improvements were seen in functional status (p < 0.0001), depressive symptoms (p < 0.0001), and pain catastrophizing (p < 0.0001) after participation in the intensive multicomponent treatment program.

Conclusions: The present study shows that an intensive multicomponent treatment program embedded in routine care delivery is effective in significantly improving functional status and psychological distress in a large sample of FM patients. The significant improvements were durable and maintained at follow-up.
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http://dx.doi.org/10.1097/RHU.0000000000001555DOI Listing
September 2020

Opioid Use in Fibromyalgia Continues Despite Guidelines That Do Not Support Its Efficacy or Risk.

J Clin Rheumatol 2020 Feb 6. Epub 2020 Feb 6.

From the Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL.

Background/objective: The aim of this cross-sectional study is to determine the prevalence of opioid use in a large sample of fibromyalgia (FM) patients and examine the factors associated with opioid prescription/use despite multiple clinical guidelines that do not recommend opioid use in this population.

Methods: Data were collected from a convenience sample of 698 patients admitted from August 2017 to May 2019 into an intensive 2-day Fibromyalgia Treatment Program at a tertiary medical center in the United States after FM diagnosis. Patients were administered the Fibromyalgia Impact Questionnaire-Revised, the Center for Epidemiologic Study of Depression Scale, and the Pain Catastrophizing Scale upon admission to the program. Demographic information and opioid use were self-reported. Logistic regression analysis was utilized to determine associations between patient-related variables and opioid use in this prospective study.

Results: Of 698 patients, 27.1% (n = 189) were taking opioids at intake. Extended duration of symptoms (>3 years), increased age, higher degree of functional impairment, and increased pain catastrophizing were significantly associated with opioid use.

Conclusions: Opioids are not recommended for the treatment of FM under current guidelines. Greater burden of illness appeared to be associated with the prescription and use of opioids in this population. These findings suggest that some providers may not be aware of current recommendations that have been found to be effective in the management of FM that are contained in guidelines. Alternative approaches to the management of FM that do not involve opioids are reviewed in an effort to improve care.
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http://dx.doi.org/10.1097/RHU.0000000000001273DOI Listing
February 2020

Impact of Psychiatric Comorbidities on Health Care Costs Among Patients With Cancer.

Psychosomatics 2020 Mar - Apr;61(2):145-153. Epub 2019 Nov 6.

Department of Psychiatry and Psychology, Mayo Clinic, Jacksonville, FL; Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN.

Background: Psychiatric disorders are common in cancer patients and impact outcomes. Impact on cancer care cost needs study to develop business case for psychosocial interventions.

Objective: To evaluate the impact of preexisting psychiatric comorbidities on total cost of care during 6 months after cancer diagnosis.

Methods: This retrospective cohort study examined patients diagnosed with cancer between January 1, 2009, and December 31, 2014, at one National Cancer Institute-designated cancer center. Patients who received all cancer treatment at the study site (6598 of 11,035 patients) were included. Patients were divided into 2 groups, with or without psychiatric comorbidity, based on International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes. Total costs of care during the first 6 months of treatment were based on standardized costs adjusted to 2014 dollars, determined by assigning Medicare reimbursement rates to professional billed services and applying appropriate cost-to-charge ratios. Quantile regression models with covariate adjustments were developed to assess the effect of psychiatric comorbidity across the distribution of costs.

Results: Six hundred ninety-eight (10.6%) of 6598 eligible patients had at least one psychiatric comorbidity. These patients had more nonpsychiatric Elixhauser comorbidities (mean 4 vs. 3). Unadjusted total cancer care costs were higher for patients with psychiatric comorbidity (mean [standard deviation]: $51,798 [$74,549] vs. $32,186 [$45,240]; median [quartiles]: $23,871 [$10,705-$57,338] vs. $19,073 [$8120-$38,230]). Quantile regression models demonstrated that psychiatric comorbidity had significant incremental effects at higher levels of cost: 75th percentile $8629 (95% confidence interval: $3617-13,642) and 90th percentile $42,586 (95% confidence interval: $25,843-59,330).

Conclusions: Psychiatric comorbidities are associated with increased total cancer costs, especially in patients with very high cancer care costs, representing an opportunity to develop mitigation strategies.
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http://dx.doi.org/10.1016/j.psym.2019.10.010DOI Listing
February 2021

Feasibility Study of Three-Phase Implementation of International Consortium for Health Outcomes Measurement Depression and Anxiety Standard Set in an Outpatient Consultation-Liaison Psychiatry Practice.

Psychosomatics 2020 Jan - Feb;61(1):8-18. Epub 2019 Aug 28.

Department of Psychiatry and Psychology, Mayo Clinic Florida, Jacksonville, FL.

Objective: We describe a three-phase implementation of the International Consortium for Health Outcomes Measurement Depression and Anxiety Standard Set in a Consultation-Liaison Psychiatry practice.

Methods: During the preintervention phase, we reviewed patient-reported outcome tools and engaged stakeholders and leadership. During phase 1, the standard set was converted into an electronic previsit intake assessment that was implemented in a physician champion's practice. Patients completed the intake on a tablet, and computer adaptive testing was used to reduce response burden. Physician-facing data display facilitated use during subsequent in-person visits. An electronic version of the follow-up standard set was used during follow-up visits. During phase 2, a second physician tested scalability and the intervention was disseminated department wide in phase 3.

Results: During phase 1, 186 intakes and 67 follow-up electronic patient-reported outcome sets were completed. Average patient age was 54 years, and 44% were male. On average, patients ranked the tool 4.4 out of 5 and spent 22 minutes completing the intake. Time-driven activity-based costing found the new process to be cost-effective. During phase 2, 386 patients completed electronic patient-reported outcome sets, with 315 follow-up visits. Patients ranked the tool as 4.0 out of 5 and spent 26 minutes completing the questions. During phase 3, 2166 patients completed intake electronic patient-reported outcome sets and 1249 follow-up visits. Patients ranked the tool 4.3 out of 5 and spent 26 minutes on it. Scores and completion time did not differ greatly between phases.

Conclusions: Integration of the International Consortium for Health Outcomes Measurement Depression and Anxiety Standard Set is feasible. Future research comparing International Consortium for Health Outcomes Measurement set with other approaches and in different settings is needed.
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http://dx.doi.org/10.1016/j.psym.2019.08.006DOI Listing
January 2021

Mental health and chemical dependency services at US transplant centers.

Am J Transplant 2020 04 1;20(4):1152-1161. Epub 2019 Dec 1.

Department of Transplantation, Mayo Clinic, Jacksonville, Florida.

The purpose of this study was to assess the availability of mental health (MH) and chemical dependency (CD) services at US transplant centers, because appropriate psychosocial assessment and care is associated with better transplant outcomes. We used the 2017-2018 American Hospital Association survey, Area Health Resource File, and Centers for Medicare & Medicaid Services Hospital Compare databases to quantify availability of services and examined associations of hospital- and health services area-level characteristics with odds of offering services with generalized linear mixed models. We found that 15% of transplant centers did not offer MH services and 62% did not offer CD services. Hospitals were more likely to offer MH services if they were larger (OR [95% CI]: 1.03 [1.01, 1.06]) and had a lower rate of uninsured patients in the health services area (OR [95% CI]: 0.89 [0.80, 0.99]) and were more likely to offer CD services if they were larger (OR [95% CI]: 1.02 [1.01, 1.03]) or were members of a system (OR [95% CI]: 2.31 [1.26, 4.24]). Additional research is needed to understand whether lack of MH or CD services at transplant centers affects patients' ability to access comprehensive psychosocial care and whether this affects patient outcomes.
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http://dx.doi.org/10.1111/ajt.15659DOI Listing
April 2020

Effects of a multidisciplinary quality of life intervention on sleep quality in patients with advanced cancer receiving radiation therapy.

Palliat Support Care 2020 06;18(3):307-313

Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN.

Objectives: Sleep disturbances are prevalent in cancer patients, especially those with advanced disease. There are few published intervention studies that address sleep issues in advanced cancer patients during the course of treatment. This study assesses the impact of a multidisciplinary quality of life (QOL) intervention on subjective sleep difficulties in patients with advanced cancer.

Method: This randomized trial investigated the comparative effects of a multidisciplinary QOL intervention (n = 54) vs. standard care (n = 63) on sleep quality in patients with advanced cancer receiving radiation therapy as a secondary endpoint. The intervention group attended six intervention sessions, while the standard care group received informational material only. Sleep quality was assessed using the Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS), administered at baseline and weeks 4 (post-intervention), 27, and 52.

Results: The intervention group had a statistically significant improvement in the PSQI total score and two components of sleep quality and daytime dysfunction than the control group at week 4. At week 27, although both groups showed improvements in sleep measures from baseline, there were no statistically significant differences between groups in any of the PSQI total and component scores, or ESS. At week 52, the intervention group used less sleep medication than control patients compared to baseline (p = 0.04) and had a lower ESS score (7.6 vs. 9.3, p = 0.03).

Significance Of Results: A multidisciplinary intervention to improve QOL can also improve sleep quality of advanced cancer patients undergoing radiation therapy. Those patients who completed the intervention also reported the use of less sleep medication.
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http://dx.doi.org/10.1017/S1478951519000750DOI Listing
June 2020

Liver Transplant Recipients Older Than 60 Years Show Executive and Memory Function Improvement Comparable to Younger Recipients.

Psychosomatics 2019 Sep - Oct;60(5):488-498. Epub 2019 Jan 23.

Department of Psychiatry & Psychology, Mayo Clinic, Jacksonville, FL; Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL. Electronic address:

Background: Increasing numbers of patients over the age of 60 are undergoing liver transplantation.

Objective: We sought to determine whether age or clinical morbidities were associated with pre- and post-transplant executive and memory performance using the Brief Test of Adult Cognition by Telephone (BTACT).

Methods: Participants included 36 recipients with n = 20 in the older group (>60 y) and n = 16 in the younger group (≤60 years). The BTACT was administered an average of 3 months before transplant, and at follow-up post-transplant intervals of 3, 6, and 9 months. BTACT composite scores for memory and executive function with age and education norms were obtained.

Results: Older recipients were more likely to have hepatocellular carcinoma, a lower biological MELD score at transplant, less cellular rejection, and fewer post-operative hospital days. Older and younger recipients showed comparable pre-transplant executive and memory function and comparable post-transplant improvement. Both older and younger patients showed statistically significant improvement in executive function scores at 3 months post-transplant and maintained improvement at 6 and 9 months. Memory function improved significantly in older patients by 6 months post-transplant but did not improve significantly in the younger group.

Conclusion: Older liver transplant recipients were more likely to have hepatocellular carcinoma and a lower biological MELD score than younger recipients, but both age groups showed comparable pre-transplant cognitive performance and post-transplant cognitive improvement. Additionally, a normed telephone test can be used to effectively screen and track executive and memory function post-transplant.
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http://dx.doi.org/10.1016/j.psym.2019.01.008DOI Listing
July 2020

Psychosocial Risk Impacts Mortality in Women After Liver Transplantation.

Psychosomatics 2019 Jan - Feb;60(1):56-65. Epub 2018 Jun 27.

Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN; Department of Psychiatry & Psychology, Mayo Clinic, Jacksonville, FL.

Background: Liver transplant candidates undergo psychosocial assessment as a component of their pretransplant evaluation. Global psychosocial assessment scales, including the Psychosocial Assessment of Candidates for Transplantation (PACT), capture and quantify these psychiatric and social variables.

Objective: Our primary aim was to assess for an association between global PACT score and survival in liver transplant recipients.

Methods: This retrospective cohort study examined records of all liver recipients at one U.S. Transplant Center from 2000 to 2012 with outcomes monitoring until 07/01/2016. We investigated for associations between the following variables and mortality: PACT score, age, gender, marital status, race, alcoholic liver disease (ALD), and body mass index (BMI). Statistical methods included Student's t-test, Wilcoxon rank sum test, chi-square, Fisher's exact test, Kaplan-Meier curve, and Cox proportional hazard models.

Results: Of 1040 liver recipients, 538 had a documented PACT score. Among these, PACT score was not associated with mortality. In women, a lower PACT score was associated with mortality (p = 0.003) even after adjustments for age, marital status, and BMI. Women with ALD had a 2-fold increased hazard of death (p = 0.012). Increasing age was associated with increased risk of death for the cohort as a whole (p = 0.019) and for men (p = 0.014). In men, being married and BMI were marginally protective (p = 0.10 and p = 0.13, respectively).

Conclusions: Transplant psychosocial screening scales, specifically the PACT, identify psychosocial burden and may predict post-transplant outcomes in certain populations. In female liver recipients, lower PACT scores and ALD were associated with a greater risk of post-transplant mortality.
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http://dx.doi.org/10.1016/j.psym.2018.06.008DOI Listing
August 2019

Psychosocial Risk Predicts New Episode Depression After Heart Transplant.

Psychosomatics 2019 Jan - Feb;60(1):47-55. Epub 2018 Jun 14.

Department of Psychiatry & Psychology, Mayo Clinic, Rochester, MN; Department of Psychiatry & Psychology, Mayo Clinic, Jacksonville, FL.

Background: Psychosocial assessment is an essential component of the pretransplant evaluation. Many individuals have significant psychosocial problems, and they are either denied for transplantation or deferred from listing and transplant until the psychosocial issues are addressed.

Objective: The primary aim of this study was to evaluate the outcomes of patients who initially had significant psychosocial problems, but who addressed them and received a heart transplant.

Methods: This retrospective study included heart transplant recipients from 1/1/2000 to 12/31/2012. Those with initial Psychosocial Assessment of Candidates for Transplantation (PACT) scale score <2 were compared with those whose initial score was ≥2 for the variables new onset depression and anxiety, length of stay, rejection, and survival using logistic and linear regression and Cox proportional hazards modeling.

Results: Of 164 heart recipients with pretransplant PACT scores, 46 (28%) were female, 154 (94%) were white, and the mean age was 52.7 years. Only 11 (7%) received an initial PACT score <2; these candidates underwent heart transplantation after their scores increased to ≥2. Initial PACT <2 increased the odds of new depression by 11-fold (p = 0.002), but was not associated with differences in survival, posttransplant length of stay, the occurrence of treated episodes of rejection or new anxiety (p ≥ 0.20 for all).

Conclusion: Among heart recipients, initially high pretransplant psychosocial risk, as assessed by PACT, was associated with posttransplant new episode depression. However, after addressing the primary psychosocial issues before transplant, posttransplant length of stay, organ rejection, and survival were the same as those without prior psychosocial concerns.
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http://dx.doi.org/10.1016/j.psym.2018.06.003DOI Listing
August 2019

Impact of psychiatric comorbidities on outcomes of elderly liver transplant recipients.

J Psychosom Res 2018 08 17;111:27-35. Epub 2018 May 17.

Department of Transplantation, Mayo Clinic, Jacksonville, FL, United States.

Objectives: This study evaluated the impact of psychiatric comorbidities in liver transplant (LT) recipients aged ≥65 years (elderly) on length of hospital-stay (LOS), death, and a composite outcome of graft loss or death.

Methods: This retrospective study assessed impact of psychiatric comorbidities in 122 elderly LT recipients and a matched group of 122 LT recipients aged <65 years (younger). Associations were assessed using adjusted multivariable regression models.

Results: Among elderly, median age at LT was 68 years, most were males (62%), white (85%) and 61.7% had a history of any psychiatric diagnosis. Among younger, median age was 55, most were males (67.2%), white (77.5%) and 61.5% had any psychiatric diagnosis. Median LOS was 8 days for both groups. Among elderly, after a median follow-up of 5 years, 25.4% died and 29.5% experienced graft loss or death. History of adjustment disorder, history of depression, past psychiatric medication use, and pain prior to LT were associated with an increased risk of death or the composite graft loss or death. Perioperative use of SSRIs and lack of sleeping medication use were associated with longer LOS. Among aged <65, after median follow-up of 4.7 years, 21 patients (17%) died and 25 (20%) experienced graft loss or death; history of depression, perioperative SSRIs or sleeping medications use was associated with increased mortality and graft-loss or death.

Conclusion: Six out of 10 patients among both elderly and younger cohorts had pre-LT psychiatric comorbidities, some of which adversely affected outcomes after LT.
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http://dx.doi.org/10.1016/j.jpsychores.2018.05.005DOI Listing
August 2018

Correlation of sociodemographic and clinical parameters with depression and distress in patients with hematologic malignancies.

Ann Hematol 2018 Mar 7;97(3):519-528. Epub 2017 Dec 7.

Department of Hematology-Oncology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.

A quarter of cancer patients struggle with distress or depression during their illness. Multiple organizations including the National Comprehensive Cancer Network recommend universal screening for distress and depression. Herein, we describe a universal screening program in patients with hematologic malignancies and factors associated with distress and depression. Between December 2013 and February 2015, patients with hematologic malignancies took the Patient Health Questionnaire 9 (PHQ-9) and Distress Thermometer (DT) prior to receiving their first outpatient parenteral chemotherapy. Patient demographic information as well as information regarding visit burden and baseline use of psychiatric medications were recorded. A PHQ-9 score of ≥ 9 and a DT score ≥ 4 suggested a high risk of major depression and distress. Intergroup comparisons of categorical and continuous variables were performed via chi-square and Wilcoxon rank-sum tests. Multivariate models were constructed using the stepwise selection technique using all potential variables. Two hundred forty-six patients with a median age at diagnosis 65 years (range 18-94 years) were included. In the multivariate analysis, a PHQ-9 score ≥ 9 was associated with living alone (P = 0.007), positive PHQ-2 (P = 0.003), and high Charlson comorbidity index (CCI; P = 0.02), while a DT score ≥ 4 was associated with being married (P = 0.03) and female (P = 0.03). There was no other association with high scores on either questionnaire. Patients with hematologic malignancies often have prolonged treatment and surveillance. We identified subpopulations within this group who may be at high risk of developing distress and depression and who should be aggressively screened even when universal screening programs are not available.
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http://dx.doi.org/10.1007/s00277-017-3198-0DOI Listing
March 2018

Alcoholic hepatitis: appropriate indication for liver transplantation?

Curr Opin Organ Transplant 2017 Dec;22(6):578-583

aDepartment of Psychiatry and Psychology bWilliam J. von Liebig Transplant Center cDepartment of Psychiatry and Psychology, Jacksonville, Florida dDivision of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Purpose Of Review: The majority of liver transplantation centers have required patients with alcohol-induced liver disease to demonstrate a period of abstinence (generally 6 months' duration) to qualify for transplant listing. This requirement has excluded patients with alcoholic hepatitis from transplant consideration. Since 2011, several studies have examined the outcomes of patients undergoing liver transplantation with brief abstinence as a lifesaving intervention for alcoholic hepatitis. This review includes each of the recent studies and discusses their implications for general transplant practice.

Recent Findings: A Medical Literature Analysis and Retrieval System search revealed five published studies - three prospective and two retrospective - pertaining to liver transplantation for alcoholic hepatitis. Among patients with medication-nonresponsive alcoholic hepatitis, those who underwent transplantation had superior survival. Liver recipients with alcoholic hepatitis had comparable survival to those with 6 or more months of abstinence. Their relapse rates were not statistically different in the short term over those transplanted with longer abstinence, although some patients in each prospective cohort relapsed to drinking despite narrow inclusion criteria and extensive pretransplant staff reviews and posttransplant surveillance.

Summary: Liver transplantation is a reasonable treatment consideration for highly selective cases of alcoholic hepatitis. Further research is needed to refine inclusion criteria, address posttransplant relapse prevention interventions, and monitor long-term outcomes.
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http://dx.doi.org/10.1097/MOT.0000000000000468DOI Listing
December 2017

Patient-reported distress and survival among patients receiving definitive radiation therapy.

Adv Radiat Oncol 2017 Apr-Jun;2(2):211-219. Epub 2017 Mar 20.

Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida.

Objective: Patient-reported distress (PRD) has not been well assessed in association with survival after radiation therapy (RT). The aims of this study were to evaluate the association between PRD level and survival after definitive RT and to identify the main causes of distress in definitive RT patients.

Methods And Materials: A total of 678 consecutive patients receiving definitive RT at our institution from April 2012 through May 2015 were included. All patients answered a PRD questionnaire that contained 30 items related to possible causes of distress, which could be rated from 1 (no distress) to 5 (high distress). Additionally, patients were asked to rate their overall distress level from 0 (no distress) to 10 (extreme distress). This overall distress level was our primary patient-reported distress measure and was examined as a continuous variable and as a categorical variable with 3 PRD levels (low, 0-3 [n = 295]; moderate, 4-6 [n = 222]; and high, 7-10 [n = 161]).

Results: As a continuous variable in multivariable Cox regression analysis, a higher overall PRD level was associated with poorer survival after RT (hazard ratio [HR], 1.39; = .004). As a categorical variable, compared with patients with low distress, survival was poorer for patients with moderate distress (HR, 1.62; = .038) or high distress (HR, 1.49; = .12), but the latter difference was not significant. When the moderate and high distress levels were combined, survival was significantly poorer compared with the low distress level (HR, 1.57; = .034). The top 5 specific causes of distress that patients mentioned were "How I feel during treatment," "Fatigue," "Out-of-pocket medical costs," "Pain that affects my daily functioning," and "Sleep difficulties."

Conclusions: PRD before or during RT is a prognostic factor associated with decreased survival. Distress screening guidelines and interventions should be implemented for patients receiving definitive RT.
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http://dx.doi.org/10.1016/j.adro.2017.03.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5514245PMC
March 2017

Caring for Patients With Chronic Physical and Mental Health Conditions: Lessons From TEAMcare and COMPASS.

Focus (Am Psychiatr Publ) 2017 Jul 12;15(3):279-283. Epub 2017 Jul 12.

Dr. Chauhan and Dr. Niazi are with the Department of Psychiatry and Psychology, Mayo Clinic Jacksonville, Jacksonville, Florida.

Depression is one of the leading causes of disability worldwide. It often coexists with other chronic conditions, contributing to poor self-management and subsequent poor health outcomes, increased service utilization and cost of care, and poor quality of life. Most patients with depression seek care in primary care settings. Patients given collaborative care for depression alone or for depression with commonly co-occurring general medical conditions have demonstrated improved outcomes. This article reviews findings from the TEAMcare (an integrated multicondition collaborative care program for chronic illnesses) and COMPASS (Care of Mental, Physical and Substance-Use Syndromes) programs to highlight the evidence supporting the effectiveness of the collaborative care model and its implementation in diverse settings.
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http://dx.doi.org/10.1176/appi.focus.20170008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6519546PMC
July 2017

The Psychosocial Assessment of Candidates for Transplantation: A Cohort Study of its Association With Survival Among Lung Transplant Recipients.

Psychosomatics 2016 Sep-Oct;57(5):489-97. Epub 2016 May 11.

Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN; William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN.

Background: The United Network for Organ Sharing mandates a psychosocial assessment of transplant candidates before listing. A quantified measure for determining transplant candidacy is the Psychosocial Assessment of Candidates for Transplant (PACT) scale. This instrument's predictive value for survival has not been rigorously evaluated among lung transplantation recipients.

Methods: We reviewed medical records of all patients who underwent lung transplantation at Mayo Clinic, Rochester from 2000-2012. A transplant psychiatrist had assessed lung transplant candidates for psychosocial risk with the PACT scale. Recipients were divided into high- and low psychosocial risk cohorts using a PACT score cutoff of 2. The main outcome variable was posttransplant survival. Mortality was analyzed using the Kaplan-Meier estimator and Cox proportional hazard models.

Results: This study included 110 lung recipients: 57 (51.8%) were females, 101 (91.8%) Whites, mean age: 56.4 years. Further, 7 (6.4%) recipients received an initial PACT score <2 (poor or borderline candidates) and later achieved a higher score, allowing transplant listing; 103 (93.6%) received initial scores ≥2 (acceptable, good or great candidates). An initial PACT score < 2 was modestly associated with higher mortality (adjusted hazard ratio = 2.73, p = 0.04).

Conclusions: Lung transplant recipients who initially received a low score on the PACT scale, reflecting poor or borderline psychosocial candidacy, experienced greater likelihood of mortality. This primary finding suggests that the psychosocial assessment, as measured by the PACT scale, may provide additional mortality risk stratification for lung transplant candidates.
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http://dx.doi.org/10.1016/j.psym.2016.05.003DOI Listing
August 2017

Essential articles on collaborative care models for the treatment of psychiatric disorders in medical settings: a publication by the academy of psychosomatic medicine research and evidence-based practice committee.

Psychosomatics 2014 Mar-Apr;55(2):109-22. Epub 2013 Dec 25.

Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA.

Background: Collaborative care interventions for psychiatric disorders combine several components integrated into the medical setting: (1) systematic psychiatric assessment, (2) use of a nonphysician care manager to perform longitudinal symptom monitoring, treatment interventions, and care coordination, and (3) specialist-provided stepped-care recommendations. Collaborative care interventions have now been evaluated in a wide spectrum of care settings and offer great promise as a way of increasing quality of patient care, improving health of populations, and reducing health care costs.

Methods: A systematic search of PubMed/MEDLINE databases was performed for publications between January 1970 and May 2013 to identify articles describing collaborative care and related interventions. Identified articles were then evaluated independently by multiple reviewers for quality and importance; additional articles were identified by searching reference lists and through recommendations of senior content-matter experts. The articles considered to be both of high quality and most important were then placed into categories and annotated reviews performed.

Results: Over 600 articles were identified of which 67 were selected for annotated review. The results reported in these articles indicate that collaborative care interventions for psychiatric disorders have been consistently successful in improving key outcomes in both research and clinical intervention studies; cost analyses also suggest that this model is cost effective.

Conclusions: Collaborative care models for psychiatric disorders are likely to serve an increasingly large role in health care given their effect on patient and population outcomes and their focus on integration of care.
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http://dx.doi.org/10.1016/j.psym.2013.09.002DOI Listing
June 2015

The status of physician health programs in Wisconsin and north central states: a look at statewide and health systems programs.

WMJ 2012 Oct;111(5):220-7

Marshfield Clinic, Marshfield, WI 54449, USA.

There is increased recognition of the importance of physician health and the need to actively maintain and promote it. Attending to the health and well-being of medical clinicians is considered an important component of professionalism, and is important for the sustainability of safe, high-quality practice of medicine. This report highlights the importance of physician health programs, describes their history and evolution as well as the variability in program structure in various states, and reviews the present status of physician health resources, especially in Wisconsin. It gives an example of a program within a large, integrated health system and emphasizes the advantages of a statewide program.
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October 2012