Pilot Study of a Patient Decision Aid for Valve Choices in Surgical Aortic Valve Replacement.

BACKGROUND: Objective superiority of tissue vs mechanical prostheses in surgical aortic valve replacement remains controversial, placing a greater emphasis on patients to consider personal lifestyle and risk preferences, including the burden of lifelong anticoagulation and the possible need for reoperation. A shared decision-making tool may therefore be of value in making this important choice. METHODS: A patient decision aid (PtDA) was developed using the International Patient Decision Aids Standards and used in a prospective pilot study. An intervention group received the PtDA and a survey. A control group received the same survey without a PtDA. The survey assessed patients' knowledge, treatment preferences, stage of decision-making, and decisional conflict. Both groups received these materials in the mail before their preoperative consultation for surgical aortic valve replacement. Survey results were compared between the 2 groups. RESULTS: Response rates were 13 of 17 (76%) and 10 of 18 (56%) for the control and intervention groups, respectively. Patients in the intervention group who reported reviewing the PtDA (n = 6) demonstrated significantly higher knowledge scores (median 100% vs 25%, P = .02) and were able to produce more accurate risk estimates (median 62.5% vs 0%, P = .01). These patients also had less decisional conflict, with median SURE scores (Sure of myself; Understand information; Risk-benefit ratio; Encouragement) of 4 vs 0 P = .04). Stage of decision-making, concern about risk,s and treatment preferences were similar CONCLUSIONS: Use of a PtDA for selection of valve type in surgical aortic valve replacement may improve patient understanding and decisional conflict. Revision of our tool and further studies are warranted to validate these findings in a large cohort of patients.

Educational intervention to reduce outpatient inappropriate echocardiograms: a randomized control trial.

OBJECTIVES: This study sought to prospectively study the impact of an appropriate use criteria (AUC)-based educational intervention on outpatient transthoracic echocardiography (TTE) ordering by physicians-in-training. BACKGROUND: AUC were developed in response to concerns about inappropriate utilization. It is unknown whether an educational intervention can reduce inappropriate outpatient TTE. METHODS: We conducted a randomized control trial in which physicians-in-training were randomized to an AUC-based educational intervention or a control group at an academic medical center in Boston, Massachusetts. The primary endpoints were the rates of inappropriate and appropriate TTE. RESULTS: For the cardiology physicians-in-training, the proportion of inappropriate TTE was significantly lower in the intervention than in the control group (13% vs. 34%, p < 0.001). As a corollary, the proportion of appropriate TTE ordered by the intervention group was significantly higher than that of the control group (81% vs. 58%, p < 0.001). The odds of ordering an appropriate TTE in the cardiology intervention group was 2.7 (95% confidence interval [CI]: 1.5 to 5.1, p = 0.002) relative to the control group. The internal medicine physicians-in-training ordered a small number of TTE overall, and there was a trend toward significant odds of ordering an appropriate TTE in the intervention group relative to the control group (odds ratio [OR]: 8.1, 95% CI: 0.95 to 69.0, p = 0.055). Six clinical scenarios accounted for 75% of all inappropriate TTE, with the 3 most common inappropriate indications being routine surveillance (<1 year) of known cardiomyopathy without a change in clinical status, routine surveillance of known small pericardial effusion, and routine surveillance of ventricular function with known coronary artery disease and no change in clinical status. CONCLUSIONS: In cardiology fellows with a high rate of ordering inappropriate TTE, an AUC-based educational and feedback intervention reduced the proportion of inappropriate outpatient TTE and increased the proportion of appropriate outpatient TTE. (Educational Intervention to Reduce Outpatient Inappropriate Transthoracic Echocardiograms; NCT01944202).

Educational intervention to reduce inappropriate transthoracic echocardiograms: the need for sustained intervention.

BACKGROUND: We previously demonstrated that an Appropriate Use Criteria (AUC)-based educational intervention reduced inappropriate transthoracic echocardiograms (TTE) on an inpatient medical service. Whether improved TTE ordering is sustained after discontinuation of the intervention is unknown. METHODS: We conducted a prospective, time series analysis of an educational intervention designed to reduce inappropriate TTE. Ordering patterns during the intervention were compared with a preintervention control period and a postintervention period. The goal of the present analysis was to determine the TTE ordering patterns after discontinuation of the educational intervention. The primary outcome was the proportion of inappropriate TTEs. RESULTS: Using the 2011 AUC 99.2% of all TTEs were classifiable. Compared to the control, there was a 26% reduction in the number of TTEs ordered per day during the intervention (3.9 vs. 2.9 TTEs, P < 0.001), but no significant difference between the intervention and postintervention periods (2.9 vs. 3.1, P = 0.23). The intervention produced a decrease in the inappropriate TTE rate and an increase in the appropriate TTE rate. Compared to the intervention, in the postintervention period the rate of inappropriate TTEs increased (5% vs. 11%, P = 0.01) and appropriate TTEs decreased (93% vs. 86%, P = 0.008). The postintervention rate of inappropriate TTEs was similar to the preintervention control period (11% vs. 13%, P = 0.23). CONCLUSIONS: Following completion of an AUC-based educational intervention the proportion of inappropriate TTEs increased to the preintervention level. The long-term success of an intervention designed to improve appropriate utilization of TTE requires a sustained effort of education and feedback.

An educational intervention reduces the rate of inappropriate echocardiograms on an inpatient medical service.

OBJECTIVES: This study sought to prospectively study the impact of an appropriate use criteria (AUC)-based educational intervention on transthoracic echocardiography (TTE) ordering among house staff on the inpatient general internal medicine service at an academic medical center. BACKGROUND: AUC for TTE were developed in response to concerns about inappropriate use of TTE. To date, educational interventions based on the AUC to reduce inappropriate use of TTE have not been prospectively studied. METHODS: A prospective, time series analysis of an educational intervention was conducted and then compared with TTE ordering on the same medical service during a control period. The intervention consisted of: 1) a lecture to house staff on the 2011 AUC for TTE; 2) a pocket card that applied the AUC to common clinical scenarios; and 3) biweekly e-mail feedback regarding ordering behavior. TTE ordering was tracked over the intervention period on a daily basis and feedback reports were e-mailed at 2-week intervals. The primary outcome was the proportion of inappropriate and appropriate TTE ordered during the intervention period. RESULTS: Of all TTEs ordered in the control and study periods, 99% and 98%, respectively, were classifiable using the 2011 AUC. During the study period, there was a 26% reduction in the number of TTE ordered per day compared with the number ordered during the control period (2.9 vs. 3.9 TTE, p < 0.001). During the study period, the proportion of inappropriate TTE was significantly lower (5% vs. 13%, p < 0.001) and the proportion of appropriate TTE was significantly higher (93% vs. 84%, p < 0.001). CONCLUSIONS: A simple educational intervention produced a significant reduction in the proportion of inappropriate TTE and increased the proportion of appropriate TTE ordered on an inpatient academic medical service. This study provides a practical approach for using the AUC to reduce the number of inappropriate TTE. Further study in other practice environments is warranted.

Impact of Medicare Part D on osteopathic physicians.

CONTEXT: Although there is a wealth of information for patients and physicians on the Medicare Prescription Drug, Improvement, and Modernization Act, little research exists related to its impact on osteopathic physicians (DOs). OBJECTIVE: To examine the impact of Medicare's prescription drug benefit-or Part D-on DOs and their practices. METHODS: Two electronic surveys regarding Medicare Part D were e-mailed to DOs randomly selected from the American Osteopathic Association database. The first survey was sent January 31, 2006 (within the first month of Part D implementation), and the second was sent June 1, 2006 (6 months after implementation). Both surveys focused primarily on the challenges experienced by DOs and their staff regarding Part D. Responses were subjected to univariate, bivariate, and Pearson product moment correlation analysis. RESULTS: Of the 10,000 DOs contacted, 603 (6%) responded and met inclusion criteria for the first survey and 343 (3.4%) for the second survey. More than 60% of respondents to the first survey reported challenges such as increased workload, difficulties understanding Part D, difficulties with the physician appeals process, and lack of information and education. These challenges were also reported in the second survey but by approximately 30% fewer respondents. One challenge-changing medications as a result of formulary restrictions-was reported by 17% more respondents to the second survey (P<.01). Respondents in primary care, solo practice, and rural areas as well as those treating large Medicare populations and those who were their patients' primary source of information about Part D reported more challenges. CONCLUSION: Considering the numerous challenges respondents faced with Part D, it is important to remember the role of physicians in successfully implementing healthcare programs, particularly as the US healthcare reform debate progresses.

Pulmonary thromboembolism in American Indians and Alaskan Natives.

BACKGROUND: The rate of diagnosis of deep venous thrombosis and/or pulmonary embolism (collectively, venous thromboembolism: VTE) among patients discharged from Indian Health Service hospital care from 1980 through 1996 was considerably lower than rates reported in African Americans or whites. Expansion of the national census in 1990 to include American Indians and Alaskan Natives permits a more in-depth examination of this issue. METHODS: Combined data from the National Hospital Discharge Survey (nonfederal hospitals) and the Indian Health Service (federal hospitals) from 1996 through 2001 were used to evaluate the rate of diagnosis of VTE in American Indians and Alaskan Natives. RESULTS: The diagnosis of VTE in American Indians and Alaskan Natives, based on combined data from the National Hospital Discharge Survey and the Indian Health Service was 71 per 100,000 per year compared with 155 per 100,000 per year in African Americans (P<.001) and 131 per 100,000 per year in whites (P<.001). The rate ratio comparing the rate of diagnosis of VTE in American Indians and Alaskan Natives with African Americans was 0.46 (95% confidence interval, 0.45-0.47) and comparing American Indians and Alaskan Natives with whites it was 0.54 (95% confidence interval, 0.53-0.55). CONCLUSIONS: The observed relatively low incidence of VTE in American Indians and Alaskan Natives would seem to be due to as yet undetermined genetic factors. The possibility that American Indians and Alaskan Natives have different lifestyles that affect the rate of diagnosis of VTE cannot be excluded.

Pulmonary thromboembolism in Asians/Pacific Islanders in the United States: analysis of data from the National Hospital Discharge Survey and the United States Bureau of the Census.

PURPOSE: To assess the rate of diagnosis of deep venous thrombosis, pulmonary embolism, and venous thromboembolism; the incidence in hospitalized patients; and mortality from pulmonary embolism among Asians/Pacific Islanders in the United States. METHODS: The number of patients discharged from hospitals with a diagnostic code for pulmonary embolism or deep venous thrombosis from 1990 through 1999 was obtained from the National Hospital Discharge Survey. Population estimates and deaths from pulmonary embolism from 1990 through 1998 were obtained from the United States Bureau of the Census. RESULTS: Rate ratios of 10-year age-adjusted rates of diagnosis of deep venous thrombosis, pulmonary embolism, and venous thromboembolism comparing Asians/Pacific Islanders with whites and African Americans ranged from 0.16 to 0.21. Rate ratios comparing incidences in hospitalized patients ranged from 0.32 to 0.42. The age-adjusted rate ratio of mortality in "others" (which included Asians/Pacific Islanders) was 0.29 (95% confidence interval [CI]: 0.01 to 0.87) compared with whites and 0.14 (95% CI: 0.0 to 0.58) compared with African Americans. CONCLUSION: Rates of deep venous thrombosis, pulmonary embolism, and venous thromboembolism; incidences in hospitalized patients; and the mortality rate from pulmonary embolism were markedly lower in Asians/Pacific Islanders than in whites and African Americans. Clinical assessment of the prior probability of venous thromboembolic disease at the bedside should probably be adjusted based on these ethnic differences.