Perceptions of Futility in Interventional Radiology: A Multipractice Systematic Qualitative Analysis

PURPOSE

To characterize perceptions of palliative versus futile care in interventional radiology (IR) as a roadmap for quality improvement.

METHODS

Interventional radiologists (IRs) and referring physicians were recruited for anonymous interviews and/or focus groups to discuss their perceptions and experiences related to palliative verse futile care in IR. Sessions were recorded, transcribed, and systematically analyzed using dedicated software, content analysis, and grounded theory. Data collection and analysis continued simultaneously until additional interviews stopped revealing new themes: 24 IRs (21 males, 3 females, 1-39 years of experience) and 7 referring physicians (3 males, 4 females, 6-14 years of experience) were analyzed.

RESULTS

Many IRs (75%) perceived futility as an important issue. Years of experience (r = 0.60, p = 0.03) and being in academics (r = 0.62, p = 0.04) correlated with greater perceived importance. Perceptions of futility and whether a potentially inappropriate procedure was performed involved a balance between four sets of factors (patient, clinician, procedural, and cultural). These assessments tended to be qualitative in nature and are challenged by a lack of data, education, and consistent workflows. Referring clinicians were unaware of this issue and assumed IR had guidelines for differentiating between palliation and futility.

CONCLUSION

This study characterized the complexity and qualitative nature of assessments of palliative verses futile care in IR while highlighting potential means of improving current practices. This is important given the number of critically ill patients referred to IR and costs of potentially inappropriate interventions.

Efficacy of endovascular Z-configuration stenting for malignant versus nonmalignant caval obstruction

OBJECTIVE

The objective of this study was to assess factors associated with symptom resolution after endovascular stenting for superior or inferior vena cava syndrome.

METHODS

Eighty-six consecutive vena cava Z-configuration stent placements in 82 patients (53 ± 14 years old) at a single institution were reviewed for patient demographics, comorbidities, and durability of stent patency (also evaluated were persistent or recurrent symptoms, stent occlusion, and need for repeated stenting). Logistic regression was used to identify independent factors associated with stent patency, and Φ coefficients and analysis of variance were used to compare cases subdivided by lesion location (superior vena cava, inferior vena cava) and the presence or absence of malignant disease.

RESULTS

Clinical follow-up was available in 77 of 86 (90%) cases. Technical success with clinical failure (persistent symptoms) occurred in 40% of these cases with a median follow-up of 67 (interquartile range, 14-570) days and mortality rate of 63% during this period. Malignant obstructions had a significantly higher clinical failure rate of 54% compared with 15% for nonmalignant obstructions (Φ = 0.34; P = .002). However, only metastatic disease was independently associated with clinical failure when controlling for demographics, other comorbidities, and differential follow-up (adjusted odds ratio, 8.27; 95% confidence interval, 2.79-24.50).

CONCLUSIONS

Vena cava Z-stenting effectively resolves symptoms in 85% of nonmalignant obstructions compared with only 46% of malignant obstructions. Patients should be counseled accordingly, and those with malignant obstructions may require closer follow-up to evaluate the need for reintervention and goals of care.

Reflect and Remember: The Ethics of Complications in Interventional Radiology

Clinicians, particularly those in procedural specialties, tend to feel personally responsible when complications occur. Medical errors among surgeons have been studied and provide an insightful window into the ethics of complications. Ethically we must consider what we owe patient and families, ourselves, and our colleagues. To some degree, the answers are similar: reflection, confession, and resolution . We owe patients and families an explanation and lack of abandonment; we owe ourselves thoughtful reflection on what caused the complication and how we can learn from it; and we owe our colleagues assistance managing our complications and a chance to learn from our mistakes. As a specialty that prides itself on innovation and novel therapies, interventional radiology has a unique relationship with complications that has not been well developed. As the specialty grows, it will be important to provide forums for further understanding the ethical challenges in interventional radiology.

Reinforcing the Importance and Feasibility of Implementing a Low-dose Protocol for CT-guided Biopsies

RATIONALE AND OBJECTIVES

This study sought to more definitely illustrate the impact and feasibility of implementing a low-dose protocol for computed tomography (CT)-guided biopsies using size-specific dose estimates and multivariate analyses.

MATERIALS AND METHODS

Fifty consecutive CT-guided lung and extrapulmonary biopsies were reviewed before and after implementation of a low-dose protocol (200 patients total, mean age 61 ± 15 years, 128 women). Analyses of variance with Bonferroni correction were used to compare standard and low-dose protocols in terms of patient demographics, physician experience, target lesion size, total dose-length product, total acquisitions, size-specific dose estimate, signal-to-noise ratio, contrast-to-noise ratio, and lesion conspicuity ratings. All procedures were performed on the same 16-slice CT scanner.

RESULTS

Voluntary protocol adherence was 100% (lung) and 89% (extrapulmonary). The low-dose protocol achieved significantly lower total average dose-length product [(lung) 735.6 ± 599.4 mGy × cm to 252.1 ± 101.9 mGy × cm, P < .001; (extrapulmonary) 724.7 ± 545.0 mGy × cm to 392.9 ± 239.5 mGy × cm, P < .001] and size-specific dose estimate [(lung) 5.2 ± 0.8 mGy × cm to 4.3 ± 1.5 mGy, P < .001; (extrapulmonary) 10.1 ± 6.7 mGy to 6.5 ± 2.7 mGy, P < .001]. Only the change in protocol was independently associated with lower size-specific dose estimates when controlling for the other variables (P < .0001). This was achieved with no significant differences in signal-to-noise ratio, contrast-to-noise ratio, or lesion conspicuity.

CONCLUSIONS

Implementation of a low-dose protocol for CT-guided biopsies resulted in 21% and 36% of size-specific dose estimate reduction for lung and extrapulmonary biopsies, respectively, with excellent adherence. Interventional and body radiologists should implement low dose CT-guidance protocols aiming to improve patient safety.

Characterization of Thermally Activated Metalloenediyne Cytotoxicity in Human Melanoma Cells

Enediynes are a highly cytotoxic class of compounds. However, metallation of these compounds may modulate their activation, and thus their cytotoxicity. We previously demonstrated that cytotoxicity of two different metalloenediynes, including (Z)-N,N'-bis[1-pyridyl-2-yl-meth-(E)-ylidene]octa-4-ene-2,6-diyne-1,8-diamine] (PyED), is potentiated when the compounds are administered to HeLa cells during hyperthermia treatment at concentrations that are minimally or not cytotoxic at 37°C. In this study, we further characterized the concentration, time and temperature dependence of cytotoxicity of PyED on human U-1 melanoma cells. We also investigated the potential mechanisms by which PyED cytotoxicity is enhanced during hyperthermia treatment. Cell killing with PyED was dependent on concentration, temperature during treatment and time of exposure. Potentiation of cytotoxicity was observed when cells were treated with PyED at temperatures ≥39.5°C, and enhancement of cell killing increased with temperature and with increasing time at a given temperature. All cells treated with PyED were shown to have DNA damage, but substantially more damage was observed in cells treated with PyED during heating. DNA repair was also inhibited in cells treated with the drug during hyperthermia. Thus, potentiation of PyED cytotoxicity by hyperthermia may be due to enhancement of drug-induced DNA lesions, and/or the inhibition of repair of sublethal DNA damage. While the selective thermal activation of PyED supports the potential clinical utility of metalloenediynes as cancer thermochemotherapeutic agents, therapeutic gain could be optimized by identifying compounds that produce minimal toxicity at 37°C but which become activated and show enhancement of cytotoxicity within a tumor subjected to localized hyperthermic or thermal ablative treatment, or which might act as bifunctional agents. We thus also describe the development and initial characterization of a novel cofactor complex of PyED, platinated PyED (Pt-PyED). Pt-PyED binds to DNA-like cisplatin, and much like PyED, cytotoxicity is greatly enhanced after treatment with the drug at elevated temperatures. However, in contrast to PyED, Pt-PyED is only minimally cytotoxic at 37°C, at concentrations at which cytotoxicity is enhanced by hyperthermia. Further development of cisplatin-based enediynes may result in compounds which, when activated, will possess multiple DNA binding modalities similar to cisplatin, but produce less side effects in tissues at normothermic temperatures.

Perceptions of Quality in Interventional Oncology

PURPOSE

To inductively characterize perceptions of quality in interventional oncology (IO) based on values and experiences of patients and referring providers.

MATERIALS AND METHODS

Brief ethnographic interviews were completed with referring providers and patients before and after a variety of liver-directed procedures about their experiences, concerns, and perceptions of IO services at a single institution. Constructivist grounded theory was used to systematically analyze interview transcripts for themes until thematic saturation was achieved. All transcripts were analyzed by a reviewer with 3-years of experience performing such analyses, and 50% were randomly selected to be coded by 2 additional blinded reviewers. Interreviewer agreement was assessed via Cohen κ.

RESULTS

Interviews with 22 patients (mean age, 65 y ± 13; 9 women) and 12 providers (mean age, 54 y ± 9; 6 women) were required to reach and confirm thematic saturation. Interreviewer agreement for interview themes was excellent (κ = 0.78; P < .001). Perceptions of high-quality IO care relied on interventional radiologists being responsive, friendly, and open; engaging in multidisciplinary collaboration; having thoughtful, dedicated support staff; and facilitating well-coordinated care after procedures and follow-up more than technical expertise and periprocedural comfort. Patient and provider perceptions of quality differed, but disjointed care after procedures was the most common critique among both groups.

CONCLUSIONS

An inductive qualitative approach effectively characterized specific aspects of perceptions of high-quality IO care among patients and referring providers.

Superior Abdominal 4D Flow MRI Data Consistency with Adjusted Preprocessing Workflow and Noncontrast Acquisitions

RATIONALE AND OBJECTIVES

To assess the impact of an alternative preprocessing workflow on noncontrast- and contrast-enhanced abdominal four-dimensional flow magnetic resonance imaging (4D flow MRI) data consistency.

MATERIALS AND METHODS

Twenty patients with cirrhosis and portal hypertension (5 women; 53 ± 10 years old) underwent 4D flow MRI at 3.0T before and after administration of 0.03 mmol/kg of gadofosveset trisodium with velocity sensitivities of 100 and 50 cm/s for arterial and venous flow quantifications, respectively. 4D flow MRI data were preprocessed using the conventional workflow (workflow 1), applying noise filters prior to eddy current correction, and an alternative workflow (workflow 2), first correcting for eddy currents and using noise filtering only if needed for anti-aliasing. Vessel segmentation quality was ranked by independent reviewers and compared via Wilcoxon signed-rank tests. Flow quantification and conservation of mass at two portal and one arterial branch points were compared via paired t tests.

RESULTS

Segmentation quality was significantly higher for workflow 2 (P < 0.05) with excellent interobserver agreement (κ = 0.92). Workflow 2 resulted in larger flow values (P < 0.05) with improved conservation of mass (7.3 ± 6.1% vs. 27.7 ± 25.0%, P < 0.001 [portal]; 10.7 ± 9.0% vs. 21.7 ± 21.6%, P = 0.02 [arterial]). Peak velocities and abdominal aortic flow were similar (P > 0.05). Noncontrast acquisitions yielded significantly smaller portal flow values (P < 0.05) with improved conservation of mass (5.8 ± 4.7% vs. 8.7 ± 6.9%, P = 0.05 [portal]; 6.2 ± 4.5% vs. 13.7 ± 10.2%, P = 0.03 [arterial]).

CONCLUSIONS

Superior abdominal 4D flow MRI data consistency was obtained by applying eddy current correction before any other data manipulation, using noise masking and velocity anti-aliasing cautiously, and using noncontrast acquisitions.

Fostering better policy adoption and inter-disciplinary communication in healthcare: A qualitative analysis of practicing physicians' common interests

Purpose

In response to limited physician adoption of various healthcare initiatives, we sought to propose and assess a novel approach to policy development where one first characterizes diverse physician groups’ common interests, using a medical student and constructivist grounded theory.

Methods

In 6 months, a medical student completed 36 semi-structured interviews with interventional radiologists, gynecologists, and vascular surgeons that were systematically analyzed according to constructivist grounded theory to identifying common themes. Common drivers of clinical decision making and professional values across 3 distinct specialty groups were derived from physicians’ descriptions of their clinical decision making, stories, and concerns.

Results

Common drivers of clinical decision making included patient preference/benefit, experience, reimbursement, busyness/volume, and referral networks. Common values included honesty, trustworthiness, loyalty, humble service, compassion and perseverance, and practical wisdom. Although personal gains were perceived as important interests, such values were easily sacrificed for the good of patients or other non-financial interests. This balance was largely dependent on the incentives and security provided by physicians’ environments.

Conclusions

Using a medical student interviewer and constructivist grounded theory is a feasible means of collecting rich qualitative data to guide policy development. Healthcare administrators and medical educators should consider incorporating this methodology early in policy development to anticipate how value differences between physician groups will influence their acceptance of policies and other broad healthcare initiatives.

Specialty-Specific Values Affecting the Management of Symptomatic Uterine Fibroids

PURPOSE

To better understand why interventional radiologists and gynecologists differ in their approaches to symptomatic uterine fibroids.

METHODS

Conversational interviews were conducted with 26 interventional radiologists and gynecologists about their professional roles, clinical reasoning, and practice variation within and outside their specialty. Interview transcripts were systematically analyzed using NVivo 10 software (QSR International, Burlington, Massachusetts) according to grounded theory and content analysis to identify key themes and compare themes across specialties and practice environments. Data were supplemented with retrospective analysis of 7,659 patients with symptomatic uterine fibroids treated at a large academic center over 11 years.

RESULTS

Interventional radiologists' shares of symptomatic uterine fibroid treatment and endovascular stent treatments have remained constant (P > .05) for 11 y at a large medical center, whereas minimally invasive gynecologic fibroid treatments and the percentage of interventional radiology (IR) procedures reimbursed by Medicaid/Medicare have increased significantly (r > .90, P < .001 and r = .93, P < .001). Interventional radiologists and gynecologists shared a commitment to do "the right thing" for patients, but each group possessed distinct professional values affecting how they viewed medical evidence, outcomes, and their colleagues. When differences were apparent and concerning, physicians tended to suspect ulterior motives not in patients' best interests.

CONCLUSIONS

Interventional radiologists and gynecologists demonstrated wide-ranging perspectives regarding their role in caring for patients with symptomatic uterine fibroids. To promote genuine collaboration and adoption of shared goals, stakeholders should seek and promote a deeper understanding of specialty-specific values and culture.

Physicians' professional identities: a roadmap to understanding "value" in cardiovascular imaging

BACKGROUND

Quality improvement efforts in cardiovascular imaging have been challenged by limited adoption of initiatives and policies. In order to better understand this limitation and inform future efforts, the range clinical values related to cardiovascular imaging at a large academic hospital was characterized.

MATERIALS AND METHODS

15 Northwestern Medicine physicians from internal medicine, cardiology, emergency medicine, cardiac/vascular surgery, and radiology were interviewed about their use of cardiovascular imaging and imaging guidelines. Interview transcripts were systemically analyzed according to constructivist grounded theory and combined with 56 previous interviews with interventional radiologists, interventional cardiologists, gynecologists, and vascular surgeons to develop a model describing specialty-specific values. This model was applied to the 15 pilot interviews focused on cardiovascular imaging, highlighting specialty specific differences in values and practice patterns. Transcripts were also reviewed independently by a cardiologist and 2 radiologists followed by a group discussion to assess reproducibility and achieve a consensus regarding the results.

RESULTS

Differences in perceived value of cardiovascular imaging and use of guidelines among physicians were well explained by three value-associated identity categories (managers, diagnosticians, and fixers) that were further differentiated along three axes (broad v. focused-thinkers, complex v. definitive-answer-seekers, and public visibility).

CONCLUSIONS

Quality improvement in cardiovascular imaging may be limited by a lack of understanding and incorporation of the complexity of medical culture into ongoing initiatives. Both individually and during policy development, it is important to first understand the complexity of stakeholders' diverse perceptions of "value," "quality," and "appropriateness."

Providing Context: Medical Device Litigation and Inferior Vena Cava Filters

Over the last few years, an increasing number of lawsuits have been filed involving inferior vena cava filters. This has prompted the U.S. Judicial Panel on Multidistrict Litigation to centralize these lawsuits into two multidistrict litigations: one for Cook's filters and one for Bard's. Both sets of cases share similar questions of facts, in particular whether these filters' design and manufacturing practices made them unreasonably prone to serious complications. The resolution of these cases will add to a larger legal debate concerning how much legal protection the 1976 Medical Device Amendments should offer firms from tort liability. As a specialty that often relies on medical devices, it is not only important for interventional radiologists to have a general understanding of medical device litigation but also to reflect upon the approaches to informed consent regarding these devices.

Reduction of aberrant aortic haemodynamics following aortic root replacement with a mechanical valved conduit

OBJECTIVES

Previous work suggests that aortic root and valve prostheses alter blood flow patterns in the ascending aorta, creating aberrant haemodynamics compared with those of healthy volunteers. Various valve designs have been proposed to better restore physiological haemodynamics. In this study, magnetic resonance imaging (MRI) was used to non-invasively assess three-dimensional (3D) ascending aortic haemodynamics after aortic root replacement (ARR) with a mechanical valved conduit postulated to create less turbulent blood flow.

METHODS

Ten patients (40 ± 9 years) underwent transthoracic echocardiography and contrast-enhanced multidimensional four-dimensional (4D) flow MRI at 1.5 T after ARR with an On-X mechanical valved conduit. Preoperative 4D flow MRI was available in 7 patients. Ten age- and gender-matched healthy volunteers (42 ± 13 years) were also analysed to characterize physiological flow. The presence of vortex/helix formation was graded by two blinded observers. Peak transvalvular pressure gradients were computed using the simplified Bernoulli equation. Patients' postoperative pressure gradients and helicity/vorticity grades were compared with preoperative gradients and those from healthy volunteers.

RESULTS

Intra- and interobserver ratings showed good agreement (κ = 0.93, P < 0.01 and κ = 0.84, P < 0.01, respectively). Highly helical and/or vortical flow was observed in all patients preoperatively, which was significantly reduced postoperatively (P < 0.01 and <0.01, respectively), restoring similar flow patterns similar to those seen in volunteers (P = 0.56 and 0.56). Peak transvalvular pressure gradients (ΔP) were also significantly reduced [43 ± 21 vs 12 ± 7 mmHg, P < 0.05 (Echo); 48 ± 22 vs 16 ± 9 mmHg, P < 0.05 (MRI)], but remained significantly higher than those of volunteers (6 ± 1 mmHg, P < 0.01).

CONCLUSIONS

Preliminary evidence suggests that ARR with an On-X mechanical valve significantly reduces aberrant aortic haemodynamics, producing flow patterns that resemble those in healthy volunteers.