Improving the process of informed consent for percutaneous coronary intervention: patient outcomes from the Patient Risk Information Services Manager (ePRISM) study

Merging machine learning and patient preference: a novel tool for risk prediction of percutaneous coronary interventions

BACKGROUND AND AIMS

Predicting personalized risk for adverse events following percutaneous coronary intervention (PCI) remains critical in weighing treatment options, employing risk mitigation strategies, and enhancing shared decision-making. This study aimed to employ machine learning models using pre-procedural variables to accurately predict common post-PCI complications.

METHODS

A group of 66 adults underwent a semiquantitative survey assessing a preferred list of outcomes and model display. The machine learning cohort included 107 793 patients undergoing PCI procedures performed at 48 hospitals in Michigan between 1 April 2018 and 31 December 2021 in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) registry separated into training and validation cohorts. External validation was conducted in the Cardiac Care Outcomes Assessment Program database of 56 583 procedures in 33 hospitals in Washington.

RESULTS

Overall rate of in-hospital mortality was 1.85% (n = 1999), acute kidney injury 2.51% (n = 2519), new-onset dialysis 0.44% (n = 462), stroke 0.41% (n = 447), major bleeding 0.89% (n = 942), and transfusion 2.41% (n = 2592). The model demonstrated robust discrimination and calibration for mortality {area under the receiver-operating characteristic curve [AUC]: 0.930 [95% confidence interval (CI) 0.920-0.940]}, acute kidney injury [AUC: 0.893 (95% CI 0.883-0.903)], dialysis [AUC: 0.951 (95% CI 0.939-0.964)], stroke [AUC: 0.751 (95%CI 0.714-0.787)], transfusion [AUC: 0.917 (95% CI 0.907-0.925)], and major bleeding [AUC: 0.887 (95% CI 0.870-0.905)]. Similar discrimination was noted in the external validation population. Survey subjects preferred a comprehensive list of individually reported post-procedure outcomes.

CONCLUSIONS

Using common pre-procedural risk factors, the BMC2 machine learning models accurately predict post-PCI outcomes. Utilizing patient feedback, the BMC2 models employ a patient-centred tool to clearly display risks to patients and providers (https://shiny.bmc2.org/pci-prediction/). Enhanced risk prediction prior to PCI could help inform treatment selection and shared decision-making discussions.

Factors associated with the delay in informed consent procedures of patients with ST-segment elevation myocardial infarction and its influence on door-to-balloon time: a nationwide retrospective cohort study

Background and Objectives

ST-segment elevation myocardial infarction (STEMI) is the deadliest and most time-sensitive acute cardiac event. However, failure to achieve timely informed consent is an important contributor to in-hospital delay in STEMI care in China. We investigated the factors associated with informed consent delay in patients with STEMI undergoing percutaneous coronary intervention (PCI) and the association between the delay and door-to-balloon time.

Methods

We conducted a nationally representative retrospective cohort study using patient data reported by hospital-based chest pain centers from 1 January 2016 to 31 December 2020. We applied generalized linear mixed models and negative binomial regression to estimate factors independently predicting informed consent delay time. Logistic regressions were fitted to investigate the association of the informed consent delay time and door-to-balloon time, adjusting for patient characteristics.

Results

In total, 257, 510 patients were enrolled in the analysis. Mean informed consent delay time was 22.4 min (SD = 24.0), accounting for 39.3% in door-to-balloon time. Older age (≥65 years) was significantly correlated with informed consent delay time (RR: 1.034, P = 0.001). Compared with ethnic Han patients, the minority (RR: 1.146, P < 0.001) had more likelihood to extend consent giving; compared with patients who were single, longer informed consent time was found in married patients (RR: 1.054, P = 0.006). Patients with intermittent chest pain (RR: 1.034, P = 0.011), and chest pain relief (RR: 1.085, P = 0.005) were more likely to delay informed consent. As for transfer modes, EMS (RR: 1.063, P < 0.001), transfer-in (RR: 1.820, P < 0.001), and in-hospital onset (RR: 1.099, P = 0.002) all had positive correlations with informed consent delay time compared to walk-in. Informed consent delay was significantly associated with prolonged door-to-balloon time (OR: 1.002, P < 0.001).

Conclusion

Informed consent delay is significantly associated with the door-to-balloon time which plays a crucial role in achieving better outcomes for patients with STEMI. It is essential to shorten the delay time by identifying and intervening modifiable factors that are associated with shortening the informed consent procedure in China and other countries.

Upgrading the Chemotherapy Consent: Trading in Paper for Tablet

PURPOSE

Our institution participated in the Oncology Care Model, which required us to include many of the 13 elements of the National Academy of Medicine (NAM) care plan into care pathways for our patients. We optimized our existing chemotherapy consent process to meet this need and maximized completion.

METHODS

Our multidisciplinary committee developed a three-phase Plan-Do-Study-Act process in our breast cancer clinic: (1) update and educate providers on our paper chemotherapy form with multiple components of the NAM care plan including prognosis and treatment effects on quality of life; (2) piloted an electronic chemotherapy consent form to decrease the administrative burden; and (3) autopopulated fields within the electronic consent. We assessed feedback after cycle 1 and created a Pareto chart. The outcome measure was percent completion of chemotherapy consent documents.

RESULTS

Baseline monthly random chart audit of 40 patients revealed 20% of paper chemotherapy consent forms were completed in their entirety among patients. When we re-educated clinicians about the new paper consent containing the NAM elements, compliance rose to nearly 30%. A Pareto chart confirmed that content redundancy and wordiness were leading to under-completion. After creating and piloting the electronic consent, compliance increased to 90%. Finally, autopopulation with drop-down selections increased and sustained completion to 100%.

CONCLUSION

Incorporating regulatory requirements into an existing workflow using Plan-Do-Study-Act methodology can reduce administrative burden on clinicians. Additional use of innovative technology can further increase clinician compliance with regulatory requirements while delivering high-value quality care to patients with cancer.

Personalizing the decision of dabigatran versus warfarin in atrial fibrillation: A secondary analysis of the Randomized Evaluation of Long-term anticoagulation therapY (RE-LY) trial

Background

The RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial demonstrated that higher-risk patients with atrial fibrillation had lower rates of stroke or systemic embolism and a similar rate of major bleeding, on average, when treated with dabigatran 150mg compared to warfarin. Since population-level averages may not apply to individual patients, estimating the heterogeneity of treatment effect can improve application of RE-LY in clinical practice.

Methods and results

For 18040 patients randomized in RE-LY, we used patient-level data to develop multivariable models to predict the risk for stroke or systemic embolism and for major bleeding including all three treatment groups (dabigatran 110mg, dabigatran 150mg, and warfarin) over a median follow up of 2.0 years. The mean predicted absolute risk reduction (ARR) for stroke/systemic embolism with dabigatran 150mg compared to warfarin was 1.32% (range 11.6% lower to 3.30% higher risk). The mean predicted ARR for bleeding was 0.41% (range 8.93% lower to 63.4% higher risk). Patients with increased stroke/systemic embolism risk included those with prior stroke/TIA (OR 2.01), diabetics on warfarin (OR 2.00), and older patients on dabigatran 150mg (OR 1.68 for every 10-year increase). Major bleeding risk was higher in patients on aspirin (OR 1.25), with a history of diabetes (OR 1.34) or prior stroke/TIA (OR 1.22), those with heart failure on dabigatran 110mg (OR 1.52), older patients on either dabigatran 110mg or 150mg (OR 1.57 and 1.93, respectively, for each 10-year increase), and heavier patients on dabigatran 110mg or 150mg; patients in a region outside the United States and Canada and with better renal function had lower bleeding risk.

Conclusions

There is substantial heterogeneity in the benefits and risks of dabigatran relative to warfarin among patients with atrial fibrillation. Using individualized estimates may enable shared decision making and facilitate more appropriate use of dabigatran; as such, it should be prospectively tested.

Clinical trial registration

www.clinicaltrials.gov number, NCT00262600.

Transradial Access for High-Risk Percutaneous Coronary Intervention: Implications of the Risk-Treatment Paradox

[Figure: see text].

SCAI expert consensus update on best practices in the cardiac catheterization laboratory: This statement was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS) in April 2021

The current document commissioned by the Society for Cardiovascular Angiography and Interventions (SCAI) and endorsed by the American College of Cardiology, the American Heart Association, and Heart Rhythm Society represents a comprehensive update to the 2012 and 2016 consensus documents on patient-centered best practices in the cardiac catheterization laboratory. Comprising updates to staffing and credentialing, as well as evidence-based updates to the pre-, intra-, and post-procedural logistics, clinical standards and patient flow, the document also includes an expanded section on CCL governance, administration, and approach to quality metrics. This update also acknowledges the collaboration with various specialties, including discussion of the heart team approach to management, and working with electrophysiology colleagues in particular. It is hoped that this document will be utilized by hospitals, health systems, as well as regulatory bodies involved in assuring and maintaining quality, safety, efficiency, and cost-effectiveness of patient throughput in this high volume area.

Is Better Patient Knowledge Associated with Different Treatment Preferences? A Survey of Patients with Stable Coronary Artery Disease

BACKGROUND

In stable coronary artery disease (CAD), shared decision-making (SDM) is encouraged when deciding whether to pursue percutaneous coronary intervention (PCI) given similar cardiovascular outcomes between PCI and medical therapy. However, it remains unclear whether improving patient-provider communication and patient knowledge, the main tenets of SDM, changes patient preferences or the treatment chosen. We explored the relationships between patient-provider communication, patient knowledge, patient preferences, and the treatment received.

METHODS

We surveyed stable CAD patients referred for elective cardiac catheterization at seven hospitals from 6/2016 to 9/2018. Surveys assessed patient-provider communication, medical knowledge, and preferences for treatment and decision-making. We verified treatments received by chart review. We used linear and logistic regression to examine relationships between patient-provider communication and knowledge, knowledge and preference, and preference and treatment received.

RESULTS

Eighty-seven patients completed the survey. More discussion of the benefits and risks of both medical therapy and PCI associated with higher patient knowledge scores (β=0.28, p<0.01). Patient knowledge level was not associated with preference for PCI (OR=0.78, 95% CI 0.57-1.03, p=0.09). Black patients had more than four times the odds of preferring medical therapy to PCI (OR=4.49, 1.22-18.45, p=0.03). Patients preferring medical therapy were not significantly less likely to receive PCI (OR=0.67, 0.16-2.52, p=0.57).

CONCLUSIONS

While communicating the risks of PCI may improve patient knowledge, this knowledge may not affect patient treatment preferences. Rather, other factors such as race may be significantly more influential on a patient's treatment preferences. Furthermore, patient preferences are still not well reflected in the treatment received. Improving shared decision-making in stable CAD therefore may require not only increasing patient education but also better understanding and including a patient's background and pre-existing beliefs.

An instrument for assessing the quality of informed consent documents for elective procedures: development and testing

OBJECTIVE

To develop a nationally applicable tool for assessing the quality of informed consent documents for elective procedures.

DESIGN

Mixed qualitative-quantitative approach.

SETTING

Convened seven meetings with stakeholders to obtain input and feedback on the tool.

PARTICIPANTS

Team of physician investigators, measure development experts, and a working group of nine patients and patient advocates (caregivers, advocates for vulnerable populations and patient safety experts) from different regions of the country.

INTERVENTIONS

With stakeholder input, we identified elements of high-quality informed consent documents, aggregated into three domains: content, presentation and timing. Based on this comprehensive taxonomy of key elements, we convened the working group to offer input on the development of an abstraction tool to assess the quality of informed consent documents in three phases: (1) selecting the highest-priority elements to be operationalised as items in the tool; (2) iteratively refining and testing the tool using a sample of qualifying informed consent documents from eight hospitals; and (3) developing a scoring approach for the tool. Finally, we tested the reliability of the tool in a subsample of 250 informed consent documents from 25 additional hospitals.

OUTCOMES

Abstraction tool to evaluate the quality of informed consent documents.

RESULTS

We identified 53 elements of informed consent quality; of these, 15 were selected as highest priority for inclusion in the abstraction tool and 8 were feasible to measure. After seven cycles of iterative development and testing of survey items, and development and refinement of a training manual, two trained raters achieved high item-level agreement, ranging from 92% to 100%.

CONCLUSIONS

We identified key quality elements of an informed consent document and operationalised the highest-priority elements to define a minimum standard for informed consent documents. This tool is a starting point that can enable hospitals and other providers to evaluate and improve the quality of informed consent.

Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design

Background Drug-eluting stents reduce the risk of restenosis in patients undergoing percutaneous coronary intervention, but their use necessitates prolonged dual antiplatelet therapy, which increases costs and bleeding risk, and which may delay elective surgeries. While >80% of patients in the United States receive drug-eluting stents, less than a third report that their physicians discussed options with them. Methods and Results An individualized shared decision-making (SDM) tool for stent selection was designed and implemented at 2 US hospitals. In the postimplementation phase, all patients received the SDM tool before their procedure, with or without decision coaching from a trained nurse. All patients were interviewed with respect to their knowledge of stents, their participation in SDM, and their stent preference. Between May 2014 and December 2016, 332 patients not receiving the SDM tool, 113 receiving the SDM tool with coaching, and 136 receiving the tool without coaching were interviewed. Patients receiving the SDM tool + coaching, as compared with usual care, demonstrated higher knowledge scores (mean difference +1.8; P<0.001), reported more frequent participation in SDM (odds ratio=2.96; P<0.001), and were more likely to state a stent preference (odds ratio=2.00; P<0.001). No significant differences were observed between the use of the SDM tool without coaching and usual care. For patients who voiced a stent preference, concordance between stent desired and stent received was 98% for patients who preferred a drug-eluting stent and 50% for patients who preferred a bare metal stent. The SDM tool (with or without coaching) had no impact on stent selection or concordance. Conclusions An SDM tool for stent selection was associated with improvements in patient knowledge and SDM only when accompanied by decision coaching. However, the SDM tool (with or without coaching) had no impact on stent selection or concordance between patients' stent preference and stent received, suggesting that physician-level barriers to SDM may exist. Clinical Trial Information URL: https://www.clinicaltrials.gov . Unique Identifier: NCT02046902.

Improving Consent Documentation in the Medical Intensive Care Unit

The contemporary patient-centered medical practice relies upon the acquisition of informed consent, which serves as written proof that the patient has recognized and agreed to the risks and benefits of their treatment. Well-documented informed consent forms are not only reflective of important ethical practices in medicine but can also serve as legal documents to protect healthcare providers from undue liabilities. We conducted a quality improvement project with the intention to improve the accuracy and completeness of consent form documentation in the medical intensive care unit. The evaluation of consent forms before our intervention revealed that only 6.8% were correctly completed, with an average of 10.2 out of 14 (73%) essential items correct. Our intervention involved a multifaceted approach that included targeted education in combination with process improvement. The post-intervention results at one month revealed improvement in consent form accuracy from 6.8% to 60% (p = 0.0001), with an increase in the average number of essential items documented correctly from 10.2 to 13.5 (p = 0.0001). Data were collected three months post-intervention to evaluate for sustained improvement. Results revealed a significant decrease in consent form accuracy to 39% when compared to the one-month post-intervention data but still maintained a statistically significant improvement when compared to initial baseline data; 6.8% to 39% (p = <0.01). Following the intervention, overall consent form accuracy improved significantly at our institution. Furthermore, these positive adjustments persisted when assessed at three months post-intervention despite the decrease as compared to one-month post-intervention. This trend suggests that our multifaceted intervention was able to increase the quality and accuracy of consent form documentation successfully.

Infringement of the right to surgical informed consent: negligent disclosure and its impact on patient trust in surgeons at public general hospitals - the voice of the patient

BACKGROUND

There is little dispute that the ideal moral standard for surgical informed consent calls for surgeons to carry out a disclosure dialogue with patients before they sign the informed consent form. This narrative study is the first to link patient experiences regarding the disclosure dialogue with patient-surgeon trust, central to effective recuperation and higher adherence.

METHODS

Informants were 12 Israelis (6 men and 6 women), aged 29-81, who underwent life-saving surgeries. A snowball sampling was used to locate participants in their initial recovery process upon discharge.

RESULTS

Our empirical evidence indicates an infringement of patients' right to receive an adequate disclosure dialogue that respects their autonomy. More than half of the participants signed the informed consent form with no disclosure dialogue, and thus felt anxious, deceived and lost their trust in surgeons. Surgeons nullified the meaning of informed consent rather than promoted participants' moral agency and dignity.

DISCUSSION

Similarity among jarring experiences of participants led us to contend that the conduct of nullifying surgical informed consent does not stem solely from constraints of time and resources, but may reflect an underlying paradox preserving this conduct and leading to objectification of patients and persisting in paternalism. We propose a multi-phase data-driven model for informed consent that attends to patients needs and facilitates patient trust in surgeons.

CONCLUSIONS

Patient experiences attest to the infringement of a patient's right to respect for autonomy. In order to meet the prima facie right of respect for autonomy, moral agency and dignity, physicians ought to respect patient's needs. It is now time to renew efforts to avoid negligent disclosure and implement a patient-centered model of informed consent.

Predicting the Benefits of Percutaneous Coronary Intervention on 1-Year Angina and Quality of Life in Stable Ischemic Heart Disease: Risk Models From the COURAGE Trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation)

BACKGROUND

Percutaneous coronary intervention (PCI) is a therapy to reduce angina and improve quality of life in patients with stable ischemic heart disease. However, it is unclear whether the quality of life after PCI is more dependent on the PCI or other patient-related factors. To address this question, we created models to predict angina and quality of life 1 year after PCI and medical therapy.

METHODS AND RESULTS

Using data from the 2287 stable ischemic heart disease patients randomized in the COURAGE trial (Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation) to PCI plus optimal medical therapy (OMT) versus OMT alone, we built prediction models for 1-year Seattle Angina Questionnaire angina frequency, physical limitation, and quality of life scores, both as continuous outcomes and categorized by clinically desirable states, using multivariable techniques. Although most patients improved regardless of treatment, marked variability was observed in Seattle Angina Questionnaire scores 1 year after randomization. Adding PCI conferred a greater mean improvement (about 2 points) in Seattle Angina Questionnaire scores that were not affected by patient characteristics (P values for all interactions >0.05). The proportion of patients free of angina or having very good/excellent physical limitation (physical function) or quality of life at 1 year was 57%, 58%, 66% with PCI+OMT and 50%, 55%, 59% with OMT alone group, respectively. However, other characteristics, such as baseline symptoms, age, diabetes mellitus, and the magnitude of myocardium subtended by narrowed coronary arteries were as, or more, important than revascularization in predicting symptoms (partial R²=0.07 versus 0.29, 0.03 versus 0.22, and 0.05 versus 0.24 in the domain of angina frequency, physical limitation, and quality of life, respectively). There was modest/good discrimination of the models (C statistic=0.72-0.82) and excellent calibration (coefficients of determination for predicted versus observed deciles=0.83-0.97).

CONCLUSIONS

The health status outcomes of stable ischemic heart disease patients treated by OMT+PCI versus OMT alone can be predicted with modest accuracy. Angina and quality of life at 1 year is improved by PCI but is more strongly associated with other patient characteristics.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT00007657.

Evaluating the Perceptions of Teleconsent in Urban and Rural Communities

BACKGROUND

Obtaining informed consent from research study participants continues to meet difficulties. New ways to connect with potential participants are necessary to address barriers, expand enrollment and offer more services to underserved populations.

OBJECTIVES

Electronic consent is designed to complete consenting sessions remotely and may help combat the obstacles inherent in the traditional informed consent process. We investigate the implementation of an electronic consent platform, Teleconsent, to broaden and diversify recruitment for clinical research.

METHODS

Semi-structured interviews were conducted with community members to assess their perceptions regarding the acceptability and usability of Teleconsent, a form of electronic consent. Interviews were structured to determine the main benefits, challenges and concerns as detailed by each participant. Participants were divided into rural and urban groupings.

RESULTS

We interviewed 40 participants to gather first-time perceptions of Teleconsent. We found overall positive results. Predominately in urban communities, participants possessed the technological skills and amenities to support smooth implementation of this technology. However, many participants reflect on the challenges regarding logistics, privacy and reliability of utilizing Teleconsent in underserved, rural areas. 5 of 19 participants, more than a quarter for the rural group, experienced Teleconsent software problems. During these sessions, an alternative process with paper templates was employed to complete interviews.

CONCLUSION

Perceptions regarding Teleconsent demonstrate current challenges along with potential acceptance within different communities. This is despite the fact that on its own it will not be able to overcome the barriers currently found in the informed consent process. Still, investment in electronic consent, including the development of enhanced and interactive content, can potentially revolutionize this process. Our findings offer a preliminary step towards determining the feasibility and acceptance of Teleconsent, a form of electronic consent, in different communities. More research surrounding the logistics of adoption is necessary in order to determine success.

Comparison of Machine Learning Methods With National Cardiovascular Data Registry Models for Prediction of Risk of Bleeding After Percutaneous Coronary Intervention

IMPORTANCE

Better prediction of major bleeding after percutaneous coronary intervention (PCI) may improve clinical decisions aimed to reduce bleeding risk. Machine learning techniques, bolstered by better selection of variables, hold promise for enhancing prediction.

OBJECTIVE

To determine whether machine learning techniques better predict post-PCI major bleeding compared with the existing National Cardiovascular Data Registry (NCDR) models.

DESIGN, SETTING, AND PARTICIPANTS

This comparative effectiveness study used the NCDR CathPCI Registry data version 4.4 (July 1, 2009, to April 1, 2015), machine learning techniques were used (logistic regression with lasso regularization and gradient descent boosting [XGBoost, version 0.71.2]), and output was then compared with the existing simplified risk score and full NCDR models. The existing models were recreated, and then performance was evaluated through additional techniques and variables in a 5-fold cross-validation in analysis conducted from October 1, 2015, to October 27, 2017. The setting was retrospective modeling of a nationwide clinical registry of PCI. Participants were all patients undergoing PCI. Percutaneous coronary intervention procedures were excluded if they were not the index PCI of admission, if the hospital site had missing outcomes measures, or if the patient underwent subsequent coronary artery bypass grafting.

EXPOSURES

Clinical variables available at admission and diagnostic coronary angiography data were used to determine the severity and complexity of presentation.

MAIN OUTCOMES AND MEASURES

The main outcome was in-hospital major bleeding within 72 hours after PCI. Results were evaluated by comparing C statistics, calibration, and decision threshold-based metrics, including the F score (harmonic mean of positive predictive value and sensitivity) and the false discovery rate.

RESULTS

The post-PCI major bleeding rate among 3 316 465 procedures (patients' median age, 65 years; interquartile range, 56-73 years; 68.1% male) was 4.5%. The existing full model achieved a mean C statistic of 0.78 (95% CI, 0.78-0.78). The use of XGBoost and full range of selected variables achieved a C statistic of 0.82 (95% CI, 0.82-0.82), with an F score of 0.31 (95% CI, 0.30-0.31). XGBoost correctly identified an additional 3.7% of cases identified as high risk who experienced a bleeding event and an overall improvement of 1.0% of cases identified as low risk who did not experience a bleeding event. The data-driven decision threshold helped improve the false discovery rate of the existing techniques. The existing simplified risk score model improved the false discovery rate from more than 90% to 78.7%. Modifying the model and the data decision threshold improved this rate from 78.7% to 73.4%.

CONCLUSIONS AND RELEVANCE

Machine learning techniques improved the prediction of major bleeding after PCI. These techniques may help to better identify patients who would benefit most from strategies to reduce bleeding risk.

Improving quality of the informed consent process: Developing an easy-to-read, multimodal, patient-centered format in a real-world setting

OBJECTIVE

To develop a patient-centered informed consent and assessment tool written at a 6th grade-level that is multimodal, affordable, transportable, and readily modifiable for protocol updates.

METHODS

This quality improvement initiative was performed in two phases on an actively-recruiting study at a pediatric diabetes clinic. In phase I, 38 volunteers underwent the standard-paper consent process, a comprehension assessment and provided feedback. Using feedback and the structure of the Plan-Do-Study-Act cycle a multimodal consent and assessment were developed. In phase II, volunteers were randomized to the standard (n = 25) or the multimodal consent (n = 25) and all completed the same comprehension assessment via touch-screen tablet. Primary outcomes were comparison of the individual and total comprehension assessment scores.

RESULTS

Total comprehension scores were higher in the multimodal versus the standard consent group (p <  0.001) and on the elements of benefits (p <  0.001), risks (p <  0.001), volunteerism (p <  0.012), results (p <  0.001), confidentiality (p <  0.004) and privacy (p < 0.001).

CONCLUSION

A multimodal consent and assessment presented sequentially on a touch-screen tablet were patient-centered enhancements to standard consent.

PRACTICE IMPLICATIONS

Multimodal standardization of delivery with improved readability may strengthen the informed consent process.

Reversing the "Risk-Treatment Paradox" of Bleeding in Patients Undergoing Percutaneous Coronary Intervention: Risk-Concordant Use of Bleeding Avoidance Strategies Is Associated With Reduced Bleeding and Lower Costs

Background Bleeding is a common, morbid, and costly complication of percutaneous coronary intervention. While bleeding avoidance strategies ( BAS ) are effective, they are used paradoxically less in patients at high risk of bleeding. Whether a patient-centered approach to specifically increase the risk-concordant use of BAS and, thus, reverse the risk-treatment paradox is associated with reduced bleeding and costs is unknown. Methods and Results We implemented an intervention to reverse the bleeding risk-treatment paradox at Barnes-Jewish Hospital, St. Louis, MO, and examined: (1) the temporal trends in BAS use and (2) the association of risk-concordant BAS use with bleeding and hospital costs of percutaneous coronary intervention. Among 3519 percutaneous coronary interventions, there was a significantly increasing trend ( P=0.002) in risk-concordant use of BAS . The bleeding incidence was 2% in the risk-concordant group versus 9% in the risk-discordant group (absolute risk difference, 7%; number needed to treat, 14). Risk-concordant BAS use was associated with a 67% (95% confidence interval, 52-78%; P<0.001) reduction in the risk of bleeding and a $4738 (95% confidence interval, 3353-6122; P<0.001) reduction in per-patient percutaneous coronary intervention hospitalization costs (21.6% cost-savings). Conclusions In this study, patient-centered care directly aimed to make treatment-related decisions based on predicted risk of bleeding, led to more risk-concordant use of BAS and reversal of the risk-treatment paradox. This, in turn, was associated with a reduction in bleeding and hospitalization costs. Larger multicentered studies are needed to corroborate these results. As clinical medicine moves toward personalization, both patients and hospitals can benefit from a simple practice change that encourages objectivity and mitigates variability in care.

Validation of the Seattle angina questionnaire in women with ischemic heart disease

BACKGROUND

Although the Seattle Angina Questionnaire (SAQ) has been widely used to assess disease-specific health status in patients with ischemic heart disease, it was originally developed in a predominantly male population and its validity in women has been questioned.

METHODS

Using data from 8892 men and 4013 women across 2 multicenter trials and 5 registries, we assessed the construct validity, test-retest reliability, responsiveness to clinical change, and predictive validity of the SAQ Summary Score (SS) and its 5 subdomains (Physical Limitation (PL), Anginal Stability (AS), Angina Frequency (AF), Treatment Satisfaction (TS), and Quality of Life (QoL)) separately in men and women.

RESULTS

Comparable correlations of the SAQ SS with Canadian Cardiovascular Society class was demonstrated in both men and women (-0.48 for men, -0.46 for women). Similar correlations between the SAQ PL scale with treadmill exercise duration and Short Form-12 (SF-12) Physical Component Summary were observed in women and men (0.34-0.63 and 0.40-0.63, respectively). SAQ AS scores were significantly lower for both men and women with acute syndromes compared with 1 month later. The SAQ AF scale was strongly correlated with daily angina diaries (0.62 for men and 0.66 for women). The SAQ QoL scores were moderately correlated with the EQ5D visual analog scale and SF-12 general health question in men (0.43-0.50) and women (0.33-0.39). All SAQ scales demonstrated excellent reliability (intraclass correlation ≥0.78) in both men and women with stable CAD and were very sensitive to change after percutaneous coronary intervention (≥15-point difference in scores, standardized response mean ≥ 0.67). The SAQ SS was similarly predictive of 1-year mortality and cardiac re-hospitalizations for both men and women.

CONCLUSION

The SAQ demonstrates similar psychometric properties in men and women with CAD. These findings provide evidence for validity of the SAQ in assessing women with IHD.

Residual Angina After Elective Percutaneous Coronary Intervention in Patients With Diabetes Mellitus

BACKGROUND

Previous studies suggest that among patients with stable coronary artery disease, patients with diabetes mellitus (DM) have less angina and more silent ischemia when compared with those without DM. However, the burden of angina in diabetic versus nondiabetic patients after elective percutaneous coronary intervention (PCI) has not been recently examined.

METHODS AND RESULTS

In a 10-site US PCI registry, we assessed angina before and at 1, 6, and 12 months after elective PCI with the Seattle Angina Questionnaire angina frequency score (range, 0-100, higher=better). We also examined the rates of antianginal medication prescriptions at discharge. A multivariable, repeated-measures Poisson model was used to examine the independent association of DM with angina over the year after treatment. Among 1080 elective PCI patients (mean age, 65 years; 74.7% men), 34.0% had DM. At baseline and at each follow-up, patients with DM had similar angina prevalence and severity as those without DM. Patients with DM were more commonly prescribed calcium channel blockers and long-acting nitrates at discharge (DM versus not: 27.9% versus 20.9% [P=0.01] and 32.8% versus 25.5% [P=0.01], respectively), whereas β-blockers and ranolazine were prescribed at similar rates. In the multivariable, repeated-measures model, the risk of angina was similar over the year after PCI in patients with versus without DM (relative risk, 1.04; range, 0.80-1.36).

CONCLUSIONS

Patients with stable coronary artery disease and DM exhibit a burden of angina that is at least as high as those without DM despite more antianginal prescriptions at discharge. These findings contradict the conventional teachings that patients with DM experience less angina because of silent ischemia.

Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association

Health literacy is the degree to which individuals are able to access and process basic health information and services and thereby participate in health-related decisions. Limited health literacy is highly prevalent in the United States and is strongly associated with patient morbidity, mortality, healthcare use, and costs. The objectives of this American Heart Association scientific statement are (1) to summarize the relevance of health literacy to cardiovascular health; (2) to present the adverse associations of health literacy with cardiovascular risk factors, conditions, and treatments; (3) to suggest strategies that address barriers imposed by limited health literacy on the management and prevention of cardiovascular disease; (4) to demonstrate the contributions of health literacy to health disparities, given its association with social determinants of health; and (5) to propose future directions for how health literacy can be integrated into the American Heart Association's mandate to advance cardiovascular treatment and research, thereby improving patient care and public health. Inadequate health literacy is a barrier to the American Heart Association meeting its 2020 Impact Goals, and this statement articulates the rationale to anticipate and address the adverse cardiovascular effects associated with health literacy.

Impact of video on the understanding and satisfaction of patients receiving informed consent before elective inpatient coronary angiography: A randomized trial

BACKGROUND

Appropriate information about the benefits and risks of invasive procedures is crucial, but limited data is available in this field. The aim of this study was to evaluate the incremental value of a short video about coronary angiography compared with standard information, in terms of patient understanding, satisfaction and anxiety.

METHODS

This prospective multicenter study included patients admitted for scheduled coronary angiography, who were randomized to receive either standard information or video information by watching a three-dimensional educational video. After information was delivered, patients were asked to complete a dedicated 16-point information questionnaire, as well as satisfaction and anxiety scales.

RESULTS

From 21 September to 4 October 2015, 821 consecutive patients were randomized to receive either standard information (n=415) or standard information with an added educational video (n=406). The information score was higher in the video information group than in the standard group (11.8±2.8 vs 9.5±3.1; P<.001). This result was consistent across age and education level subgroups. Self-reported satisfaction was also higher in the video information group (8.4±1.9 vs. 7.7±2.3; P<.001), while anxiety level did not differ between groups. The variables associated with a higher information score were the use of the educational video, younger age, higher level of education, previous follow-up by a cardiologist, prior information about coronary angiography and previous coronary angiography.

CONCLUSIONS

In comparison with standard information, viewing a dedicated educational video improved patients' understanding and satisfaction before scheduled coronary angiography. These results are in favor of widespread use of this incremental information tool.

Palliative treatment of coronary "atherosclerotic cancer" by drug-eluting or bare-metal stents: From oculo-stenotic reflex period to age of precision medicine

Medications and treatments are said to have a palliative effect if they relieve symptoms without having a curative effect on the underlying disease such as atherosclerosis or cancer. Some authors speculated that atherosclerotic coronary artery disease (CAD) could be considered a "cancer of the coronary arterial wall". Although the percutaneous coronary intervention (PCI) has proven to be effective in decreasing mortality rates among patients with acute coronary syndromes, the previous meta-analyses of PCI versus optimal medical therapy for stable CAD have not been able to demonstrate a reduction in major adverse cardiac outcomes. However, few cardiologists discussed the evidence-based benefits of angiogram and PCI for stable CAD, and some implicitly or explicitly overstated the benefits. Recently, the precision medicine is defined as an evidence-based approach that uses innovative tools and biological and data science to customize disease prevention, detection, and treatment, and improve the effectiveness and quality of patient care. Providing patients with accurate and complete information appears to be an effective way to combat the reliance on the oculostenotic reflex. The foundation of precision medicine is the ability to tailor therapy based upon the expected risks and benefits of treatment for each individual patient. As said by Doctor William Osler, "The good physician treats the disease; the great physician treats the patient who has the disease."

Development and pilot testing of an informed consent video for patients with limb trauma prior to debridement surgery using a modified Delphi technique

BACKGROUND

Ensuring adequate informed consent for surgery in a trauma setting is challenging. We developed and pilot tested an educational video containing information regarding the informed consent process for surgery in trauma patients and a knowledge measure instrument and evaluated whether the audiovisual presentation improved the patients' knowledge regarding their procedure and aftercare and their satisfaction with the informed consent process.

METHODS

A modified Delphi technique in which a panel of experts participated in successive rounds of shared scoring of items to forecast outcomes was applied to reach a consensus among the experts. The resulting consensus was used to develop the video content and questions for measuring the understanding of the informed consent for debridement surgery in limb trauma patients. The expert panel included experienced patients. The participants in this pilot study were enrolled as a convenience sample of adult trauma patients scheduled to receive surgery.

RESULTS

The modified Delphi technique comprised three rounds over a 4-month period. The items given higher scores by the experts in several categories were chosen for the subsequent rounds until consensus was reached. The experts reached a consensus on each item after the three-round process. The final knowledge measure comprising 10 questions was developed and validated. Thirty eligible trauma patients presenting to the Emergency Department (ED) were approached and completed the questionnaires in this pilot study. The participants exhibited significantly higher mean knowledge and satisfaction scores after watching the educational video than before watching the video.

CONCLUSIONS

Our process is promising for developing procedure-specific informed consent and audiovisual aids in medical and surgical specialties. The educational video was developed using a scientific method that integrated the opinions of different stakeholders, particularly patients. This video is a useful tool for improving the knowledge and satisfaction of trauma patients in the ED. The modified Delphi technique is an effective method for collecting experts' opinions and reaching a consensus on the content of educational materials for informed consent. Institutions should prioritize patient-centered health care and develop a structured informed consent process to improve the quality of care.

TRIAL REGISTRATION

The ClinicalTrials.gov Identifier is NCT01338480 . The date of registration was April 18, 2011 (retrospectively registered).

The Impact of De-escalation of Antianginal Medications on Health Status After Percutaneous Coronary Intervention

BACKGROUND

Antianginal medications (AAMs) can be perceived to be less important after percutaneous coronary intervention (PCI) and may be de-escalated after revascularization. We examined the frequency of AAM de-escalation at discharge post-PCI and its association with follow-up health status.

METHODS AND RESULTS

In a 10-center PCI registry, the Seattle Angina Questionnaire was assessed before and 6 months post-PCI. AAM de-escalation was defined as fewer AAMs at discharge versus admission or >25% absolute dose decrease. Of 2743 PCI patients (70% male), AAM were de-escalated, escalated, and unchanged in 299 (11%), 714 (26%), and 1730 (63%) patients, respectively. Patients whose AAM were de-escalated were more likely to report angina at 6 months, compared with unchanged or escalated AAM (34% versus 24% versus 21%; P<0.001). The association of AAM de-escalation with health status was examined using multivariable models adjusting for the predicted risk of post-PCI angina, completeness of revascularization, and the interaction of AAM de-escalation×completeness of revascularization. There was a significant interaction between AAM de-escalation and completeness of revascularization (P<0.001), suggesting that AAM de-escalation was associated with greater impairment of health status among patients with incomplete revascularization. In patients with incomplete revascularization, de-escalation of AAM at discharge was associated with 43% increased angina risk (relative risk, 1.43; 95% confidence interval, 1.26-1.63) and worse angina-related health status at 6 months post-PCI.

CONCLUSIONS

De-escalation of AAM occurs in 1 in 10 patients post-PCI, and it is associated with an increased risk of angina and worse health status, particularly among those with incomplete revascularization.

Permission form synopses to improve parents' understanding of research: a randomized trial

OBJECTIVE

We hypothesized that, among parents of potential neonatal research subjects, an accompanying cover sheet added to the permission form (intervention) would increase understanding of the research, when compared to a standard form (control).

STUDY DESIGN

This pilot study enrolled parents approached for one of two index studies: one randomized trial and one observational study. A one-page cover sheet described critical study information. Families were randomized 1:1 to receive the cover sheet or not. Objective and subjective understanding and satisfaction were measured.

RESULTS

Thirty-two parents completed all measures (17 control, 15 intervention). There were no differences in comprehension score (16.8±5.7 vs 16.3±3.5), subjective understanding (median 6 vs 6.5), or overall satisfaction with consent (median 7 vs 6.5) between control and intervention groups (all P>0.50).

CONCLUSION

A simplified permission form cover sheet had no effect on parents' understanding of studies for which their newborns were being recruited.

Predictors and variability of drug-eluting vs bare-metal stent selection in contemporary percutaneous coronary intervention: Insights from the PRISM study

Drug-eluting stents (DES) reduce risk of in-stent restenosis after percutaneous coronary intervention (PCI) but require dual antiplatelet therapy (DAPT) for a longer term than bare-metal stents (BMS). Few studies have examined clinical predictors of DES vs BMS, and variability in provider selection between DES and BMS in clinical practice has not been well described. These insights can inform our understanding of current practice and may identify opportunities to improve decision-making stent selection decinsion-making. In a multicenter registry, 3295 consecutive patients underwent PCI by 158 interventional cardiologists across 10 US sites. Eighty percent of patients with treated with DES. Using hierarchical regression, diabetes mellitus, multivessel disease, health insurance, and white race were independently associated with greater DES use, whereas increasing age, history of hypertension, anticipated surgery, use of warfarin, lower hemoglobin, prior history of bleeding, and treatment of right coronary and left circumflex artery lesions as compared with PCI of left anterior descending artery were associated with lower likelihood of receiving DES. Adjusted rates of DES use across providers varied from 52.3% to 94.6%, and adjusted median odds ratio for DES selection was 1.69. DES selection appeared to reflect physicians' attempts to balance benefits of DES against risks of prolonged DAPT. Nevertheless, marked residual variability in DES selection across providers persisted after adjusting for predictors of restenosis, bleeding, and other factors. Further studies are needed to better understand drivers of this variability and identify the impact of patient and provider preferences on stent selection at the time of PCI.

Beyond restenosis: Patients' preference for drug eluting or bare metal stents

OBJECTIVES

To assess patients' perspective about factors associated with stent choice.

BACKGROUND

Drug eluting stents (DES) markedly reduce the risk of repeat percutaneous coronary intervention (PCI), but necessitate a longer duration of dual anti-platelet therapy (DAPT) as compared with bare metal stents (BMS). Thus, understanding patients' perspective about factors associated with stent choice is paramount.

METHODS

Patients undergoing angiography rated, on a 10-point scale, the importance (1 = not important, 10 = most important) of avoiding repeat revascularization and avoiding the following potential DAPT drawbacks: bleeding/bruising, more pills/day, medication costs and delaying elective surgery. The factor, or group of factors, that was rated highest by each patient was identified.

RESULTS

Among 311 patients, repeat revascularization was the single most important consideration to 14.4% of patients, while 20.6% considered avoiding one of the DAPT drawbacks as most important. Most patients (65%) considered avoiding at least one DAPT drawback as important as avoiding repeat revascularization. In no subgroup of patients did more than a quarter of patients prefer avoiding repeat revascularization above all other concerns. Among patients undergoing PCI, more than three quarters received a DES, regardless of their stated preferences (DES use among those most valuing DES benefits, avoiding DAPT drawbacks, or both equally were 78.7%, 86.2%, and 85.6%, respectively, P = 0.56).

CONCLUSION

Most patients reported that avoiding DAPT drawbacks was as important as avoiding repeat revascularization. Eliciting patient preferences regarding stent type can enhance shared decision-making and allow physicians to better tailor stent choice to patients' goals and values.

TRIAL REGISTRATION

Developing and Testing a Personalized Evidence-based Shared Decision-making Tool for Stent Selection (DECIDE-PCI). ClinicalTrials.gov Identifier: NCT02046902. URL: https://clinicaltrials.gov/ct2/show/NCT02046902 © 2017 Wiley Periodicals, Inc.

Cardiac Pacing and Defibrillation Devices: Cost and Effectiveness

Implantable cardiac pacing and defibrillation devices are effective and commonly used therapies for patients with cardiac rhythm disorders. Because device implantation is not easily reversible, as well as the high healthcare costs inherent in device use, a clear understanding of the clinical benefits relative to costs is essential for both appropriate clinical use and rational policy making. Cardiac implantable electronic devices (CIEDs) have been among the best-investigated therapies in medicine; these devices have been the topic of numerous clinical and economic evaluations during the past 30 years. However, many important questions remain unclarified. We review the evidence supporting the clinical benefits of CIEDs, including effectiveness in extending survival as well as improving quality of life. We also summarize the economic studies that have investigated costs associated with these devices and their overall cost effectiveness, and we highlight important potential areas for future research.

Predicting long-term bleeding after percutaneous coronary intervention

OBJECTIVES

To construct a model to predict long-term bleeding events following percutaneous coronary intervention (PCI).

BACKGROUND

Treatment with dual antiplatelet therapy following PCI involves balancing the benefits of preventing ischemic events with the risks of bleeding. There are no models to predict long-term bleeding events after PCI.

METHODS

We analyzed 1-year bleeding outcomes from 3,128 PCI procedures in the Patient Risk Information Services Manager (PRISM) observational study. Patient-reported bleeding events were categorized according to Bleeding Academic Research Consortium (BARC) definitions. Logistic regression analysis was used to develop a model predicting BARC ≥ 1 bleeding.

RESULTS

BARC 0, 1, 2 or 3 bleeding was observed in 574 (18.4%); 2382 (76.2%); 114 (3.6%); and 58 (1.8%) patients, respectively. Compared to patients who had no bleeding, patients with BARC ≥ 1 bleeding were more often female (30 vs. 23%), Caucasian (94 vs. 83%), had a higher incidence of drug eluting stent (DES) implantation (83 vs. 76%) and warfarin therapy (7.4 vs. 3.9%), and a lower incidence of diabetes (31 vs. 45%; P-value <0.01 for all comparisons). A 27-variable model had moderate discrimination (c-statistic of 0.674), and good calibration, as did a parsimonious model with 10 variables (c-statistic = 0.667). This model performed well in predicting BARC ≥ 2 bleeding events as well (c-statistic = 0.653).

CONCLUSIONS

Bleeding is common in the first year after PCI, and can be predicted by pre-procedural patient characteristics and use of DES. Objective estimates of bleeding risk may help support shared decision-making with respect to stent selection and duration of antiplatelet therapy following PCI. © 2016 Wiley Periodicals, Inc.

Association of smoking status with health-related outcomes after percutaneous coronary intervention

BACKGROUND

Patients who smoke at the time of percutaneous coronary intervention (PCI) would ideally have a strong incentive to quit, but most do not. We sought to compare the health status outcomes of those who did and did not quit smoking after PCI with those who were not smoking before PCI.

METHODS AND RESULTS

A cohort of 2765 PCI patients from 10 US centers were categorized into never, past (smoked in the past but had quit before PCI), quitters (smoked at time of PCI but then quit), and persistent smokers. Health status was measured with the disease-specific Seattle Angina Questionnaire and the EuroQol 5 dimensions, adjusted for baseline characteristics. In unadjusted analyses, persistent smokers had worse disease-specific and overall health status when compared with other groups. In fully adjusted analyses, persistent smokers showed significantly worse health-related quality of life when compared with never smokers. Importantly, of those who smoked at the time of PCI, quitters had significantly better adjusted Seattle Angina Questionnaire angina frequency scores (mean difference, 2.73; 95% confidence interval, 0.13-5.33) and trends toward higher disease specific (Seattle Angina Questionnaire quality of life mean difference, 1.97; 95% confidence interval, -1.24 to 5.18), and overall (EuroQol 5 dimension visual analog scale scores mean difference, 2.45; 95% confidence interval, -0.58 to 5.49) quality of life when compared with persistent smokers at 12 months.

CONCLUSIONS

Smokers at the time of PCI have worse health status at 1 year than those who never smoked, whereas smokers who quit after PCI have less angina at 1 year than those who continue smoking.

Patient satisfaction in cardiology after cardiac catheterization : Effects of treatment outcome, visit characteristics, and perception of received care

BACKGROUND

Patient satisfaction is a key indicator for quality of care. However, recent data on determinants of satisfaction in invasive cardiology are lacking. Hence this study was conducted to identify determinants of patient satisfaction after hospitalization for cardiac catheterization.

PATIENTS AND METHODS

Data were obtained from 811 randomly selected patients discharged from ten hospitals responding to a mailed post-visit questionnaire. The satisfaction dimension was measured with a validated 42-item inventory assessing demographic and visit characteristics as well as medical, organizational, and service aspects of received care. Bivariate and multivariate statistical analyses were performed to identify predictors of satisfaction.

RESULTS

Patients were most satisfied with the kindness of medical practitioners and nurses. The lowest ratings were observed for discharge procedures and instructions. Multivariate analysis revealed five predictors of satisfaction: treatment outcome (OR, 2.14), individualized medical care (OR, 1.64), clear reply to patient's inquiries by physicians (OR, 1.63), kindness of nonmedical professionals (OR, 3.01), and room amenities (OR, 2.02). No association between demographic data and overall satisfaction was observed.

CONCLUSION

Five key determinants that can be addressed by health-care providers in order to improve patient satisfaction were identified. Our findings highlight the importance of the communicational behavior of health-care professionals and the transparency of discharge management.

Individual patient data network meta-analysis of mortality effects of implantable cardiac devices

OBJECTIVE

Implantable cardioverter defibrillators (ICD), cardiac resynchronisation therapy pacemakers (CRT-P) and the combination therapy (CRT-D) have been shown to reduce all-cause mortality compared with medical therapy alone in patients with heart failure and reduced EF. Our aim was to synthesise data from major randomised controlled trials to estimate the comparative mortality effects of these devices and how these vary according to patients' characteristics.

METHODS

Data from 13 randomised trials (12 638 patients) were provided by medical technology companies. Individual patient data were synthesised using network meta-analysis.

RESULTS

Unadjusted analyses found CRT-D to be the most effective treatment (reduction in rate of death vs medical therapy: 42% (95% credible interval: 32-50%), followed by ICD (29% (20-37%)) and CRT-P (28% (15-40%)). CRT-D reduced mortality compared with CRT-P (19% (1-33%)) and ICD (18% (7-28%)). QRS duration, left bundle branch block (LBBB) morphology, age and gender were included as predictors of benefit in the final adjusted model. In this model, CRT-D reduced mortality in all subgroups (range: 53% (34-66%) to 28% (-1% to 49%)). Patients with QRS duration ≥150 ms, LBBB morphology and female gender benefited more from CRT-P and CRT-D. Men and those <60 years benefited more from ICD.

CONCLUSIONS

These data provide estimates for the mortality benefits of device therapy conditional upon multiple patient characteristics. They can be used to estimate an individual patient's expected relative benefit and thus inform shared decision making. Clinical guidelines should discuss age and gender as predictors of device benefits.

Prediction of residual angina after percutaneous coronary intervention

Aims

Angina relief is a major goal of percutaneous coronary intervention (PCI); however, about one in five patients continue to have angina after PCI. Understanding patient factors associated with residual angina would enable providers to more accurately calibrate patients' expectations of angina relief after PCI, may support different follow-up strategies or approaches to coronary revascularization, and could potentially serve as a marker of PCI quality.

Methods and results

Among 2573 patients who had PCI at 10 US hospitals for stable angina, unstable angina, or non-ST-elevation myocardial infarction (NSTEMI), 24% reported angina 6 months after PCI, as assessed with the Seattle Angina Questionnaire angina frequency score (categorized as none vs. any angina; score = 100 vs. <100). Post-PCI angina was more common in those patients treated for unstable angina (30 vs. 20% stable angina and 21% NSTEMI, P < 0.001). Using a hierarchical logistic regression model, eight variables were independently associated with angina after PCI, including younger age, poor economic status, depression, and greater number of antianginal medications at the time of PCI (c-index = 0.75). The amount of angina at the time of PCI was more predictive of post-PCI angina in patients with stable or unstable angina when compared with NSTEMI (pinteraction = 0.01). The model demonstrated excellent calibration, both in the original sample (slope 1.04, intercept -0.01, r = 0.98) and in bootstrap validation.

Conclusion

Based on a large, multicentre cohort of PCI patients, we created a model of residual angina 6 months after PCI that can provide patients realistic expectations of angina relief, guide follow-up strategies, support the use of residual angina as a means of comparing PCI quality, and enable comparative effectiveness research.

Precision medicine to improve use of bleeding avoidance strategies and reduce bleeding in patients undergoing percutaneous coronary intervention: prospective cohort study before and after implementation of personalized bleeding risks

OBJECTIVE

To examine whether prospective bleeding risk estimates for patients undergoing percutaneous coronary intervention could improve the use of bleeding avoidance strategies and reduce bleeding.

DESIGN

Prospective cohort study comparing the use of bleeding avoidance strategies and bleeding rates before and after implementation of prospective risk stratification for peri-procedural bleeding.

SETTING

Nine hospitals in the United States.

PARTICIPANTS

All patients undergoing percutaneous coronary intervention for indications other than primary reperfusion for ST elevation myocardial infarction.

MAIN OUTCOME MEASURES

Use of bleeding avoidance strategies, including bivalirudin, radial approach, and vascular closure devices, and peri-procedural bleeding rates, stratified by bleeding risk. Observed changes were adjusted for changes observed in a pool of 1135 hospitals without access to pre-procedural risk stratification. Hospital level and physician level variability in use of bleeding avoidance strategies was examined.

RESULTS

In a comparison of 7408 pre-intervention procedures with 3529 post-intervention procedures, use of bleeding avoidance strategies within intervention sites increased with pre-procedural risk stratification (odds ratio 1.81, 95% confidence interval 1.44 to 2.27), particularly among higher risk patients (2.03, 1.58 to 2.61; 1.41, 1.09 to 1.83 in low risk patients, after adjustment for control sites; P for interaction = 0.05). Bleeding rates within intervention sites were significantly lower after implementation of risk stratification (1.0% v 1.7%; odds ratio 0.56, 0.40 to 0.78; 0.62, 0.44 to 0.87, after adjustment); the reduction in bleeding was greatest in high risk patients. Marked variability in use of bleeding avoidance strategies was observed across sites and physicians, both before and after implementation.

CONCLUSIONS

Prospective provision of individualized bleeding risk estimates was associated with increased use of bleeding avoidance strategies and lower bleeding rates. Marked variability between providers highlights an important opportunity to improve the consistency, safety, and quality of care. Study registration Clinicaltrials.gov NCT01383382.