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Spertus JA, Mack MJ, Ohman EM. Improving the National Cardiovascular Data Registry's Value to Elevate the Quality of Cardiovascular Care. J Am Coll Cardiol 2022; 79:1713-1716. [PMID: 35483760 DOI: 10.1016/j.jacc.2022.02.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 02/22/2022] [Indexed: 11/28/2022]
Affiliation(s)
- John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri, Kansas City, Missouri, USA.
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Moss SR, Martinez KA, Nathan C, Pfoh ER, Rothberg MB. Physicians' Views on Utilization of an Electronic Health Record-Embedded Calculator to Assess Risk for Venous Thromboembolism among Medical Inpatients: A Qualitative Study. TH OPEN : COMPANION JOURNAL TO THROMBOSIS AND HAEMOSTASIS 2022; 6:e33-e39. [PMID: 35088025 PMCID: PMC8786561 DOI: 10.1055/s-0041-1742227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/29/2021] [Indexed: 11/04/2022]
Abstract
Background Venous thromboembolism (VTE) causes preventable in-hospital morbidity. Pharmacologic prophylaxis reduces VTE in at-risk patients but also increases bleeding. To increase appropriate prescribing, a risk calculator to guide prophylaxis decisions was developed. Despite efforts to promote its use, providers accessed it infrequently. Objective This study aimed to understand provider perspectives on VTE prophylaxis and facilitators and barriers to using the risk calculator. Design This is a qualitative study exploring provider perspectives on VTE prophylaxis and the VTE risk calculator. Participants We interviewed attending physicians and advanced practice providers who used the calculator, and site champions who promoted calculator use. Providers were categorized by real-world usage over a 3-month period: low (<20% of the time), moderate (20-50%), or high (>50%). Approach During semistructured interviews, we asked about experiences with VTE, calculator use, perspectives on its implementation, and experiences with other risk assessment tools. Once thematic saturation was reached, transcripts were analyzed using content analysis to identify themes. Results Fourteen providers participated. Five were high utilizers, three were moderate utilizers, and six were low utilizers. Three site champions participated. Eight major themes were identified as follows: (1) ease of use, (2) perception of VTE risk, (3) harms of thromboprophylaxis, (4) overestimation of calculator use, (5) confidence in own ability, (6) underestimation of risk by calculator, (7) variability of trust in calculator, and (8) validation to withhold prophylaxis from low-risk patients. Conclusions While providers found the calculator is easy to use, routine use may be hindered by distrust of its recommendations. Inaccurate perception of VTE and bleeding risk may prevent calculator use.
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Affiliation(s)
- Stephanie R. Moss
- Department of Hospital Medicine, Cleveland Clinic Community Care; Department of Pediatric Hospital Medicine, Pediatrics Institute; Cleveland Clinic, Cleveland, Ohio, United States,Address for correspondence Stephanie R. Moss, MD Department of Hospital Medicine, Cleveland Clinic, Cleveland Clinic Community Care9500 Euclid Avenue, S1-20, Cleveland, OH 44195United States
| | - Kathryn A. Martinez
- Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio, United States
| | | | - Elizabeth R. Pfoh
- Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio, United States
| | - Michael B. Rothberg
- Center for Value-Based Care Research, Cleveland Clinic Community Care, Cleveland Clinic, Cleveland, Ohio, United States
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3
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Amin AP, Frogge N, Kulkarni H, Ridolfi G, Ewald G, Miller R, Hall B, Rogers S, Gluckman T, Curtis J, Masoudi FA, Rao SV. The bleeding risk treatment paradox at the physician and hospital level: Implications for reducing bleeding in patients undergoing percutaneous coronary intervention. Am Heart J 2022; 243:221-231. [PMID: 34543645 DOI: 10.1016/j.ahj.2021.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 08/30/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Bleeding is a common and costly complication of percutaneous coronary intervention (PCI). Bleeding avoidance strategies (BAS) are used paradoxically less in patients at high-risk of bleeding: "bleeding risk-treatment paradox" (RTP). We determined whether hospitals and physicians, who do not align BAS to PCI patients' bleeding risk (ie, exhibit a RTP) have higher bleeding rates. METHODS We examined 28,005 PCIs from the National Cardiovascular Data Registry CathPCI Registry for 7 hospitals comprising BJC HealthCare. BAS included transradial intervention, bivalirudin, and vascular closure devices. Patients' predicted bleeding risk was based on National Cardiovascular Data Registry CathPCI bleeding model and categorized as low (<2.0%), moderate (2.0%-6.4%), or high (≥6.5%) risk tertiles. BAS use was considered risk-concordant if: at least 1 BAS was used for moderate risk; 2 BAS were used for high risk and bivalirudin or vascular closure devices were not used for low risk. Absence of risk-concordant BAS use was defined as RTP. We analyzed inter-hospital and inter-physician variation in RTP, and the association of RTP with post-PCI bleeding. RESULTS Amongst 28,005 patients undergoing PCI by 103 physicians at 7 hospitals, RTP was observed in 12,035 (43%) patients. RTP was independently associated with a higher likelihood of bleeding even after adjusting for predicted bleeding risk, mortality risk and potential sources of variation (OR 1.66, 95% CI 1.44-1.92, P < .001). A higher prevalence of RTP strongly and independently correlated with worse bleeding rates, both at the physician-level (Wilk's Lambda 0.9502, F-value 17.21, P < .0001) and the hospital-level (Wilk's Lambda 0.9899, F-value 35.68, P < .0001). All the results were similar in a subset of PCIs conducted since 2015 - a period more reflective of the contemporary practice. CONCLUSIONS Bleeding RTP is a strong, independent predictor of bleeding. It exists at the level of physicians and hospitals: those with a higher rate of RTP had worse bleeding rates. These findings not only underscore the importance of recognizing bleeding risk upfront and using BAS in a risk-aligned manner, but also inform and motivate national efforts to reduce PCI-related bleeding.
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Takahashi K, Serruys PW, Fuster V, Farkouh ME, Spertus JA, Cohen DJ, Park SJ, Park DW, Ahn JM, Kappetein AP, Head SJ, Thuijs DJ, Onuma Y, Kent DM, Steyerberg EW, van Klaveren D. Redevelopment and validation of the SYNTAX score II to individualise decision making between percutaneous and surgical revascularisation in patients with complex coronary artery disease: secondary analysis of the multicentre randomised controlled SYNTAXES trial with external cohort validation. Lancet 2020; 396:1399-1412. [PMID: 33038944 DOI: 10.1016/s0140-6736(20)32114-0] [Citation(s) in RCA: 109] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 07/12/2020] [Accepted: 07/13/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Randomised controlled trials are considered the gold standard for testing the efficacy of novel therapeutic interventions, and typically report the average treatment effect as a summary result. As the result of treatment can vary between patients, basing treatment decisions for individual patients on the overall average treatment effect could be suboptimal. We aimed to develop an individualised decision making tool to select an optimal revascularisation strategy in patients with complex coronary artery disease. METHODS The SYNTAX Extended Survival (SYNTAXES) study is an investigator-driven extension follow-up of a multicentre, randomised controlled trial done in 85 hospitals across 18 North American and European countries between March, 2005, and April, 2007. Patients with de-novo three-vessel and left main coronary artery disease were randomly assigned (1:1) to either the percutaneous coronary intervention (PCI) group or coronary artery bypass grafting (CABG) group. The SYNTAXES study ascertained 10-year all-cause deaths. We used Cox regression to develop a clinical prognostic index for predicting death over a 10-year period, which was combined, in a second stage, with assigned treatment (PCI or CABG) and two prespecified effect-modifiers, which were selected on the basis of previous evidence: disease type (three-vessel disease or left main coronary artery disease) and anatomical SYNTAX score. We used similar techniques to develop a model to predict the 5-year risk of major adverse cardiovascular events (defined as a composite of all-cause death, non-fatal stroke, or non-fatal myocardial infarction) in patients receiving PCI or CABG. We then assessed the ability of these models to predict the risk of death or a major adverse cardiovascular event, and their differences (ie, the estimated benefit of CABG versus PCI by calculating the absolute risk difference between the two strategies) by cross-validation with the SYNTAX trial (n=1800 participants) and external validation in the pooled population (n=3380 participants) of the FREEDOM, BEST, and PRECOMBAT trials. The concordance (C)-index was used to measure discriminative ability, and calibration plots were used to assess the degree of agreement between predictions and observations. FINDINGS At cross-validation, the newly developed SYNTAX score II, termed SYNTAX score II 2020, showed a helpful discriminative ability in both treatment groups for predicting 10-year all-cause deaths (C-index=0·73 [95% CI 0·69-0·76] for PCI and 0·73 [0·69-0·76] for CABG) and 5-year major adverse cardiovascular events (C-index=0·65 [0·61-0·69] for PCI and C-index=0·71 [0·67-0·75] for CABG). At external validation, the SYNTAX score II 2020 showed helpful discrimination (C-index=0·67 [0·63-0·70] for PCI and C-index=0·62 [0·58-0·66] for CABG) and good calibration for predicting 5-year major adverse cardiovascular events. The estimated treatment benefit of CABG over PCI varied substantially among patients in the trial population, and the benefit predictions were well calibrated. INTERPRETATION The SYNTAX score II 2020 for predicting 10-year deaths and 5-year major adverse cardiovascular events can help to identify individuals who will benefit from either CABG or PCI, thereby supporting heart teams, patients, and their families to select optimal revascularisation strategies. FUNDING The German Heart Research Foundation and the Patient-Centered Outcomes Research Institute.
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Affiliation(s)
- Kuniaki Takahashi
- Department of Cardiology, Amsterdam Universities Medical Centers, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Patrick W Serruys
- Department of Cardiology, National University of Ireland, Galway, Ireland.
| | - Valentin Fuster
- Zena and Michael Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Centro Nacional De Investigaciones Cardiovasculares Carlos III, Madrid, Spain
| | - Michael E Farkouh
- Peter Munk Cardiac Centre and The Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, ON, Canada
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri-Kansas City, Kansas City, MO, USA
| | - David J Cohen
- University of Missouri-Kansas City, Kansas City, MO, USA
| | - Seung-Jung Park
- Department of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Duk-Woo Park
- Department of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Jung-Min Ahn
- Department of Cardiology, Asan Medical Center, Seoul, South Korea
| | - Arie Pieter Kappetein
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Daniel Jfm Thuijs
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Yoshinobu Onuma
- Department of Cardiology, National University of Ireland, Galway, Ireland
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, USA
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden, Netherlands; University Medical Centre, Leiden, Netherlands
| | - David van Klaveren
- Department of Public Health, Erasmus University Medical Centre, Rotterdam, Netherlands
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Chhatriwalla AK, Decker C, Gialde E, Catley D, Goggin K, Jaschke K, Jones P, deBronkart D, Sun T, Spertus JA. Developing and Testing a Personalized, Evidence-Based, Shared Decision-Making Tool for Stent Selection in Percutaneous Coronary Intervention Using a Pre-Post Study Design. Circ Cardiovasc Qual Outcomes 2020; 12:e005139. [PMID: 30764654 PMCID: PMC6383794 DOI: 10.1161/circoutcomes.118.005139] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Adnan K Chhatriwalla
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO (A.K.C., C.D., E.G., K.J., P.J., J.A.S.).,Department of Medicine, Division of Cardiology, University of Missouri-Kansas City, Kansas City, MO (A.K.C., C.D., J.A.S.)
| | - Carole Decker
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO (A.K.C., C.D., E.G., K.J., P.J., J.A.S.).,Department of Medicine, Division of Cardiology, University of Missouri-Kansas City, Kansas City, MO (A.K.C., C.D., J.A.S.)
| | - Elizabeth Gialde
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO (A.K.C., C.D., E.G., K.J., P.J., J.A.S.)
| | - Delwyn Catley
- Center for Children's Healthy Lifestyles & Nutrition, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO (D.C.).,University of Missouri-Kansas City School of Medicine (D.C.)
| | - Kathy Goggin
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City, MO (K.G.).,University of Missouri-Kansas City Schools of Medicine and Pharmacy, Kansas City, MO (K.G.)
| | - Katie Jaschke
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO (A.K.C., C.D., E.G., K.J., P.J., J.A.S.)
| | - Philip Jones
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO (A.K.C., C.D., E.G., K.J., P.J., J.A.S.)
| | - Dave deBronkart
- Society for Participatory Medicine, Newburyport, MA (D.d.B.)
| | - Tony Sun
- United Healthcare, Overland Park, KS (T.S.)
| | - John A Spertus
- Division of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, MO (A.K.C., C.D., E.G., K.J., P.J., J.A.S.).,Department of Medicine, Division of Cardiology, University of Missouri-Kansas City, Kansas City, MO (A.K.C., C.D., J.A.S.)
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6
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Kent DM, Paulus JK, van Klaveren D, D'Agostino R, Goodman S, Hayward R, Ioannidis JPA, Patrick-Lake B, Morton S, Pencina M, Raman G, Ross JS, Selker HP, Varadhan R, Vickers A, Wong JB, Steyerberg EW. The Predictive Approaches to Treatment effect Heterogeneity (PATH) Statement. Ann Intern Med 2020; 172:35-45. [PMID: 31711134 PMCID: PMC7531587 DOI: 10.7326/m18-3667] [Citation(s) in RCA: 193] [Impact Index Per Article: 48.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Heterogeneity of treatment effect (HTE) refers to the nonrandom variation in the magnitude or direction of a treatment effect across levels of a covariate, as measured on a selected scale, against a clinical outcome. In randomized controlled trials (RCTs), HTE is typically examined through a subgroup analysis that contrasts effects in groups of patients defined "1 variable at a time" (for example, male vs. female or old vs. young). The authors of this statement present guidance on an alternative approach to HTE analysis, "predictive HTE analysis." The goal of predictive HTE analysis is to provide patient-centered estimates of outcome risks with versus without the intervention, taking into account all relevant patient attributes simultaneously. The PATH (Predictive Approaches to Treatment effect Heterogeneity) Statement was developed using a multidisciplinary technical expert panel, targeted literature reviews, simulations to characterize potential problems with predictive approaches, and a deliberative process engaging the expert panel. The authors distinguish 2 categories of predictive HTE approaches: a "risk-modeling" approach, wherein a multivariable model predicts the risk for an outcome and is applied to disaggregate patients within RCTs to define risk-based variation in benefit, and an "effect-modeling" approach, wherein a model is developed on RCT data by incorporating a term for treatment assignment and interactions between treatment and baseline covariates. Both approaches can be used to predict differential absolute treatment effects, the most relevant scale for clinical decision making. The authors developed 4 sets of guidance: criteria to determine when risk-modeling approaches are likely to identify clinically important HTE, methodological aspects of risk-modeling methods, considerations for translation to clinical practice, and considerations and caveats in the use of effect-modeling approaches. The PATH Statement, together with its explanation and elaboration document, may guide future analyses and reporting of RCTs.
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Affiliation(s)
- David M Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts (D.M.K., J.K.P., J.B.W.)
| | - Jessica K Paulus
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts (D.M.K., J.K.P., J.B.W.)
| | - David van Klaveren
- Erasmus Medical Center, Rotterdam, the Netherlands, and Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts (D.V.)
| | | | - Steve Goodman
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California (S.G., J.P.I.)
| | | | - John P A Ioannidis
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California (S.G., J.P.I.)
| | - Bray Patrick-Lake
- Duke Clinical Research Institute, Duke University, Durham, North Carolina (B.P., M.P.)
| | - Sally Morton
- Virginia Polytechnic Institute and State University, Blacksburg, Virginia (S.M.)
| | - Michael Pencina
- Duke Clinical Research Institute, Duke University, Durham, North Carolina (B.P., M.P.)
| | - Gowri Raman
- Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts (G.R.)
| | - Joseph S Ross
- Schools of Medicine and Public Health, Yale University, New Haven, Connecticut (J.S.R.)
| | - Harry P Selker
- Center for Cardiovascular Health Services Research, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, and Tufts Clinical and Translational Science Institute, Boston, Massachusetts (H.P.S.)
| | - Ravi Varadhan
- Center on Aging and Health, Johns Hopkins University, Baltimore, Maryland (R.V.)
| | - Andrew Vickers
- Memorial Sloan Kettering Cancer Center, New York, New York (A.V.)
| | - John B Wong
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts (D.M.K., J.K.P., J.B.W.)
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7
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Kent DM, van Klaveren D, Paulus JK, D'Agostino R, Goodman S, Hayward R, Ioannidis JPA, Patrick-Lake B, Morton S, Pencina M, Raman G, Ross JS, Selker HP, Varadhan R, Vickers A, Wong JB, Steyerberg EW. The Predictive Approaches to Treatment effect Heterogeneity (PATH) Statement: Explanation and Elaboration. Ann Intern Med 2020; 172:W1-W25. [PMID: 31711094 PMCID: PMC7750907 DOI: 10.7326/m18-3668] [Citation(s) in RCA: 80] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The PATH (Predictive Approaches to Treatment effect Heterogeneity) Statement was developed to promote the conduct of, and provide guidance for, predictive analyses of heterogeneity of treatment effects (HTE) in clinical trials. The goal of predictive HTE analysis is to provide patient-centered estimates of outcome risk with versus without the intervention, taking into account all relevant patient attributes simultaneously, to support more personalized clinical decision making than can be made on the basis of only an overall average treatment effect. The authors distinguished 2 categories of predictive HTE approaches (a "risk-modeling" and an "effect-modeling" approach) and developed 4 sets of guidance statements: criteria to determine when risk-modeling approaches are likely to identify clinically meaningful HTE, methodological aspects of risk-modeling methods, considerations for translation to clinical practice, and considerations and caveats in the use of effect-modeling approaches. They discuss limitations of these methods and enumerate research priorities for advancing methods designed to generate more personalized evidence. This explanation and elaboration document describes the intent and rationale of each recommendation and discusses related analytic considerations, caveats, and reservations.
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Ebinger J, Henry T, Kim S, Inkelas M, Cheng S, Nuckols T. Development and Evaluation of Novel Electronic Medical Record Tools For Avoiding Bleeding After Percutaneous Coronary Intervention. J Am Heart Assoc 2019; 8:e013954. [PMID: 31707946 PMCID: PMC6915282 DOI: 10.1161/jaha.119.013954] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background Bleeding remains the most common complication of percutaneous coronary intervention. Guidelines recommend assessing bleeding risk before percutaneous coronary intervention to target use of bleeding avoidance strategies and mitigate bleeding events. Cedars‐Sinai Medical Center undertook an initiative to integrate these recommendations into the electronic medical record. Methods and Results The intervention included a voluntary clinical decision alert to assess bleeding risk before percutaneous coronary intervention, a bleeding risk calculator tool based on the NCDR (National Cardiovascular Data Registry) risk prediction model and, when indicated, a second alert to consider 4 bleeding avoidance strategies. We tested for changes in the use of bleeding avoidance strategies and bleeding event rates by comparing procedures performed before versus after implementation of the electronic medical record–based intervention and with versus without use of the bleeding risk calculator tool. Use of radial access increased (47.6% versus 64.8%; P<0.001) and glycoprotein IIb/IIIa inhibitors decreased (12.8% versus 3.17%; P<0.001) from before to after implementation, though risk‐adjusted bleeding event rates were stable (odds ratio, 0.82; P=0.164), even for high‐risk procedures. Use versus nonuse of the bleeding risk calculator tool was associated with increased radial access and reductions in glycoprotein IIb/IIIa inhibitors, but no change in bleeding events. Conclusions Integrating guideline recommendations into the electronic medical record to promote assessments of bleeding risk and use of bleeding avoidance strategies was feasible and associated with changes in clinical practice. Future work is needed to ensure that bleeding avoidance strategies are not overused among lower‐risk patients, and that, for high‐risk patients, the potential benefits of elective percutaneous coronary intervention are carefully weighed against the risk of bleeding.
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Affiliation(s)
- Joseph Ebinger
- Cedars-Sinai Smidt Heart Institute Los Angeles CA.,Department of Medicine Cedars-Sinai Medical Center Los Angeles CA
| | - Timothy Henry
- Christ Hospital Heart and Vascular Center Cincinnati OH
| | - Sungjin Kim
- Biostatistics and Bioinformatics Research Center Cedars-Sinai Medical Center Los Angeles CA
| | - Moira Inkelas
- Fielding School of Public Health University of California Los Angeles CA
| | - Susan Cheng
- Cedars-Sinai Smidt Heart Institute Los Angeles CA.,Department of Medicine Cedars-Sinai Medical Center Los Angeles CA
| | - Teryl Nuckols
- Department of Medicine Cedars-Sinai Medical Center Los Angeles CA
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9
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Blankenship JC, Kirchner HL. Parsing the Patients of FREEDOM. J Am Coll Cardiol 2019; 74:2085-2087. [PMID: 31623767 DOI: 10.1016/j.jacc.2019.08.1010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 08/06/2019] [Indexed: 11/16/2022]
Affiliation(s)
| | - H Lester Kirchner
- Department of Biomedical and Translational Informatics, Geisinger Health System, Danville, Pennsylvania
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10
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Kent DM, Steyerberg E, van Klaveren D. Personalized evidence based medicine: predictive approaches to heterogeneous treatment effects. BMJ 2018; 363:k4245. [PMID: 30530757 PMCID: PMC6889830 DOI: 10.1136/bmj.k4245] [Citation(s) in RCA: 202] [Impact Index Per Article: 33.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The use of evidence from clinical trials to support decisions for individual patients is a form of "reference class forecasting": implicit predictions for an individual are made on the basis of outcomes in a reference class of "similar" patients treated with alternative therapies. Evidence based medicine has generally emphasized the broad reference class of patients qualifying for a trial. Yet patients in a trial (and in clinical practice) differ from one another in many ways that can affect the outcome of interest and the potential for benefit. The central goal of personalized medicine, in its various forms, is to narrow the reference class to yield more patient specific effect estimates to support more individualized clinical decision making. This article will review fundamental conceptual problems with the prediction of outcome risk and heterogeneity of treatment effect (HTE), as well as the limitations of conventional (one-variable-at-a-time) subgroup analysis. It will also discuss several regression based approaches to "predictive" heterogeneity of treatment effect analysis, including analyses based on "risk modeling" (such as stratifying trial populations by their risk of the primary outcome or their risk of serious treatment-related harms) and analysis based on "effect modeling" (which incorporates modifiers of relative effect). It will illustrate these approaches with clinical examples and discuss their respective strengths and vulnerabilities.
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Affiliation(s)
- David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA 02111, USA
| | - Ewout Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Einthovenweg 20, 2333 ZC, Leiden, Netherlands
| | - David van Klaveren
- Predictive Analytics and Comparative Effectiveness Center, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA 02111, USA
- Department of Biomedical Data Sciences, Leiden University Medical Center, Einthovenweg 20, 2333 ZC, Leiden, Netherlands
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11
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Amin AP, Miller S, Rahn B, Caruso M, Pierce A, Sorensen K, Kurz H, Zajarias A, Bach R, Singh J, Lasala JM, Kulkarni H, Crimmins-Reda P. 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. J Am Heart Assoc 2018; 7:e008551. [PMID: 30376760 PMCID: PMC6404202 DOI: 10.1161/jaha.118.008551] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
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.
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Affiliation(s)
- Amit P Amin
- 1 Cardiovascular Division Washington University School of Medicine St. Louis MO.,2 Barnes-Jewish Hospital St. Louis MO.,3 Center for Value and Innovation Washington University School of Medicine St. Louis MO
| | - Samantha Miller
- 2 Barnes-Jewish Hospital St. Louis MO.,3 Center for Value and Innovation Washington University School of Medicine St. Louis MO
| | - Brandon Rahn
- 2 Barnes-Jewish Hospital St. Louis MO.,3 Center for Value and Innovation Washington University School of Medicine St. Louis MO
| | - Mary Caruso
- 2 Barnes-Jewish Hospital St. Louis MO.,3 Center for Value and Innovation Washington University School of Medicine St. Louis MO
| | | | - Katrine Sorensen
- 1 Cardiovascular Division Washington University School of Medicine St. Louis MO
| | - Howard Kurz
- 1 Cardiovascular Division Washington University School of Medicine St. Louis MO.,2 Barnes-Jewish Hospital St. Louis MO
| | - Alan Zajarias
- 1 Cardiovascular Division Washington University School of Medicine St. Louis MO.,2 Barnes-Jewish Hospital St. Louis MO
| | - Richard Bach
- 1 Cardiovascular Division Washington University School of Medicine St. Louis MO.,2 Barnes-Jewish Hospital St. Louis MO
| | - Jasvindar Singh
- 1 Cardiovascular Division Washington University School of Medicine St. Louis MO.,2 Barnes-Jewish Hospital St. Louis MO
| | - John M Lasala
- 1 Cardiovascular Division Washington University School of Medicine St. Louis MO.,2 Barnes-Jewish Hospital St. Louis MO
| | | | - Patricia Crimmins-Reda
- 2 Barnes-Jewish Hospital St. Louis MO.,3 Center for Value and Innovation Washington University School of Medicine St. Louis MO
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12
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Graham MM, James MT, Spertus JA. Decision Support Tools: Realizing the Potential to Improve Quality of Care. Can J Cardiol 2018; 34:821-826. [DOI: 10.1016/j.cjca.2018.02.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/17/2018] [Accepted: 02/28/2018] [Indexed: 12/27/2022] Open
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13
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Ozcan Cetin EH, Ozeke O, Ilkay E, Aras D, Topaloglu S, Golbasi Z, Aydogdu S, Ozer C. Palliative treatment of coronary "atherosclerotic cancer" by drug-eluting or bare-metal stents: From oculo-stenotic reflex period to age of precision medicine. Indian Heart J 2018; 70:191-193. [PMID: 29455777 PMCID: PMC5902819 DOI: 10.1016/j.ihj.2017.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2017] [Revised: 07/04/2017] [Accepted: 07/13/2017] [Indexed: 02/07/2023] Open
Abstract
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."
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Affiliation(s)
- Elif Hande Ozcan Cetin
- Health Sciences University, Turkiye Yuksek Ihtisas Training and Research Hospital , Department of Cardiology, Ankara, Turkey
| | - Ozcan Ozeke
- Health Sciences University, Turkiye Yuksek Ihtisas Training and Research Hospital , Department of Cardiology, Ankara, Turkey.
| | - Erdogan Ilkay
- Health Sciences University, Turkiye Yuksek Ihtisas Training and Research Hospital , Department of Cardiology, Ankara, Turkey
| | - Dursun Aras
- Health Sciences University, Turkiye Yuksek Ihtisas Training and Research Hospital , Department of Cardiology, Ankara, Turkey
| | - Serkan Topaloglu
- Health Sciences University, Turkiye Yuksek Ihtisas Training and Research Hospital , Department of Cardiology, Ankara, Turkey
| | - Zehra Golbasi
- Health Sciences University, Turkiye Yuksek Ihtisas Training and Research Hospital , Department of Cardiology, Ankara, Turkey
| | - Sinan Aydogdu
- Health Sciences University, Turkiye Yuksek Ihtisas Training and Research Hospital , Department of Cardiology, Ankara, Turkey
| | - Can Ozer
- Health Sciences University, Turkiye Yuksek Ihtisas Training and Research Hospital , Department of Cardiology, Ankara, Turkey
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14
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Rothberg MB, Martinez KA. Risky business: Personalizing the approach to percutaneous coronary intervention. Am Heart J 2016; 178:185-7. [PMID: 27502867 DOI: 10.1016/j.ahj.2016.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Michael B Rothberg
- Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH.
| | - Kathryn A Martinez
- Center for Value-Based Care Research, Medicine Institute, Cleveland Clinic, Cleveland, OH
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