Quantifying Patient-Physician Communication and Perceptions of Risk During Admissions for Possible Acute Coronary Syndromes

Teaching Medical Students to Communicate Risks Like Military Intelligence Analysts

Communication about health often involves descriptions of risk: the probability or likelihood of an unfavorable outcome. Communicating risk helps individuals make choices about their own health by building understanding of potential outcomes and providing context for the importance of procedures, health interventions, and lifestyle choices. However, medical education in the United States does not provide future physicians with adequate statistical literacy to communicate risk effectively and rarely encourages them to practice communicating risk in pre-clinical years. Risk communication in military intelligence, a field with formalized risk language and training, offers a unique perspective into potential improvements for medical risk communication. With backgrounds in the military, public health, communication, surgery, and medical education, the authors offer the following recommendations to improve risk communication for medical students. (1) Encourage the use of numerical absolute risk when communicating among health practitioners to avoid varied interpretations of what different risk descriptors ("uncommon," "likely," or "low") might mean; (2) build efficient, teachable skills in use of patient-facing risk communication tools like comparative probabilities and visual aids; and (3) practice estimating risk through role-play of risk communication between medical students and standardized patients. By improving risk communication in medical education, future doctors will be better equipped to build trust through open communication and improve the health of the patients and the communities for whom they care.

Improving Communication with Patients Discharged from the Emergency Department with Noncardiac Chest Pain: A Scoping Review with Narrative Synthesis

Background

This scoping review with narrative synthesis aimed to analyze scholarly peer-reviewed articles reporting on improving communication with patients discharged from the emergency department with noncardiac chest pain and qualitatively narrate on and summarize items that can be used in guiding communication with patients discharged from the emergency department with noncardiac chest pain.

Methods

The databases of EMBASE/PubMed, Scopus, COCHRANE, CInAHL/EBESCO, UW libraries, and Google Scholar were searched using relevant MeSH and key terms up to February 06, 2020. The selected articles were analyzed for their contents. Items guiding discharge communication were summarized qualitatively.

Results

Twenty-five articles were eligible for full review. These were published in between 1994 and 2020. Of those, 16 (64.0%) originated from the United States and 4 (16%) used some interventional design. A total of 45 different items that could be used in guiding discharge communication with patients presenting to the emergency department with chest pain were identified from the studies included in this review. Items were grouped under 6 categories that were related to initial assessment (8 items), information on diagnosis (7 items), information on discharge (9 items), follow-up suggestions (7 items), symptoms that promote return to the emergency department (7 items), and treatment plan (7 items).

Conclusion

Communication with patients discharged from the emergency department with noncardiac chest pain can be improved. Results of this investigation might be helpful in guiding quality improvement projects aimed for further improvement of communication with patients discharged from the emergency department with noncardiac chest pain.

Implementation of the HEART Pathway: Using the Consolidated Framework for Implementation Research

OBJECTIVE

The HEART Pathway is an evidence-based decision tool for identifying emergency department (ED) patients with acute chest pain who are candidates for early discharge, to reduce unhelpful and potentially harmful hospitalizations. Guided by the Consolidated Framework for Implementation Research, we sought to identify important barriers and facilitators to implementation of the HEART Pathway.

STUDY SETTING

Data were collected at 4 academic medical centers.

STUDY DESIGN

We conducted semi-structured interviews with 25 key stakeholders (e.g., health system leaders, ED physicians). We conducted interviews before implementation of the HEART Pathway tool to identify potential barriers and facilitators to successful adoption at other regional academic medical centers. We also conducted postimplementation interviews at 1 medical center, to understand factors that contributed to successful adoption.

DATA COLLECTION

Interviews were recorded and transcribed verbatim. We used a Consolidated Framework for Implementation Research framework-driven deductive approach for coding and analysis.

PRINCIPAL FINDINGS

Potential barriers to implementation include time and resource burden, challenges specific to the electronic health record, sustained communication with and engagement of stakeholders, and patient concerns. Facilitators to implementation include strength of evidence for reduced length of stay and unnecessary testing and iatrogenic complications, ease of use, and supportive provider climate for evidence-based decision tools.

CONCLUSIONS

Successful dissemination of the HEART Pathway will require addressing institution-specific barriers, which includes engaging clinical and financial stakeholders. New SMART-FHIR technologies, compatible with many electronic health record systems, can overcome barriers to health systems with limited information technology resources.

Utility of Mobile Apps for Video Conferencing to Follow Patients at Home After Outpatient Surgery

Introduction:

Outpatient surgery has a great opportunity to demonstrate the role of using mobile video conference (VC) postoperatively. Our patients use technology to help decision making in finding physicians. The authors aim to assess patient's perception on the use of mobile apps for VC with the surgeon and/or staff.

Methods:

Consenting patients completed a questionnaire of 10 questions preoperatively and postoperatively to assess the difference in opinion.

Results:

Overall, 120 patients completed the questionnaire preoperatively with 58% female population, 71% younger than 65 years, and 67% having a GED/higher education. Fifty-two patients had surgery with 54% female population, and 60% were younger than 65 years. All patients had mobile apps for VC with 55% using WhatsApp, 40% using Facetime, and 5% other. In person, being with a trained educator at the office was the preferred method for learning about surgical procedures. Overall, four patients contacted the surgeon directly preoperatively. After surgery, 8 of 52 patients (15%) used VC to the surgeon directly, and 37 patients used the VC with the team.

Conclusion:

With advances in new technology, the use of mobile video conferencing adds a new forum for communication with patients. In the outpatient surgical setting, this forum would improve patient-physician relations.

Provocative biomarker stress test: stress-delta N-terminal pro-B type natriuretic peptide

Objective

Stress testing is commonly performed in emergency department (ED) patients with suspected acute coronary syndrome (ACS). We hypothesised that changes in N-terminal pro-B type natriuretic peptide (NT-proBNP) concentrations from baseline to post-stress testing (stress-delta values) differentiate patients with ischaemic stress tests from controls.

Methods

We prospectively enrolled 320 adult patients with suspected ACS in an ED-based observation unit who were undergoing exercise stress echocardiography. We measured plasma NT-proBNP concentrations at baseline and at 2 and 4  hours post-stress and compared stress-delta NT-proBNP between patients with abnormal stress tests versus controls using non-parametric statistics (Wilcoxon test) due to skew. We calculated the diagnostic test characteristics of stress-delta NT-proBNP for myocardial ischaemia on imaging.

Results

Among 320 participants, the median age was 51 (IQR 44-59) years, 147 (45.9%) were men, and 122 (38.1%) were African-American. Twenty-six (8.1%) had myocardial ischaemia. Static and stress-deltas NT-proBNP differed at all time points between groups. The median stress-deltas at 2  hours were 10.4 (IQR 6.0-51.7) ng/L vs 1.7 (IQR -0.4 to 8.7) ng/L, and at 4  hours were 14.8 (IQR 5.0-22.3) ng/L vs 1.0 (-2.0 to 10.3) ng/L for patients with ischaemia versus those without. Areas under the receiver operating curves were 0.716 and 0.719 for 2-hour and 4-hour stress-deltas, respectively. After adjusting for baseline NT-proBNP levels, the 4-hour stress-delta NT-proBNP remained significantly different between the groups (p=0.009).

Conclusion

Among patients with ischaemic stress tests, static and 4-hour stress-delta NT-proBNP values were significantly higher. Further study is needed to determine if stress-delta NT-proBNP is a useful adjunct to stress testing.

Communication behaviors and patient autonomy in hospital care: A qualitative study

BACKGROUND

Little is known about how hospitalized patients share decisions with physicians.

METHODS

We conducted an observational study of patient-doctor communication on an inpatient medicine service among 18 hospitalized patients and 9 physicians. A research assistant (RA) approached newly hospitalized patients and their physicians before morning rounds and obtained consent. The RA audio recorded morning rounds, and then separately interviewed both patient and physician. Coding was done using integrated analysis.

RESULTS

Most patients were white (61%) and half were female. Most physicians were male (66%) and of Southeast Asian descent (66%). All physicians explained the plan of care to the patients; most believed that their patient understood. However, many patients did not. Physicians rarely asked the patient for their opinion. In all those cases, the decision had been made previously by the doctors. No decisions were made with the patient. Patients sometimes disagreed.

CONCLUSIONS

Shared decision-making may not be the norm in hospital care. Although physicians do explain treatment plans, many hospitalized patients do not understand enough to share in decisions. When patients do assert their opinion, it can result in conflict.

PRACTICE IMPLICATIONS

Some hospitalized patients are interested in discussing treatment. Improving hospital communication can foster patient autonomy.

A 0-Hour/1-Hour Protocol for Safe, Early Discharge of Chest Pain Patients

OBJECTIVES

Guidelines recommend a 0-hour/1-hour high-sensitivity cardiac troponin T (hs-cTnT) diagnostic strategy in acute chest pain patients. There are, however, little data on the performance of this strategy when combined with clinical risk stratification. We aimed to evaluate the diagnostic accuracy of an accelerated diagnostic protocol (ADP) using the 0-hour/1-hour hs-cTnT strategy together with an adapted Thrombolysis In Myocardial Infarction (TIMI) score and electrocardiogram (ECG) for ruling out major adverse cardiac events (MACE) within 30 days.

METHODS

This prospective observational study enrolled consecutive emergency department (ED) chest pain patients. TIMI score variables, ED physicians' assessments of the ECG, and 0- and 1-hour hs-cTnT were collected. Thirty-day MACE was defined as acute myocardial infarction (AMI), unstable angina (UA), cardiogenic shock, ventricular arrhythmia, atrioventricular block, cardiac arrest, or death of cardiac or unknown cause.

RESULTS

A total of 1,020 patients were included in the final analysis. The combination of an adapted TIMI score ≤1, a nonischemic ECG, and either a 0-hour hs-cTnT < 5 ng/L or a 0-hour hs-cTnT < 12 ng/L combined with a 1-hour increase < 3 ng/L identified 432 (42.4%) patients as very low risk with a negative predictive value of 99.5% (95% confidence interval [CI] = 98.3%-99.9%) and a negative likelihood ratio of 0.04 (95% CI = 0.01-0.14) for 30-day MACE. The ADP missed only two patients with UA and no patients with AMI or other forms of MACE.

CONCLUSION

An ADP using the guideline recommended 0-hour/1-hour hs-cTnT strategy rapidly identified patients with a very low risk of 30-day MACE including UA where no further cardiac testing would be needed. This could potentially allow safe early discharge of about 40% of ED chest pain patients.