Perceptions of benefit and risk of patients undergoing first-time elective percutaneous coronary revascularization

Evolution of symptoms in patients with stable angina after normal regadenoson myocardial perfusion imaging: The Radionuclide Imaging and Symptomatic Evolution study (RISE)

BACKGROUND

Assessment of quality of life in patients with stable angina and normal gated single-photon emission computed tomography myocardial perfusion imaging (MPI) remains undefined. Symptom evolution in response to imaging findings has important implications on further diagnostic testing and therapeutic interventions.

METHODS

Prospective cohort study was conducted at the University of Alabama at Birmingham enrolling 87 adult participants with stable chest pain from the emergency room, hospital setting, and outpatient clinics. Patients underwent MPI with technetium-99m Sestamibi and had a normal study. Participants filled out Seattle Angina Questionnaires initially and at 3-month follow-up.

RESULTS

Among the 87 participants (60 ± 12 years; 40% African American, 70% women, 29% diabetes), the mean score increased by an absolute value of 14.2 [95% CI 10.4-18.7, P < .001] in physical limitation, 23.2 [95% CI 17.1-29.4, P < .001] in angina stability, 10.9 [95% CI 7.6-14.1, P < .001] in angina frequency, and 20.6 [95% CI 16.5-24.7, P < .001] in disease perception. There was no significant change in the mean score of treatment satisfaction [- 1.4, 95% CI - 4.7 to 1.8, P = .38]. At 3-month follow-up, 28 of 87 participants (32%) were angina free.

CONCLUSIONS

Patients with stable chest pain and normal MPI experience significant improvement in functional status, quality of life, and disease perception in the short term.

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.

Cardiologists' and patients' views about the informed consent process and their understanding of the anticipated treatment benefits of coronary angioplasty: A survey study

BACKGROUND

Percutaneous coronary intervention is a common revascularisation technique. Serious complications are uncommon, but death is one of them. Seeking informed consent in advance of percutaneous coronary intervention is mandatory. Research shows that percutaneous coronary intervention patients have inaccurate perceptions of risks, benefits and alternative treatments.

AIM

To assess cardiologists' and patients' views about the informed consent process and anticipated treatment benefits.

METHODS

Two cross-sectional, anonymous surveys were distributed in England: an electronic version to a sample of cardiologists and a paper-based version to patients recruited from 10 centres.

RESULTS

A sample of 118 cardiologists and 326 patients completed the surveys. Cardiologists and patients shared similar views on the purpose of informed consent; however, over 40% of patients and over a third of cardiologists agreed with statements that patients do not understand, or remember, the information given to them. Patients placed less value than cardiologists on the consent process and over 60% agreed that patients depended on their doctor to make the decision for them. Patients' and cardiologists' views on the benefits of percutaneous coronary intervention were significantly different; notably, 60% of patients mistakenly believed that percutaneous coronary intervention was curative.

CONCLUSIONS

The percutaneous coronary intervention informed consent process requires improvement to ensure that patients are more involved and accurately understand treatment benefits to make an informed decision. Redesign of the patient pathway is recommended to allow protected time for health professionals to engage in discussions using evidence-based approaches such as 'teach back' and decision support which improve patient comprehension.

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.

Identifying Knowledge Gaps among LVAD Candidates

Education is an important aspect of evaluation and consent for left ventricular assist device (LVAD) candidates. A better understanding of candidate knowledge during the education process can help identify knowledge gaps and improve informed consent processes. This paper presents the results from a validated, LVAD-specific Knowledge Scale administered to candidates before and after education to identify items most and least frequently answered correctly. At baseline and 1-week, both candidates educated with a standard education and an LVAD-specific decision aid were most likely to answer logistical items relating to support and self-care correctly with ≥90% of candidates answering these items correctly after education. Candidates were least likely to answer questions about risks, transplant eligibility, and expenses correctly with <60% of candidates answering them correctly after education. Items with the greatest improvement in correct answers from baseline to 1-week were primarily related to the logistics of living with an LVAD. Candidates educated with the decision aid showed significant improvements on more knowledge items including those related to the forecasting of recovery and complications when compared to candidates educated with a standard education. The 20-item scale provides a standardized way for clinicians to identify knowledge gaps with LVAD candidates, potentially helping to tailor education. Targeted improvements in LVAD education should focus on the understanding of risk and potential complications to ensure that decision-making and informed consent processes emphasize both the patient and clinicians’ conceptualizations of knowledge needs for informed consent.

Differences of patients' perceptions for elective diagnostic coronary angiography and percutaneous coronary intervention in stable coronary artery disease between elderly and younger patients

Aims

There is limited evidence of the differences in expectations between elderly (≥80 years) and younger patients (<80 years) regarding treatment success of percutaneous coronary interventions (PCI). We conducted a survey in patients undergoing diagnostic coronary angiography (DA) and/or intervention (PCI) to identify differences in patient perceptions between elderly and younger patients.

Methods and results

This is an all-comers study of consecutive patients who underwent DA and/or PCI. Patients were asked to fill out a questionnaire prior to DA/PCI. This questionnaire consisted of ten questions with potential patient expectations based on an increasing scale of importance from 0 to 5 which were related to the procedure (eg, extend life, decrease symptoms etc.) and the value of "hard" cardiac endpoints like death, stroke, acute myocardial infarction and target lesion revascularization for the patient. Among 200 patients (mean age 76.6±9.3 years, 60.5% male, ejection fraction 63.7%±13.2%), 100 patients (50%) were ≥80 years. For these elderly patients the questions "to remain independent," "to maintain mobility, so that I can maintain my current life," and "to prevent myocardial infarction" were rated highest. Regarding "hard" cardiac endpoints "to avoid PCI in the future" was rated lowest in younger and in elderly patients. Significant differences were found between the age groups with the items "to avoid myocardial infarction," "avoid heart insufficiency," "to extend my life" and "to maintain mobility so that I can maintain my current life" (P<0.001).

Conclusions

In our survey we found significant differences in patient expectations between elderly and younger patients regarding the outcome of DA/PCI.

Assessing the Informed Consent Skills of Emergency Medicine Resident Physicians

BACKGROUND

Informed consent (IC) is an essential component of shared medical decision making between patients and providers in emergency medicine (EM). The basic components required for adequate consent are well described, yet little is published investigating whether EM residents demonstrate adequate IC skills.

OBJECTIVE

The objectives were to assess the ability of EM residents to obtain IC for an invasive emergency procedure using a novel assessment tool and to assess reliability and validity of the tool.

METHODS

This was an observational study in which participants were initially blinded to the primary objectives of the study. Each participant conducted a video-recorded history and physical examination with a standardized patient, requiring tube thoracostomy due to spontaneous pneumothorax. Two faculty EM physicians independently reviewed the videos and evaluated the participants' IC skills. First, they gave an overall impression of whether IC was obtained; they then evaluated the participants using a 30-point scoring tool based on the five elements of IC (decision-making capacity, disclosure, voluntariness, understanding, and physician recommendation). Upon all participants' case completion, we revealed the primary objectives and gave participants the option to withdraw from the study. Descriptive statistics and kappa coefficient were generated from the data collected.

RESULTS

Twenty-two residents completed the study. None withdrew from the study after the primary objectives were revealed. Twenty residents (91%) obtained adequate IC based on both reviewers' overall impression. One disagreement occurred between reviewers (κ = 0.64). The mean IC score on a 30-point scale was 18.5 ± 0.5.

CONCLUSIONS

In a simulated setting, most EM residents at this training program possess the knowledge and skills necessary to obtain IC prior to an invasive procedure. The assessment tool appears reliable and demonstrates construct validity.

How cardiologists present the benefits of percutaneous coronary interventions to patients with stable angina: a qualitative analysis

IMPORTANCE

Patients with stable coronary artery disease (CAD) attribute greater benefit to percutaneous coronary interventions (PCI) than indicated in clinical trials. Little is known about how cardiologists' presentation of the benefits and risks may influence patients' perceptions.

OBJECTIVES

To broadly describe the content of discussions between patients and cardiologists regarding angiogram and PCI for stable CAD, and to describe elements that may affect patients' understanding.

DESIGN, SETTING, AND PARTICIPANTS

Qualitative content analysis of encounters between cardiologists and patients with stable CAD who participated in the Verilogue Point-of-Practice Database between March 1, 2008, and August 31, 2012. Transcripts in which angiogram and PCI were discussed were retrieved from the database. Patients were aged 44 to 88 years (median, 64 years); 25% were women; 50% reported symptoms of angina; and 6% were taking more than 1 medication to treat angina.

MAIN OUTCOMES AND MEASURES

Results of conventional and directed qualitative content analysis.

RESULTS

Forty encounters were analyzed. Five major categories and subcategories of factors that may affect patients' understanding of benefit were identified: (1) rationale for recommending angiogram and PCI (eg, stress test results, symptoms, and cardiologist's preferences); (2) discussion of benefits (eg, accurate discussion of benefit [5%], explicitly overstated benefit [13%], and implicitly overstated benefit [35%]); (3) discussion of risks (eg, minimization of risk); (4) cardiologist's communication style (eg, humor, teach-back, message framing, and failure to respond to patient questions); and (5) patient and family member contributions to the discussion.

CONCLUSIONS AND RELEVANCE

Few cardiologists discussed the evidence-based benefits of angiogram and PCI for stable CAD, and some implicitly or explicitly overstated the benefits. The etiology of patient misunderstanding is likely multifactorial, but if future quantitative studies support the findings of this hypothesis-generating analysis, modifications to cardiologists' approach to describing the risks and benefits of the procedure may improve patient understanding.

Variation in patients' perceptions of elective percutaneous coronary intervention in stable coronary artery disease: cross sectional study

OBJECTIVES

To assess the perceptions of patients with stable coronary artery disease of the urgency and benefits of elective percutaneous coronary intervention and to examine how they vary across centers and by providers.

DESIGN

Cross sectional study.

SETTING

10 US academic and community hospitals performing percutaneous coronary interventions between 2009 and 2011.

PARTICIPANTS

991 patients with stable coronary artery disease undergoing elective percutaneous coronary intervention.

MAIN OUTCOME MEASURES

Patients' perceptions of the urgency and benefits of percutaneous coronary intervention, assessed by interview. Multilevel hierarchical logistic regression models examined the variation in patients' understanding across centers and operators after adjusting for patient characteristics, using median odds ratios.

RESULTS

The most common reported benefits from percutaneous coronary intervention were to extend life (90%, n=892; site range 80-97%) and to prevent future heart attacks (88%, n=872; site range 79-97%). Although nearly two thirds of patients (n=661) reported improvement of symptoms as a benefit of percutaneous coronary intervention (site range 52-87%), only 1% (n=9) identified this as the only benefit. Substantial variability was noted in the ways informed consent was obtained at each site. After adjusting for patient and operator characteristics, the median odds ratios showed significant variation in patients' perceptions of percutaneous coronary intervention across sites (range 1.4-3.1) but not across operators within a site.

CONCLUSION

Patients have a poor understanding of the benefits of elective percutaneous coronary intervention, with significant variation across sites. No sites had a high proportion of patients accurately understanding the benefits. Coupled with the wide variability in the ways in which hospitals obtain informed consent, these findings suggest that hospital level interventions into the structure and processes of obtaining informed consent for percutaneous coronary intervention might improve patient comprehension and understanding.

Rating the preferences for potential harms of treatments for cardiovascular disease: a survey of community-dwelling adults

BACKGROUND

The Institute of Medicine has called for a new health care paradigm that integrates patient values into discussions of the risks and benefits of treatment. Although cardiovascular disease (CVD) affects one-third of Americans, little is known about how adults regard the potential harms or complications of treatment.

OBJECTIVE

We sought to determine the preferences of community-dwelling adults for 15 potential harms or complications resulting from treatment of CVD.

METHODS

In a telephone survey, adults older than 18 years residing on Long Island, New York, were asked to score the preferences for 15 potential harms or complications of treatment of CVD on a scale from 0 to 100. All statistical analyses were based on nonparametric methods. Multivariable general linear model analyses were performed to identify demographic factors associated with the score assigned for each adverse outcome.

RESULTS

The 807 individuals surveyed generated 723 unique sequences of scores for the 15 outcomes. The ranking of scores from least to most acceptable was stroke, major myocardial infarction (MI), cognitive dysfunction, renal failure, death, prolonged ventilator support, heart failure, angina, sternal wound infection, major bleeding, reoperation, prolonged recovery in a nursing home, cardiac readmission, minor MI, and percutaneous coronary intervention. Demographic factors accounted for less than 7% of the observed variation in the score attributed to each outcome.

CONCLUSIONS

Individual community-dwelling adults living on Long Island, New York, assign unique values to their preferences for potential harms encountered following treatment of CVD. Thus, risk-benefit discussions and treatment decisions regarding CVD should be harmonized to the value system of each individual.

Patients, providers, and systems need to acquire a specific set of competencies to achieve truly patient-centered care

Studies show that patients want to be more involved in their own health care. Yet insufficient attention has been paid to the specific competencies of both patients and providers that are needed to optimize such patient engagement and shared decision making. In this article we address the knowledge, skills, and attitudes that patients, physicians, and health care systems require to effectively engage patients in their health care. For example, many patient-physician interactions still follow the traditional office visit format, in which the patient is passive, trusting, and compliant. We recommend imaginative models for redesigned office care, restructured reimbursement schemes, and increased support services for patients and professionals. We present three clinical scenarios to illustrate how these competencies must work together. We conclude that effective shared decision making takes time to deliver proficiently and that among other measures, policy makers must change payment models to focus on value and support education and discussion of competencies for a modern health care system.

Patients overestimate the potential benefits of elective percutaneous coronary intervention

OBJECTIVE

Although percutaneous coronary intervention (PCI) reduces mortality in the setting of myocardial infarction (MI), recent studies suggest that the benefits of PCI for chronic Coronary Artery Disease (CAD) are predominantly related to angina relief and improved quality of life. Whether patients in the current era understand these benefits of elective PCI, or perceive that they also derive protection against death and MI is unknown.

PATIENTS & METHODS

We surveyed 498 consecutive elective PCI patients a mean of 13.7 months after being treated between 1/06-10/07, 2007, at two hospitals. We used a one-page questionnaire quantifying their perceptions of the benefits from PCI.

RESULTS

Of 498 eligible subjects, 350 responded (70%). The mean age was 67.8 +/- 10.9 years, and 76% were male. One-third believed that their PCI was emergent (despite the fact that all were elective), 71% believed the procedure would prevent future heart attacks, 66% thought it would extend their life, 42% reported that it saved their life, 42% stated that it would improve abnormalities on their stress test, and only 31'% believed it would decrease their angina.

CONCLUSION

Although considerable attention is given to facilitating informed consent at our center, patients' perceived benefits of elective PCI do not match existing evidence, as they overestimated both the benefits and urgency of their procedures. These findings suggest that an even greater effort at patient education is needed prior to elective PCI to facilitate fully informed decision-making.

Shared Decision Making Guidance Reminders in Practice (SDM-GRIP)

OBJECTIVE

Develop a system of practice tools and procedures to prompt shared decision making in primary care. SDM-GRIP (Shared Decision Making Guidance Reminders in Practice) was developed for suspected stable coronary artery disease (CAD), prior to the percutaneous coronary intervention (PCI) decision.

METHODS

Program evaluation of SDM-GRIP components: Grand Rounds, provider training (communication skills and clinical evidence), decision aid (DA), patient group visit, encounter decision guide (EDG), SDM provider visit.

RESULTS

Participation-Physician training=73% (21/29); patient group visits=25% of patients with diagnosis of CAD contacted (43/168). SDM visits=16% (27/168). Among SDM visit pairs, 82% of responding providers reported using the EDG in SDM encounters. Patients valued the SDM-GRIP program, and wanted to discuss comparative effectiveness information with a cardiologist. SDM visits were routinely reimbursed.

CONCLUSION

Program elements were well received and logistically feasible. However, recruitment to an extra educational group visit was low. Future implementation will move SDM-GRIP to the point of routine ordering of non-emergent stress tests to retain pre-decision timing of PCI and to improve coordination of care, with SDM tools available across primary care and cardiology.

PRACTICE IMPLICATIONS

Guidance prompts and provider training appear feasible. Implementation at stress testing requires further investigation.

Perception of cardiovascular risk following a percutaneous coronary intervention: a cross sectional study

BACKGROUND

An individual's perception of the risk of, and their susceptibility to, future cardiovascular events is crucial in engaging in effective secondary prevention.

AIM

To investigate the perception of a cardiovascular event by examining the level of agreement between individuals with CHD views of their actual and perceived risk.

METHODS

This study examined the individual's perception of the risk of a subsequent cardiac event among 220 patients hospitalised for a percutaneous coronary intervention (PCI) at a metropolitan, tertiary referral hospital in Sydney, Australia. Baseline clinical and demographic characteristics were collected, and actual risk (Personal Risk Score) calculated based on the presence or absence of nine cardiovascular risk factors: diabetes, hypertension, high cholesterol, cigarette smoking, previous history of CHD, family history of CHD, depression, overweight or obesity, and physical inactivity. Perception of risk was determined using an investigator-developed 4-item, 11-point Likert scale instrument (Perceived Heart Risk Questionnaire--PHRQ) which measured two dimensions of health threat: perceived seriousness, and perceived susceptibility. The correlation between the Personal Risk Score and the PHRQ was assessed using the Pearson product-moment correlation coefficient.

RESULTS

The calculated mean Personal Risk Score was 4.63±1.71 and the PHRQ was 25.5±7.04. The correlation between the Personal Risk Score (actual risk) and the PHRQ (perceived risk) was r=0.26 (p<0.01).

CONCLUSIONS

The weak relationship between actual and perceived risk is of concern, particularly in a population at higher risk for future cardiovascular events. Implementing strategies to personalise risk should be explored to improve the accuracy of risk perception, and facilitate tailoring of behaviour change strategies.

Converting the informed consent from a perfunctory process to an evidence-based foundation for patient decision making

BACKGROUND

Standard consent forms result in highly variable communication between patients and physicians. To enhance the consent process and facilitate shared decision making, we developed a World Wide Web-based program, PREDICT (Patient Refined Expectations for Deciding Invasive Cardiac Treatments), to systematically embed patient-specific estimates of death, bleeding, and restenosis into individualized percutaneous coronary intervention informed consent documents. We then compared patients' experiences with informed consent before and after implementation of PREDICT.

METHODS AND RESULTS

Between August 2006 and May 2007, patients undergoing nonemergent cardiac catheterization who received the original consent form (n=142) were interviewed and compared with those who received the PREDICT consent form (n=193). Hierarchical modified Poisson regression models were used to adjust for clustering of patients within physicians. Compared with the original consent group, those in the PREDICT group reported higher rates of reading the consent form (72% versus 44%, relative risk [RR] 1.64, 95% confidence interval [CI] 1.24 to 2.16), increased perception of shared decision making (67% versus 45%, RR 1.48, 95% CI 0.99 to 2.22), and decreased anxiety (35% versus 55%, RR 0.70, 95% CI 0.53 to 0.91). Although there were no differences between groups in patients' ability to name complications of percutaneous coronary intervention, among patients who identified either death or bleeding as a potential complication, more patients in the PREDICT group recalled being informed of their estimated risk of that complication (death: 85% versus 62%, RR 1.37, 95% CI 1.03 to 1.82; bleeding: 92% versus 71%, RR 1.28, 95% CI 1.06 to 1.56).

CONCLUSIONS

In this preliminary, single-center experience, individualized consent forms with patient-specific risks were associated with improved participation in the consent process, reduced anxiety, and better risk recall. PREDICT is one potential strategy for improving the current practice of obtaining informed consent for percutaneous coronary intervention.

Explicit risk in acute coronary syndrome management

At least implicitly, most clinical decisions represent an integration of disease and treatment-based risk assessments. Often, as is the case with acute coronary syndrome (ACS), these decisions need to be made quickly at a time when data elements are limited, and published risk models are very useful in clarifying time-dependent determinants of risk. The present review emphasizes the value of explicit risk assessment and reinforces the fact that patients at highest risk are often those most likely to benefit from newer and more invasive therapies. Suggested ways to incorporate published ACS risk models into clinical practice are included. In addition, the need to adopt a longer-term view of risk in ACS patients is stressed, with particular regard to the important role of heart failure prediction and treatment.

Why physicians favor use of percutaneous coronary intervention to medical therapy: a focus group study

BACKGROUND

Percutaneous coronary intervention (PCI) is performed in many patients with stable coronary artery disease, despite evidence of little clinical benefit over optimal medical therapy.

OBJECTIVE

To examine physicians' beliefs, practices, and decision-making regarding elective PCI.

DESIGN

Six focus groups, three with primary care physicians and three with cardiologists. Participants discussed PCI using hypothetical case scenarios. Transcripts were analyzed using grounded theory, and commonly expressed themes regarding the decision-making pathway to PCI were identified.

PARTICIPANTS

Twenty-eight primary care physicians and 20 interventional and non-interventional cardiologists in Butte County, Orange County, and San Francisco Bay Area, California, in 2006.

RESULTS

A number of factors led primary care physicians to evaluate non-symptomatic or minimally symptomatic patients for coronary artery disease and refer them to a cardiologist. The use of screening tests often led to additional testing and referral, as well as fear of missing a coronary stenosis, perceived patient expectations, and medicolegal concerns. The end result was a cascade such that any positive test would generally lead to the catheterization lab, where an "oculostenotic reflex" made PCI a virtual certainty.

CONCLUSIONS

The widespread use of PCI in patients with stable coronary artery disease--despite evidence of little benefit in outcomes over medical therapy--may in part be due to psychological and emotional factors leading to a cascade effect wherein testing leads inevitably to PCI. Determining how to help physicians better incorporate evidence-based medicine into decision-making has important implications for patient outcomes and the optimal use of new technologies.

Exploring Patient Preferences for Infrainguinal Bypass Operation

BACKGROUND

Surgical risk and outcomes for patients undergoing infrainguinal bypass operation vary by identifiable patient characteristics, yet little is known about whether patients understand the risks, benefits, and alternatives to operation.

STUDY DESIGN

Cross-sectional surveys administered to 50 patients undergoing infrainguinal bypass operation at one institution an average of 7 days (median 4 days) before operations.

RESULTS

Most patients rated their health as fair or poor (53%) or good (35%), and the majority reported their vascular disease was associated with difficulty doing activities they enjoyed (71%), leg pain (86%), and difficulty walking (98%). About one-half of patients (54%) thought they would require additional operations, 21% reported being at risk for postoperative myocardial infarction and 24% believed they would require a major amputation despite operations. Over two-thirds of patients (69%) believed their overall health would improve postoperatively, although more than four-fifths (80% to 86%) believed their ability to perform activities, leg pain, and walking would improve. Eighty-eight percent of patients reported willingness to have the operation even with a 10% postoperative mortality rate and 96% of patients reported a preference for operations if the chance of successful outcomes was only 75%.

CONCLUSIONS

Although patients appear to be willing to undertake considerable postoperative risk, expectations for benefits from infrainguinal bypass operation appear greater than outcomes suggested by earlier research. These findings, if confirmed in larger studies, challenge how patient preferences should optimally be used to inform decisions about whether to undertake infrainguinal bypass operations.

Attitudes, psychology, and risk taking of potential live kidney donors: strangers, relatives, and the general public

It is unclear whether potential living kidney donors and the general public differ in attitudes and psychological characteristics. We performed a case-control study to explore differences in these groups using a standardized questionnaire (analyzed using conditional logistic regression). Strangers (N = 42) were more willing than controls (N = 126) to incur risks: 64% strangers versus 35% controls accepting >50% medical complications (MC) risk; 90% strangers versus 61% controls accepting >8 days hospitalization; 71% strangers versus 43% controls accepting >3 months unpaid; 55% strangers versus 16% controls accepting 100% kidney failure (KF) risk; 70% strangers versus 34% controls accepting < or =10% likelihood of successful transplant (all p < 0.01). Relatives (N = 251) were also more willing than controls (N = 251) to incur risks. Strangers were most willing to incur MC, KF and transplant failure. Groups did not differ in attitudes, depression or anxiety. Potential stranger and related donors are willing to undergo greater risks with donation than the general public, but do not differ in other attitudes, depression or anxiety. This should help reassure transplant centers and the public that both forms of live donation do not necessarily involve increased ethical risks of donor coercion or irrational thought processes. Still, careful attention to communication of all risks of donation is warranted.

The validity of patient and physician estimates of walking distance

OBJECTIVE

To establish the validity of patient and physician estimates of maximum walking distance versus actual measured maximum walking distance.

DESIGN

Assessment of concurrent validity (patient and physician estimates were compared with a gold standard measure at the same time).

SETTING

University-affiliated rehabilitation department in a tertiary care hospital.

SUBJECTS

A sequential sample of 31 patients over the age of 17 referred to the physical medicine and rehabilitation outpatients department between 1 May 2000 and 20 July 2001, who had at least some degree of walking difficulty.

INTERVENTIONS

Patients and their physicians were asked to provide estimates of walking distance independently after a regular appointment prior to the patient being escorted along a pre-measured walking course.

MAIN OUTCOME MEASURES

Actual distance walked was compared with estimates using Pearson correlation coefficients.

RESULTS

Pearson correlation coefficients for patient estimate versus actual was 0.789 (p < or = 0.0001), and mean estimate of patient and physician estimates versus actual was 0.812 (p < or = 0.0001). Physician estimate versus actual and patient estimate versus physician estimate were 0.349 and -0.139 (neither significant). Sixty-seven per cent (20/30) of patients overestimated how far they thought they could walk versus 23% (7.30) of physicians who overestimated. Neither group were found to be 'good' estimators of maximal walking distance.

CONCLUSIONS

Neither patients nor physicians provide valid estimates of maximal walking distance. Patients consistently overestimate their maximal walking distance, whereas physicians tend to underestimate. Interestingly, patients' estimates (although over inflated) do correlate well with actual walking distance, while physician estimates are not at all correlated. This study suggests that reliance on self-reported or physician-estimated maximum walking distances (whether for clinical, research or other reasons) is potentially flawed.

The Seattle angina questionnaire: reliability and validity in women with chronic stable angina

Angina pectoris causes substantial psychological and functional disability and adversely effects health-related quality of life, particularly in women. Studies of cardiac disease-specific quality of life in women with coronary artery disease and angina are limited because little reliability and validity data for these instruments exist for women. Therefore, the purpose of this study was to examine reliability and validity of the Seattle Angina Questionnaire (SAQ), a cardiac disease-related quality-of-life measure, in a sample of women with chronic stable angina. A secondary analysis was performed on SAQ data from 175 women with a confirmed diagnosis of CAD and angina pectoris. The majority of the women were older, white, living with their spouse, had a previous acute myocardial infarction, and had undergone revascularization. The Cronbach alpha was used to assess reliability of the SAQ's five subscales, and factor analysis was used to assess the SAQ's validity. Results suggest that the SAQ is a reliable and valid quality-of-life measure in women with CAD. The physical limitations subscale factored into two separate factors, suggesting that the subscale measures two domains of physical function: self-care and exercise tolerance/mobility. Future research is needed to determine whether examining different combinations of SAQ items might provide a more sensitive assessment of cardiac disease-specific quality of life in women.