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

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Development, piloting, and evaluation of an evidence-based informed consent form for total knee arthroplasty (EvAb-Pilot): a protocol for a mixed methods study

BACKGROUND

Practitioners frequently use informed consent forms to support the physician-patient communication and the informed consent process. Informed consent for surgery often focuses on risk centered information due to high liability risks for treatment errors. This may affect patients' anxiety of adverse events and the nocebo effect. This study focuses on the optimization of pre-surgical information on risks and complications, and at the same time reconciles these information with legal requirements.

METHODS

The development, piloting, and evaluation of evidence-based informed consent forms for total knee arthroplasty (TKA) and related anesthesia procedures will follow the UK MRC Framework for developing and evaluating complex interventions. Conducting different sub-studies, we will (I) qualitatively explore the information acquisition and decision-making processes, (II) develop and pilot test evidence-based informed consent forms on the example of TKA and related anesthesia procedures, (III) conduct a monocentric interrupted time series (ITS) pilot study to evaluate the effects of evidence-based informed consent forms in comparison with standard consent forms, and (IV) perform a process evaluation to identify barriers and facilitators to the implementation of the intervention and to analyze mechanisms of impact.

DISCUSSION

The evidence-based and understandable presentation of risks in informed consent forms aims at avoiding distorted risk depiction and strengthening the patients' competencies to correctly assess the risks of undergoing surgery. This might reduce negative expectations and anxiety of adverse events, which in turn might reduce the nocebo effect. At the same time, the practitioners' acceptance of evidence-based informed consent forms meeting legal requirements could be increased.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04669483 . Registered 15 December 2020. German Clinical Trials Registry, DRKS00022571 . Registered 15 December 2020.

From the Patient Perspective, Consent Forms Fall Short of Providing Information to Guide Decision Making

OBJECTIVE

This study aimed to gather qualitative feedback on patient perceptions of informed consent forms and elicit recommendations to improve readability and utility for enhanced patient safety and engagement in shared decision making.

METHODS

Sixty interviews in personal interviews were conducted consisting of a literacy and numeracy assessment, a comprehension quiz to assess retention of key information, and open-ended questions to determine reactions, clarity of information, and suggestions for improvement.

RESULTS

Although 68% of the participants had education beyond high school, many still missed comprehension questions and found the forms difficult to read. Recurrent suggestions included specific formatting changes to enhance readability, a need for additional sources of information, mixed attitudes toward inclusion of risk information, and the recognized importance of physician-patient conversations.

CONCLUSIONS

This study provides evidence from the patient perspective that consent forms are too complex and fail to achieve comprehension. Future studies should be conducted using patients' suggestions for form redesign and inclusion of supplemental educational tools to optimize communication and safety to achieve more informed health care decision making.

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

OBJECTIVE

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

DESIGN

Mixed qualitative-quantitative approach.

SETTING

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

PARTICIPANTS

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

INTERVENTIONS

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

OUTCOMES

Abstraction tool to evaluate the quality of informed consent documents.

RESULTS

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

CONCLUSIONS

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

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.

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

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

Predictive Value of CHA2DS2-VASc Score for Ischemic Events in Patients Undergoing Percutaneous Coronary Intervention

We evaluated the association of preprocedure CHA₂DS₂-VASc (congestive heart failure, hypertension, age, diabetes mellitus, stroke, vascular disease, and sex) score with ischemic events in patients undergoing percutaneous coronary intervention (PCI). The Dryad Digital Repository enrolled 2533 patients between July 2009 and August 2011. We recorded 1-year ischemic events. Univariate and multivariable logistic regression analyses were used to analyze the association between CHA₂DS₂-VASc score and ischemic events. Receiver operating characteristic curves were used to evaluate the accuracy of CHA₂DS₂-VASc score in predicting long-term ischemic events. Long-term death (9.5 vs 2.8%), cardiac death (2.9 vs 1.4%), and nonfatal stroke (1.9 vs 0.7%) were significantly higher in the CHA₂DS₂-VASc score ≥2 group than the CHA₂DS₂-VASc score ≤1 group. The CHA₂DS₂-VASc score was a predictor for all-cause death (odds ratio [95% confidence interval]: 3.71 [1.89-7.30]). The risk factors for all-cause death in CHA₂DS₂-VASc score ≥2 patients included age, diagnosis, heart failure, older myocardial infarction, diabetes, and chronic obstructive pulmonary disease, while the risk factor for CHA₂DS₂-VASc score ≤1 patients was age. In conclusion, the CHA₂DS₂-VASc score is associated with long-term all-cause death, cardiac death, and stroke in patients undergoing PCI, and it may have a potential use for risk stratification for patients who undergo PCI.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Novel Patient-Centered Approach to Facilitate Same-Day Discharge in Patients Undergoing Elective Percutaneous Coronary Intervention

Background

Same‐day discharge (SDD) after elective percutaneous coronary intervention is safe, less costly, and preferred by patients, but it is usually performed in low‐risk patients, if at all. To increase the appropriate use of SDD in more complex patients, we implemented a “patient‐centered” protocol based on risk of complications at Barnes‐Jewish Hospital.

Methods and Results

Our objectives were as follows: (1) to evaluate time trends in SDD; (2) to compare (a) mortality, bleeding, and acute kidney injury, (b) patient satisfaction, and (c) hospital costs by SDD versus no SDD (NSDD); and (3) to compare SDD eligibility by our patient‐centered approach versus Society for Cardiovascular Angiography and Interventions guidelines. Our patient‐centered approach was based on prospectively identifying personalized bleeding, mortality, and acute kidney injury risks, with a personalized safe contrast limit and mitigating those risks. We analyzed Barnes‐Jewish Hospital's National Cardiovascular Data Registry CathPCI Registry data from July 1, 2009 to September 30, 2015 (N=1752). SDD increased rapidly from 0% to 77% (P<0.001), independent of radial access. Although SDD patients were comparable to NSDD patients, SDD was not associated with adverse outcomes (0% mortality, 0% bleeds, and 0.4% acute kidney injury). Patient satisfaction was high with SDD. Propensity score–adjusted costs were $7331 lower/SDD patient (P<0.001), saving an estimated $1.8 million annually. Only 16 patients (6.95%) met the eligibility for SDD by Society for Cardiovascular Angiography and Interventions guidelines, implying our patient‐centered approach markedly increased SDD eligibility.

Conclusions

With a patient‐centered approach, SDD rapidly increased and was safe in 75% of patients undergoing elective percutaneous coronary intervention, despite patient complexity. Patient satisfaction was high, and hospital costs were lower. Patient‐centered decision making to facilitate SDD is an important opportunity to improve the value of percutaneous coronary intervention.

Drivers of poor medical care

The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain.

Prediction of adverse events after catheter-based procedures in adolescents and adults with congenital heart disease in the IMPACT registry

AIMS

We sought to identify factors associated with major adverse events (MAE) after cardiac catheterization in adolescents and adults with congenital heart disease (CHD), and create the first model to individualize risk discussions in this growing population.

METHODS AND RESULTS

Improving Pediatric and Adult Congenital Treatment (IMPACT), a National Cardiovascular Data Registry, contains congenital catheterization data from over 87 hospitals in the United States. Demographics, pre-procedure, and procedural variables were collected for patients over age 10. Multivariable logistic regression was used to identify significant predictors of MAE, a composite of death, urgent surgery or procedure due to a catheterization complication, transfusion, embolic stroke, tamponade, extracorporeal membrane oxygenation or ventricular assist device placement, and device embolization, malposition or thrombosis requiring surgical intervention. A risk score was built based on the effect sizes of each predictor and validated in a split sample. A MAE occurred in 686 (2.5%) of the 27 293 index procedures meeting inclusion criteria. The independent multivariate predictors of MAE were older age, pre-procedural anticoagulation use, renal disease, lower haemoglobin, lower oxygen saturation, non-elective procedure, higher index procedure risk and having had no prior cardiac procedures. Being underweight or overweight had borderline significance and was added to the model. The C-statistic for the model was robust at 0.787 in the derivation and 0.773 in the validation cohort.

CONCLUSION

The factors predicting adverse events after cardiac catheterization in adolescents and adults with CHD are different than in the general population. Validation of this model in other national or multi-institutional datasets is the next step.

Predictors of Consent in a Randomized Field Study in Child Welfare

PURPOSE

Randomized controlled trials (RCTs) are often viewed as the "gold standard" for proving the efficacy and effectiveness of new interventions. However, some are skeptical of the generalizability of the findings that RCTs produce. The characteristics of those willing to participate in research studies have the potential to affect the generalizability of its findings. This study examined factors that could influence consent among families recruited to participate in a randomized field trial in a real-world child welfare setting.

METHODS

This study tested the Parent Management Training Oregon Model for children in foster care with serious emotional disturbance. It employed a post-randomization consent design, whereby the entire sample of eligible participants, not just those who are willing to consent to randomization, are included in the sample. Initial eligibility assessment data and data from the federally mandated reporting system for public child welfare agencies provided the pool of potential predictors of consent. Bivariate and multivariate analyses were conducted to identify statistically significant predictors of consent.

RESULTS

Being a dual reunification family was the most significant factor in predicting consent. Unmarried individuals, younger, female parents, cases where parental incarceration was the reason for removal and cases where the removal reason was not due to their children's behavioral problem(s) were also more likely to participate.

DISCUSSION

As one of the first research studies to examine predictors of consent to a randomized field study in child welfare settings, results presented here can act as a preliminary guide for conducting RCTs in child welfare settings.

Myocardial Infarction Risk in Arthroplasty vs Arthroscopy: How Much Does Procedure Type Matter?

BACKGROUND

This study aimed at assessing short-term risk of serious cardiac events after elective total joint arthroplasty (TJA) as compared to a less-invasive procedure, knee arthroscopy (KA).

METHODS

Patients who underwent elective primary total hip arthroplasty (THA), total knee arthroplasty (TKA), or KA from 2011 to 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. A 1:1 propensity matching was used to generate 2 control cohorts of KA patients with similar characteristics. Bivariate and multivariate analyses were assessed using perioperative variables.

RESULTS

A total of 24,203 THA, 21,740 TKA, and 45,943 KA patients were included. Bivariate analysis revealed significantly higher rates of serious 30-day cardiac events (myocardial infarction or cardiac arrest) among THA (0.15% vs 0.05%, P < .001) and TKA patients (0.14% vs 0.05%, P < .03) vs KA controls. In multivariate analysis controlling for patient characteristics and comorbidities, THA and TKA were associated with a 2.61 and 1.98 times odds of serious 30-day cardiac events as compared to controls (P ≤ .03 for both). Additional independent predictors of serious 30-day cardiac events included age, smoking, cardiac disease, and American Society of Anesthesiologists class 3/4. In the THA and TKA cohorts, serious cardiac events occurred within the first 3 days postoperation compared to 4 days in controls.

CONCLUSION

After controlling for patient characteristics and comorbidities, TJA increased the short-term risk of serious cardiac event compared to a less-invasive procedure. This information better quantifies the risk differential for patients considering surgery as they engage in shared decision making with their providers. In addition, our data may have an impact on perioperative management of antithrombotic medications used in patients with cardiac disease. The median time in days to serious cardiac event was 2 in THA and 3 in TKA vs 4 in KA, which may have implications in postoperative monitoring of patients after surgery.

Bleeding risk following percutaneous coronary intervention in patients with diabetes prescribed dual anti-platelet therapy

BACKGROUND

Patients with diabetes mellitus (DM) experience higher rates of in-stent restenosis and greater benefit from drug-eluting stents implant at the time of percutaneous coronary intervention (PCI), necessitating prolonged dual anti-platelet therapy (DAPT). While DAPT reduces risk of ischemic events post-PCI, it also increases risk of bleeding. Whether bleeding rates differ among patients with and without DM, receiving long-term DAPT is unknown.

METHODS

Among patients who underwent PCI and were maintained on DAPT for 1 year in a multicenter US registry, we assessed patient-reported bleeding over one year following PCI in patients with and without DM. Multivariable, hierarchical Poisson regression was used to evaluate the association of DM with bleeding during follow-up.

RESULTS

Among 2334 PCI patients from 10 US hospitals (mean age 64, 54% ACS), 32.6% had DM. In unadjusted analyses, patients with DM had fewer bleeding events over the year following PCI (DM vs no DM: BARC = 1: 78.0% vs 87.7%, P < .001; BARC ≥2: 4.3% vs 5.3%, P = .33). Following adjustment, patients with (vs without DM) had a lower risk of BARC ≥1 bleeding during follow-up (relative risk [RR] 0.89, 95% CI 0.83-0.96). This decreased bleeding risk persisted after removing bruising from the endpoint definition.

CONCLUSIONS

In a real-world PCI registry, patients with DM experienced lower risk of bleeding risk on DAPT. As patients with DM also derive greater ischemic benefit from drug-eluting stents, which requires prolonged DAPT, our findings suggest that the balance between benefit and risk of this therapeutic approach may be even more favorable in patients with DM than previously considered.

Predicting long-term bleeding after percutaneous coronary intervention

OBJECTIVES

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Management of Complications

Percutaneous coronary intervention (PCI) has matured rapidly to tackle increasingly complex coronary disease. Operators must be aware of the incidence of the basic risks involved with coronary angiography and PCI to appropriately inform patients and obtain procedural consent. Even before a wire enters a coronary artery, specific risks, including vascular access complications, renal injury, allergic reaction, and radiation injury, are constantly present. With initiation of PCI, new risks to the coronary circulation arise. A fundamental knowledge of the presentation of these complications and expert ability to emergently manage them are of the utmost importance to the successful completion of PCI.

Communicating radiation risk to patients and referring physicians in the emergency department setting

Heightened awareness about the radiation risks associated with CT imaging has increased patients' wishes to be informed of these risks, and has motivated efforts to reduce radiation dose and eliminate unnecessary imaging. However, many ordering providers, including emergency physicians, are ill prepared to have an informed discussion with patients about the cancer risks related to medical imaging. Radiologists, who generally have greater training in radiation biology and the risks of radiation, often do not have a face-to-face relationship with the patients who are being imaged. A collaborative approach between emergency physicians and radiologists is suggested to help explain these risks to patients who may have concerns about getting medical imaging.

Validated contemporary risk model of acute kidney injury in patients undergoing percutaneous coronary interventions: insights from the National Cardiovascular Data Registry Cath-PCI Registry

Background

We developed risk models for predicting acute kidney injury (AKI) and AKI requiring dialysis (AKI‐D) after percutaneous coronary intervention (PCI) to support quality assessment and the use of preventative strategies.

Methods and Results

AKI was defined as an absolute increase of ≥0.3 mg/dL or a relative increase of 50% in serum creatinine (AKIN Stage 1 or greater) and AKI‐D was a new requirement for dialysis following PCI. Data from 947 012 consecutive PCI patients and 1253 sites participating in the NCDR Cath/PCI registry between 6/09 and 7/11 were used to develop the model, with 70% randomly assigned to a derivation cohort and 30% for validation. AKI occurred in 7.33% of the derivation and validation cohorts. Eleven variables were associated with AKI: older age, baseline renal impairment (categorized as mild, moderate, and severe), prior cerebrovascular disease, prior heart failure, prior PCI, presentation (non‐ACS versus NSTEMI versus STEMI), diabetes, chronic lung disease, hypertension, cardiac arrest, anemia, heart failure on presentation, balloon pump use, and cardiogenic shock. STEMI presentation, cardiogenic shock, and severe baseline CKD were the strongest predictors for AKI. The full model showed good discrimination in the derivation and validation cohorts (c‐statistic of 0.72 and 0.71, respectively) and identical calibration (slope of calibration line=1.01). The AKI‐D model had even better discrimination (c‐statistic=0.89) and good calibration (slope of calibration line=0.99).

Conclusion

The NCDR AKI prediction models can successfully risk‐stratify patients undergoing PCI. The potential for this tool to aid clinicians in counseling patients regarding the risk of PCI, identify patients for preventative strategies, and support local quality improvement efforts should be prospectively tested.

Predictors of clinical outcomes in acute decompensated heart failure: Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure outcome models

BACKGROUND

Patients hospitalized for acute decompensated heart failure (ADHF) are at high risk for early mortality and rehospitalization. Risk stratification of ADHF using clinically available data on admission is increasingly important to integrate with clinical pathways. Our goal was to create a simple method of screening patients upon admission to identify those with increased risk of future adverse events.

METHODS

Using ASCEND-HF, a pragmatic clinical trial conducted in 398 sites globally, we developed and validated logistic regression risk models for (a) 30-day mortality/HF rehospitalization, (b) 30-day mortality/all-cause rehospitalization, (c) 30-day all-cause mortality, and (d) 180-day all-cause mortality. Fifty-one candidate variables were evaluated based on prior publications and clinical review. Final models were selected based on stepwise selection with entry and a staying criterion of P < .01. The 30-day mortality model was externally validated, and coefficients were converted to an additive risk score.

RESULTS

Among 7,141 patients, the median age was 67 years, 34% were female, and 80% had a left ventricular ejection fraction <40%. The models had between 5 and 12 risk factors with c-indices ranging from 0.68 to 0.75. A simplified score, including age, systolic blood pressure, sodium, blood urea nitrogen, and dyspnea at rest, discriminated 30-day mortality risk from 0.5% (score 0) to 53% (score 10).

CONCLUSIONS

Commonly available clinical variables provide simple risk stratification for clinical outcomes among patients with ADHF, and these models may be considered for integration into routine clinical care.

Prediction of residual angina after percutaneous coronary intervention

Aims

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

Methods and results

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

Conclusion

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

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

OBJECTIVE

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

DESIGN

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

SETTING

Nine hospitals in the United States.

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

While the process of informed consent is designed to transfer knowledge of the risks and benefits of treatment and to engage patients in shared medical decision-making, this is poorly done in routine clinical care. We assessed the impact of a novel informed consent form for percutaneous coronary intervention (PCI) that is more simply written, includes images of the procedure, and embeds individualized estimates of outcomes on multiple domains of successful informed consent and shared decision-making.

METHODS

We interviewed 590 PCI patients receiving traditional consent documents and 527 patients receiving novel ePRISM consents at 9 US centers and compared patients' perceptions, knowledge transfer, and engagement in medical decision-making. Heterogeneity across sites was assessed and adjusted for using hierarchical models.

RESULTS

Site-adjusted analyses revealed more frequent review (72% for ePRISM vs 45% for original consents) and better understanding of the ePRISM consents (ORs=1.8-3.0, depending upon the outcome) with marked heterogeneity across sites (median relative difference [MRD] in the ORs of ePRISM's effect =2-3.2). Patients receiving ePRISM consents better understood the purposes and risks of the procedure (ORs=1.9-3.9, MRDs=1.1-6.2), engaged more in shared decision-making (proportional OR=2.1 [95% CI=1.02-4.4], MRD=2.2) and discussed stent options with their physicians (58% vs. 31%; site-adjusted odds ratio=2.7 [95% CI=1.2, 6.3], MRD=2.6) more often.

CONCLUSIONS

A personalized consent document improved the process of informed consent and shared decision-making. Marked heterogeneity across hospitals highlights that consent documents are but one aspect of engaging patients in understanding and participating in treatment.

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.

An updated bleeding model to predict the risk of post-procedure bleeding among patients undergoing percutaneous coronary intervention: a report using an expanded bleeding definition from the National Cardiovascular Data Registry CathPCI Registry

OBJECTIVES

This study sought to develop a model that predicts bleeding complications using an expanded bleeding definition among patients undergoing percutaneous coronary intervention (PCI) in contemporary clinical practice.

BACKGROUND

New knowledge about the importance of periprocedural bleeding combined with techniques to mitigate its occurrence and the inclusion of new data in the updated CathPCI Registry data collection forms encouraged us to develop a new bleeding definition and risk model to improve the monitoring and safety of PCI.

METHODS

Detailed clinical data from 1,043,759 PCI procedures at 1,142 centers from February 2008 through April 2011 participating in the CathPCI Registry were used to identify factors associated with major bleeding complications occurring within 72 h post-PCI. Risk models (full and simplified risk scores) were developed in 80% of the cohort and validated in the remaining 20%. Model discrimination and calibration were assessed in the overall population and among the following pre-specified patient subgroups: females, those older than 70 years of age, those with diabetes mellitus, those with ST-segment elevation myocardial infarction, and those who did not undergo in-hospital coronary artery bypass grafting.

RESULTS

Using the updated definition, the rate of bleeding was 5.8%. The full model included 31 variables, and the risk score had 10. The full model had similar discriminatory value across pre-specified subgroups and was well calibrated across the PCI risk spectrum.

CONCLUSIONS

The updated bleeding definition identifies important post-PCI bleeding events. Risk models that use this expanded definition provide accurate estimates of post-PCI bleeding risk, thereby better informing clinical decision making and facilitating risk-adjusted provider feedback to support quality improvement.

Risk scores for 30-day mortality after percutaneous coronary intervention: new insights into causes and risk of death

OBJECTIVE

To determine the causes and risk of death after percutaneous coronary interventions (PCIs) and to compare the discriminatory ability of the New York State Risk Score (NYSRS) with the Mayo Clinic Risk Score (MCRS).

PATIENTS AND METHODS

We studied in-hospital and 30-day mortality after PCI in 4898 patients treated at Mayo Clinic in Rochester, Minnesota, from January 1, 2007, through December 31, 2010, to validate the NYSRS equation with recalibrated predicted probabilities of death.

RESULTS

Of the 4898 patients studied, 93 (1.9%) died during the index hospitalization, and 36 (0.7%) died within 30 days after discharge. For the in-hospital and 30-day mortality, respectively, the area under the receiver operating characteristic curve was 0.92 and 0.88 for the NYSRS and 0.93 and 0.90 for the MCRS, indicating excellent discrimination. The NYSRS model underpredicted event rates when applied in Mayo Clinic data (2.6% observed [127 of 4898 patients] vs 2.3% predicted [114 of 4898 patients]), even after recalibration. The instantaneous hazard over time revealed the highest risk of death in the first 3 days after PCI (daily probability, >0.2%), declined to 0.1% until about day 12, and then decreased below 0.1%. Cardiac causes (mainly myocardial infarction) dominated in the first week (83 of 85 deaths [97.6%]) and then decreased to 59.5% (25 of 42 deaths) between 8 and 30 days after PCI.

CONCLUSION

The discriminatory ability of the NYSRS and the MCRS for in-hospital and 30-day mortality after PCI is roughly interchangeable. The risk of death is highest during the first 2 weeks and is dominated by cardiac causes of death.

Event-based versus process-based informed consent to address scientific evidence and uncertainties in ionising medical imaging

Background

Inappropriate ionising medical imaging has been escalating in the last decades. This trend leads to potential damage to health and has been associated to bioethical and legal issues of patient autonomy.

Methods

While the doctrine underlines the importance of using informed consent to improve patient autonomy and physician-patient communication, some researchers have argued that it often falls short of this aim. There are basically two different informed consent practices. The first — the so-called “event-based model” — regards informed consent as a passive signature of a standard unreadable template, performed only once in each medical pathway. The second — the so-called “process-based model” — integrates information into the continuing dialogue between physician and patient, vital for diagnosis and treatment.

Results

Current medical behaviour often embraces the event-based model, which is considered ineffective and contributes to inappropriateness. We sought, in this review, to analyse from juridical and communication standpoints whether process-based informed consent can deal with scientific uncertainties in radiological decision-making. The informed consent is still a distinctive process in defence of both patients’ and physicians’ health and dignity in rule-of-law states and consequently in curtailing the abuse of ionising medical radiation.

Main Messages

• Inappropriate ionising medical imaging is widespread and increasing worldwide.

• This trend leads to noteworthy damage to health and is linked to the issue of patient autonomy.

• Some authors have argued that informed consent often falls short of improving patient autonomy.

• Process-based informed consent can deal with scientific uncertainties to contrast inappropriateness.

• Informed consent is still a distinctive process in defence of both patients and physicians.

Improved patient awareness and satisfaction using procedure specific consent forms in carpal tunnel decompression surgery

Carpal tunnel decompression (CTD) is a common procedure amenable to procedure specific consent forms (PSCFs). These may help better inform patients and so increase patient satisfaction with the consent process. We assessed the use of a PSCF for CTD. The PSCF mentions eight complications of carpal tunnel surgery and alternative non-operative treatments. Two groups of 40 patients each were compared prospectively. Patients in one group were issued with a PSCF prior to admission whereas those in the other group were not. After standard pre-operative consent, patients were interviewed prior to surgery and assessed for their awareness of complications and alternative treatment options. The patients who received a PSCF showed greater awareness of different complications and alternative treatments and reported greater satisfaction with the consent process. We conclude that using PSCFs is a very useful and inexpensive adjunct to improve patient awareness and satisfaction with the consent process.

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.

Shared decision making in patients with stable coronary artery disease: PCI choice

BACKGROUND

Percutaneous coronary intervention (PCI) and optimal medical therapy (OMT) are comparable, alternative therapies for many patients with stable angina; however, patients may have misconceptions regarding the impact of PCI on risk of death and myocardial infarction (MI) in stable coronary artery disease (CAD).

METHODS AND RESULTS

We designed and developed a patient-centered decision aid (PCI Choice) to promote shared decision making for patients with stable CAD. The estimated benefits and risks of PCI+OMT as compared to OMT were displayed in a decision aid using pictographs with natural frequencies and text. We engaged patients, clinicians, health service researchers, and designers with over 20 successive iterations of the decision aid, which were field tested during real-world clinical encounters involving clinicians and patients. The decision aid is intended to facilitate knowledge transfer, deliberation based on patient values and preferences, and shared decision making.

CONCLUSIONS

We describe the methods and outcomes of the design and development of a decision aid (PCI Choice) to promote shared decision making between clinicians and patients regarding the choice of PCI+OMT vs. OMT for treatment of stable CAD. We will evaluate the impact of PCI Choice on patient knowledge, decisional conflict, participation in decision-making, and treatment choice in an upcoming randomized trial.