In the queue for coronary artery bypass grafting: patients' perceptions of risk and 'maximal acceptable waiting time'

Are colorectal surgery patients willing to accept an increased risk of surgical site infection to avoid mechanical bowel preparation? Implications for future trial design

AIM

Recent evidence has shown no difference in the risk of surgical site infection (SSI) with oral antibiotics alone (OA) and oral antibiotics in combination with mechanical bowel preparation (OA + MBP), suggesting that the use of MBP may be safely avoided. The aim of this work was to determine the absolute risk of SSI that patients would accept with OA relative to OA + MBP.

METHOD

Standardized, in-person interviews were conducted using the threshold task with patients attending colorectal surgery clinics who had previously had MBP. Participants were asked which option they preferred when the absolute risk of SSI was 7% for both options. Next, their switch point was determined by increasing the risk of SSI with OA by 1% intervals until their preference changed from OA to OA + MBP. Median switch point scores were reported and represented the absolute increased risk of SSI that patients would accept with OA relative to OA + MBP.

RESULTS

Fifty patients completed the interview. All participants chose OA over OA + MBP when the risk of SSI was 7% for both options. Switch points ranged from 8% to 25%, with a median of 10%, indicating that participants were willing to accept up to a 3% increase in absolute risk of developing a SSI with OA to avoid MBP.

CONCLUSIONS

The results showed that patients are willing to accept an increased risk of up to 3% for SSI with OA relative to OA + MBP. Incorporating patient preferences into the planning of future trials has the potential to improve the uptake of trial results into clinical practice.

Using the Threshold Technique to Elicit Patient Preferences: An Introduction to the Method and an Overview of Existing Empirical Applications

Patient preference information (PPI) is a topic of interest to regulators and industry. One of many known methods for eliciting PPI is the threshold technique (TT). However, empirical studies of the TT differ from each other in many ways and no effort to date has been made to summarize them or the evidence regarding the performance of the method. We sought to describe the TT and summarize the empirical applications of the method. Forty-three studies were reviewed. Most studies estimated the minimum level of benefit required to make a treatment worthwhile, and over half estimated the maximum level of risk patients would accept to achieve a treatment benefit. The evidence demonstrates that the TT can be used to elicit multiple types of thresholds and can be used to explore preference heterogeneity and preference non-linearity. Some evidence suggests that the method may be sensitive to anchoring and shift-framing effects; however, no evidence suggests that the method is more or less sensitive to these potential biases than other stated-preference methods. The TT may be a viable method for eliciting PPI to support regulatory decision-making; however, additional understanding of the performance of this method may be needed. Future research should focus on TT performance compared with other stated-preference methods, the extent to which results predict patient choice, and the ability of the TT to inform individual treatment decisions at the point of healthcare delivery.

Patient and Physician Preferences for Nonoperative Management for Low Rectal Cancer: Is It a Reasonable Treatment Option?

BACKGROUND

Although the body of evidence supporting nonoperative management for rectal cancer has been accumulating, there has been little systematic investigation to explore how physicians and patients value the tradeoffs between oncologic and functional outcomes after abdominal perineal resection and nonoperative management.

OBJECTIVE

The purpose of this study was to elicit patient and physician preferences for nonoperative management relative to abdominal perineal resection in the setting of low rectal cancer.

DESIGN

We conducted a standardized interviews of patients and a cross-sectional survey of physicians.

SETTINGS

Patients from 1 tertiary care center and physicians from across Canada were included.

PATIENTS

The study involved 50 patients who were previously treated for rectal cancer and 363 physicians who treat rectal cancer.

INTERVENTIONS

Interventions included standardized interviews using the threshold technique with patients and surveys mailed to physicians.

MAIN OUTCOMES MEASURES

We measured absolute increase risk in local regrowth and absolute decrease in overall survival that patients and physicians would accept with nonoperative management relative to abdominal perineal resection.

RESULTS

Patients were willing to accept a 20% absolute increase for local regrowth (ie, from 0% to 20%) and a 20% absolute decrease in overall survival (ie, from 80% to 60%) with nonoperative management relative to abdominal perineal resection, whereas physicians were willing to accept a 5% absolute increase for local regrowth (ie, from 0% to 5%) and a 5% absolute decrease in overall survival (ie, from 80% to 75%) with nonoperative management relative to abdominal perineal resection.

LIMITATIONS

Data were subject to response bias and generalizable to only a select group of patients with low rectal cancer.

CONCLUSIONS

Offering nonoperative management as an option to patients, even if oncologic outcomes are not equivalent, may be more consistent with the values of patients in this setting. See Video Abstract at http://links.lww.com/DCR/A688.

Longer in-hospital wait times do not result in worse outcomes for patients requiring urgent coronary artery bypass graft surgery

BACKGROUND

In certain health care systems, patients wait for non-emergency services. Although waiting may not be considered acceptable, the delay may allow for patient optimization, such as giving time for "toxic" agents to be cleared, that could improve outcomes. We sought to determine the relationship between wait times and outcomes in in-hospital patients undergoing urgent coronary artery bypass graft (CABG) surgery.

METHODS AND RESULTS

A prospectively collected database of consecutive, medically urgent, but clinically stable patients undergoing CABG surgery from 1995 to 2007, was analyzed. A total of 3067 patients with need for urgent CABG surgery with various in-hospital wait times (n = 440, 0-2 days; n = 799, 3-5 days; n = 1317, 6-10 days; n = 511, 11-15 days) were included. There were no differences in mortality, intensive care unit (ICU) or post-surgery hospital length of stay (LOS) among the patient groups. Multivariate logistic regression analysis revealed that wait time was not associated with mortality (P = 0.625). Due to changes in the nonsurgical management of coronary artery disease, a separate analysis of patients, from 2002 to 2007, was also performed to explore contemporary results. In the latter subset, 1495 patients (n = 175, 341, 720, 259, in the same 4 respective wait-time groups) were included; the 0-2 days patient group underwent more blood transfusions (50% vs 38%; P = 0.01), prolonged ventilation (6% vs 2%; P = 0.05), post-operative dialysis (2% vs 0%; P = 0.08), and longer ICU LOS (26 vs 23 hours; P = 0.02) compared with the 3-5 days patient group. The Society of Thoracic Surgeons mortality risk scores of the 0-2 days and 3-5 days groups were the same (1.5%). Multivariate regression analysis revealed that increased wait time was associated with fewer patients requiring blood transfusion (P < 0.05) for CABG surgery.

CONCLUSION

Waiting for in-hospital urgent CABG surgery does not lead to worse patient outcomes and may, in fact, reduce the procedural and medical risks of postoperative blood transfusions, prolonged ventilation, dialysis, and shorten ICU LOS.

Characterizing the public's preferential attitudes toward end-of-life care options: a role for the threshold technique?

OBJECTIVES

To assess the Threshold Technique's (TT) feasibility in community-wide surveys of U.S. Medicare beneficiaries' preferences for end-of-life (EOL) care options.

STUDY SETTING

Study participants were community-dwelling Medicare beneficiaries in four different regions in the United States.

STUDY DESIGN

During personal interviews, participants considered four EOL scenarios, each presenting a choice between a less intense and more intense care option.

DATA COLLECTION

Participants selected their initially favored option. Depending on that choice, in the subsequent TT the length of life offered by the more intense option was systematically increased or decreased until the participant "switched" to his or her initially rejected option.

PRINCIPAL FINDINGS

Participants were able to select an initially favored option (in 3 of the 4 scenarios; this was the less intense option). The majority of participants were able to engage with the subsequent TT. In all scenarios, regardless of the increase/decrease in the length of life offered by the more intense option, the majority of participants were unwilling to "switch" to their initially rejected option.

CONCLUSIONS

In surveys of populations' preferential attitudes toward EOL care options, the TT was a feasible elicitation method, engaging most participants and measuring the strength of their attitudes. Further methodological work is merited, involving (1) populations with various participant characteristics, and (2) different attributes in the TT task itself.

The importance of measuring strength-of-preference scores for health care options in preference-sensitive care

OBJECTIVE

The objective was to determine whether a paired-comparison/Leaning Scale (LS) method: 1) could feasibly be used to elicit strength-of-preference scores for elective health care options in large community-based survey settings and 2) could reveal preferential subgroups that would have been overlooked if only a categorical-response format had been used.

STUDY DESIGN

Medicare beneficiaries in four different regions of the United States were interviewed in person. Participants considered eight clinical scenarios, each with two to three different health care options. For each scenario, participants categorically selected their favored option, then indicated how strongly they favored that option relative to the alternative on a paired-comparison bidirectional LS.

RESULTS

Two hundred two participants were interviewed. For seven of the eight scenarios, a clear majority (>50%) indicated that, overall, they categorically favored one option over the alternative(s). However, the bidirectional strength-of-preference LS scores revealed that, in four scenarios, for half of those participants, their preference for the favored option was actually "weak" or "neutral."

CONCLUSION

Investigators aiming to assess population-wide preferential attitudes toward different elective health care scenarios should consider gathering ordinal-level strength-of-preference scores and could feasibly use the paired-comparison/bidirectional LS to do so.

Do patients consider preoperative chemoradiation for primary rectal cancer worthwhile?

BACKGROUND

The objective of this study was to elicit future patients' preferences for preoperative chemoradiation (pre-CRT) for rectal cancer to determine whether patients' preferences are consistent with current treatment guidelines.

METHODS

During a standardized interview, the treatment protocol, risks, benefits, and long-term outcomes associated with 1) surgery alone (SA) and 2) pre-CRT followed by surgery (CR + S) were described to healthy individuals, and a threshold task was performed. Each participant was asked which treatment option they would prefer when the risk of local recurrence was set initially at 15% for both options. If the participant indicated SA (which was expected), then the risk of local recurrence for CR + S was lowered systematically until the participant's preference changed from SA to CR + S. This threshold point represented the risk of local recurrence for pre-CRT that the participant would require before they would choose treatment with pre-CRT.

RESULTS

Fifty individuals participated in the study, and the majority were well educated. Twenty-seven of 50 participants (54%) required a risk of local recurrence with CR + S of ≤ 5% (ie, equivalent to an absolute risk reduction ≥ 10%) before they would choose treatment with pre-CRT. Regression analysis did not identify any variables that were predictive of the participants' preferences.

CONCLUSIONS

Participants seemed to highly value functional outcomes and seemed willing to accept a higher risk of local recurrence to achieve this. Therefore, developers of future guidelines may need to downgrade the use of pre-CRT for all patients with stage II/III tumors from a guideline to an option.

Wait times for gastroenterology consultation in Canada: the patients' perspective

Long wait times for health care have become a significant issue in Canada. As part of the Canadian Association of Gastroenterology's Human Resource initiative, a questionnaire was developed to survey patients regarding wait times for initial gastroenterology consultation and its impact. A total of 916 patients in six cities from across Canada completed the questionnaire at the time of initial consultation. Self-reported wait times varied widely, with 26.8% of respondents reporting waiting less than two weeks, 52.4% less than one month, 77.1% less than three months, 12.5% reported waiting longer than six months and 3.6% longer than one year. One-third of patients believed their wait time was too long, with 9% rating their wait time as 'far too long'; 96.4% believed that maximal wait time should be less than three months, 78.9% believed it should be less than one month and 40.3% believed it should be less than two weeks. Of those working or attending school, 22.6% reported missing at least one day of work or school because of their symptoms in the month before their appointment, and 9.0% reported missing five or more days in the preceding month. A total of 20.2% of respondents reported being very worried about having a serious disease (ie, scored 6 or higher on 7-point Likert scale), and 17.6% and 14.8%, respectively, reported that their symptoms caused major impairment of social functioning and with the activities of daily living. These data suggest that a significant proportion of Canadians with digestive problems are not satisfied with their wait time for gastroenterology consultation. Furthermore, while awaiting consultation, many patients experience an impaired quality of life because of their gastrointestinal symptoms.

Uncertainty and Health-Related Quality of Life 1 Year After Coronary Angiography

Background Little is known about illness-related uncertainty and decreased health-related quality of life in patients undergoing initial coronary angiography or about the long-term effects of uncertainty.

Objectives To compare patients with and without high levels of uncertainty before angiography and to examine the influence of uncertainty on health-related quality of life 1 year after angiography.

Methods In a prospective, longitudinal study, measurements of perceived control, uncertainty, affective distress, and health-related quality of life were collected from 93 patients before angiography (baseline) and 1 year later. At baseline, patients were classified into high- and low-uncertainty groups by median split. At 1 year, analysis of variance was used to compare health-related quality of life and psychological outcomes in the 2 groups, and multiple linear regression with stepwise entry was used to identify independent determinants of health-related quality of life.

Results Compared with patients with low baseline uncertainty, patients with high baseline uncertainty had higher levels of anxiety and depression and lower levels of perceived control and health-related quality of life 1 year after angiography. Baseline health-related quality of life, uncertainty, and life stress accounted for 54% of the variance in health-related quality of life, even when angiographic outcome was controlled for (P &lt; .001). Baseline uncertainty was independently associated with health-related quality of life (β = −0.25; 95% confidence interval, −9.40 to −0.05; P = .02).

Conclusions At initial angiography, high levels of uncertainty about illness portend negative health-related quality of life outcomes up to 1 year later.

Do patients consider postoperative maintenance therapy for Crohn's disease worthwhile?

BACKGROUND

Treatment decision making for postoperative Crohn's disease is complex because of the increasing number of maintenance therapies available with competing risk-benefit profiles. The main objective of this study was to determine the distribution of patients' preferences for selected postoperative maintenance therapies.

METHODS

The study was a cross-sectional survey in which patients with Crohn's disease completed a standardized interview. Each participant completed 5 tasks that compared: (1) no medication and 5-ASA, (2) fish oil and 5-ASA, (3) metronidazole and 5-ASA, (4) budesonide and 5-ASA, and (5) azathioprine and 5-ASA. For each task, the minimum change in treatment effect size between the 2 treatments that the participant considered worthwhile was determined.

RESULTS

The distribution of the participants' preference scores varied widely for each task. When fish oil, metronidazole, budesonide, and azathioprine were considered equally effective to 5-ASA, 92.9%, 28.8%, 38.4%, and 19% of the participants, respectively, preferred these medications relative to 5-ASA. These percentages increased to 98.4%, 54.8%, 61.9%, and 50.8%, respectively, when fish oil, metronidazole, budesonide, and azathioprine were considered to offer a 5% absolute risk reduction relative to 5-ASA. Regression analysis did not identify any clinical or demographic variables predictive of the participants' treatment preferences.

CONCLUSIONS

The participants' preferences for postoperative maintenance therapies were widely distributed, and no clinical or demographic factors predicted these preferences. This emphasizes the need for effective communication between physician and patient in order to select the treatment options most consistent with a patient's informed preferences.

Quality of life at referral predicts outcome of elective coronary artery angiogram

BACKGROUND

Patients' anxiety and quality of life (HRQL) are affected by waiting for diagnostic tests such as coronary artery angiogram (CATH). It is unknown whether HRQL and psychological status at the time of referral are related to likelihood of coronary artery disease (CAD) as diagnosed by CATH.

PURPOSE

The purposes of this study were (1) to determine patients' anxiety and HRQL at the time of referral for elective CATH and (2) to assess the impact of baseline HRQL on likelihood of CAD.

METHODS

This was a prospective observational study of 1009 patients referred for elective CATH. Questionnaires were mailed to patients within 2 weeks of referral. Packages contained a general HRQL measure (SF-36), a condition-specific HRQL measure (Seattle Angina Questionnaire) and the State-Trait Anxiety Inventory (STAI). Patients returned the baseline questionnaires in a postage-paid envelope.

RESULTS

: Complete data were available for 90.6% of patients (n=914). At baseline, general HRQL was significantly lower than population norms for healthy individuals (p<0.0001), but significantly higher than population norms for patients living with angina (p<0.02). Also at baseline, patients' (n=971) mean state anxiety score on the STAI was 44.3 (SD=13.3), reflecting 'high anxiety'. Logistic regression analysis revealed 3 predictors of angiographically documented CAD: male sex (OR 5.76; CI 3.75-8.84), the SF-36 physical functioning subscale (OR 1.05; CI 1.01-1.07) and older age (OR 2.38; CI 1.48-3.82).

CONCLUSION

At the time of referral for elective CATH patients have high levels of anxiety and poor HRQL. It is possible that patient-rated physical HRQL at the time of referral adds to our ability to triage patients according to urgency ratings.

Waiting for urgent procedures on the weekend among emergently hospitalized patients

PURPOSE

Many hospital departments tend to have lower staffing levels on weekends. We evaluated the use of selected urgent procedures for emergently hospitalized patients and measured the time until procedure based upon the day of hospital admission.

METHODS

We analyzed all acute care admissions from all 190 emergency departments in Ontario, Canada, between 1988 and 1997. We selected patients (n = 126,754) who underwent one of six prespecified procedures as their most responsible procedure: fiberoptic bronchoscopy, esophageal gastroduodenoscopy, magnetic resonance imaging, echocardiography, ventilation-perfusion scanning, or coronary angiography. We noted each patient's day of procedure and day of hospital admission. For waits of less than 8 days, we analyzed the time to procedure based upon the day of admission.

RESULTS

Only 5% (n = 5903) of the urgent procedures were performed on the weekend. Of the six selected procedures, coronary angiography showed the most skewed pattern of performance (1.5% performed on the weekend) and esophageal gastroduodenoscopy showed the least skewed pattern (8% performed on the weekend). Patients admitted on Fridays or Saturdays had the longest waits for procedures. For all six procedures, patients with relatively longer waits had relatively longer total in-hospital stays (P <0.001 for each).

CONCLUSION

Relatively few urgent procedures are performed in emergently hospitalized patients on the weekend, suggesting that greater attention to weekend care might result in more timely interventions and shorter lengths of stay.

Anxiety and health-related quality of life in patients awaiting elective coronary angiography

OBJECTIVE

The purpose of this study was to document the impact of waiting for first-time elective coronary angiography (CA) on patients' anxiety and health-related quality of life (HRQL).

DESIGN

A prospective, observational inception cohort pretest and posttest design was used.

SETTING

The study was conducted in a tertiary community cardiac center in Toronto, Canada.

MEASURES

Disease-specific HRQL was measured using the Seattle Angina Questionnaire at baseline (Time 1 [T1]) and 1 week before CA (Time 2 [T2]). The association between time on the waiting list and subjects' perceived anxiety was analyzed.

RESULTS

Paired-sample t tests comparing mean anxiety levels at T1 and T2 indicated a statistically significant increase in anxiety levels at T2 that did not seem to be related to the waiting time for CA (P =.000). Comparison of mean Seattle Angina Questionnaire scores at T1 and T2 indicated a trend toward deterioration in HRQL over time.

CONCLUSIONS

Waiting for elective CA may have a negative impact on patients' psychologic status and HRQL. Nursing and clinical interventions to reduce anxiety and improve HRQL are indicated for this population.

Primary prevention drug therapy: can it meet patients' requirements for reduced risk?

The objective was to identify, in primary prevention, patients whose "required risk reduction" (ReqRR) is greater than the "achievable risk reduction" (ARR) that cholesterol-lowering or antihypertensive medication could provide. Individualized estimates of 10-year coronary heart disease or stroke risk were derived for 66 hypercholesterolemic (HC) and 64 hypertensive (HT) patients without symptomatic cardiovascular disease. These estimates were used in trade-off tasks identifying each individual's ReqRR. Then individual ARRs were estimated (in HC patients by assuming total cholesterol/high density lipoprotein ratio reductions to 5.0; in HT patients by assuming systolic blood pressure reductions to 120 mmHg). 12 (18%) HC and 12 (19%) HT subjects would refuse medication regardless of the risk reduction offered. Of the remaining patients, 15/54 (28%; 95% C.I.:16-40%) HC and 19/52 (37%; 95% C.I: 24-51%) HT subjects were "over-requirers," in that their ReqRR/ARR ratio was 1.5. There maybe a notable proportion of patients whose ReqRR is considerably greater than what is achievable, implying that decision aids may help individuals clarify preferences about accepting/refusing medication for the primary prevention of cardiovascular disease.

Nurse led shared care for patients on the waiting list for coronary artery bypass surgery: a randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of a nurse led shared care programme to improve coronary heart disease risk factor levels and general health status and to reduce anxiety and depression in patients awaiting coronary artery bypass grafting (CABG).

DESIGN

Randomised controlled trial.

SETTING

Community, January 1997 to March 1998.

STUDY GROUPS

98 (75 male) consecutive patients were recruited to the study within one month of joining the waiting list for elective CABG at Glasgow Royal Infirmary University NHS Trust. Patients were randomly assigned to usual care (control; n = 49) or a nurse led intervention programme (n = 49).

INTERVENTION

A shared care programme consisting of health education and motivational interviews, according to individual need, was carried out monthly. Care was provided in the patients' own homes by the community based cardiac liaison nurse alternating with the general practice nurse at the practice clinic.

OUTCOME MEASURES

Smoking status, obesity, physical activity, anxiety and depression, general health status, and proportion of patients exceeding target values for blood pressure, plasma cholesterol, and alcohol intake.

RESULTS

Compared with patients who received usual care, those participating in the nurse led programme were more likely to stop smoking (25% v 2%, p = 0.001) and to reduce obesity (body mass index > 30 kg/m(2)) (16.3% v 8.1%, p = 0.01). Target systolic blood pressure improved by 19.8% compared with a 10.7% decrease in the control group (p = 0.001) and target diastolic blood pressure improved by 21.5% compared with 10.2% in the control group (p = 0.000). However, there was no significant difference between groups in the proportion of patients with cholesterol concentrations exceeding target values. There was a significant improvement in general health status scores across all eight domains of the 36 item short form health survey with changes in difference in mean scores between the groups ranging from 8.1 (p = 0.005) to 36.1 (p < 0.000). Levels of anxiety and depression improved (p < 0.000) and there was improvement in time spent being physically active (p < 0.000).

CONCLUSIONS

This nurse led shared care intervention was shown to be effective for improving care for patients on the waiting list for CABG.