Effect of a Decision Aid on Agreement Between Patient Preferences and Repair Type for Abdominal Aortic Aneurysm: A Randomized Clinical Trial.

Importance: Patients with abdominal aortic aneurysm (AAA) can choose open repair or endovascular repair (EVAR). While EVAR is less invasive, it requires lifelong surveillance and more frequent aneurysm-related reinterventions than open repair. A decision aid may help patients receive their preferred type of AAA repair. Objective: To determine the effect of a decision aid on agreement between patient preference for AAA repair type and the repair type they receive. Design, Setting, and Participants: In this cluster randomized trial, 235 patients were randomized at 22 VA vascular surgery clinics. All patients had AAAs greater than 5.0 cm in diameter and were candidates for both open repair and EVAR. Data were collected from August 2017 to December 2020, and data were analyzed from December 2020 to June 2021. Interventions: Presurgical consultation using a decision aid vs usual care. Main Outcomes and Measures: The primary outcome was the proportion of patients who had agreement between their preference and their repair type, measured using χ2 analyses, κ statistics, and adjusted odds ratios. Results: Of 235 included patients, 234 (99.6%) were male, and the mean (SD) age was 73 (5.9) years. A total of 126 patients were enrolled in the decision aid group, and 109 were enrolled in the control group. Within 2 years after enrollment, 192 (81.7%) underwent repair. Patients were similar between the decision aid and control groups by age, sex, aneurysm size, iliac artery involvement, and Charlson Comorbidity Index score. Patients preferred EVAR over open repair in both groups (96 of 122 [79%] in the decision aid group; 81 of 106 [76%] in the control group; P = .60). Patients in the decision aid group were more likely to receive their preferred repair type than patients in the control group (95% agreement [93 of 98] vs 86% agreement [81 of 94]; P = .03), and κ statistics were higher in the decision aid group (κ = 0.78; 95% CI, 0.60-0.95) compared with the control group (κ = 0.53; 95% CI, 0.32-0.74). Adjusted models confirmed this association (odds ratio of agreement in the decision aid group relative to control group, 2.93; 95% CI, 1.10-7.70). Conclusions and Relevance: Patients exposed to a decision aid were more likely to receive their preferred AAA repair type, suggesting that decision aids can help better align patient preferences and treatments in major cardiovascular procedures. Trial Registration: ClinicalTrials.gov Identifier: NCT03115346.

Discharge-ready volume status in acute decompensated heart failure: a survey of hospitalists.

Acute decompensated heart failure is the leading cause of hospitalization in older adults. Clinical practice guidelines recommend patients should be euvolemic at hospital discharge - yet accurate assessment of volume status is recognized to be exceptionally challenging. This conundrum led us to investigate how hospitalists are assessing volume status and discharge- readiness of patients hospitalized with heart failure. We collected audience response data during a didactic heart failure presentation at the 2019 Society of Hospital Medicine annual meeting. Respondents (n = 216), 76% of whom were practicing physician hospitalists caring for more than 20 acute heart failure patients per year, were presented six questions. Eighteen percent of respondents reported not being able to determine the completeness of decongestion on discharge and 32% reported that complete decongestion was not a treatment target. These findings suggest important differences between guideline recommendations and how hospitalists treat heart failure in current clinical practice.

Association of Regional Practice Environment Intensity and the Ability of Internists to Practice High-Value Care After Residency.

Importance: Use of health care services and physician practice patterns have been shown to vary widely across the United States. Although practice patterns-in particular, physicians' ability to provide high-quality, high-value care-develop during training, the association of a physician's regional practice environment with that ability is less well understood. Objective: To examine the association between health care intensity in the region where physicians practice and their ability to practice high-value care, specifically for physicians whose practice environment changed due to relocation after residency. Design, Setting, and Participants: This cohort study included a national sample of 3896 internal medicine physicians who took the 2002 American Board of Internal Medicine initial certification examination followed approximately 1 decade (April 21, 2011, to May 7, 2015) later by the Maintenance of Certification (MOC) examination. At the time of the MOC examination, 2714 of these internists were practicing in a new region. Data were analyzed from March 6, 2016, to May 21, 2018. Exposures: Intensity of care in the Dartmouth Atlas hospital referral region (HRR), measured by per-enrollee end-of-life physician visits (primary) and current practice type (secondary). Main Outcomes and Measures: The outcome, a physician's ability to practice high-value care, was assessed using the Appropriately Conservative Management (ACM) score on the MOC examination, measuring performance across all questions for which the correct answer was the most conservative option. The exposure, regional health care intensity, was measured as per-enrollee end-of-life physician visits in the Dartmouth Atlas HRR of the physician's practice. Results: Among the 3860 participating internists included in the analysis (2030 men [52.6%]; mean [SD] age, 45.6 [4.5] years), those who moved to regions in the quintile of highest health care intensity had an ACM score 0.22 SD lower (95% CI, -0.32 to -0.12) than internists who moved to regions in the quintile of lowest intensity, controlling for postresidency ACM scores. This difference reflected scoring in the 44th compared with the 53rd percentile of all examinees. This association was mildly attenuated (0.18 SD less; 95% CI, -0.28 to -0.09) after adjustment for physician and practice characteristics. Conclusions and Relevance: This study found that practice patterns of internists who relocate after residency training appear to migrate toward norms of the new region. The demands of practicing in high-intensity regions may erode the ability to practice high-value conservative care.

The Burden of Cystoscopic Bladder Cancer Surveillance: Anxiety, Discomfort, and Patient Preferences for Decision Making.

OBJECTIVE: To examine discomfort, anxiety, and preferences for decision making in patients undergoing surveillance cystoscopy for non-muscle-invasive bladder cancer (NMIBC). METHODS: Veterans with a prior diagnosis of NMIBC completed validated survey instruments assessing procedural discomfort, worry, and satisfaction, and were invited to participate in semistructured focus groups about their experience and desire to be involved in surveillance decision making. Focus group transcripts were analyzed qualitatively, using (1) systematic iterative coding, (2) triangulation involving multiple perspectives from urologists and an implementation scientist, and (3) searching and accounting for disconfirming evidence. RESULTS: Twelve patients participated in 3 focus groups. Median number of lifetime cystoscopy procedures was 6.5 (interquartile range 4-10). Based on survey responses, two-thirds of participants (64%) experienced some degree of procedural discomfort or worry, and all participants reported improvement in at least 2 dimensions of overall well-being following cystoscopy. Qualitative analysis of the focus groups indicated that participants experience preprocedural anxiety and worry about their disease. Although many participants did not perceive themselves as having a defined role in decision making surrounding their surveillance care, their preferences to be involved in decision making varied widely, ranging from acceptance of the physician's recommendation, to uncertainty, to dissatisfaction with not being involved more in determining the intensity of surveillance care. CONCLUSION: Many patients with NMIBC experience discomfort, anxiety, and worry related to disease progression and not only cystoscopy. Although some patients are content to defer surveillance decisions to their physicians, others prefer to be more involved. Future work should focus on defining patient-centered approaches to surveillance decision making.

Association between apple consumption and physician visits: appealing the conventional wisdom that an apple a day keeps the doctor away.

IMPORTANCE: Fruit consumption is believed to have beneficial health effects, and some claim, "An apple a day keeps the doctor away." OBJECTIVE: To examine the relationship between eating an apple a day and keeping the doctor away. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional study of a nationally representative sample of the noninstitutionalized US adult population. A total of 8728 adults 18 years and older from the 2007-2008 and 2009-2010 National Health and Nutrition Examination Survey completed a 24-hour dietary recall questionnaire and reported that the quantity of food they ate was reflective of their usual daily diet. EXPOSURES: Daily apple eaters (consuming the equivalent of at least 1 small apple daily, or 149 g of raw apple) vs non-apple eaters, based on the reported quantity of whole apple consumed during the 24-hour dietary recall period. MAIN OUTCOMES AND MEASURES: The primary outcome measure was success at "keeping the doctor away," measured as no more than 1 visit (self-reported) to a physician during the past year; secondary outcomes included successful avoidance of other health care services (ie, no overnight hospital stays, visits to a mental health professional, or prescription medications). RESULTS: Of 8399 eligible study participants who completed the dietary recall questionnaire, we identified 753 adult apple eaters (9.0%)--those who typically consume at least 1 small apple per day. Compared with the 7646 non-apple eaters (91.0%), apple eaters had higher educational attainment, were more likely to be from a racial or ethnic minority, and were less likely to smoke (P<.001 for each comparison). Apple eaters were more likely, in the crude analysis, to keep the doctor (and prescription medications) away: 39.0% of apple eaters avoided physician visits vs 33.9% of non-apple eaters (P=.03). After adjusting for sociodemographic and health-related characteristics, however, the association was no longer statistically significant (OR, 1.19; 95% CI, 0.93-1.53; P=.15). In the adjusted analysis, apple eaters also remained marginally more successful at avoiding prescription medications (odds ratio, 1.27; 95% CI, 1.00-1.63). There were no differences seen in overnight hospital stay or mental health visits. CONCLUSIONS AND RELEVANCE: Evidence does not support that an apple a day keeps the doctor away; however, the small fraction of US adults who eat an apple a day do appear to use fewer prescription medications.

The association between residency training and internists' ability to practice conservatively.

IMPORTANCE: Growing concern about rising costs and potential harms of medical care has stimulated interest in assessing physicians' ability to minimize the provision of unnecessary care. OBJECTIVE: To assess whether graduates of residency programs characterized by low-intensity practice patterns are more capable of managing patients' care conservatively, when appropriate, and whether graduates of these programs are less capable of providing appropriately aggressive care. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional comparison of 6639 first-time takers of the 2007 American Board of Internal Medicine certifying examination, aggregated by residency program (n = 357). EXPOSURES: Intensity of practice, measured using the End-of-Life Visit Index, which is the mean number of physician visits within the last 6 months of life among Medicare beneficiaries 65 years and older in the residency program's hospital referral region. MAIN OUTCOMES AND MEASURES: The mean score by program on the Appropriately Conservative Management (ACM) (and Appropriately Aggressive Management [AAM]) subscales, comprising all American Board of Internal Medicine certifying examination questions for which the correct response represented the least (or most, respectively) aggressive management strategy. Mean scores on the remainder of the examination were used to stratify programs into 4 knowledge tiers. Data were analyzed by linear regression of ACM (or AAM) scores on the End-of-Life Visit Index, stratified by knowledge tier. RESULTS: Within each knowledge tier, the lower the intensity of health care practice in the hospital referral region, the better residency program graduates scored on the ACM subscale (P < .001 for the linear trend in each tier). In knowledge tier 4 (poorest), for example, graduates of programs in the lowest-intensity regions had a mean ACM score in the 38th percentile compared with the 22nd percentile for programs in the highest-intensity regions; in tier 2, ACM scores ranged from the 75th to the 48th percentile in regions from lowest to highest intensity. Graduates of programs in low-intensity regions tended, more weakly, to score better on the AAM subscale (in 3 of 4 knowledge tiers). CONCLUSIONS AND RELEVANCE: Regardless of overall medical knowledge, internists trained at programs in hospital referral regions with lower-intensity medical practice are more likely to recognize when conservative management is appropriate. These internists remain capable of choosing an aggressive approach when indicated.

Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis.

BACKGROUND: Hip fracture surgery and lower extremity arthroplasty are associated with increased risk of both venous thromboembolism and bleeding. The best pharmacologic strategy for reducing these opposing risks is uncertain. PURPOSE: To compare venous thromboembolism (VTE) and bleeding rates in adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery. DATA SOURCES: Medline, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library through June 2013; reference lists, ClinicalTrials.gov, and scientific meeting abstracts. STUDY SELECTION: Randomized trials comparing aspirin to anticoagulants for prevention of VTE following major lower extremity orthopedic surgery. DATA EXTRACTION: Two reviewers independently extracted data on rates of VTE, bleeding, and mortality. DATA SYNTHESIS: Of 298 studies screened, 8 trials including 1408 participants met inclusion criteria; all trials screened participants for deep venous thrombosis (DVT). Overall rates of DVT did not differ statistically between aspirin and anticoagulants (relative risk [RR]: 1.15 [95% confidence interval {CI}: 0.68-1.96]). Subgrouped by type of surgery, there was a nonsignificant trend favoring anticoagulation following hip fracture repair but not knee or hip arthroplasty (hip fracture RR: 1.60 [95% CI: 0.80-3.20], 2 trials; arthroplasty RR: 1.00 [95% CI: 0.49-2.05], 5 trials). The risk of bleeding was lower with aspirin than anticoagulants following hip fracture repair (RR: 0.32 [95% CI: 0.13-0.77], 2 trials), with a nonsignificant trend favoring aspirin after arthroplasty (RR: 0.63 [95% CI: 0.33-1.21], 5 trials). Rates of pulmonary embolism were too low to provide reliable estimates. CONCLUSION: Compared with anticoagulation, aspirin may be associated with higher risk of DVT following hip fracture repair, although bleeding rates were substantially lower. Aspirin was similarly effective after lower extremity arthroplasty and may be associated with lower bleeding risk. Journal of Hospital Medicine 2014;9:579-585. © 2014 Society of Hospital Medicine.

Did you hear the one about the doctor? An examination of doctor jokes posted on Facebook.

BACKGROUND: Social networking sites such as Facebook have become immensely popular in recent years and present a unique opportunity for researchers to eavesdrop on the collective conversation of current societal issues. OBJECTIVE: We sought to explore doctor-related humor by examining doctor jokes posted on Facebook. METHODS: We performed a cross-sectional study of 33,326 monitored Facebook users, 263 (0.79%) of whom posted a joke that referenced doctors on their Facebook wall during a 6-month observation period (December 15, 2010 to June 16, 2011). We compared characteristics of so-called jokers to nonjokers and identified the characteristics of jokes that predicted joke success measured by having elicited at least one electronic laugh (eg, an LOL or "laughing out loud") as well as the total number of Facebook "likes" the joke received. RESULTS: Jokers told 156 unique doctor jokes and were the same age as nonjokers but had larger social networks (median Facebook friends 227 vs 132, P<.001) and were more likely to be divorced, separated, or widowed (P<.01). In 39.7% (62/156) of unique jokes, the joke was at the expense of doctors. Jokes at the expense of doctors compared to jokes not at the expense of doctors tended to be more successful in eliciting an electronic laugh (46.5% vs 37.3%), although the association was statistically insignificant. In our adjusted models, jokes that were based on current events received considerably more Facebook likes (rate ratio [RR] 2.36, 95% CI 0.97-5.74). CONCLUSIONS: This study provides insight into the use of social networking sites for research pertaining to health and medicine, including the world of doctor-related humor.

Too Little? Too Much? Primary care physicians' views on US health care: a brief report.

BACKGROUND: Some believe that a substantial amount of US health care is unnecessary, suggesting that it would be possible to control costs without rationing effective services. The views of primary care physicians-the frontline of health care delivery-are not known. METHODS: Between June and December 2009, we conducted a nationally representative mail survey of US primary care physicians (general internal medicine and family practice) randomly selected from the American Medical Association Physician Masterfile (response rate, 70%; n=627). RESULTS: Forty-two percent of US primary care physicians believe that patients in their own practice are receiving too much care; only 6% said they were receiving too little. The most important factors physicians identified as leading them to practice more aggressively were malpractice concerns (76%), clinical performance measures (52%), and inadequate time to spend with patients (40%). Physicians also believe that financial incentives encourage aggressive practice: 62% said diagnostic testing would be reduced if it did not generate revenue for medical subspecialists (39% for primary care physicians). Almost all physicians (95%) believe that physicians vary in what they would do for identical patients; 76% are interested in learning how aggressive or conservative their own practice style is compared with that of other physicians in their community. CONCLUSIONS: Many US primary care physicians believe that their own patients are receiving too much medical care. Malpractice reform, realignment of financial incentives, and more time with patients could remove pressure on physicians to do more than they feel is needed. Physicians are interested in feedback on their practice style, suggesting they may be receptive to change. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00853918.

Health behaviors and utilization among users of complementary and alternative medicine for treatment versus health promotion.

OBJECTIVE: To compare the characteristics, health behaviors, and health services utilization of U.S. adults who use complementary and alternative medicine (CAM) to treat illness to those who use CAM for health promotion. DATA SOURCE: The 2007 National Health Interview Survey (NHIS). STUDY DESIGN: We compared adult (age ≥18 years) NHIS respondents based on whether they used CAM in the prior year to treat an illness (n=973), for health promotion (n=3,281), or for both purposes (n=3,031). We used complex survey design methods to make national estimates and examine respondents' self-reported health status, health behaviors, and conventional health services utilization. PRINCIPAL FINDINGS: Adults who used CAM for health promotion reported significantly better health status and healthier behaviors overall (higher rates of physical activity and lower rates of obesity) than those who used CAM as treatment. While CAM Users in general had higher rates of conventional health services utilization than those who did not use CAM; adults who used CAM as treatment consumed considerably more conventional health services than those who used it for health promotion. CONCLUSION: This study suggests that there are two distinct types of CAM User that must be considered in future health services research and policy decisions.

Regional variations in palliative care: do cardiologists follow guidelines?

OBJECTIVES: Regional variation in health care use in the last 6 months of life is well documented. Our objective was to examine whether an association exists between cardiologists' tendencies to discuss palliative care for patients with advanced heart failure and the regional use of health care in the last 6 months of life. METHODS: We performed a national mail survey of a random sample of 994 eligible Cardiologists from the American Medical Association Masterfile. Hypothetical patient scenarios were used to explore physician management of patient scenarios. RESULTS: We received 614 responses (response rate: 62%). In a 75-year-old with symptomatic chronic heart failure and asymptomatic nonsustained ventricular tachycardia, cardiologists in regions with high use in the last 6 months of life were less likely to have discussions about palliative care (23% versus 32% for comparisons between the highest and lowest quintiles, p = 0.04). Similarly, in an 85 year-old with symptomatic chronic heart failure and an acute exacerbation, cardiologists in high use regions were less likely to have discussions about palliative care (35% versus 47%, p = 0.0008). CONCLUSIONS: Despite professional guidelines suggesting that cardiologists discuss palliative care with patients with late stage heart failure, less than half of cardiologists would discuss palliative care in two elderly patients with late-stage heart failure and this guideline discordance was worse in the regions with more health care use in the last 6 months of life.

Variation in cardiologists' propensity to test and treat: is it associated with regional variation in utilization?

BACKGROUND: Regional variation in healthcare utilization, including cardiac testing and procedures, is well documented. Some factors underlying such variation are understood, including resource supply. However, less is known about how physician behaviors and attitudes may influence variation in utilization across regions. METHODS AND RESULTS: We performed a survey of a national sample of cardiologists using patients vignettes to ascertain physicians' self-reported propensity to test and treat patients with cardiovascular problems, computing a Cardiac Intensity Score for each physician based on his/her responses intended to measure the physician's propensity to recommend high-tech and/or invasive tests and treatments. In addition, we asked under what circumstances they would order a cardiac catheterization "for other than purely clinical reasons." For some survey items, there was substantial variation in physician responses. We found that the Cardiac Intensity Score was associated with 2 measures of population based healthcare utilization measured within geographic regions, with a stronger association with general healthcare spending than with delivery of cardiac services. Although nearly all physicians denied ordering a potentially unnecessary cardiac catheterization for financial reasons, some physicians acknowledged ordering the test for other reasons, including meeting patient and referring physician expectations, meeting peer expectations, and malpractice concerns. More than 27% of respondents reported ordering a cardiac catheterization if a colleague would in the same situation frequently or sometimes, and nearly 24% reported doing so out of fear of malpractice. These 2 factors were significantly associated with the propensity to test and treat, but only fear of malpractice was associated with regional utilization. CONCLUSIONS: Variability in cardiologists' propensity to test and treat partly underlies regional variation in utilization of general health and cardiology services. The factor most closely associated with this propensity was fear of malpractice suits. This factor may be an appropriate target of intervention.

Utilization and expenditures on chiropractic care in the United States from 1997 to 2006.

OBJECTIVE: To investigate national utilization and expenditures on chiropractic care between 1997 and 2006. DATA SOURCE: The nationally representative Medical Expenditure Panel Survey (MEPS). STUDY DESIGN: We performed descriptive analyses and generated national estimates from data obtained from U.S. adult (>or=18 years) MEPS respondents who reported having visited a chiropractor (annual sample size between 789 and 1,082). For each year, we examined the estimated total national expenditure, the total number of U.S. adults who received chiropractic care, the total number of ambulatory visits to U.S. chiropractors, and the inflation-adjusted charges and expenditures per U.S. adult chiropractic patient. PRINCIPAL FINDINGS: The total number of U.S. adults who visited a chiropractor increased 57 percent from 7.7 million in 2000 to 12.1 million in 2003. From 1997 to 2006, the inflation-adjusted national expenditures on chiropractic care increased 56 percent from U.S.$3.8 billion to U.S.$5.9 billion. Inflation-adjusted total mean expenditures per patient and expenditures per office visit remained unchanged. CONCLUSION: The large increase in U.S. adult expenditures on chiropractic care between 1997 and 2006 was due to a 57 percent increase in the total number of U.S. adult chiropractic patients that occurred from 2000 to 2003. From 2003 to 2006, the total number of U.S. adult chiropractic patients has remained stable.