The impact of the Affordable Care Act Medicaid Expansion in Medicare beneficiaries with peripheral artery disease.

Background: In 2014, the Affordable Care Act Medicaid Expansion (ME) increased Medicaid eligibility for adults with an income level up to 138% of the federal poverty level. In this study, we examined the impact of ME on mortality and amputation in patients with peripheral artery disease (PAD). Methods: The 100% MedPAR and Part-B Carrier files from 2011 to 2018 were queried to identify all fee-for-service Medicare beneficiaries with PAD using International Classification of Diseases codes. Our primary exposure was whether a state had adopted the ME on January 1, 2014. Our primary outcomes were the change in all-cause 1-year mortality and leg amputation. We used a state-level difference-in-differences (DID) analysis to compare the rates of the primary outcomes among patients who were in states (including the District of Columbia) who adopted ME (n = 25) versus those who were in states that did not (n = 26). We performed a subanalysis stratifying by sex, race, region, and dual-eligibility status. Results: Over the 8-year period, we studied 37,743,929 patients. The average unadjusted 1-year mortality decreased from 2011 to 2018 in both non-ME (9.5% to 8.7%, p < 0.001) and ME (9.1% to 8.3%, p < 0.001) states. The average unadjusted 1-year amputation rate did not improve in either the non-ME (0.86% to 0.87%, p = 0.17) or ME (0.69% to 0.69%, p = 0.65) states. Across the entire cohort, the DID model revealed that ME did not lead to a significant change in mortality (p = 0.15) or amputation (p = 0.34). Conclusion: Medicaid Expansion was not associated with reduced mortality or leg amputation in Medicare beneficiaries with PAD.

IV Diuresis in Alternative Treatment Settings for the Management of Heart Failure: Implications for Mortality, Hospitalizations and Cost.

BACKGROUND: Recent advances in heart failure (HF) care have sought to shift management from inpatient to outpatient and observation settings. We evaluated the association among HF treatment in the (1) inpatient; (2) observation; (3) emergency department (ED); and (4) outpatient settings with 30-day mortality, hospitalizations and cost. METHODS: Using 100% Medicare inpatient, outpatient and Part B files from 2011-2018, 1,534,708 unique patient encounters in which intravenous (IV) diuretics were received for a primary diagnosis of HF were identified. Encounters were sorted into mutually exclusive settings: (1) inpatient; (2) observation; (3) ED; or (4) outpatient IV diuretic clinic. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 30-day hospitalization and total 30-day costs. Multivariable logistic and linear regression were used to examine the association between treatment location and the primary and secondary outcomes. RESULTS: Patients treated in observation and outpatient settings had lower 30-day mortality rates (observation OR 0.67, 95% CI 0.66-0.69; P < 0.001; outpatient OR 0.53, 95% CI 0.51-0.55; P < 0.001) compared to those treated in inpatient settings. Observation and outpatient treatment were also associated with decreased 30-day total cost compared to inpatient treatment. Observation relative cost -$5528.77, 95% CI -$5613.63 to -$5443.92; outpatient relative cost -$7005.95; 95% CI -$7103.94 to -$6907.96). Patients treated in the emergency department and discharged had increased mortality rates (OR 1.15, 95% CI 1.13-1.17; P < 0.001) and increased rates of hospitalization (OR 1.72, 95% CI 1.70-1.73; P < 0.001) compared to patients treated as inpatients. CONCLUSIONS: Medicare beneficiaries who received IV diuresis for acute HF in the outpatient and observation settings had lower mortality rates and decreased costs of care compared to patients treated as inpatients. Outpatient and observation management of acute decompensated HF, when available, is a safe and cost-effective strategy in certain populations of patients with HF.

Trends of Concomitant Diabetes and Peripheral Artery Disease and Lower Extremity Amputation in US Medicare Patients, 2007 to 2019.

BACKGROUND: Previous studies demonstrate geographic and racial/ethnic variation in diagnosis and complications of diabetes and peripheral artery disease (PAD). However, recent trends for patients diagnosed with both PAD and diabetes are lacking. We assessed the period prevalence of concurrent diabetes and PAD across the United States from 2007 to 2019 and regional and racial/ethnic variation in amputations among Medicare patients. METHODS: Using Medicare claims from 2007 to 2019, we identified patients with both diabetes and PAD. We calculated period prevalence of concomitant diabetes and PAD and incident cases of diabetes and PAD for every year. Patients were followed to identify amputations, and results were stratified by race/ethnicity and hospital referral region. RESULTS: 9 410 785 patients with diabetes and PAD were identified (mean age, 72.8 [SD, 10.94] years; 58.6% women, 74.7% White, 13.2% Black, 7.3% Hispanic, 2.8% Asian/API, and 0.6% Native American). Period prevalence of diabetes and PAD was 23 per 1000 beneficiaries. We observed a 33% relative decrease in annual new diagnoses throughout the study. All racial/ethnic groups experienced a similar decline in new diagnoses. Black and Hispanic patients had on average a 50% greater rate of disease compared with White patients. One- and 5-year amputation rates remained stable at ≈1.5% and 3%, respectively. Native American, Black, and Hispanic patients were at greater risk of amputation compared with White patients at 1- and 5-year time points (5-year rate ratio range, 1.22-3.17). Across US regions, we observed differential amputation rates, with an inverse relationship between the prevalence of concomitant diabetes and PAD and overall amputation rates. CONCLUSIONS: Significant regional and racial/ethnic variation exists in the incidence of concomitant diabetes and PAD among Medicare patients. Black patients in areas with the lowest rates of PAD and diabetes are at disproportionally higher risk for amputation. Furthermore, areas with higher prevalence of PAD and diabetes have the lowest rates of amputation.

Comparative Effectiveness of Left Atrial Appendage Occlusion Versus Oral Anticoagulation by Sex.

BACKGROUND: The comparative real-world outcomes of older patients with atrial fibrillation (AF) treated with anticoagulation compared with left atrial appendage occlusion (LAAO) may be different from those in clinical trials because of differences in anticoagulation strategies and patient demographics, including a greater proportion of women. We sought to compare real-world outcomes between older patients with AF treated with anticoagulation and those treated with LAAO by sex. METHODS: Using Medicare claims data from 2015 to 2019, we identified LAAO-eligible beneficiaries and divided them into sex subgroups. Patients receiving LAAO were matched 1:1 to those receiving anticoagulation alone through propensity score matching. The risks of mortality, stroke or systemic embolism, and bleeding were compared between matched groups with adjustment for potential confounding characteristics in Cox proportional hazards models. RESULTS: Among women, 4085 LAAO recipients were matched 1:1 to those receiving anticoagulation; among men, 5378 LAAO recipients were similarly matched. LAAO was associated with a significant reduction in the risk of mortality for women and men (hazard ratio [HR], 0.509 [95% CI, 0.447-0.580]; and HR, 0.541 [95% CI, 0.487-0.601], respectively; P<0.0001), with a similar finding for stroke or systemic embolism (HR, 0.655 [95% CI, 0.555-0.772]; and HR, 0.649 [95% CI, 0.552-0.762], respectively; P<0.0001). Bleeding risk was significantly greater in LAAO recipients early after implantation but lower after the 6-week periprocedural period for women and men (HR, 0.772 [95% CI, 0.676-0.882]; and HR, 0.881 [95% CI, 0.784-0.989], respectively; P<0.05). CONCLUSIONS: In a real-world population of older Medicare beneficiaries with AF, compared with anticoagulation, LAAO was associated with a reduction in the risk of death, stroke, and long-term bleeding among women and men. These findings should be incorporated into shared decision-making with patients considering strategies for reduction in AF-related stroke.

Predicting When Women Will Achieve Equitable Representation in Four Specialties: The WHEN Study.

BACKGROUND: For 2 decades, women have made up nearly half of medical school graduates, yet this has not translated to equity in promotion. We compare historical trends in the academic career pipeline among 4 specialties by sex. METHODS: Using the Association of American Medical Colleges database, faculty sex and rank were examined in oncology, gastroenterology, cardiovascular medicine, and general surgery for the years 2000 and 2020. RESULTS: Cardiovascular medicine, gastroenterology, and general surgery all had similar lower representation of women faculty in 2000 (17%, 17%, and 15%, respectively) compared with oncology (26%). Cardiovascular medicine and general surgery have seen smaller increases in representation over the last 20 years compared with gastroenterology and oncology. Oncology and gastroenterology are projected to reach sex parity in 2024 and 2029, followed by general surgery in 2054. At the current rate, cardiovascular medicine will not reach sex parity until 2070. CONCLUSION: Oncology and gastroenterology, compared with cardiovascular medicine and general surgery, have seen larger gains in representation of women over the past 2 decades, including at Professor rank. Disparities persist in specific fields; lessons may be learned from other specialties in which women are more likely to be promoted to leadership positions.

Women in procedural leadership roles in cardiology: The Women In Local Leadership (WILL) observational study.

BACKGROUND: Although 50% of U.S. medical students are women, this percentage fails to translate to cardiology. Gender disparities are striking in interventional cardiology (IC) and electrophysiology (EP) and in leadership. Left atrial appendage closure with the WATCHMAN device, as a novel procedure, is a lens into inequities. OBJECTIVE: The purpose of this study was to identify the characteristics and prevalence of women (1) as early WATCHMAN implanters and (2) in related leadership. METHODS: Data were collected on WATCHMAN implanters and hospitals from January 2017 to December 2018. The gender of physicians in leadership positions was identified via survey as Director of IC, Director of EP, and Chief of Cardiology. The Firth logistic model controlling for covariates modeled the rare event of a woman implanter. RESULTS: Data were obtained for 100% of the cohort. Men comprised 97% of implanters (860/886). No differences in subspecialty or implants by gender were observed. There were 414 hospitals performing WATCHMAN: 24% academic, 97% urban, and most medium/large size (94%). EP made up 61% of implanters. Only 4.8% of hospitals had women in selected leadership roles. Women represented <1% of Directors of IC and only 2.6% of both Directors of EP and Chiefs of Cardiology. Hospitals with a woman in leadership had a 4 times greater odds of a woman implanter (odds ratio 4.24; 95% confidence interval 1.16-15.41; P = .028). CONCLUSION: Women are underrepresented in cardiology procedural subspecialties in the use of novel technology and in key leadership roles. There was a greater odds of women early implanters of WATCHMAN if a woman led locally. Increasing women in leadership may improve gender diversity through visibility of role models.

Association Between Diagnosis Code Expansion and Changes in 30-Day Risk-Adjusted Outcomes for Cardiovascular Diseases.

BACKGROUND In January 2011, Centers for Medicare and Medicaid Services expanded the number of inpatient diagnosis codes from 9 to 25, which may influence comorbidity counts and risk-adjusted outcome rates for studies spanning January 2011. This study examines the association between (1) limiting versus not limiting diagnosis codes after 2011, (2) using inpatient-only versus inpatient and outpatient data, and (3) using logistic regression versus the Centers for Medicare and Medicaid Services risk-standardized methodology and changes in risk-adjusted outcomes. METHODS AND RESULTS Using 100% Medicare inpatient and outpatient files between January 2009 and December 2013, we created 2 cohorts of fee-for-service beneficiaries aged ≥65 years. The acute myocardial infarction cohort and the heart failure cohort had 578 728 and 1 595 069 hospitalizations, respectively. We calculate comorbidities using (1) inpatient-only limited diagnoses, (2) inpatient-only unlimited diagnoses, (3) inpatient and outpatient limited diagnoses, and (4) inpatient and outpatient unlimited diagnoses. Across both cohorts, International Classification of Diseases, Ninth Revision (ICD-9) diagnoses and hierarchical condition categories increased after 2011. When outpatient data were included, there were no significant differences in risk-adjusted readmission rates using logistic regression or the Centers for Medicare and Medicaid Services risk standardization. A difference-in-differences analysis of risk-adjusted readmission trends before versus after 2011 found that no significant differences between limited and unlimited models for either cohort. CONCLUSIONS For studies that span 2011, researchers should consider limiting the number of inpatient diagnosis codes to 9 and/or including outpatient data to minimize the impact of the code expansion on comorbidity counts. However, the 2011 code expansion does not appear to significantly affect risk-adjusted readmission rate estimates using either logistic or risk-standardization models or when using or excluding outpatient data.

Geographic and Demographic Variability in Transcatheter Aortic Valve Replacement Dispersion in the United States.

Background Transcatheter aortic valve replacement (TAVR) has transformed the management of aortic valve stenosis. However, little national data are available characterizing the geographic and demographic dispersion of this disruptive technology relative to surgical aortic valve replacement (SAVR). Methods and Results In this US claims-based study, we analyzed a 100% sample of fee-for-service Medicare beneficiaries from 2012 to 2017 and examined national rates of TAVR versus SAVR. Procedure rates were compared across years as a function of age, sex, race, and geography for TAVR and SAVR beneficiaries. There was significant growth in TAVR from 15.4 beneficiaries/100 000 enrollees in 2012 to 90.6 in 2017 (P<0.001). SAVR rates declined from 92.8 beneficiaries/100 000 enrollees in 2012 to 63.5 in 2017 (P<0.001). The growth of TAVR varied as a function of age (P<0.0001). While TAVR was the dominant strategy among beneficiaries ≥85 and 75 to 84 years old, SAVR was more common among beneficiaries 65 to 74 years old. TAVR was also used more frequently than SAVR among women (P<0.001). While TAVR increased among all races, it was less commonly used among non-White beneficiaries (P<0.001). Contemporary use of TAVR relative to SAVR varied significantly by geographic location, with a TAVR:SAVR ratio in 2017 of 1.24 in the Midwest and 1.68 in the Northeast (P<0.001). Conclusions In 2017, the number of Medicare beneficiaries receiving TAVR exceeded SAVR for the first time in the United States. There is significant variation, however, in the geographic expansion of TAVR and in patient demographics relative to SAVR.

Decision Aid Implementation and Patients' Preferences for Hip and Knee Osteoarthritis Treatment: Insights from the High Value Healthcare Collaborative.

BACKGROUND: Shared decision making (SDM) research has emphasized the role of decision aids (DAs) for helping patients make treatment decisions reflective of their preferences, yet there have been few collaborative multi-institutional efforts to integrate DAs in orthopedic consultations and primary care encounters. OBJECTIVE: In the context of routine DA implementation for SDM, we investigate which patient-level characteristics are associated with patient preferences for surgery versus medical management before and after exposure to DAs. We explored whether DA implementation in primary care encounters was associated with greater shifts in patients' treatment preferences after exposure to DAs compared to DA implementation in orthopedic consultations. DESIGN: Retrospective cohort study. SETTING: 10 High Value Healthcare Collaborative (HVHC) health systems. STUDY PARTICIPANTS: A total of 495 hip and 1343 adult knee osteoarthritis patients who were exposed to DAs within HVHC systems between July 2012 to June 2015. RESULTS: Nearly 20% of knee patients and 17% of hip patients remained uncertain about their treatment preferences after viewing DAs. Older patients and patients with high pain levels had an increased preference for surgery. Older patients receiving DAs from three HVHC systems that transitioned DA implementation from orthopedics into primary care had lower odds of preferring surgery after DA exposure compared to older patients in seven HVHC systems that only implemented DAs for orthopedic consultations. CONCLUSION: Patients' treatment preferences were largely stable over time, highlighting that DAs for SDM largely do not necessarily shift preferences. DAs and SDM processes should be targeted at older adults and patients reporting high pain levels. Initiating treatment conversations in primary versus specialty care settings may also have important implications for engagement of patients in SDM via DAs.

The Impact Of Decision Aids On Adults Considering Hip Or Knee Surgery.

Trials of decision aids developed for use in shared decision making find that patients engaged in that process tend to choose more conservative treatment for preference-sensitive conditions. Shared decision making is a collaborative process in which clinicians and patients discuss trade-offs and benefits of specific treatment options in light of patients' values and preferences. Decision aids are paper, video, or web-based tools intended to help patients match personal preferences with available treatment options. We analyzed data for 2012-15 about patients within the ten High Value Healthcare Collaborative member systems who were exposed to condition-specific decision aids in the context of consultations for hip and knee osteoarthritis, with the intention that the aids be used to support shared decision making. Compared to matched patients not exposed to the decision aids, those exposed had two-and-a-half times the odds of undergoing hip replacement surgery and nearly twice the odds of undergoing knee replacement surgery within six months of the consultation. These findings suggest that health care systems adopting decision aids developed for use in shared decision making, and used in conjunction with hip and knee osteoarthritis consultations, should not expect reduced surgical utilization.

Can Decision Support Help Patients With Spinal Stenosis Make a Treatment Choice?: A Prospective Study Assessing the Impact of a Patient Decision Aid and Health Coaching.

STUDY DESIGN: A prospective, randomized study on patients with lumbar spinal stenosis who received a decision support intervention to facilitate their treatment choice. OBJECTIVE: The aim of this study was to assess the impact of telephone health coaching (HC) in addition to a video decision aid (DA) compared with a DA alone for patients with spinal stenosis. SUMMARY OF BACKGROUND DATA: Treatment options for lumbar spinal stenosis include surgical and nonsurgical approaches. Patient DAs and HC have been shown to help patients make an informed treatment choice consistent with personal preferences. METHODS: Eligible patients with spinal stenosis were identified by an orthopedic surgeon or a nonsurgical spine specialist. Consenting participants were randomly assigned to either a video DA or a video DA along with HC (DA + HC). Patients completed baseline and follow-up questionnaires at 2 weeks, and 6 months after the decision support intervention(s). RESULTS: Ninety-eight patients were randomized to the DA + HC group and 101 to the DA-only group; 168 of 199 (84%) patients completed responses at all time points. Both groups showed improved understanding of spinal stenosis treatments and progress in decision making after watching the DA (P < 0.001). At 2 weeks, more patients in the coaching group had made a treatment decision (DA + HC 74% vs. DA only 52%, P < 0.01). At 6-month follow-up, the uptake of surgery was similar for both groups (DA + HC 21% had surgery vs. DA only 17%); satisfaction with the treatments received was similar for both groups (DA + HC, 84% satisfied vs. DA only, 85%). CONCLUSION: These results suggest that watching the video DA improved patient knowledge and reduced decisional uncertainty about their spinal stenosis treatment choice. The addition of telephone coaching helped some patients choose a treatment more quickly; 6-month decisional outcomes were similar for both groups. LEVEL OF EVIDENCE: 3.

Use of a web-based survey to facilitate shared decision making for patients eligible for cancer screening.

OBJECTIVE: Our aim was to facilitate shared decision making (SDM) during preventive visits by utilizing a web-based survey system to offer colorectal cancer (CRC) and prostate cancer screening decision aids (DAs) to appropriately identified patients prior to the visit. METHODS: Patients completed a web-based questionnaire before their preventive medicine appointment. Age- and gender-appropriate patients completed additional questions to determine eligibility for CRC or prostate-specific antigen (PSA) screening. Eligible patients were offered a choice of video or print DA, and completed questions assessing their knowledge, values, and preferences regarding the screening decision. Responses were summarized and fed forward to clinician and patient reports. RESULTS: Overall, 11,493 CRC and 4,384 PSA questionnaires were completed. Patient responses were used to identify those eligible for cancer-screening DAs: 2,187 (19 %) for CRC and 2,962 (68 %) for PSA; 15 % of eligible patients requested a DA. Many patients declined a DA because they indicated they "already know enough to make their decision" (34 % for CRC, 46 % for PSA). CONCLUSION: A web-based questionnaire provides an efficient means to identify patients eligible for cancer screening decisions and to offer them DAs before an appointment. Pre-visit use of DAs along with reports giving feedback to patients and clinicians provides an opportunity for SDM to occur at the visit.

Factors associated with the quality of patients' surgical decisions for treatment of hip and knee osteoarthritis.

BACKGROUND: Shared decision making requires informing patients and ensuring that treatment decisions reflect their goals. It is not clear to what extent this happens for patients considering total joint replacement (TJR) for hip or knee osteoarthritis. STUDY DESIGN: We conducted a cross-sectional mail survey of osteoarthritis patients at 4 sites, who made a decision about TJR. The survey measured knowledge and goals, the decision making process, decision confidence, and decision regret. Decision quality was defined as the percentage of patients who had high knowledge scores and received treatments that matched their goals. Multivariable regression models examined factors associated with knowledge and decision quality. RESULTS: There were 382 patients who participated (78.6% response rate). Mean knowledge score was 61% (SD 20.7%). In multivariate linear regression, higher education, having TJR, and site were associated with higher knowledge. Many patients (73%) received treatments that matched their goals. Thirty-one percent of patients met our definition for high decision quality. Higher decision making process scores, higher quality of life scores, and site were associated with higher decision quality. Patients who had high decision quality had less regret (73.1% vs 58.5%, p = 0.007) and greater confidence (9.0 [SD 1.6] vs 8.2 [SD 2.3] out of 10, p < 0.001). CONCLUSIONS: A third of patients who recently made a decision about osteoarthritis treatment met both criteria for a high quality decision. Controlling for treatment, patients reporting more involvement in the decision making process, higher quality of life, and being seen at a site that uses decision aids were associated with higher decision quality.

Psychometric evaluation of a decision quality instrument for treatment of lumbar herniated disc.

STUDY DESIGN: Retrospective and prospective patient surveys and a physician survey using a sample from American Medical Association master file. OBJECTIVE: To evaluate the performance of a new instrument designed to measure the quality of decisions about treatment of herniated disc. SUMMARY OF BACKGROUND DATA: There is growing consensus on the importance of engaging and informing patients to improve the quality of significant medical decisions, yet there are no instruments currently available to measure decision quality. METHODS: The herniated disc-decision quality instrument (HD-DQI) was developed with input from clinical experts, survey research experts, and patients. The HD-DQI produces 2 scores each scaled to 0% to 100%, with higher scores indicating better quality: (1) a total knowledge score and (2) a concordance score (indicating the percentage of patients who received treatments that matched their goals). We examined hypotheses relating to the acceptability, feasibility, validity, and reliability of the instrument, using data from 3 samples. RESULTS: The HD-DQI survey was feasible to implement and acceptable to patients, with good response rates and low missing data. The knowledge score discriminated between patients who had seen a decision aid or no decision aid (55% vs. 38%, P < 0.001) and between providers and patients (73% vs. 46%, P < 0.001). The knowledge score also had good retest reliability (intraclass correlation coefficient = 0.85). Most patients (78%) received treatments that matched their goals. Patients who received treatments that matched their goals were less likely to regret the decision than those who did not (13% vs. 39%, P = 0.004). CONCLUSION: The HD-DQI met several criteria for high-quality patient-reported survey instruments. It can be used to determine the quality of decisions for treatment of herniated disc. More work is needed to examine acceptability for use as part of routine patient care.

Decision quality instrument for treatment of hip and knee osteoarthritis: a psychometric evaluation.

BACKGROUND: A high quality decision requires that patients who meet clinical criteria for surgery are informed about the options (including non-surgical alternatives) and receive treatments that match their goals. The aim of this study was to evaluate the psychometric properties and clinical sensibility of a patient self report instrument, to measure the quality of decisions about total joint replacement for knee or hip osteoarthritis. METHODS: The performance of the Hip/Knee Osteoarthritis Decision Quality Instrument (HK-DQI) was evaluated in two samples: (1) a cross-sectional mail survey with 489 patients and 77 providers (study 1); and (2) a randomized controlled trial of a patient decision aid with 138 osteoarthritis patients considering total joint replacement (study 2). The HK-DQI results in two scores. Knowledge items are summed to create a total knowledge score, and a set of goals and concerns are used in a logistic regression model to develop a concordance score. The concordance score measures the proportion of patients whose treatment matched their goals. Hypotheses related to acceptability, feasibility, reliability and validity of the knowledge and concordance scores were examined. RESULTS: In study 1, the HK-DQI was completed by 382 patients (79%) and 45 providers (58%), and in study 2 by 127 patients (92%), with low rates of missing data. The DQI-knowledge score was reproducible (ICC = 0.81) and demonstrated discriminant validity (68% decision aid vs. 54% control, and 78% providers vs. 61% patients) and content validity. The concordance score demonstrated predictive validity, as patients whose treatments were concordant with their goals had more confidence and less regret with their decision compared to those who did not. CONCLUSIONS: The HK-DQI is feasible and acceptable to patients. It can be used to assess whether patients with osteoarthritis are making informed decisions about surgery that are concordant with their goals.

Are you SURE?: Assessing patient decisional conflict with a 4-item screening test.

OBJECTIVE: To assess the reliability and validity of the 4-item SURE (Sure of myself; Understand information; Risk-benefit ratio; Encouragement) screening test for decisional conflict in patients. DESIGN: Cross-sectional study. SETTING: Four family medicine groups in Quebec and 1 rural academic medical centre in New Hampshire. PARTICIPANTS: One hundred twenty-three French-speaking pregnant women considering prenatal screening for Down syndrome and 1474 English-speaking patients referred to watch condition-specific video decision aids. MAIN OUTCOME MEASURES: Cronbach alpha was used to assess the reliability of SURE. A factorial analysis was performed to assess its unidimensionality. The Pearson correlation coefficient was computed between SURE and the Decisional Conflict Scale to assess concurrent validation. A t test procedure comparing the SURE scores of patients who had made decisions with the scores of those who had not was used to assess construct validation. RESULTS: Among the 123 French-speaking pregnant women, 105 (85%) scored 4 out of 4 (no decisional conflict); 10 (8%) scored 3 (

Utility of quantitative computerized pain drawings in a sample of spinal stenosis patients.

OBJECTIVE: To evaluate the utility of quantitative computerized pain drawings (CPDs) in a sample of spine patients before and after surgery. DESIGN: Analysis of changes in quantified CPDs, the Oswestry Disability Index (ODI), the Short Form-36 Health Survey Questionnaire (SF-36), and numerical ratings of pain intensity before and after surgery. SETTING: Private clinic in large metropolitan area. Patients. Forty-six patients with spinal stenosis. Interventions. Surgery for the relief of pain due to spinal stenosis. OUTCOME MEASURES: A total points (TP) score was calculated from the CPD that reflected the total number of pixels filled by the patient, and the percentage of total pain area indicated as aching, stabbing, numbness, pins and needles, burning, and other, were each calculated separately. CPD scores, ODI score, Physical Components Summary (PCS) and Mental Components Summary scores of the SF-36, and pain intensity ratings (0-10 scale) were all recorded before and after surgical intervention. Results. After surgery, patients showed significant improvements in the extent of shaded pain area of the CPD, pain intensity ratings, ODI, and SF-36 PCS scores (paired t-test, P < or = 0.01). Changes in TP scores calculated from the CPDs were significantly correlated (P < or = 0.05) with changes in ODI scores (r = 0.34) and pain intensity ratings (r = 0.37). Changes in the percentage of total pain area covered by specific qualities of pain were not significant. CONCLUSIONS: Results from the present study provide initial support for the use of automated quantified data collected from CPDs to evaluate treatment interventions and to serve the clinician as a record of changes in spatial location, radiation or extent of pain, and the sensory quality of pain when evaluating individual patient needs.

Validation of a preparation for decision making scale.

OBJECTIVE: The Preparation for Decision Making (PrepDM) scale was developed to evaluate decision processes relating to the preparation of patients for decision making and dialoguing with their practitioners. The objective of this study was to evaluate the scale's psychometric properties. METHODS: From July 2005 to March 2006, after viewing a decision aid prescribed during routine clinical care, patients completed a questionnaire including: demographic information, treatment intention, decisional conflict, decision aid acceptability, and the PrepDM scale. RESULTS: Four hundred orthopaedic patients completed the questionnaire. The PrepDM scale showed significant correlation with the informed (r=-0.21, p<0.01) and support (r=-0.13, p=0.01) subscales (DCS); and discriminated significantly between patients who did and did not find the decision aid helpful (p<0.0001). Alpha coefficients for internal consistency ranged from 0.92 to 0.96. The scale is strongly unidimensional (principal components analysis) and Item Response Theory analyses demonstrated that all ten scale items function very well. CONCLUSION: The psychometric properties of the PrepDM scale are very good. PRACTICE IMPLICATIONS: The scale could allow more comprehensive evaluation of interventions designed to prepare patients for shared-decision making encounters regarding complex health care decisions.