Bringing competency-based communication training to scale: A multi-institutional virtual simulation-based mastery learning curriculum for Emergency Medicine residents.

PURPOSE: Serious illness communication skills are essential for physicians, yet competency-based training is lacking. We address scalability barriers to competency-based communication skills training by assessing the feasibility of a multi-center, virtual simulation-based mastery learning (vSBML) curriculum on breaking bad news (BBN). METHODS: First-year emergency medicine residents at three academic medical centers participated in the virtual curriculum. Participants completed a pretest with a standardized patient (SP), a workshop with didactics and small group roleplay with SPs, a posttest with an SP, and additional deliberate practice sessions if needed to achieve the minimum passing standard (MPS). Participants were assessed using a previously published BBN assessment tool that included a checklist and scaled items. Authors compared pre- and posttests to evaluate the impact of the curriculum. RESULTS: Twenty-eight (90%) of 31 eligible residents completed the curriculum. Eighty-nine percent of participants did not meet the MPS at pretest. Post-intervention, there was a statistically significant improvement in checklist performance (Median= 93% vs. 53%, p < 0.001) and on all scaled items assessing quality of communication. All participants ultimately achieved the MPS. CONCLUSIONS: A multi-site vSBML curriculum brought all participants to mastery in the core communication skill of BBN and represents a feasible, scalable model to incorporate competency-based communication skills education in a widespread manner.

Patient and limb outcomes 10 years after endovascular revascularization of the superficial femoral artery for peripheral artery disease: The Boston Femoral Artery Endovascular Revascularization Outcomes (Boston FAROUT) study.

BACKGROUND: We aimed to describe patient and limb outcomes in the decade after endovascular revascularization for chronic lower-extremity peripheral artery disease (PAD). METHODS: We assessed outcomes in patients having endovascular revascularization of the superficial femoral artery in two centers between 2003 and 2011 and followed for a median 9.3 (25-75%: 6.8, 11.1) years. Outcomes included death, myocardial infarction, stroke, repeat limb revascularizations, and amputations. We used competing risks analysis with clustering by patient to determine the hazard ratios (HR) and 95% CI for patients, and procedural characteristics for cause of death, cardiovascular events, and major adverse limb events (MALE). RESULTS: There were 253 index limb revascularizations in 202 patients followed for a median 9.3 years. Patients had intensive medical treatment with 90% on statins and 80% on beta-blockers. During follow up there were 57 (28%) cardiovascular deaths and 62 (31%) noncardiovascular deaths. Of the 253 limbs, 227 (90%) were free of MALE over follow up and 93 (37%) had MALE or minor repeat revascularization. In multivariable models, cardiovascular death significantly associated with critical limb ischemia (HR = 3.21, 95% CI = 1.84, 5.61) and noncardiovascular death with chronic kidney disease (HR = 2.69, 95% CI = 1.68, 4.30), and smoking (HR = 2.75, 95% CI = 1.01, 7.52). MALE or minor repeat revascularization associated with critical limb ischemia (HR = 1.43, 95% CI = 0.84, 2.43), smoking (HR = 2.49, 95% CI = 1.26, 4.90), and lesion length > 200 mm (HR = 1.51, 95% CI = 0.98, 2.33). CONCLUSIONS: Among patients with intensive medical therapy, the risk of noncardiovascular death was high and similar to cardiovascular death. Endovascular intervention can have acceptable long-term results. Future studies should evaluate strategies to reduce both cardiovascular and noncardiovascular deaths.

Long-term outcomes in patients with acute coronary syndromes related to prolonging dual antiplatelet therapy more than 12 months after coronary stenting.

OBJECTIVES: To assess the impact of stent type on the risk of death or myocardial infarction (MI) related to dual antiplatelet therapy (DAPT) more than 12 months (prolonged DAPT) versus 12 or less months after PCI for an acute coronary syndrome (ACS). BACKGROUND: The recent DAPT study reported lower recurrent ischemic events from prolonged DAPT in patients treated with PCI for an ACS, but was underpowered to determine the impact of stent type. METHODS: We determined clinical outcomes after PCI for an ACS (median follow-up: DES = 26 months, BMS = 46 months) in 18,484 patients in the Veterans Affairs system treated with first generation drug-eluting stents (DES) or bare-metal stents (BMS). We used landmark analyses starting 1 year after the index PCI to assess the risk of prolonged DAPT on the primary endpoint of death or MI. Multivariable and propensity models adjusted for confounding. RESULTS: There was a significant interaction between stent type and prolonged DAPT for death and MI (P = 0.0036), death (P = 0.054), and major bleeding (P = 0.0013). Patients treated with prolonged DAPT had lower risks of death or MI (HR = 0.71, 95% CI = 0.61, 0.82) and death (HR = 0.74, 95%CI = 0.62, 0.89) with DES, but not BMS, and higher risks of major bleeding, particularly with BMS (HR = 1.67, P < 0.001) than DES (HR = 1.24, p = 0.01). CONCLUSIONS: Prolonging DAPT more than 12 months after PCI for ACS only associated with a lower risk of ischemic events in the 1-4 years after PCI in those receiving first generation DES. Stent type may influence the benefit of prolonged DAPT. © 2016 Wiley Periodicals, Inc.

Risk of Mortality Related to Recurrent Limb Events After Endovascular Revascularization of the Superficial Femoral Artery for Peripheral Artery Disease: The Boston Femoral Artery Endovascular Revascularization Outcomes (Boston FAROUT) Study.

Endovascular revascularization of the superficial femoral artery (SFA) may lead to recurrent ischemic syndromes, revascularization, or amputation. The impact of these events on mortality is unknown. We followed all patients having SFA endovascular revascularization for claudication or chronic limb-threatening ischemia in 2 cardiovascular (CV) divisions in Boston, Massachusetts. Any recurrent limb event after the initial SFA revascularization included recurrent claudication (67%), limb ulceration or gangrene (13%), repeat endovascular revascularization (61%), surgical revascularization (15%), or major (9%) or minor amputation (8%). We linked data to the National Death Index to ascertain cause of death grouped into CV mortality, or non-CV mortality. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) from Cox proportional hazards and sub-HRs from Fine-Gray competing risks analyses were clustered by patient. Overall, there were 202 patients with 253 index limb endovascular procedures. A recurrent limb event occurred in 123 limbs (49%) and 93 patients (46%). Patients with and without recurrent limb events had similar numbers of deaths over follow-up (76 [62%] vs 71 [55%], respectively). In multivariable models, recurrent limb event was not related to all-cause death (HR 0.92, 95% CI 0.64 to 1.33), CV death (HR 1.29, 95% CI 0.72 to 1.30), or non-CV death (HR 0.65, CI 0.39 to 1.07). Competing risk analyses suggested male gender and chronic limb-threatening ischemia were more strongly related to CV death, and chronic kidney more strongly related to disease to non-CV death. In conclusion, recurrent limb events, which contribute to patient morbidity, do not increase the risk of all-cause or cause-specific mortality, and should not discourage repeat revascularization to relieve symptoms or ischemia.

Current reporting of usability and impact of mHealth interventions for substance use disorder: A systematic review.

BACKGROUND: Connected interventions use data collected through mobile/wearable devices to trigger real-time interventions and have great potential to improve treatment for substance use disorder (SUD). This review aims to describe the current landscape, effectiveness and usability of connected interventions for SUD. METHODS: A systematic review was conducted to identify articles evaluating connected health interventions for SUD in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three databases (PubMed, IEEE, and Scopus) were searched over a five-year period. Included articles described a connected health intervention targeting SUD and provided outcomes data. Data were extracted using a standardized reporting tool. RESULTS: A total of 1676 unique articles were identified during the initial search, with 32 articles included in the final analysis. Seven articles of the 32 were derived from two large studies. The most commonly studied SUD was alcohol use disorder. Sixteen articles reported at least one statistically significant result with respect to reduced craving and/or substance use. The majority of articles used ecological momentary assessment to trigger interventions, while four used biologic/physiologic data. Two articles used a wearable device. Common intervention types included craving management, coping assistance, and tailored feedback. Twenty-three articles measured usability factors, and acceptability was generally reported as high. CONCLUSION: Identified themes included a focus on AUD, use of smart phones, use of EMA for intervention delivery, positive effects on SUD related outcomes, and overall high acceptability. Wearables that directly monitor biologic data and predictive analytics using integrated data streams represent understudied opportunities for new research.