Statutes Governing Default Surrogate Decision Making for Mental Health Treatment.

OBJECTIVE: The authors sought to describe state-to-state variations in the scope of statutory authority granted to default surrogates who decide on mental health treatment for incapacitated patients. METHODS: The authors investigated state statutes delineating the powers of default surrogates to make decisions about mental health treatment. Statutes in all 50 U.S. states and the District of Columbia were identified and analyzed independently by three reviewers. Research was conducted from August 2017 to November 2018 and updated in January 2020. RESULTS: State statutes varied in approaches to default surrogate decision making for mental health treatment. Eight states' statutes delegate broad authority to surrogates, whereas 25 states prohibit surrogates from giving consent for specific therapies. Thirteen states are silent on whether surrogates may make decisions. CONCLUSIONS: Heterogeneity among state statutory laws contributes to complexity of treating patients without decisional capacity. This variability encumbers efforts to support surrogates and clinicians and may contribute to health disparities.

COVID-19 and Disruptive Modifications to Cardiac Critical Care Delivery: JACC Review Topic of the Week.

The COVID-19 pandemic has presented a major unanticipated stress on the workforce, organizational structure, systems of care, and critical resource supplies. To ensure provider safety, to maximize efficiency, and to optimize patient outcomes, health systems need to be agile. Critical care cardiologists may be uniquely positioned to treat the numerous respiratory and cardiovascular complications of the SARS-CoV-2 and support clinicians without critical care training who may be suddenly asked to care for critically ill patients. This review draws upon the experiences of colleagues from heavily impacted regions of the United States and Europe, as well as lessons learned from military mass casualty medicine. This review offers pragmatic suggestions on how to implement scalable models for critical care delivery, cultivate educational tools for team training, and embrace technologies (e.g., telemedicine) to enable effective collaboration despite social distancing imperatives.

The Fast Literature Assessment and Review (FLARE) Initiative. A Collaborative Effort for Timely Literature Appraisal during the Coronavirus Disease Pandemic.

The emergence and worldwide spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused major disruptions to the healthcare system and medical education. In response, the scientific community has been acquiring, releasing, and publishing data at a remarkable pace. At the same time, medical practitioners are taxed with greater professional duties than ever before, making it challenging to stay current with the influx of medical literature.To address the above mismatch between data release and provider capacity and to support our colleagues, physicians at the Massachusetts General Hospital have engaged in an electronic collaborative effort focused on rapid literature appraisal and dissemination regarding SARS-CoV-2 with a focus on critical care.Members of the Division of Pulmonary and Critical Care, the Division of Cardiology, and the Department of Medicine at Massachusetts General Hospital established the Fast Literature Assessment and Review (FLARE) team. This group rapidly compiles, appraises, and synthesizes literature regarding SARS-CoV-2 as it pertains to critical care, relevant clinical questions, and anecdotal reports. Daily, FLARE produces and disseminates highly curated scientific reviews and opinion pieces, which are distributed to readers using an online newsletter platform.Interest in our work has escalated rapidly. FLARE was quickly shared with colleagues outside our division, and, in a short time, our audience has grown to include more than 4,000 readers across the globe.Creating a collaborative group with a variety of expertise represents a feasible and acceptable way of rapidly appraising, synthesizing, and communicating scientific evidence directly to frontline clinicians in this time of great need.

Low-Value Transthoracic Echocardiography, Healthcare Utilization, and Clinical Outcomes in Patients With Coronary Artery Disease.

BACKGROUND: The relationship between ordering frequency of rarely appropriate transthoracic echocardiograms on healthcare utilization and patient outcomes in coronary artery disease (CAD) is not known. Our objective was to investigate practice patterns of cardiologists who order a high frequency of low-value transthoracic echocardiograms in patients with CAD and whether practice behavior influences patient outcomes. METHODS AND RESULTS: A retrospective cohort of outpatient CAD patients was accrued by identifying patients with at least 1 visit to 1 of 35 Ontario-based cardiologists in the EchoWISELY randomized clinical trial (Will Inappropriate Scenarios for Echocardiography Lessen Significantly) control group. The main outcomes of interest were patient-level receipt of diagnostic tests, physician visits, medication prescriptions, and clinical outcomes at 1 year. Our cohort consisted of 3966 patients with CAD (mean [SD] age, 67.8 [12.0] years; 72% men), with an outpatient visit to 1 of 35 eligible cardiologists, stratified into 3 ordering tertiles. Patients of cardiologists in the top ordering tertile of rarely appropriate transthoracic echocardiograms had significantly lower odds of receiving the following services at 1 year compared with patients in the low ordering group: cholesterol assessment (odds ratio [OR], 0.77 [95% CI, 0.65-0.91]); hemoglobin A1c assessment (OR, 0.79 [95% CI, 0.66-0.94]); ß-blocker prescription (OR, 0.70 [95% CI, 0.55-0.90]); and aldosterone receptor antagonist prescription (OR, 0.46 [95% CI, 0.22-0.98]). Patients of high ordering cardiologists had greater odds of all-cause mortality at 1 year (OR, 1.54 [95% CI, 1.04-2.28]), although all other outcomes were similar. CONCLUSIONS: Patients with CAD seen by cardiologist who ordered a high rate of rarely appropriate transthoracic echocardiograms were less likely to receive potentially high-value screening tests and evidence-based medications than low ordering cardiologists. CLINICAL TRIAL REGISTRATION: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02038101.

Methicillin-Resistant Staphylococcus aureus Prosthetic Valve Endocarditis: Pathophysiology, Epidemiology, Clinical Presentation, Diagnosis, and Management.

Staphylococcus aureus prosthetic valve endocarditis (PVE) remains among the most morbid bacterial infections, with mortality estimates ranging from 40% to 80%. The proportion of PVE cases due to methicillin-resistant Staphylococcus aureus (MRSA) has grown in recent decades, to account for more than 15% of cases of S. aureus PVE and 6% of all cases of PVE. Because no large studies or clinical trials for PVE have been published, most guidelines on the diagnosis and management of MRSA PVE rely upon expert opinion and data from animal models or related conditions (e.g., coagulase-negative Staphylococcus infection). We performed a review of the literature on MRSA PVE to summarize data on pathogenic mechanisms and updates in epidemiology and therapeutic management and to inform diagnostic strategies and priority areas where additional clinical and laboratory data will be particularly useful to guide therapy. Major updates discussed in this review include novel diagnostics, indications for surgical management, the utility of aminoglycosides in medical therapy, and a review of newer antistaphylococcal agents used for the management of MRSA PVE.

Characterization of Medical Professional Liability Risks Associated With Transesophageal Echocardiography.

BACKGROUND: Medical claim data offer the possibility to improve patient care and mitigate liability. Although published analyses exist in cardiology, no information is available for transesophageal echocardiography (TEE). In this study, the authors reviewed medical claims involving TEE to identify potential risk management concerns so that these lessons could be used to improve the safety and quality of transesophageal echocardiographic practice. METHODS: The authors reviewed anonymized clinical and claims data from all closed claims from 2008 to 2013 for a single national physician liability insurer. RESULTS: There were no claims involving transthoracic echocardiography and eight involving TEE. Three claims involved esophageal perforation, a known risk of TEE. Two claims involved quadriplegia allegedly due to neck manipulation in the setting of a cervical spinal abscess that should have been suspected. Three claims involved the cardiologist's failure to diagnose endocarditis, with allegations that the cardiologist did not perform TEE in an appropriate time frame to avoid major morbidity and mortality from endocarditis. CONCLUSIONS: Liability claims associated with TEE involve failure to order and perform TEE in an appropriate clinical scenario and in a timely manner; failure to properly document medical decision making; failure to inform patients regarding risks of TEE; failure to properly monitor the patient before, during, and after TEE; and technical difficulties in performing the procedure. Cardiologists should recognize guideline-based indications when TEE is needed and be mindful of the complication rates of this procedure. When screening a patient for TEE, consider expert input that may reduce the risks of TEE (e.g., a spine specialist for a neck injury, a gastroenterologist for esophageal comorbidity). Informed consent and medical record documentation should be practiced as a vehicle to inform patients of these risks and chronicle decision-making processes.

Personal and Professional Characteristics of U.S. Dual-Boarded Critical Care Cardiologists in 2015.

OBJECTIVES: Evaluate the characteristics of U.S. physicians who are board certified in cardiology and critical care medicine ("dual-boarded cardiologists"). DESIGN: Retrospective cross-sectional study using a comprehensive database of licensed U.S. physicians linked to Medicare claims. SETTING: The United States. SUBJECTS: Dual-boarded cardiologists. MEASUREMENTS AND MAIN RESULTS: We used a comprehensive physician database to identify all physicians who were board certified in cardiology and critical care medicine before July 2015. We assessed physicians' characteristics and compared dual-boarded cardiologists with and without active board certification in critical care medicine and estimated the maximum proportion of 2014 Medicare Cardiac ICU admissions treated by dual-boarded cardiologists. Among 473 dual-boarded cardiologists, 16 (3.4%) were women; 468 (99%) and 85 (18%) maintained active board certification in cardiology and critical care medicine, respectively. Overall, 98 dual-boarded cardiologists (21%) submitted 1,215 total claims for critical care services in 2014. Compared to dual-boarded cardiologists without active board certification in critical care medicine, those with active certification had more publications (median publications: 6.5 vs 3.0; p = 0.002), were more likely to be professors (22.3% vs 9.5%; p = 0.003), and were more likely to bill Medicare for critical care services (29% vs 17.8%; p = 0.002). We estimated that no more than 0.47% of all 2014 Medicare Cardiac ICU admissions were treated by a dual-boarded cardiologist. CONCLUSIONS: Dual-boarded cardiologists appear to deliver a small proportion of all Cardiac ICU services received by Medicare beneficiaries. Optimizing the modern Cardiac ICU workforce will require greater efforts to promote and support the training of dual-boarded cardiologists.

Assessment of Right Ventricular Strain by Computed Tomography Versus Echocardiography in Acute Pulmonary Embolism.

BACKGROUND: Right ventricular strain (RVS) identifies patients at risk of hemodynamic deterioration from pulmonary embolism (PE). Our hypothesis was that chest computed tomography (CT) can provide information about RVS analogous to transthoracic echocardiography (TTE) and that RVS on CT is associated with adverse outcomes after PE. METHODS: Consecutive emergency department patients with acute PE were prospectively enrolled and clinical, biomarker, and imaging data were recorded. CTs were overread by two radiologists. We compared diagnoses of RVS on CT (defined as right ventricle:left ventricle ratio ≥ 0.9 or interventricular septal bowing) to echocardiography (defined as right ventricular hypokinesis, right ventricular dilatation, or interventricular septal bowing). We calculated the test characteristics (with 95% confidence interval) of CT and TTE for a composite outcome of severe clinical deterioration, thrombolysis/thrombectomy, or death within 5 days. RESULTS: A total of 298 patients were enrolled; 274 had CT and 118 had formal TTE. Of the 104 patients who had both CT and TTE, the mean (±SD) age was 58 (±17) years; 50 (48%) were female and 88 (85%) were Caucasian. Forty-two (40%) had RVS by TTE and 75 (72%) had RVS by CT. CT and TTE agreed on the presence or absence of RVS in 61 (59%) cases (κ = 0.24). Using TTE as criterion standard, the test characteristics of CT for RVS were as follows: sensitivity = 88%, specificity = 39%, positive predictive value = 49%, and negative predictive value = 83%. Fourteen (13%) patients experienced severe clinical deterioration or required hospital-based intervention within 5 days. This occurred in 30% of patients with RVS on both TTE and CT, 20% of patients with RVS on TTE alone, 3% of patients with RVS on CT alone, and 4% of patients without RVS on either modality. CONCLUSIONS: In acute PE, CT is highly sensitive but only moderately specific for RVS compared to TTE. RVS on both CT and TTE predicts more events than either modality alone. TTE confers additional positive prognostic value compared to CT in predicting post-PE clinical deterioration.

Assessment of inpatient multimodal cardiac imaging appropriateness at large academic medical centers.

BACKGROUND: Responding to concerns regarding the growth of cardiac testing, the American College of Cardiology Foundation (ACCF) published Appropriate Use Criteria (AUC) for various cardiac imaging modalities. Single modality cardiac imaging appropriateness has been reported but there have been no studies assessing the appropriateness of multiple imaging modalities in an inpatient environment. METHODS: A retrospective study of the appropriateness of cardiac tests ordered by the inpatient General Internal Medicine (GIM) and Cardiology services at three Canadian academic hospitals was conducted over two one-month periods. Cardiac tests characterized were transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), single-photon emission tomography myocardial perfusion imaging (SPECT), and diagnostic cardiac catheterization. RESULTS: Overall, 553 tests were assessed, of which 99.8% were classifiable by AUC. 91% of all studies were categorized as appropriate, 4% may be appropriate and 5% were rarely appropriate. There were high rates of appropriate use of all modalities by GIM and Cardiology throughout. Significantly more appropriate diagnostic catheterizations were ordered by Cardiology than GIM (93% vs. 82%, p = <0.01). Cardiology ordered more appropriate studies overall (94% vs. 88%, p = 0.03) but there was no difference in the rate of rarely appropriate studies (3% vs. 6%, p = 0.23). CONCLUSION: The ACCF AUC captured the vast majority of clinical scenarios for multiple cardiac imaging modalities in this multi-centered study on Cardiology and GIM inpatients in the acute care setting. The rate of appropriate ordering was high across all imaging modalities. We recommend further work towards improving appropriate utilization of cardiac imaging resources focus on the out-patient setting.

Access, quality, and costs of care at physician owned hospitals in the United States: observational study.

OBJECTIVE: To compare physician owned hospitals (POHs) with non-POHs on metrics around patient populations, quality of care, costs, and payments. DESIGN: Observational study. SETTING: Acute care hospitals in 95 hospital referral regions in the United States, 2010. PARTICIPANTS: 2186 US acute care hospitals (219 POHs and 1967 non-POHs). MAIN OUTCOME MEASURES: Proportions of patients using Medicaid and those from ethnic and racial minority groups; hospital performance on patient experience metrics, care processes, risk adjusted 30 day mortality, and readmission rates; costs of care; care payments; and Medicare market share. RESULTS: The 219 POHs were more often small (<100 beds), for profit, and in urban areas. 120 of these POHs were general (non-specialty) hospitals. Compared with patients from non-POHs, those from POHs were younger (77.4 v 78.4 years, P<0.001), less likely to be admitted through an emergency department (23.2% v. 29.0%, P<0.001), equally likely to be black (5.1% v 5.5%, P=0.85) or to use Medicaid (14.9% v 15.4%, P=0.75), and had similar numbers of chronic diseases and predicted mortality scores. POHs and non-POHs performed similarly on patient experience scores, processes of care, risk adjusted 30 day mortality, 30 day readmission rates, costs, and payments for acute myocardial infarction, congestive heart failure, and pneumonia. CONCLUSION: Although POHs may treat slightly healthier patients, they do not seem to systematically select more profitable or less disadvantaged patients or to provide lower value care.

Peri-operative assessment of right heart function: role of echocardiography.

The right heart contributes significantly to overall cardiac function. Right ventricular (RV) haemodynamics and function have been defined to be physiologically different from the left ventricle, and yet independently associated with outcomes in a spectrum of conditions. In particular, RV function has been shown to influence prognosis of patients undergoing surgery. The assessment of right heart function during the intra-operative and immediate postoperative periods plays an important role in the clinical management of patients having surgery. While a number of techniques are available for the assessment of the right heart intra-operatively, echocardiography remains the prime choice being least invasive, relatively safe, readily accessible and cost-effective. Advancements in the field of echocardiographic have improved ability to assess right heart function. This review examines the role echocardiography and advances in this imaging modality in the assessment of right heart function within the peri-operative setting.

Echocardiographic assessment of ischemic mitral regurgitation.

Ischemic mitral regurgitation is an important consequence of LV remodeling after myocardial infarction. Echocardiographic diagnosis and assessment of ischemic mitral regurgitation are critical to gauge its adverse effects on prognosis and to attempt to tailor rational treatment strategy. There is no single approach to the echocardiographic assessment of ischemic mitral regurgitation: standard echocardiographic measures of mitral regurgitation severity and of LV dysfunction are complemented by assessments of displacement of the papillary muscles and quantitative indices of mitral valve deformation. Development of novel approaches to understand mitral valve geometry by echocardiography may improve understanding of the mechanism, clinical trajectory, and reparability of ischemic mitral regurgitation.