"Passing Out is a Serious Thing": Patient Expectations for Syncope Evaluation and Management.

PURPOSE: Syncope is a complex symptom requiring thoughtful evaluation. The ACC/AHA/HRS published syncope management guidelines in 2017. Effective guideline implementation hinges on overcoming multilevel barriers, including providers' perceptions that patients prefer aggressive diagnostic testing when presenting to the emergency department (ED) with syncope, which conflicts with the 2017 Guideline on Syncope. To better understand this perceived barrier, we explored patient and family caregiver expectations and preferences when presenting to the ED with syncope. PATIENTS AND METHODS: We conducted semi-structured focus groups (N=12) and in-depth interviews (N=19) with patients presenting to the ED with syncope as well as with their family caregivers. Interviews were recorded, transcribed verbatim, and analyzed by a team of researchers following a directed content analysis. Results were reviewed and shared iteratively with all team members to confirm mutual understanding and agreement. RESULTS: Syncope patients and caregivers discussed three main desires when presenting to the ED with syncope: 1) clarity regarding their diagnosis,; 2) context surrounding their care plan and diagnostic approach; and 3) to feel seen, heard and cared about by their health care team. CONCLUSION: Clinicians have cited patient preferences for aggressive diagnostic testing as a barrier to adhering to the 2017 Guideline on Syncope, which recommends against routine administration of imaging testing (eg, echocardiograms). Our results suggest that while participants preferred diagnostic testing as a means to achieve clarity and even a feeling of being cared for, other strategies, such as a patient-engaged approach to communication and shared decision-making, may address the spectrum of patient expectations when presenting to the ED with syncope while adhering to guideline recommendations.

Identifying Guideline-Practice Gaps to Optimize Evaluation and Management for Patients With Syncope.

Syncope is a common and complex symptom that requires efficient evaluation to determine the cause. Recent guidelines focus on high-value testing, but a systematic evaluation of their implementation has not been performed. To this end, we used a mixed-methods approach of surveys, chart reviews, and focus groups to understand current practices relating to the diagnosis and management of patients with syncope and to identify barriers and facilitators to the implementation of guideline-supported recommendations. Surveys were distributed to 1500 providers in the specialties of hospital medicine, cardiology, emergency medicine, and family medicine, and 175 responses were received. Knowledge of class I and III guideline recommendations were assessed with the use of clinical vignettes, which were answered correctly 60%-80% of the time. Chart reviews focused on patient history and testing for syncope. Per the guidelines, < 50% of charts met criteria for bare minimum history and physical examination. Based on the documentation, 25% of echocardiograms and 90% of neurologic testing obtained would not have been appropriate per the guidelines. Self-reported and actual practice patterns were similar in rates of testing. Our results indicate that there remains a gap between guideline-directed management and actual practice for syncope. Focus groups revealed barriers across multiple levels of care that need to be addressed to improve care. Our findings emphasize the need for proactive strategies to improve syncope testing practices, potentially saving millions of dollars in the health care system.

Evaluating the clinical dyad leadership model: a narrative review.

PURPOSE: Dyadic leadership models, in which two professionals jointly lead and share unit responsibilities, exemplifies a recent trend in health care. Nonetheless, much remains unknown about their benefits and drawbacks. In order to understand their potential impact, we conducted a review of literature evaluating dyad leadership models in health systems. DESIGN/METHODOLOGY/APPROACH: Our narrative review began with a search of PubMed, CINAHL, Web of Science and Scopus using key terms related to dyads and leadership. The search yielded 307 articles. We screened titles/abstracts according to these criteria: (1) focus on dyadic leadership model, i.e. physician-nurse or clinician-administrator, (2) set in health care environment and (3) peer-reviewed with an evaluative component of dyadic model. This yielded 22 articles for full evaluation, of which six were relevant for this review. FINDINGS: These six articles contribute an assessment of (1) teamwork and communication perceptions and their changes through dyad implementation, (2) dyad model functionality within the health system, (3) lessons learned from dyad model implementation and (4) dyad model adoption and model fidelity. RESEARCH LIMITATIONS/IMPLICATIONS: Research in this area remains nascent, and most articles focused on implementation over evaluation. It is possible that some articles were excluded due to our methodology, which excluded nonEnglish articles. PRACTICAL IMPLICATIONS: Findings provide guidance for health care organizations seeking to implement dyadic leadership models. Rigorous studies are needed to establish the impact of dyadic leadership models on quality and patient outcomes. ORIGINALITY/VALUE: This review consolidates evidence surrounding the implementation and evaluation of a leadership model gaining prominence in health care.

Value-based syncope evaluation and management: Perspectives of health care professionals on readiness, barriers and enablers.

BACKGROUND: Syncope is a common condition seen in the emergency department. Given the multitude of etiologies, research exists on the evaluation and management of syncope. Yet, physicians' approach to patients with syncope is variable and often not value based. The 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients with Syncope includes a focus on unnecessary medical testing. However, little research assesses implementation of the guidelines. METHODS: Mixed methods approach was applied. The targeted provider specialties include emergency medicine, hospital medicine and cardiology. The Evidence-based Practice Attitude Scale-36 and the Organizational Readiness to Change Assessment surveys were distributed to four different hospital sites. We then conducted focus groups and key informant interviews to obtain more information about clinicians' perceptions to guideline-based practice and barriers/facilitators to implementation. Descriptive statistics and bivariate analyses were used for survey analysis. Two-stage coding was used to identify themes with NVivo. RESULTS: Analysis of surveys revealed that overall attitude toward evidence-based practices was moderate and implementation of new guidelines were seen as a burden, potentially decreasing compliance. There were differences across hospital settings. Five common themes emerged from interviews: uncertainty of a syncope diagnosis, rise of consumerism in health care, communication challenge with patient, provider differences in standardized care, and organizational processes to change. CONCLUSIONS: Despite recommendations for the use of syncope guidelines, adherence is suboptimal. Overcoming barriers to use will require a paradigm shift. A multifaceted approach and collaborative relationships are needed to adhere to the Guidelines to improve patient care and operational efficiency.

Reliability and validity of the work and social adjustment scale in phobic disorders.

The Work and Social Adjustment Scale (WSAS) is a simple widely used 5-item measure of disability whose psychometric properties need more analysis in phobic disorders. The reliability, factor structure, validity, and sensitivity to change of the WSAS were studied in 205 phobic patients (73 agoraphobia, 62 social phobia, and 70 specific phobia) who participated in various open and randomized trials of self-exposure therapy. Internal consistency of the WSAS was excellent in all phobics pooled and in agoraphobics and social phobics separately. Principal components analysis extracted a single general factor of disability. Specific phobics gave less consistent ratings across WSAS items, suggesting that some items were less relevant to their problem. Internal consistency was marginally higher for self-ratings than clinician ratings of the WSAS. Self-ratings and clinician ratings correlated highly though patients tended to rate themselves as more disabled than clinicians did. WSAS total scores reflected differences in phobic severity and improvement with treatment. The WSAS is a valid, reliable, and change-sensitive measure of work/social and other adjustment in phobic disorders, especially in agoraphobia and social phobia.

The PAS-ADD Checklist: independent replication of its psychometric properties in a community sample.

BACKGROUND: The development of reliable, valid measures of psychopathology in people with intellectual disabilities is an important task. However, independent replication studies are rarely reported. AIMS: To report data on the psychometric properties of the Psychiatric Assessment Schedule for Adults with Developmental Disabilities (PAS-ADD) Checklist. METHOD: The PAS-ADD Checklist was completed for 226 adults as part of the assessment process for a specialist mental health service for people with intellectual disabilities. RESULTS: Internal consistency was acceptable. Factor analysis revealed one main factor that was characterised by items related to mood. The Checklist was sensitive to differences between diagnostic groups and had an overall sensitivity of 66%; its specificity was 70%. CONCLUSIONS: The PAS-ADD Checklist is a quick and easy to use screening tool. Although at present it is the best measure available, it should not be the only method used to identify psychiatric disorders in people with intellectual disabilities.

Psychiatric inpatient admissions of adults with intellectual disabilities: predictive factors.

Information on admission to psychiatric inpatient units is lacking from the literature on contemporary services for people with intellectual disability and mental health needs. Here we report on predictors of admission for a cohort of 752 adults from this population living in community settings; 83 were admitted. We also report on two subsamples of this cohort for whom different psychometric measures concerned with psychiatric symptoms and behavior had been completed. Schizophrenia spectrum disorders and mild intellectual disabilities independently predicted admission for the total cohort. The presence of symptoms associated with psychosis and the presence of physical aggression predicted admission in the subsamples.

Descriptive psychopathology in people with mental retardation.

This article considers variables associated with the presence of a psychiatric diagnosis in those referred to a specialist mental health service for people with mental retardation (MR). Data were collected on 752 newly referred clients. The presence of a psychiatric diagnosis was assessed by two psychiatrists based on International Classification of Diseases, 10th Revision, criteria. A series of binary logistic regression analyses were conducted. Older age, mild MR, admission to an inpatient unit, referral from generic mental health services, and detention under current mental health legislation were associated with an increased presence of any psychopathology. Severe MR, the presence of epilepsy, and residence with the family were associated with a lower incidence of any psychopathology. Findings relating to specific psychiatric diagnoses on the whole supported previous research. Clear service arrangements are necessary for people with mild MR who have a high incidence of psychiatric disorders.