A Process Evaluation of a Palliative Care Social Work Intervention for Cancer Patients in Skilled Nursing Facilities.

Background: Assessing and Listening to Individual Goals and Needs (ALIGN) is a palliative care social work intervention that aims to improve delivery of goal-concordant care for hospitalized older adults with cancer discharged to skilled nursing facilities. Objective: Explore processes through which ALIGN may improve delivery of goal-concordant care to substantiate the conceptual model grounding the intervention and to inform mechanistic hypotheses of how the intervention might be effective. Design: A process evaluation triangulating findings from patient and caregiver interviews with a matrix analysis of ALIGN social worker notes. Setting/Participants: Patients (n = 6) and caregivers (n = 13) who participated in a single-arm pilot study of ALIGN in the United States and 113 intervention notes (n = 18 patients) written by 2 ALIGN social workers. Measurement: Qualitative thematic content analysis Results: Themes included the following: (1) ALIGN helped reconcile participants' misaligned expectations of rehabilitation with the reality of the patient's progressive illness; (2) ALIGN helped participants manage uncertainty and stress about forthcoming medical decision making; (3) the longitudinal nature of ALIGN allowed for iterative value-based goals of care discussions during a time when patients were changing their focus of treatment; and (4) ALIGN activated participants to advocate for their needs. Conclusions: ALIGN offers support in prognostic understanding, communication, and decision making during a pivotal time when patient and caregivers' goals have not been met and they are reassessing priorities. A larger trial is needed to understand how these processes may improve the ability of participants to make value-based decisions and aide in delivery of goal-concordant care. Clinical Trial Registration Number: NCT04882111.

Federal Advance Care Planning Policy Primer - Key Aspects, Barriers, and Opportunities.

Advance care planning (ACP) is a nuanced process where patients identify their goals and consider their preferences for medical care over time. Recent systematic reviews have shown mixed findings about the association of ACP with the provision of goal-concordant care, completion of advance directives, and health care utilization. Despite a lack of consistent benefit, patients and clinicians value ACP and policy makers at the state and federal level have been moving ACP policies forward. All fifty states have policies regarding advance directives, and federal policy has had important implications on promoting awareness of ACP and its corresponding legal documents such as advance directives. However, challenges to effectively incentivize and facilitate the delivery of high-quality ACP exist. This paper provides an overview of key federal policy aspects and barriers that affect ACP use including: limitations of Medicare ACP billing codes, disparities in telemedicine access, difficulties with interoperability of advance directives, and underutilization of ACP as a mandatory measure in federal programs. This paper highlights key opportunities to improve federal ACP policy. Because ACP is an essential part of high-quality care and is deeply embedded in state and federal policies, it is imperative that clinicians are knowledgeable about these issues so they may more effectively engage in ACP policy.

Post-Acute Care Outcomes of Cancer Patients <65 Reveal Disparities in Care Near the End of Life.

Background: Post-acute care outcomes for patients with cancer <65 with multiple payers are largely unknown. Objective: Describe the population and outcomes of younger adults discharged to skilled nursing facility (SNF) and those discharged home or with home health care six months following hospitalization. Design: Descriptive cohort analysis. Setting/Subjects: Using a linkage between the Colorado All Payers Claims Database and the Colorado Central Cancer Registry, we studied patients <65 with stage III or IV advanced cancer between 2012 and 2017. Measurements: Receipt of cancer treatment, 30-day readmission, death, and hospice use. Groups of interest were compared by patient demographics and disease characteristics using chi-square tests. Logistic regression was used to describe unadjusted and adjusted outcome rates among discharge setting. Kaplan-Meier method was used to estimate survival by discharge destination. Results: Three percent of patients were discharged to SNF, 79.0% to home, and 18.0% to home health care. SNF discharges were less likely to receive cancer treatment. Among decedents, 39.0%, 51.0%, and 58.0% of SNF, home, and home health care discharges received hospice, respectively. Patients with Medicaid were more likely to be discharged to an SNF. Black/Hispanic patients were more likely to have Medicaid and received less radiation and hospice care, irrespective of discharge location. Those who were discharged to SNF were more likely to receive radiation compared to White patients. Conclusions: Younger patients with cancer discharged to SNF were unlikely to receive cancer treatment and hospice care before death. Racial disparities exist in cancer treatment receipt and hospice use warranting further investigation.

Optimizing Endoscopy Procedure Documentation Improves Guideline-Adherent Care in Upper Gastrointestinal Bleeding.

BACKGROUND AND AIMS: Upper GI bleeding (UGIB) is a common indication for inpatient esophagogastroduodenoscopy (EGD). Guideline adherence improves post-EGD care, including appropriate medication dosing/duration and follow-up procedures that reduce UGIB-related morbidity. We aimed to optimize and standardize post-EGD documentation to improve process and clinical outcomes in UGIB-related care. METHODS: We performed a prospective quality improvement study of inpatient UGIB endoscopies at an academic tertiary referral center during 6/2019-7/2021. Guidelines were used to develop etiology/severity-specific electronic health record note templates. Participants (39 faculty/15 trainees) completed 10-min training in template content/use. We collected pre/post-intervention process data on "Minimal Standard Report" (MSR) documentation including patient disposition, diet, and medications. We also recorded documentation of re-bleed precautions and follow-up procedures. Study outcomes included guideline-based medication prescriptions, ordering of follow-up EGD, and post-discharge re-bleeding. Pre/post-intervention analysis was performed using chi-square tests. RESULTS: From a pre-intervention baseline of 199 patients to 459 patients post-intervention, compliance improved with inpatient PPI (53.4-77.9%, p < 0.001) and discharge PPI (31.3-61.0%, p < 0.001) prescriptions. There was improvement in MSR completion (28.6-42.5%, p < 0.001). Compliance improved with octreotide prescriptions (75.0-93.6%, p = 0.002) and follow-up EGD order (61.3-87.1%, p < 0.001). There was no change in post-discharge re-bleeding. 82.6% of cases used templates. CONCLUSIONS: Our project leveraged endoscopy software to standardize documentation, resulting in improved clinical care behavior and efficiency. Our intervention required low burden of maintenance, and sustainability with high utilization over 9 months. Similar endoscopy templates can be applied to other health systems and procedures to improve care.

Pilot Trial of a Social Work Intervention to Provide Palliative Care for Adults with Cancer in Skilled Nursing Facilities.

Background: Hospitalized patients with cancer and their caregivers discharged to skilled nursing facilities (SNFs) have unmet palliative care needs. Objective: To determine feasibility and acceptability of Assessing and Listening to Individual Goals and Needs (ALIGN), a palliative care social worker (PCSW) intervention, for older adults and their caregivers in SNFs. Design: Single-arm, single-site pilot study. Predefined feasibility goals were >70% intervention completion and study retention rates (postintervention outcomes completed at one week). Setting/Subjects: Twenty-three patients with cancer and their 21 caregivers discharged to 12 SNFs posthospitalization. Measurements: Primary outcomes were feasibility and acceptability. Exploratory patient and caregiver-reported outcomes, including goals of care were collected at baseline and one week postintervention. Health care utilization, mortality, and hospice utilization was collected at the six-month follow-up. Results: Of 73 patients screened, 35 (48%) were eligible and 23 (66%) patients and 21 caregivers enrolled. Eighteen (78%) patients completed the intervention and 10 (44%) patients and 13 (62%) caregivers provided follow-up outcomes. Average age of patients was 73, and 19 (83%) had stage III or IV cancer. Average age of caregivers was 55. Eight (44%) patients' preferences changed to prefer less aggressive care. Nineteen (83%) patients died during or shortly after intervention completion. Qualitative feedback from participant and SNF staff interviews supported high acceptability. PCSW involvement increased illness understanding and patient engagement with advance care planning. SNF staff valued increased palliative support. Conclusions: Intervention completion was >70%, however, not study retention due to higher-than-expected mortality. Future study should account for high mortality and examine whether ALIGN can better prepare surrogate decision makers and enhance the ability of SNFs to address changing goals of care. Clinical Trial Registration Number NCT04882111.

Post-Acute Care Outcomes and Functional Status Changes of Adults with New Cancer Discharged to Skilled Nursing Facilities.

OBJECTIVE: Older hospitalized adults with an existing diagnosis of cancer rarely receive cancer treatment after discharge to a skilled nursing facility (SNF). It is unclear to what degree these outcomes may be driven by cumulative effects of previous cancer treatment and their complications vs an absolute functional threshold from which it is not possible to return. We sought to understand post-acute care outcomes of adults newly diagnosed with cancer and explore functional improvement during their SNF stay. DESIGN: Retrospective cohort study, 2011-2013. SETTING AND PARTICIPANTS: Surveillance, Epidemiology, and End Results - Medicare database of patients with new stage II-IV colorectal, pancreatic, bladder, or lung cancer discharged to SNF. METHODS: Primary outcome was time to death after hospital discharge. Covariates include cancer treatment receipt and hospice use. A Minimum Data Set (MDS)-Activities of Daily Living (ADL) score was calculated to measure changes in ADLs during SNF stay. Patient groups of interest were compared descriptively using means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Logistic regression was used to compare patient groups. RESULTS: A total of 6791 cases were identified. Forty-six percent of patients did not receive treatment or hospice, 25.0% received no treatment but received hospice, 20.8% received treatment but no hospice, and 8.5% received both treatment and hospice. Only 43% of decedents received hospice. Patients who received treatment but not hospice had the best survival. There were limited improvements in MDS-ADL scores in the subset of patients for whom we have complete data. Those with greater functional improvement had improved survival. CONCLUSIONS AND IMPLICATIONS: The majority of patients did not receive future cancer treatment or hospice care prior to death. There was limited improvement in MDS-ADL scores raising concern this population might not benefit from the rehabilitative intent of SNFs.

Impact of a Physician Clinical Support Supervisor in Supporting Patients and Families, Staff, and the Health-Care System During the COVID-19 Pandemic.

As coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-COV2), became a pandemic, hospitals activated Hospital Incident Command Systems (HICS). At our institution, we included a role of Physician Clinical Support Supervisor (PCSS) in the HICS structure. The PCSS role was filled by physicians who served hospital leadership positions, such as Physician Advisor, Medical Staff leadership, Chief Quality Officer, and Chief Medical Informatics Officer. In an effort to summarize the lessons learned by implementation of the PCSS role during the COVID-19 pandemic, we evaluated a PCSS working Microsoft Teams™ spreadsheet and the experience of physicians in the PCSS role. Through efficient daily 2-way communication between frontline providers, HICS, and hospital leadership, the PCSS role facilitated rapid change and improved support for frontline staff, patients and families, and the health-care system. We recommend including the role of PCSS in HICS structure in the event of future pandemics or other crises.

Indications for the Use of Proton Pump Inhibitors for Stress Ulcer Prophylaxis and Peptic Ulcer Bleeding in Hospitalized Patients.

Proton pump inhibitors are widely used throughout the world for the treatment of gastrointestinal disorders that are related to acid secretion, such as peptic ulcer disease and dyspepsia. Another common indication for proton pump inhibitors is stress ulcer prophylaxis. Proton pump inhibitors have proven efficacy for the treatment of acid-related gastrointestinal disorders, but there is concern that their use may be associated with the development of significant complications, such as fractures, Clostridium difficile infection, acute kidney injury, chronic kidney disease, and hypomagnesemia. Proton pump inhibitors are overused in the hospital setting, both for stress ulcer prophylaxis and gastrointestinal bleeding, and then they are often inappropriately continued after discharge from the hospital. This narrative review article outlines the evidence surrounding appropriate proton pump inhibitor use for stress ulcer prophylaxis and peptic ulcer bleeding.

Patterns of treatment in older patients with newly diagnosed advanced bladder cancer: A SEER dataset analysis.

Background: Bladder cancer is one of the top 10 cancers diagnosed in Americans with a median age of 73. This is the patient population that tends to be older with multiple medical conditions, and previously described variability in treatment in the earlier stages of the disease. This study aimed to evaluate the first-line therapeutic choices for older adults newly diagnosed with advanced bladder cancer. In addition, this work evaluated predictors of response as well as the role of events of functional importance in relation to treatment assignment. Methods: A population-based cohort study was conducted using the SEER-Medicare database of patients with advanced stage bladder cancer not eligible for curative intent therapy between 2010 and 2013. Patient groups of interest were compared via univariate and multivariate associations. Additionally, a latent class analysis was applied to identify classes with similar features in reference to events of functional importance-events linked to the maintenance or improvement of physical function status. Results: Within the sample, we noted that a minority of patients received a standard cisplatin-containing regimen (14.77%) and a majority did not receive any chemotherapy (59.69%). Most patients were over age 75. The adjusted odds ratio of no chemo versus cisplatin in patients aged 76 and older compared to patients 66-75 was 6.61 (4.79-9.13; p < 0.0001). We applied latent class analysis methods to the dataset, and three classes demonstrated very low and moderate levels of functional events in the 12 months prior to a person's first outpatient visit for advanced bladder cancer care. Conclusions: Patients with new diagnosis of advanced bladder cancer largely do not receive the recommended first-line systemic therapy of cisplatin chemotherapy, and a significant majority does not receive any treatment. When evaluating the association between class assignment and predictors of chemotherapy use, such as comorbidity and age, patients with "low usage overall" were more likely to receive chemotherapy. Yet even patients who received chemotherapy had some events of functional importance.

The patient-driven payment model: A missed opportunity for patient-centered cancer care.

Hospitalized older patients with advanced cancer who were discharged to a skilled nursing facility (SNF) for rehabilitation are unlikely to receive future cancer treatment, have high 30-day readmission rates, and high mortality yet minimal hospice use. The Medicare SNF benefit was designed to be a bridge and provide short-term nursing and rehabilitation care for patients after a hospitalization. However, advanced cancer patients churn through the health system cycling between the hospital, post-acute care facilities, and home in the last months of life. This article explores the potential impact of the patient-driven payment model, a new SNF reimbursement model introduced by the Center for Medicare and Medicaid Services in 2019, on the experience of older cancer patients. Previously, SNF reimbursement was based on the hours of rehabilitative therapy provided to patients, unintentionally incentivizing SNFs to provide more therapy resulting in long lengths of stay and increased Medicare expenditure. The new patient-driven payment model bases reimbursement on patient clinical characteristics and resources utilized during their SNF stay. We discuss the impact this payment model might have on cancer patients in the SNF setting and highlight the importance of access to palliative care for this population. We discuss challenges policymakers face in creating palliative care guidelines and developing palliative care delivery models in SNFs. We highlight the policy gaps that remain in creating a system that achieves high-quality SNF care and conclude by offering suggestions that might better incorporate a patient's illness trajectory, prognosis, and goals of care.

Reducing Overuse of Proton Pump Inhibitors for Stress Ulcer Prophylaxis and Nonvariceal Gastrointestinal Bleeding in the Hospital: A Narrative Review and Implementation Guide.

Proton pump inhibitors (PPIs) are among the most commonly used medications in the world; however, these drugs carry the risk of patient harm, including acute and chronic kidney disease, Clostridium difficile infection, hypomagnesemia, and fractures. In the hospital setting, PPIs are overused for stress ulcer prophylaxis and gastrointestinal bleeding, and PPI use often continues after discharge. Numerous multifaceted interventions have demonstrated safe and effective reduction of PPI use in the inpatient setting. This narrative review and the resulting implementation guide summarize published interventions to reduce inappropriate PPI use and provide a strategy for quality improvement teams.

Increasing Medical Power of Attorney Completion for Hospitalized Patients During the COVID Pandemic: A Social Work Led Quality Improvement Intervention.

BACKGROUND: The high risk of mechanical ventilation with COVID hospitalizations requires health-care systems to rapidly innovate advance care planning (ACP) delivery for hospitalized patients to promote goal-concordant care. MEASURES: Assess the impact of a social work and care management intervention on the proportion of admitted patients each week with a Medical Durable Power of Attorney (MDPOA). INTERVENTION: Social workers were consulted to assist with identification of a surrogate decision maker and completion of MDPOA forms for hospitalized patients. This intervention utilized change management strategies and was implemented between April and June 2020. OUTCOMES: From a baseline average of 30.1%, the weekly percentage of admitted patients with MDPOA forms rose to 42.8% with correlating evidence of nonrandom special cause variation. LESSONS LEARNED: Use of change management strategies resulted in rapid implementation of an effective ACP initiative. Ongoing needs include focusing on intervention sustainability and education of interprofessional providers about ACP processes.

Outcomes of Patients With Cancer Discharged to a Skilled Nursing Facility After Acute Care Hospitalization.

BACKGROUND: After discharge from an acute care hospitalization, patients with cancer may choose to pursue rehabilitative care in a skilled nursing facility (SNF). The objective of this study was to examine receipt of anticancer therapy, death, readmission, and hospice use among patients with cancer who discharge to an SNF compared with those who are functionally able to discharge to home or home with home healthcare in the 6 months after an acute care hospitalization. METHODS: A population-based cohort study was conducted using the SEER-Medicare database of patients with stage II-IV colorectal, pancreatic, bladder, or lung cancer who had an acute care hospitalization between 2010 and 2013. A total of 58,770 cases were identified and patient groups of interest were compared descriptively using means and standard deviations for continuous variables and frequencies and percentages for categorical variables. Logistic regression was used to compare patient groups, adjusting for covariates. RESULTS: Of patients discharged to an SNF, 21%, 17%, and 2% went on to receive chemotherapy, radiotherapy, and targeted chemotherapy, respectively, compared with 54%, 28%, and 6%, respectively, among patients discharged home. Fifty-six percent of patients discharged to an SNF died within 6 months of their hospitalization compared with 36% discharged home. Thirty-day readmission rates were 29% and 28% for patients discharged to an SNF and home, respectively, and 12% of patients in hospice received <3 days of hospice care before death regardless of their discharge location. CONCLUSIONS: Patients with cancer who discharge to an SNF are significantly less likely to receive subsequent oncologic treatment of any kind and have higher mortality compared with patients who discharge to home after an acute care hospitalization. Further research is needed to understand and address patient goals of care before discharge to an SNF.

Accuracy of the Surprise Question on an Inpatient Oncology Service: A Multidisciplinary Perspective.

The surprise question (SQ), "Would you be surprised if your patient died within a year?", has been studied in the cancer population as a prognostic prompt. Studies have almost exclusively directed the SQ to physicians, whereas perspectives of nurses remain underevaluated. We asked the SQ for patients admitted to an inpatient medical oncology service to medical oncology, palliative care, and hospital medicine teams and bedside nurses. We performed a 1-year retrospective chart review to identify how concordant various provider types were in their prognostic estimations and identified the missed opportunity rate (MOR) defined as the number of patients who died within a particular time frame but who the providers had predicted would be alive and may not have had a palliative approach. Oncologists had higher MORs for the 6-month and 1-year SQ when compared with hospital medicine providers. Bedside nurses were least concordant in their estimations of prognosis and had higher MORs for all time frames of the SQ. Missed opportunities might have significant implications for the end-of-life care for cancer patients, and continued research is needed to understand what influences provider prognostication and how this impacts palliative care utilization for patients with life-limiting disease.

Usefulness of the Surprise Question on an Inpatient Oncology Service.

BACKGROUND: Prognostication of survival in patients with advanced cancer has been challenging and contributes to poor illness understanding. Prognostic disagreement occurs even among providers and is a less studied phenomenon. OBJECTIVE: We introduced the surprise question (SQ), "Would I be surprised if this patient died in the next 1 year, 6 months, and 1 month?," at multidisciplinary rounds to increase palliative care referrals through the introduction of this prognostic prompt. DESIGN, SETTING, PATIENTS: This quality improvement project took place from March 2016 to May 2016 on the medical oncology service at a tertiary academic medical center. The question was asked 3 times a week at multidisciplinary rounds which are attended by the hospital medicine provider, palliative care provider, and consulting oncologist. Primary oncologists and bedside nurses were also asked the SQ. MEASUREMENTS: Referral rates to outpatient palliative care clinic, community-based palliative care clinic, inpatient palliative care consults, and hospice 3 months prior to, during, and 5 months postintervention. RESULTS: Regular discussion of prognosis of patients with cancer in an inpatient medical setting did not increase referrals to inpatient or outpatient palliative care or hospice. Increased clinical experience impacted hospital medicine providers and bedside nurses' estimation of prognosis differently than oncology providers. Medical oncologists were significantly more optimistic than hospital medicine providers.

Characterizing the Nature of Scan Results Discussions: Insights Into Why Patients Misunderstand Their Prognosis.

INTRODUCTION: Patients with incurable cancer have poor prognostic awareness. We present a detailed analysis of the dialogue between oncologists and patients in conversations with prognostic implications. METHODS: A total of 128 audio-recorded encounters from a large multisite trial were obtained, and 64 involved scan results. We used conversation analysis, a qualitative method for studying human interaction, to analyze typical patterns and conversational devices. RESULTS: Four components consistently occurred in sequential order: symptom-talk, scan-talk, treatment-talk, and logistic-talk. Six of the encounters (19%) were identified as good news, 15 (45%) as stable news, and 12 (36%) as bad news. The visit duration varied by the type of news: good, 15 minutes (07:00-29:00); stable, 17 minutes (07:00-41:00); and bad, 20 minutes (07:00-28:00). Conversational devices were common, appearing in half of recordings. Treatment-talk occupied 50% of bad-news encounters, 31% of good-news encounters, and 19% of stable-news encounters. Scan-talk occupied less than 10% of all conversations. There were only four instances of frank prognosis discussion. CONCLUSION: Oncologists and patients are complicit in constructing the typical encounter. Oncologists spend little time discussing scan results and the prognostic implications in favor of treatment-related talk. Conversational devices routinely help transition from scan-talk to detailed discussions about treatment options. We observed an opportunity to create prognosis-talk after scan-talk with a new conversational device, the question "Would you like to talk about what this means?" as the oncologist seeks permission to disclose prognostic information while ceding control to the patient.

A case series of real-time hemodynamic assessment of high output heart failure as a complication of arteriovenous access in dialysis patients.

Congestive heart failure (CHF) is an important source of morbidity and mortality in end-stage renal disease patients. Although CHF is commonly associated with low cardiac output (CO), it may also occur in high CO states. Multiple conditions are associated with increased CO including congenital or acquired arteriovenous fistulae or arteriovenous grafts. Increased CO resulting from permanent AV access in dialysis patients has been shown to induce structural and functional cardiac changes, including the development of eccentric left ventricle hypertrophy. Often, the diagnosis of high output heart failure requires invasive right heart monitoring in the acute care setting such as a medical or cardiac intensive care unit. The diagnosis of an arteriovenous access causing high output heart failure is usually confirmed after the access is ligated surgically. We present for the first time, a case for real-time hemodynamic assessment of high output heart failure due to AV access by interventional nephrology in the cardiac catheterization suite.

Comparing patient outcomes between multiple ipsilateral iliac artery stents and isolated iliac artery stents.

OBJECTIVE: Endovascular stents are accepted therapy for iliac artery stenoses and occlusions. Surgery is the recommended therapy for patients with severe iliac artery disease, including those with the combination of ipsilateral common iliac artery (CIA) and external iliac artery (EIA) stenoses/occlusions. This study compared patient outcomes, including late open conversion rates, for combined ipsilateral CIA and EIA stenting vs CIA or EIA stents alone. METHODS: Between 1998 and 2010, 588 patients underwent iliac artery stenting at two institutions. Patient comorbidities and outcomes were retrospectively reviewed, and analyses were performed using multivariate regression and Kaplan-Meier methods. RESULTS: There were 436 extremities with CIA stents, 195 with EIA stents, and 157 with CIA and EIA stents. The groups did not differ significantly in demographics, comorbidities, or treatment indications. During follow-up, 183 patients died, 95 underwent an endovascular reintervention, and 48 required late open conversion. For patients in the CIA or EIA stent group, the mean ± standard error survival was 5.3 ± 0.3 years, secondary endovascular intervention-free survival was 7.4 ± 0.6 years, late open conversion-free survival was 9.8 ± 0.4 years, and amputation-free survival was 7.6 ± 0.4 years. In the CIA and EIA stent group, survival was 6.1 ± 0.6 years, secondary endovascular intervention-free survival was 7.2 ± 0.6 years, late open conversion-free survival was 9.0 ± 1.1 years, and amputation-free survival was 8.4 ± 0.5 years. Survival, reintervention-free survival, late open conversion-free survival, and amputation-free survival were all similar between patient groups (all P > .05). CIA and EIA stenting in combination was not a predictor of death, reintervention, late open conversion, or amputation. CONCLUSIONS: Outcomes are similar for patients with CIA or EIA stents and for those with combined ipsilateral CIA and EIA stents. Late open conversions for iliac artery stent failure are uncommon and not influenced by the location or extent of prior iliac artery stent placement. Endovascular therapy for aortoiliac disease should be extended to consider selected patients with ipsilateral CIA and EIA stenoses/occlusions.