The 2018 ISHLT/APM/AST/ICCAC/STSW Recommendations for the Psychosocial Evaluation of Adult Cardiothoracic Transplant Candidates and Candidates for Long-term Mechanical Circulatory Support.

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support.

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.

Consideration of psychosocial factors in the evaluation of living donors.

Results of donor outcome studies indicate that most living donors report a positive psychosocial response to donation. However, negative psychosocial outcomes have also been reported. Evaluation guidelines have been proposed, although a standardized evaluation specific to living donors is not yet available. In an effort to determine what psychosocial factors should be considered in a comprehensive evaluation of living donors, an extensive literature review was undertaken that was focused on previously proposed guidelines for the psychosocial evaluation of living donors, research on outcomes among living donors, and other relevant psychosocial data.

Spirituality and job satisfaction among hospice interdisciplinary team members.

As a continuing effort to enhance the quality of palliative care for the dying, this study examined (1) the prevalence of spirituality among hospice interdisciplinary team (IDT) members; (2) whether spirituality is related to job satisfaction; and (3) the structural path relationships among four variables: spiritual belief, integration of spirituality at work, self actualization and job satisfaction. The study surveyed 215 hospice IDT members who completed the Jarel Spiritual Well-Being Scale, the Chamiec-Case Spirituality Integration and Job Satisfaction Scales. Multiple regression and structural path modeling methods were applied to explain the path relationships involving all four variables. The IDT members surveyed were: nurses, 46.4%; home health aids, 24.9%; social workers, 17.4%; chaplains, 4.2%; physicians, 2.3%; and other, 4.8%. Ninety-eight percent of the respondents viewed themselves as having spiritual well-being. On a 0-100 scale, IDT staff reported high spiritual belief (mean = 89.4) and they were self-actualizing (mean = 82.6). Most reported high job satisfaction (mean = 79.3) and spiritual integration (mean = 67.9). In multiple regression, spirituality, integration and self-actualization explained 22% of the variation in job satisfaction (R = 0.48; adjusted R(2) = 0.218; df = 3,175; F = 17.2; p = 0.001). Structural path models revealed that job satisfaction is more likely to be realized by a model that transforms one's spirituality into processes of integrating spirituality at work and self actualization (chi(2) = 0.614; df = 1; p = 0.433) than a model that establishes a direct path from spirituality to job satisfaction (chi(2) = 1.65; df = 1; p = 0.199). Hospice IDT member's integration of their spirituality at work and greater self actualization significantly improve job satisfaction.

Ruling out the need for antibiotics: are we sending the right message?

OBJECTIVES: To examine the relationships among physician-parent communication practices, physicians' perceptions of parental expectations for antibiotic treatment, and inappropriate antibiotic prescribing for viral upper respiratory tract infections. DESIGN: Cross-sectional study of pediatric encounters motivated by cold symptoms between October 1, 2000, and June 30, 2001. Each encounter was videotaped. Physicians completed a postvisit survey that measured whether they perceived the parent as expecting antibiotics. Coded communication variables were merged with survey variables. Multivariate analyses identified key predictors of parent-physician communication practices, physician perceptions of parents' expectations for antibiotics, and inappropriate antibiotic prescribing for viral conditions. SETTING: Twenty-seven pediatric practices in Los Angeles, Calif. PARTICIPANTS: Thirty-eight pediatricians and 522 consecutively approached parents of children with cold symptoms. MAIN OUTCOME MEASURES: Physicians' perceptions of parental expectations for antibiotics, inappropriate antibiotic prescribing, and parental questioning of nonantibiotic treatments. RESULTS: Physicians were 20.2% more likely to perceive parents as expecting antibiotics when they questioned the physician's treatment plan (P = .004; 95% confidence interval, 6.3%-34.0%). When physicians perceived parents as expecting antibiotics, they were 31.7% more likely to inappropriately prescribe them (P<.001; 95% confidence interval, 16.0%-47.3%). Parents were 24.0% more likely to question the treatment plan when the physician ruled out the need for antibiotics (P = .004; 95% confidence interval, 7.7%-40.3%). CONCLUSIONS: Parental questioning of the treatment plan increases physicians' perceptions that antibiotics are expected and thus increases inappropriate antibiotic prescribing. Treatment plans that focus on what can be done to make a child feel better, rather than on what is not needed, ie, antibiotics, may decrease inappropriate antibiotic prescribing.

Measuring the quality of antibiotic prescribing for upper respiratory infections and bronchitis in 5 US health plans.

OBJECTIVE: To develop and test the validity of a quality-of-care performance measure that examines antibiotic prescribing rates in children diagnosed as having upper respiratory infection (URI) or bronchitis. DESIGN AND METHODS: The measure developed examines the annual rate of antibiotic prescribing to children aged 3 months to 18 years with an episode of URI or bronchitis. Administrative data from 5 US health plans were used to identify episodes of URI or bronchitis using International Classification of Diseases, Ninth Revision, codes 460, 465, 466, and 490. Pharmacy data (National Drug Codes) were used to determine whether antibiotics were prescribed for the URI or bronchitis episode. Medical record abstractions were performed on a random sample of 465 cases to assess percentage agreement with pharmacy claims data for antibiotic prescribing. RESULTS: For the 84,166 children and adolescents aged 3 months to 18 years who had at least 1 episode of URI or bronchitis during the measurement year, 31% received antibiotics. Prescribing rates for URI and/or bronchitis varied widely among the 5 participating health plans (2%-75%; P < .001). Inappropriate antibiotic prescribing occurred most frequently for bronchitis episodes, with 4 of 5 health plans prescribing antibiotics in 60% of such cases (range, 60%-80%). Percentage agreement between administrative and medical records data for antibiotic prescribing was 88%. CONCLUSIONS: This quality measure is feasible to implement at the health plan level and validly assesses antibiotic prescribing rates using administrative data. Improvements in adhering to judicious use guidelines for antibiotic prescribing in children with URI and bronchitis are warranted.

Measuring the quality of care for group A streptococcal pharyngitis in 5 US health plans.

BACKGROUND: There is a high degree of professional consensus that children diagnosed with pharyngitis should only receive antibiotics if they have a positive test for group A streptococcus (GAS). OBJECTIVES: To develop and test the validity of a quality of care performance measure that examines GAS testing rates in children diagnosed with pharyngitis and prescribed an antibiotic. DESIGN: The measure developed examines the annual rate of GAS testing in children aged 2 to 18 years with an episode of pharyngitis who were prescribed antibiotics. The measure was tested for feasibility of implementation and validity in 5 health plans in the United States. Health plan administrative data were used to identify episodes of pharyngitis using International Classification of Diseases, Ninth Revision (ICD-9) codes 462, 463, and 034.0. Pharmacy data (National Drug Codes) were used to determine if antibiotics were prescribed for the pharyngitis episode. Laboratory claims data (Current Procedural Terminology codes) were used to determine whether a GAS test was performed. Rates of GAS testing in children with pharyngitis who received antibiotics were calculated for each health plan. Medical record abstractions were performed on a random sample (n = 465) of cases to assess percent agreement with laboratory claims data for GAS testing. Sensitivity of the administrative data for accurately identifying when GAS tests were performed was also assessed. RESULTS: Of the 120 158 children aged 2 to 18 years who had at least 1 episode of pharyngitis during the measurement year, 51 172 (43%) received antibiotics. Group A streptococcal testing rates for patients who were prescribed antibiotics varied widely among the participating health plans (59%-83% of cases; P<.05). Percent agreement between administrative and medical records data for GAS tests was 86%. The sensitivity of the administrative data for accurately identifying when GAS tests were performed was 85%. CONCLUSIONS: This quality measure is feasible to implement at the health plan level and validly assesses GAS testing rates using administrative data. The participating health plans are not performing GAS tests as indicated by current expert practice guidelines in a substantial proportion of cases. Improvements in adhering to these guidelines are warranted given the current levels of antibiotic overuse and antibiotic resistance nationally.

Racial/ethnic variation in parent expectations for antibiotics: implications for public health campaigns.

CONTEXT: Widespread overuse and inappropriate use of antibiotics are a major public health concern. Little is known about racial/ethnic differences in parents seeking antibiotics for their children's upper respiratory illnesses. OBJECTIVE: To examine racial/ethnic differences in parent expectations about the need for antibiotics and physician perceptions of those expectations. DESIGN: We conducted a nested, cross-sectional survey of parents who were coming to see their child's pediatrician because of cold symptoms between October 2000 and June 2001. Parents completed a previsit survey that collected information on demographics, their child's illness, and a 15-item previsit expectations inventory that included an item asking how necessary it was for the physician to prescribe antibiotics. Physicians completed a postvisit survey that collected information on diagnosis, treatment, and whether the physician perceived the parent expected an antibiotic. The encounter was the unit of analysis. Multivariate logistic regression analyses were performed to evaluate predictors of dichotomized parental expectations for antibiotics, dichotomized physician perceptions of those expectations, diagnostic patterns, and antibiotic-prescribing patterns. SETTING: Twenty-seven community pediatric practices in the Los Angeles, Calif, metropolitan area. PARTICIPANTS: A volunteer sample of 38 pediatricians (participation rate: 64%) and a consecutive sample of 543 parents (participation rate: 83%; approximately 15 participating for each enrolled pediatrician) seeking care for their children's respiratory illnesses. Pediatricians were eligible to participate if they worked in a community-based managed care practice in the Los Angeles area. Parents were eligible to participate if they could speak and read English and presented to participating pediatricians with a child 6 months to 10 years old who had cold symptoms but had not received antibiotics within 2 weeks. MAIN OUTCOME MEASURES: Parental beliefs about the necessity of antibiotics for their child's illness, physician perceptions of parental expectations for antibiotics, bacterial diagnosis rates, and antibiotic-prescribing rates. RESULTS: Forty-three percent of parents believed that antibiotics were definitely necessary, and 27% believed that they were probably necessary for their child's illness. Latino and Asian parents were both 17% more likely to report that antibiotics were either definitely or probably necessary than non-Hispanic white parents. Physicians correctly perceived that Asian parents expected antibiotics more often than non-Hispanic white parents but underestimated the greater expectations of Latino parents for antibiotics. Physicians also correctly perceived that parents of children with ear pain or who were very worried about their child's condition were significantly more likely to expect antibiotics. Physicians were 7% more likely to make a bacterial diagnosis and 21% more likely to prescribe antibiotics when they perceived that antibiotics were expected. CONCLUSIONS: Parent expectations for antibiotics remain high in Los Angeles County. With time, traditional public health messages related to antibiotic use may decrease expectations among non-Hispanic white parents. However, both public health campaigns and physician educational efforts may need to be designed differently to reach other racial/ethnic groups effectively. Despite public health campaigns to reduce antibiotic overprescribing in the pediatric outpatient setting, physicians continue to respond to parental pressure to prescribe them. To effectively intervene to decrease rates of inappropriate antibiotic prescribing further, physicians need culturally appropriate tools to better communicate and negotiate with parents when feeling pressured to prescribe antibiotics.

Why do physicians think parents expect antibiotics? What parents report vs what physicians believe.

OBJECTIVE: To examine the relation between parent expectations for antibiotics, parent communication behaviors, and physicians' perceptions of parent expectations for antibiotics. STUDY DESIGN: A nested cross-sectional study with parallel measures of parents presenting children for acute respiratory infections (previsit) and physicians (postvisit) and audiotaping of the encounters. POPULATION: Ten physicians in 2 private pediatric practices (1 community-based and 1 university-based) and a consecutive sample of 306 eligible parents (response rate, 86%) who were attending sick visits for their children between October 1996 and March 1997. OUTCOMES MEASURED: Communication behaviors used by parents expecting antibiotics and physicians' perceptions of parents' expectations. RESULTS: Parents' use of "candidate diagnoses" during problem presentation increased the likelihood that physicians would perceive parents as expecting antibiotics (from 29% to 47%; P=.04), as did parents' use of "resistance to the diagnosis" (an increase from 7% to 20%). In the multivariate model, parents' use of candidate diagnoses increased the odds that a doctor would perceive a parental expectation for antibiotics by more than 5 times (odds ratio, 5.23; 95% confidence interval, 3.74-7.31; Plt.001), and parents' use of resistance to a viral diagnosis increased these odds by nearly 3 times (odds ratio, 2.73; 95% confidence interval, 1.97-3.79; Plt.001). CONCLUSIONS: Parents perceived as expecting antibiotics may be seeking reassurance that their child is not seriously ill or that they were correct to obtain medical care. Physicians were significantly more likely to perceive parents as expecting antibiotics if they used certain communication behaviors. This study revealed an incongruity between parents' reported expectations, their communication behaviors, and physicians' perceptions of parents' expectations.

Online commentary during the physical examination: a communication tool for avoiding inappropriate antibiotic prescribing?

A previously identified communication behavior, online commentary, is physician talk that describes what he/she is seeing, feeling, or hearing during the physical examination of the patient. The investigators who identified this communication behavior hypothesized that its use may be associated with successful physician resistance to perceived or actual patient expectations for inappropriate antibiotic medication. This paper examines the relationship between actual and perceived parental expectations for antibiotics and physician use of online commentary as well as the relationship between online commentary use and the physician's prescribing decision. We conducted a prospective observational study in two private pediatric practices. Study procedures included a pre-visit parent survey, audiotaping of study consultations, and post-visit surveys of the participating physicians. Ten pediatricians participated (participation rate=77%) and 306 eligible parents participated (participation rate=86%) who were attending sick visits for their children with upper respiratory tract infections between October 1996 and March 1997. The main outcomes measured were the proportion of consultations with online commentary and the proportion of consultations where antibiotics were prescribed. Two primary types of online commentaries were observed: (1) online commentary suggestive of a problematic finding on physical examination that might require antibiotic treatment ('problem' online commentary), e.g., "That cough sounds very chesty"; and (2) online commentary that indicated the physical examination findings were not problematic and antibiotics were probably not necessary ('no problem' online commentary), e.g., "Her throat is only slightly red". For presumed viral cases where the physician thought the parent expected to receive antibiotics, if the physician used at least some 'problem' online commentary, he/she prescribed antibiotics in 91% (10/11) of cases. Conversely, when the physician exclusively employed 'no problem' online commentary, antibiotics were prescribed 27% (4/15) of the time (p = 0.07). Use of 'no problem' online commentary did not add significantly to visit length. 'No problem' online commentary is a communication technique that may provide an effective and efficient method for resisting perceived expectations to prescribe antibiotics.

An observational study of antibiotic prescribing behavior and the Hawthorne effect.

OBJECTIVES: To assess whether prospective, observational study procedures, including questionnaires and audio recording, are associated with different patterns of physician diagnostic decision making and antibiotic prescribing. DATA SOURCES/SETTING: (1) Survey data from a prospective observational study of treatment patterns for children with acute upper respiratory illnesses (10/96-3/97) and (2) retrospective medical record abstraction data of nonobserved encounters for the same problems occurring during (10/96-3/97) and one year after (10/97-3/98) the observational study period. Ten pediatricians in two community practices were studied. STUDY DESIGN: Patterns of diagnoses recorded in the medical record and antibiotics ordered for visits occurring outside of the observational study (same time period and one year later) were compared with the pattern of diagnoses and antibiotics ordered during the observational study. DATA COLLECTION/EXTRACTION METHODS: For the observational study (10/96-2/97), diagnosis and treatment choices were obtained from questionnaires completed by physicians immediately following the visit. For the nonstudy encounters (10/96-3/97 and 10/97-3/98), data were abstracted from medical records one year after the observational study was completed. PRINCIPAL FINDINGS: The proportion of viral cases in which an antibiotic was prescribed was 29 percentage points lower for the observational study compared to the retrospective analysis (p < .05). In one of two study sites, the proportion of cases assigned a bacterial diagnosis was 29 percentage points lower in the observational study period compared to the retrospective study (p <.05). CONCLUSIONS: Observational study procedures including questionnaires and audio recording can affect antibiotic prescribing behavior. Future observational studies aimed at examining the frequency of inappropriate antibiotic prescribing should measure and adjust for the Hawthorne effect; without such adjustments, the results will likely underestimate the true degree of the problem. Future interventions aimed at decreasing inappropriate antibiotic prescribing should consider "harnessing" the Hawthorne effect through performance feedback to participating physicians.