Physician Estimates Research Articles

Clinical Utility of the 12-Gene DCIS Score Assay: Impact on Radiotherapy Recommendations for Patients with Ductal Carcinoma In Situ

ObjectiveThe aim of this study was to determine the impact of the results of the 12-gene DCIS Score assay on (i) radiotherapy recommendations for patients with pure ductal carcinoma in situ (DCIS) following breast-conserving surgery (BCS), and (ii) patient decisional conflict and state anxiety.MethodsThirteen sites across the US enrolled patients (March 2014–August 2015) with pure DCIS undergoing BCS. Prospectively collected data included clinicopathologic factors, physician estimates of local recurrence risk, DCIS Score results, and pre-/post-assay radiotherapy recommendations for each patient made by a surgeon and a radiation oncologist. Patients completed pre-/post-assay decisional conflict scale and state-trait anxiety inventory instruments.ResultsThe analysis cohort included 127 patients: median age 60 years, 80 % postmenopausal, median size 8 mm (39 % ≤5 mm), 70 % grade 1/2, 88 % estrogen receptor-positive, 75 % progesterone receptor-positive, 54 % with comedo necrosis, and 18 % multifocal. Sixty-six percent of patients had low DCIS Score results, 20 % had intermediate DCIS Score results, and 14 % had high DCIS Score results; the median result was 21 (range 0–84). Pre-assay, surgeons and radiation oncologists recommended radiotherapy for 70.9 and 72.4 % of patients, respectively. Post-assay, 26.4 % of overall recommendations changed, including 30.7 and 22.0 % of recommendations by surgeons and radiation oncologists, respectively. Among patients with confirmed completed questionnaires (n = 32), decision conflict (p = 0.004) and state anxiety (p = 0.042) decreased significantly from pre- to post-assay.ConclusionsIndividualized risk estimates from the DCIS Score assay provide valuable information to physicians and patients. Post-assay, in response to DCIS Score results, surgeons changed treatment recommendations more often than radiation oncologists. Further investigation is needed to better understand how such treatment changes may affect clinical outcomes.

Development and Validation of a Mortality Prediction Model for Patients Receiving 14 Days of Mechanical Ventilation

For an increasing number of patients, critical illness or injury is neither self-limited nor imminently fatal1. As survival from life-threatening illness improves, pre-existing disease and newly-acquired organ dysfunction may conspire against recovery, leaving patients dependent on life supporting therapies for extended time periods. This syndrome, termed “chronic critical illness”, is commonly typified by persistent respiratory failure that requires prolonged mechanical ventilation (PMV). Long-term mortality is high, approaching rates of 40% to 60% at one-year in inclusive cohorts2–10. Patients have a very high symptom burden during the weeks of prolonged ventilation11,12 and chances of living at home with functional independence at the end of the year are as low as 10%9,13. Most PMV patients are unable to participate in their own clinical decision making and must therefore rely on surrogates to guide their goals of care. These surrogate decision makers report that physicians rarely discuss prognosis, and studies have shown that physician and family estimates of one year outcome are highly discordant14,15. Traditional approaches to ICU mortality prediction, such as APACHE, are ill-suited to predicting longer term outcomes, particularly in this population16. Our research group developed and validated the ProVent mortality prediction model which estimates one-year mortality for patients receiving at least 21 days of mechanical ventilation to address prognostic uncertainty for these unique patients2,3,17. However, many important decisions regarding the care of PMV patients occur before 21 days have elapsed, including electing to perform tracheotomy18 or transfer care to a long-term acute care hospital (LTACH), both of which in are in some form decisions to continue life sustaining therapies19,20. If compelling prognostic data were available sooner for the patient whose goals of care are known, these decisions might be made more easily and earlier in the course of illness21–23. Building on our previous work, we hypothesized that a simple mortality prediction model constructed from factors clinically available by day 14 in the course of mechanical ventilation could discriminate between PMV patients at high and low risk of death at one year. Using a heterogeneous multicenter cohort of PMV patients in addition to a contemporaneous cohort of patients with acute lung injury (ALI) who were enrolled in a randomized, controlled trial, we sought to develop and validate a new model using data collected on day 14 of mechanical ventilation rather than on day 21 as in our previous model.

Indirect Calorimetry: Is it Required to Maximize Patient Outcome from Nutrition Therapy?

Nutrition support regimens which fail to meet caloric requirements may adversely affect morbidity. This study evaluated the importance of accuracy of nutritional regimens and whether indirect calorimetry (IC) is required to optimize patient response. Patients admitted to a long-term acute care hospital, on mechanical ventilation, made nil per os NPO and placed on enteral nutrition (EN), were enrolled. At baseline and weekly for 3 weeks, two experienced critical care physicians estimated caloric needs, followed by IC. Patients were randomized to receive EN determined by physician estimates or by IC. Accuracy of physician estimates and adequacy of nutrition therapy were the primary study endpoints. Results showed that while estimates of caloric requirements appeared to be accurate, averaging 109.3 ± 26 % of actual requirements measured by IC for all subjects (n = 27), there was wide variation above and below the mean. Only 32 % of estimated values were within 10 % of measured requirements. Delivery of nutrition in both groups was suboptimal, with all patients receiving only 82.0 ± 15.4 % of goal requirements. There were no differences between groups regarding outcome (duration mechanical ventilation, healing of pressure sores). Physiologic consequences to hypocaloric feeding were seen nonetheless, with adequacy of feeding correlating significantly (p < 0.05) to mean respiratory quotient (RQ), albumin, and prealbumin. Increasing BMI was shown to correlate significantly with a reduction in accuracy of physician estimates (p < 0.001). BMI was found to be inversely correlated with prealbumin level and RQ. While caloric requirements of critically ill patients can be estimated by predictive equations, estimates decrease in accuracy as BMI increases. In this experience, use of IC failed to improve clinical outcomes. Delivery of the prescribed EN regimen continues to be a limiting factor.

Differences between patient and physician opinions on adherence to medication for hypertension and diabetes mellitus

Background: Non-adherence to prescribed medication presents a barrier to effective treatment. In order to find improved ways of tackling non-adherence, it is important to understand the perspective of both patients and physicians.Method: A web-based survey study was performed to obtain the views and opinions of patients receiving medical treatment for hypertension or diabetes mellitus in Japan, and physicians treating such patients, on adherence to medication.Results: Forty-four percent of both physicians and patients placed great importance on medication adherence, but 11% of patients considered it of low importance. Overall, 85% of patients reported taking their medication correctly. Patients missed a mean of 4.8 or 5.4 daily doses per 30 day prescription based on patient and physician estimates, respectively. Both patients (64%) and physicians (23%) considered the main reason patients forgot to take their medication was that they “inadvertently forgot”. Only 1% of physicians said they do not specifically check for residual drugs, but 46% of patients said they do not report missed doses to their doctor. Measures taken by physicians to reduce residual drugs included use of single packs (64%) and reductions in administration frequency (55%); 63% adjusted prescriptions to take account of any remaining drugs. Only 4% of physicians were satisfied with the effectiveness of measures to reduce non-adherence, whereas 59% of patients felt they managed to successfully perform measures to avoid forgetting to take drugs.Limitation: The study questionnaires were newly developed and did not incorporate validated instruments to assess adherence.Conclusion: Similar proportions of physicians and patients consider medication adherence to be important, but their opinions about measures used to improve adherence differ to some extent. Importantly, almost half of patients do not tell their doctor about missed doses.

Prevalence of and Factors Related to Discordance About Prognosis Between Physicians and Surrogate Decision Makers of Critically Ill Patients.

Misperceptions about prognosis by individuals making decisions for incapacitated critically ill patients (surrogates) are common and often attributed to poor comprehension of medical information. To determine the prevalence of and factors related to physician-surrogate discordance about prognosis in intensive care units (ICUs). Mixed-methods study comprising quantitative surveys and qualitative interviews conducted in 4 ICUs at a major US medical center involving surrogate decision makers and physicians caring for patients at high risk of death from January 4, 2005, to July 10, 2009. Discordance about prognosis, defined as a difference between a physician's and a surrogate's prognostic estimates of at least 20%; misunderstandings by surrogates (defined as any difference between a physician's prognostic estimate and a surrogate's best guess of that estimate); differences in belief (any difference between a surrogate's actual estimate and their best guess of the physician's estimate). Two hundred twenty-nine surrogate decision makers (median age, 47 [interquartile range {IQR}, 35-56] years; 68% women) and 99 physicians were involved in the care of 174 critically ill patients (median age, 60 [IQR, 47-74] years; 44% women). Physician-surrogate discordance about prognosis occurred in 122 of 229 instances (53%; 95% CI, 46.8%-59.7%). In 65 instances (28%), discordance was related to both misunderstandings by surrogates and differences in belief about the patient's prognosis; 38 (17%) were related to misunderstandings by surrogates only; 7 (3%) were related to differences in belief only; and data were missing for 12. Seventy-five patients (43%) died. Surrogates' prognostic estimates were much more accurate than chance alone, but physicians' prognostic estimates were statistically significantly more accurate than surrogates' (C statistic, 0.83 vs 0.74; absolute difference, 0.094; 95% CI, 0.024-0.163; P = .008). Among 71 surrogates interviewed who had beliefs about the prognosis that were more optimistic than that of the physician, the most common reasons for optimism were a need to maintain hope to benefit the patient (n = 34), a belief that the patient had unique strengths unknown to the physician (n = 24), and religious belief (n = 19). Among critically ill patients, discordant expectations about prognosis were common between patients' physicians and surrogate decision makers and were related to misunderstandings by surrogates about physicians' assessments of patients' prognoses and differences in beliefs about patients' prognoses.

Understanding consumer preferences for care of adolescents with pelvic inflammatory disease.

The objective of this study is to estimate consumers' maximum willingness-to-pay (WTP) for follow-up PID services by physicians and community health nurses (CHNs), differences by consumer type (adolescents versus parents), and the differences in health-provider predicted WTP consumer estimates and actual consumer WTP estimates. In this IRB-approved study, a contingent valuation method was used to collect WTP data regarding co-payments to physicians or nurses for clinical service delivery from the consumers of adolescent PID services (parents and adolescents) and health providers using a national convenience sample. Consumers were recruited from an academic pediatric and adolescent medicine clinic and five health department school-based health clinics in a large urban community with high (sexually transmitted infection) STI prevalence. Participants completed a web-based survey. Data were analyzed using linear regression analyses. Adolescents were willing to pay $36 more (95 % Cl : $27.9-44.3) for community health nursing care and parents were willing to pay $48 more dollars (95 % Cl : $40.3-$57.4) than physician's predicted. There were no significant differences in adolescent and parents WTP for physician or nursing services Consumers (adolescents & parents) WTP for physician PID services were on average $18.50 higher than CHN PID services (p = 0.01). Using physician estimates for WTP as the reference group, adolescents were willing to pay $56 more (95 % Cl : $48.6-$63.4) for physician care and parents were willing to pay $66 more (95 % Cl : $59.0-$72.8) than physician's predicted. Adolescents and parents are willing to pay more for physician follow-up for PID, but they are open to CHN follow-up visits based on the mean WTP for CHN visits. Since WTP also reflects the value that individuals place on a service, our data demonstrate that providers consistently underestimate the value consumers place on clinical services for x adolescents with PID.

Economic Burden of Hypoglycemia in Patients with Type 2 Diabetes Mellitus from Korea.

BackgroundHypoglycemia is a very serious complication in patients with type 2 diabetes mellitus (T2DM) and affects the economic burden of treatment. This study aims to create models of the cost of treating hypoglycemia in patients with T2DM based upon physician estimates of medical resource usage.MethodsUsing a literature review and personal advice from endocrinologists and emergency physicians, we developed several models for managing patients with hypoglycemia. The final model was approved by the consulting experts. We also developed 3 unique surveys to allow endocrinologists, emergency room (ER) physicians, and primary care physicians to evaluate the resource usage of patients with hypoglycemia. Medical costs were calculated by multiplying the estimated medical resource usage by the corresponding health insurance medical care costs reported in 2014.ResultsIn total, 40 endocrinologists, 20 ER physicians, and 30 primary care physicians completed the survey. We identified 12 types of standard medical models for secondary or tertiary hospitals and 4 for primary care clinics based on the use of ER, general ward, or intensive care unit (ICU) and patients’ status of consciousness and self-respiration. Estimated medical costs per person per hypoglycemic event ranged from $17.28 to $1,857.09 for secondary and tertiary hospitals. These costs were higher for patients who were unconscious and for those requiring ICU admission.ConclusionHypoglycemia has a substantial impact on the medical costs and its prevention will result in economic benefits for T2DM patients and society.

Abstract P5-17-03: The 12-gene DCIS score assay: Impact on radiation treatment (XRT) recommendations and clinical utility

Abstract Background: In the management of DCIS clinicians and patients (pts) must choose between the various options for breast conservation treatment based on an assessment of local recurrence (LR) risk. Traditional clinicopathologic (CP) factors such as age, size, grade, margin width or comedo necrosis, provide an average LR risk derived from clinical trials and population studies. The Oncotype DX® 12-gene assay for DCIS gives individual 10-yr LR risk estimates and has now been validated in two studies in a total of 893 pts. We report the 2nd study assessing the impact of the DCIS Score result on XRT recommendations. In addition, surveys assessing pt and physician confidence will provide insight into the overall clinical utility of the DCIS Score result. Baseline characteristics including the pre-assay LR risk and XRT recommendation are described here; final results on change in XRT recommendation from pre- to post-assay and distribution of the score across the CP factors will be presented. Methods: 13 U.S. sites enrolled pts with DCIS from 3/2014-5/2015. Pts with LCIS but no DCIS, invasive BC, or planned mastectomy were excluded. Data were prospectively collected on CP factors, physician estimates of LR risk, DCIS score, and pre/post XRT recommendation. Each pt had a surgeon and radiation oncologist complete study surveys. Pt surveys were also administered pre/post assay for decision conflict and the STAIT anxiety survey. The LR risk estimates and XRT recommendations were analyzed for all physicians as well as by specialty. Descriptive statistics summarized study variables. 95% Clopper-Pearson Exact CIs were calculated for percent change in XRT recommendation. McNemar's test was used to determine if the proportion of pts had a significant change in XRT recommendation post assay. Paired t-tests were used to compare physician estimates of recurrence risk pre/post assay. Results: Of the 121 pts enrolled, median age was 61y (34-83) and 80.2% were postmenopausal. Median size was 8mm and 40% were &amp;lt; 5mm; 22.3% were grade 1, 51.2% grade 2, and 26.4% grade 3. Comedo necrosis was noted in 55.4% and 19% had multiple foci. Median margin width was 3mm and 47.1% had margins 1-3mm. ER and PR by IHC were positive in 88.4% and 75.2% of pts. Among the 242 MD risk assessments, mean 10-yr LR risk was 14.8% (range 4-50%) for any LR; 14.2% for surgeons and 15.3% for radiation oncologists. The pre-assay XRT recommendation was 70.2%; 68.6% for surgeons and 71.9% for radiation oncologists. Conclusions: The role of new molecular tools such as the DCIS Score assay that provide individual risk estimates for LR on treatment decisions is evolving. The DCIS pts enrolled in the study reveal inclusion of baseline features like higher nuclear grade (26%), comedo necrosis (55%) and margin width of 1-3mm (47%) that have historically been associated with XRT use. This represents a continued broadening of the assay use from the predominantly lower risk DCIS cohort in the 1st validation study (E5194). The impact on XRT decisions is critical to establishing the clinical utility of the assay. The decision impact analysis, differences in use of the assay among surgeons and radiation oncologists and the impact on overall confidence with the treatment decision will be presented. Citation Format: Manders JB, Kuerer HM, Smith BD, McCluskey C, Farrar WB, Frazier TG, Li L, Leonard CE, Carter DL, Chawla S, Medeiros LE, Guenther JM, Castellini LE, Buchholz DJ, Mamounas EP, Wapnir IL, Horst KC, Chagpar A, Evans SB, Riker AI, Vali FS, Solin LJ, Jablon L, Recht A, Sharma R, Lu R, Sing AP, Hwang ES, White J. The 12-gene DCIS score assay: Impact on radiation treatment (XRT) recommendations and clinical utility. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-17-03.

Accuracy of physician prognosis in heart failure and lung cancer: Comparison between physician estimates and model predicted survival

Background: Anticipating adverse outcomes guides decisions but can be particularly challenging in heart failure. Aim: We sought to assess the accuracy and comfort of physicians in predicting prognosis in heart failure. Design: Cross-sectional survey Participants/setting: Faculty and trainees in internal medicine, cardiology, and oncology estimated survival for three standardized patients: (1) 59-year-old patient with stage IV lung cancer; (2) 79-year-old woman with New York Heart Association class 4 heart failure symptoms and preserved ejection fraction; and (3) 40-year-old man with New York Heart Association class 3 heart failure symptoms and reduced ejection fraction of 20%. Survival predictions were derived from surveillance, epidemiology, and end results-Medicare database and the Seattle Heart Failure Model. Accuracy was defined as <2-fold difference between the clinician and model estimate. Results: Totally, 79% (338/427) of participants responded. Physicians were more accurate in survival estimates for lung cancer than heart failure (74% vs 48%, respectively; p < 0.001). Cardiologists were more accurate in predicting survival in heart failure symptoms and reduced ejection fraction compared to generalists (67% vs 45%; p = 0.005) and oncologists (39%; p = 0.041) but no different at predicting heart failure symptoms and preserved ejection fraction. Cardiologists predicted longer survival in heart failure compared to others (p < 0.05). Physicians felt more uncomfortable discussing palliative care with heart failure patients compared to lung cancer. Conclusions: Less than half of physicians accurately estimate survival in heart failure. Cardiologists were more accurate than other specialties for heart failure symptoms and reduced ejection fraction but no different for heart failure symptoms and preserved ejection fraction.

Inability of Physicians and Nurses to Predict Patient Satisfaction in the Emergency Department.

IntroductionPatient satisfaction is a commonly assessed dimension of emergency department (ED) care quality. The ability of ED clinicians to estimate patient satisfaction is unknown. We sought to evaluate the ability of emergency medicine resident physicians and nurses to predict patient-reported satisfaction with physician and nursing care, pain levels, and understanding of discharge instructions.MethodsWe studied a convenience sample of 100 patients treated at an urban academic ED. Patients rated satisfaction with nursing care, physician care, pain level at time of disposition and understanding of discharge instructions. Resident physicians and nurses estimated responses for each patient. We compared patient, physician and nursing responses using Cohen’s kappa, weighting the estimates to account for the ordinal responses.ResultsOverall, patients had a high degree of satisfaction with care provided by the nurses and physicians, although this was underestimated by providers. There was poor agreement between physician estimation of patient satisfaction (weighted κ=0.23, standard error: 0.078) and nursing estimates of patient satisfaction (weighted κ=0.11, standard error: 0.043); physician estimation of patient pain (weighted κ=0.43, standard error: 0.082) and nursing estimates (weighted κ=0.39, standard error: 0.081); physician estimates of patient comprehension of discharge instruction (weighted κ=0.19, standard error: 0.082) and nursing estimates (weighted κ=0.13, standard error: 0.078). Providers underestimated pain and patient comprehension of discharge instructions.ConclusionED providers were not able to predict patient satisfaction with nurse or physician care, pain level, or understanding of discharge instructions.

The effect of framing on surrogate optimism bias: A simulation study

PurposeTo explore the effect of emotion priming and physician communication behaviors on optimism bias. Materials and MethodsWe conducted a 5 × 2 between-subject randomized factorial experiment using a Web-based interactive video designed to simulate a family meeting for a critically ill spouse/parent. Eligibility included age at least 35 years and self-identifying as the surrogate for a spouse/parent. The primary outcome was the surrogate's election of code status. We defined optimism bias as the surrogate's estimate of prognosis with cardiopulmonary resuscitation (CPR) > their recollection of the physician's estimate. ResultsOf 373 respondents, 256 (69%) logged in and were randomized and 220 (86%) had nonmissing data for prognosis. Sixty-seven (30%) of 220 overall and 56 of (32%) 173 with an accurate recollection of the physician's estimate had optimism bias. Optimism bias correlated with choosing CPR (P < .001). Emotion priming (P = .397), physician attention to emotion (P = .537), and framing of CPR as the social norm (P = .884) did not affect optimism bias. Framing the decision as the patient's vs the surrogate's (25% vs 36%, P = .066) and describing the alternative to CPR as “allow natural death” instead of “do not resuscitate” (25% vs 37%, P = .035) decreased optimism bias. ConclusionsFraming of CPR choice during code status conversations may influence surrogates' optimism bias.

Validation of the Denver Emergency Department Trauma Organ Failure Score to Predict Post-Injury Multiple Organ Failure

Early recognition of trauma patients at risk for multiple organ failure (MOF) is important to reduce the morbidity and mortality associated with MOF. The objective of the study was to externally validate the Denver Emergency Department (ED) Trauma Organ Failure (TOF) Score, a 6-item instrument that includes age, intubation, hematocrit, systolic blood pressure, blood urea nitrogen, and white blood cell count, which was designed to predict the development of MOF within 7 days of hospitalization. We performed a prospective multicenter study of adult trauma patients between November, 2011 and March, 2013. The primary outcome was development of MOF within 7 days of hospitalization, assessed using the Sequential Organ Failure Assessment Score. Hierarchical logistic regression analysis was performed to determine associations between the Denver ED TOF Score and MOF. Discrimination was assessed and quantified using a receiver operating characteristics (ROC) curve. The predictive accuracy of the Denver ED TOF score was compared with attending emergency physician estimation of the likelihood of MOF. We included 2,072 patients with a median age of 46 years (interquartile range [IQR] 30 to 61 years); 68% were male. The median Injury Severity Score was 9 (IQR 5 to 17), and 88% of patients had blunt mechanism injury. Among participants, 1,024 patients (49%) were admitted to the ICU, and 77 (4%) died. Multiple organ failure occurred in 120 (6%; 95% CI 5% to 7%) patients and of these, 37 (31%; 95% CI 23% to 40%) died. The area under the ROC curve for the Denver ED TOF Score prediction of MOF was 0.89 (95% CI 0.86 to 0.91) and for physician estimation of the likelihood of MOF was 0.78 (95% CI 0.73 to 0.83). The Denver ED TOF Score predicts development of MOF within 7 days of hospitalization. Its predictive accuracy outperformed attending emergency physician estimation of the risk of MOF.

Fractionation of palliative radiotherapy in metastatic breast cancer: Selection and survival.

201 Background: Various schedules of palliative radiotherapy (pRT) are prescribed for metastatic breast cancer (MBC) patients. Length of treatment can vary from a single day to three weeks. Single fraction pRT provides similar pain relief vs. multi-fraction pRT for bone metastases, but retreatment rates are higher. In the era of targeted and hormonal therapy, patients with MBC can survive many years after their initial diagnosis. We investigated whether patients with MBC who were prescribed single fraction pRT had poorer prognoses and experienced shorter survival than patients who were prescribed multi-fraction pRT. Methods: Patients at a single institution with MBC underwent pRT, with fractionation schedules including 8 Gy in 1 fraction (fx), 20 Gy in 5 fx, 30 Gy in 10 fx, 37.5 Gy in 15 fx between 2001-2015. 392 treatments were prescribed (109/241/29/13 in each regimen as above). Date of death was obtained from medical records, Social Security Death Index, or published obituaries. Patients who were alive or whose date of death could not be determined were censored at the date of their last encounter. Survival was calculated from the start of treatment to the date of death or censorship. Results: Patients treated with 37.5 Gy in 15 fx (MS 20 months, p = 0.002) or 30 Gy in 10 fx (MS 22 months, p = 0.03) experienced longer survival than patients treated with 8 Gy in 1 fx (MS 8 months). There was no significant survival difference between patients treated with 20 Gy in 5 fx (MS 18 months, p = 0.49) and patients treated with 8 Gy in 1 fx. There was no significant survival difference between patients treated by the three multi-fractionation schedules. Conclusions: MBC patients who were prescribed 37.5 Gy and 30 Gy lived longer than patients who were prescribed 8 Gy of pRT. No statistically significant difference was found between patients who were prescribed 20 Gy compared to 8 Gy, possibly due to the lower number of patients who received these regimens. Single fraction pRT was more likely to be prescribed to patients who would ultimately have shorter survival. More research is needed, ideally across multiple institutions, to explore the correlation between physician estimation of patient survival and selection of pRT regimen for patients with MBC.

A Decision-Making Framework for Objective Risk Assessment in Older Adults with Severe Symptomatic Aortic Stenosis

The increasing prevalence of severe symptomatic aortic stenosis (AS) in older adults is now considered a major public health concern. Since medical therapy has not been shown to improve prognosis, surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) are the best options currently available, yet not all patients benefit. Objective assessment of risk versus benefit for SAVR and TAVR is essential. Clinical prediction models (CPM) have been created to augment subjective physician estimates of risk and have been shown to improve the accuracy of risk predictions. This manuscript presents the rationale for a framework of objective evaluation of risk assessment and decision making by linking clinically relevant CPM (life expectancy, Society of Thoracic Surgery, and TAVR risk calculators) with two additional concepts of lag time to benefit and competing risks that are relatively novel to the clinical arena. We believe that such aggregate framework can improve the assessment of risk and benefit and thereby facilitate a more informed and standardized shared decision-making process in the care of older adults with severe symptomatic AS.

Impact of rapid influenza diagnostic test on physician estimation of viral infection probability in paediatric emergency department during epidemic period

BackgroundThe clinical diagnosis of influenza is difficult in the younger children. ObjectivesEvaluate the impact of rapid influenza diagnostic test (RIDT) on clinicians’ estimation of the clinical probability of influenza in children. Study designThis prospective study included children aged from 1 month to 5 years who were admitted in a university paediatric emergency department during an influenza epidemic period and presented with fever without source. The RIDT Quickvue® was performed on nasopharyngeal aspiration and results were confirmed with immunofluorescence and/or PCR. The clinical probability of influenza and serious bacterial infection (SBI) was evaluated for each child before and after the physician(s) was informed of the RIDT results. Results170 children were included from January 15th through March 18th, 2013. After the only clinical examination, the overall clinical probability of influenza was 66.0% [CI 95%: 63.04–68.4], and was significantly increased at 92.4% [CI 95%: 89.5–95.3] in case of positive RIDT and significantly decreased at 30.8% [CI 95%: 29.0–32.5] in case of negative RIDT without knowing the results of laboratory tests. Whereas the initial clinical probability of influenza were appropriate regarding the prevalence (66.0% vs. 57.0%), the probability of SBI was overestimated (30.2% vs. 8.8%). The RIDT result positive enabled a significant decrease in orders for chest X-rays (64,4% vs. 45.8%, p<0,05) and laboratory tests (71,1% vs. 41.1%, p<0,05). ConclusionsThe RIDT seems to be a useful diagnostic tool for ED clinicians in epidemic conditions. Improving clinician estimation of flu probability would reduce orders for imaging and testing.

Incorporation of life expectancy estimates in the treatment of palliative care patients receiving radiotherapy: treatment approaches in light of incomplete prognostic models.

Physician estimates of patients' survival times have historically been inaccurate. In particular, physicians have often been overly optimistic in their predictions. Our review begins by documenting some of the literature addressing these concerns and proceeds to a discussion of prognostic models that have been created to aid physicians in providing more accurate estimates. We then discuss new findings showing survival to be influenced by particular treatment factors. Given such findings, currently existing prognostic models are now incomplete. However, with the abundance of evidence-based treatment options in a wide variety of patient populations, we propose that radiation oncologists need no longer rely so heavily on the precise prognostic capacity of survival models. Patients of different age demographics and survival prognoses benefit from palliative radiation treatment. More specifically, our report documents studies which show that for uncomplicated bone metastases, a single 8 Gy fraction of radiation is an equally effective tool for palliation regardless of whether a patient will have a short or long duration of survival. In addition we discuss evidence-based treatment options for patients with complicated bone metastases, lung and brain metastases. Further research is required to incorporate treatment factors in future survival prediction models.

Quantifying Patient-Physician Communication and Perceptions of Risk During Admissions for Possible Acute Coronary Syndromes

Disposition decision for patients with possible acute coronary syndrome in the emergency department (ED) is driven primarily by perception of short-term risks. We sought to evaluate communication between patient and physician about these risks by ascertaining the content of discussions surrounding disposition decision. We conducted matched-pair surveys of patients admitted for possible acute coronary syndrome and their physicians in 2 academic, inner-city EDs. After disposition conversation, trained research assistants administered surveys querying perceived and communicated risk estimates and purpose of admission. Primary exclusion criteria were ECG or troponin value diagnostic of acute coronary syndrome. The primary outcome measure was agreement in assessment of the risk of myocardial infarction, defined as the proportion of patient-physician pairs whose risk estimates were within 10% of each other. A total of 425 patient-physician survey pairs were collected. Fifty-three percent of patients were men. Patients reported discussing the likelihood of their symptoms' being due to myocardial infarction in 65% of cases, whereas physicians reported this in 46%. After their discussion, physicians' (n=415) median estimate of short-term risk was 5% (95% confidence interval [CI] 3% to 7%), whereas patients' (n=401) was 8% (95% CI 5% to 11%). Most patients (63%; 95% CI 57% to 67%) reported that this estimate remained the same or increased after their conversation. Risk agreement within 10% occurred in 36% of cases (n=404; 95% CI 32% to 41%). Patients' median estimates of the mortality of myocardial infarction at home versus in the hospital were 80% (n=398; 95% CI 76% to 84%) and 10% (n=390; 95% CI 7% to 13%), respectively, whereas physician estimates were 15% (n=403; 95% CI 12% to 18%) and 10% (n=398; 95% CI 7% to 13%). Our survey demonstrates poor communication, with overestimation of both the risks of myocardial infarction and potential benefit of hospital admission. These findings suggest that communication surrounding disposition decisions in chest pain patients may at times be ineffective or misleading.

Accuracy of physician-estimated probability of brain injury in children with minor head trauma.

To evaluate the accuracy of physician estimates of the probability of intracranial injury in children with minor head trauma. This is a subanalysis of a large prospective multicentre cohort study performed from July 2001 to November 2005. During data collection for the derivation of a clinical prediction rule for children with minor head trauma, physicians indicated their estimate of the probability of brain injury visible on computed tomography (P-Injury) and the probability of injury requiring intervention (P-Intervention) by choosing one of the following options: 0%, 1%, 2%, 3%, 4%, 5%, 10%, 20%, 30%, 40%, 50%, 75%, 90%, and 100%. We compared observed frequencies to expected frequencies of injury using Pearson's χ2-test in analyses stratified by the level of each type of predicted probability and by year of age. In 3771 eligible subjects, the mean predicted risk was 4.6% (P-Injury) and 1.4% (P-Intervention). The observed frequency of injury was 4.1% (any injury) and 0.6% (intervention). For all levels of P-Injury from 1% to 40%, the observed frequency of injury was consistent with the expected frequency. The observed frequencies for the 50%, 75%, and 90% levels were lower than expected (p<0.05). For estimates of P-Intervention, the observed frequency was consistently higher than the expected frequency. Physicians underestimated risk for infants (mean P-Intervention 6.2%, actual risk 12.3%, p<0.001). Physician estimates of probability of any brain injury in children were collectively accurate for children with low and moderate degrees of predicted risk. Risk was underestimated in infants.

BM-13 * THE (F)UTILITY OF PREDICTIVE MODELS

PURPOSE/OBJECTIVES: Physician estimates of cancer patients' survival are notoriously inaccurate. A number of models have been developed in an effort to better predict patient lifespan based on clinical factors. The Graded Prognostic Assessment (GPA), most recently published in 2012 by Sperduto et al, estimates median survival (MS) for patients who had undergone treatment for new brain metastases from June 1993 to January 2010. While independently validated in numerous studies, we investigated the applicability of the GPA model in the modern era for a smaller cohort of patients with brain metastases who were specifically selected for SRS by retrospectively calculating the diagnosis-specific GPA predicted median survival for patients with brain metastases treated with SRS at our institution between 2006 and 2012. RESULTS: 100 patients underwent SRS; 73 received whole brain radiation therapy. Observed (O) and predicted (P) MS were 13.3 and 9.4 months. The difference between predicted and actual survival was computed for each patient, and the mean difference was 10.8 months (95% CI, 8.95 - 14.8 months); the mean actual/predicted ratio was 2.07 (95% CI, 1.64 - 2.50). Compared to the predicted, actual survival was 25/35/50% longer (an arbitrarily chosen yet clinically significant amount of time) in almost half (53/49/48%) of our patients. Even when KPS was overestimated (increasing GPA predicted survival), actual survival 25/35/50% longer than predicted survival was observed in 49/46/44% of patients. CONCLUSIONS: Our deliberate selection bias of recently treated patients with modern imaging and more advanced therapies confirms that clinical models such as the GPA must be used with awareness of the current clinical setting as well as a full understanding of the model and its derivation to be of greatest benefit.

Psychiatrist and Patient Responses to Suspected Medication Nonadherence in Schizophrenia Spectrum Disorders

Long-term results in schizophrenia treatment continue to be unsatisfactory, with many patients nonadherent to treatment and relapsing frequently. This study aimed to examine how perceived nonadherence leads psychiatrists to implement adherence-enhancing measures and to identify barriers and facilitators for the implementation of adherence-enhancing measures. A cross-sectional survey was conducted with German hospital psychiatrists and their inpatients who had a diagnosis of schizophrenia or schizoaffective disorder. Interviews were conducted with 121 psychiatrists or resident psychiatrists and their 213 inpatients. Psychiatrists recognized nonadherence as an important factor for hospital admission only when directly asked about it. Psychiatrists implemented a plethora of adherence interventions that in many cases constituted only intensive talks and no structured interventions. Of four core interventions addressed in the survey-depot administration of medication, psychoeducation for patients, psychoeducation for relatives, and arrangement of first follow-up visit-the implementation rates were surprisingly high for depot prescription of antipsychotics (>30%) and psychoeducation for patients but dramatically low for arrangement of follow-up visits and psychoeducation for relatives. Patients with poor previous adherence (according to the physician's estimate) received more adherence measures. In addition, patients with involuntary admission were more likely to receive depot medications, and psychoeducation was more often implemented for younger patients and for patients at university hospitals. Treatment nonadherence is often underestimated by psychiatrists. Obstacles to the implementation of adherence-enhancing interventions occur in routine daily care. Integrated-care programs addressing adherence issues, communication between inpatient and outpatient treatment, implementation of adherence measures, and better involvement of patients in clinical decisions may help to overcome these barriers.