Professional Preferences and Perceptions of Cardiology Among Internal Medicine Residents: Temporal Trends Over the Past Decade

Importance

Internal medicine residents' professional development preferences were discordant with their perceptions of cardiology in a survey circulated a decade ago; no contemporary data exist. This information is important for effective recruitment and retention of a highly talented and diverse future cardiology workforce.

Objective

To identify residents' professional development preferences and cardiology perceptions, in relation to specialty choice, and compare the findings with those from a decade prior.

Design, Setting, and Participants

The original survey from the 2010 study was updated and sent to US internal medicine programs. Respondents (ie, internal medicine residents) rated 38 professional development preferences and 20 cardiology perceptions. Data were collected in 2020 and compared with survey results from the prior 2010 study. Multivariable models were created for specialty choice using scaled independent variables dichotomized using the top 2 options; categorical variables were recoded into binary variables for analysis.

Main Outcomes and Measures

Multivariable models were used to determine the association of demographic characterisitcs and survey responses with prospective career choice. Responses were examined by total group, by gender, by self-reported consideration of entering cardiology as a profession, and by comparison with a decade prior both as a group and by gender.

Results

A total of 840 residents (mean [SD] age, 29.24 [2.82] years; 49.8% male; 55.4% White) completed the survey. The survey incorporated a 5-point Likert scale of 1 (not important) to 5 (extremely important) for some of the questions, with additional questions on demographic characteristics. The most important professional development preferences by descending Likert score were as follows: positive role models (4.56), stimulating career (3.81), and family friendly (3.78). The cardiology perception statements with the highest agreement were as follows: interferes with family life during training (3.93) and having met positive role models or having positive views of cardiovascular disease as a topic (3.85). Multivariable analysis yielded a 22-element model predicting cardiology as career choice. Compared with the 2010 survey, the findings of this survey indicated increased importance of work-life balance components for both male and female residents, with a greater change in male residents. Contemporary residents were more likely than their predecessors to agree with negative perceptions of cardiology.

Conclusions and Relevance

This survey study found that both male and female residents place a high value on support for optimal work-life balance; these preferences have intensified over the past decade and factor into career choice. Negative perceptions of cardiology persist and, in some aspects, are worsening. Improving the culture of cardiology may make this specialty a more attractive career choice for all.

Impact of ultrasound enhancing agents on clinical management

PURPOSE OF REVIEW

Ultrasound enhancing agents (UEAs), microbubbles which are composed of lipid or albumin shells containing high molecular weight gases with nonlinear acoustic properties in the ultrasound field, are important components of the diagnostic armamentarium in echocardiography. This review highlights the substantial value of UEAs in delineating endocardial border definition and influencing downstream decision-making in cardiovascular ultrasound.

RECENT FINDINGS

In this article, we review recent updates to the clinical applications of UEAs, special circumstances regarding use, the impact of use on downstream testing and cost-effectiveness, and recommended approaches for optimizing workflow in the echocardiography laboratory with UEAs.

SUMMARY

In multiple studies, UEAs have been identified as a useful tool in echocardiography, improving study accuracy and reader confidence, while reducing downstream testing and procedures and resulting in significant changes in clinical management. Despite their proven efficacy and cost-effectiveness, recent studies have suggested utilization remains low, in part due to perceived concerns and workflow issues that impair uptake. With an increasingly broader list of indications for echocardiography, UEAs will continue to play an important role in the diagnosis and management of patients with cardiovascular and noncardiovascular diseases.

Patient and Provider Perspectives on Remote Monitoring of Pacemakers and Implantable Cardioverter-Defibrillators

The use of remote monitoring technology for cardiovascular electronic implantable devices has grown significantly in recent decades, yet several key questions remain about its integration into clinical care. We performed semi-structured interviews of patients, clinicians, and device clinic technicians involved in clinical remote monitoring of cardiovascular implantable devices at our institution. Twenty-eight interviews comprised of 15 patients and 13 clinicians were conducted from October 2019 through February 2020. Interview transcripts were analyzed using a mixed inductive and deductive approach. Perspectives among clinicians and patients varied regarding familiarity, educational experiences, and preferences regarding how remote monitoring data are handled. Three key domains emerged including knowledge and understanding, managing alerts, and cost transparency. Within these domains, key findings includedvery limited understanding of how remote monitoring functions and how alerts in particular are handled. These knowledge deficits (both patients and providers) appeared to arise in part from different equipment and platforms among manufacturers, the complexity of the technology, and lack of formalized education in remote monitoring. However, interviewees expressed generally high levels of trust in the technology and care systems supporting remote monitoring. Few respondents described concerns around cybersecurity, but patients in particular did raise concerns about cost transparency and frequent billing. In conclusion, conflicting perceptions around remote monitoring persist and indicate important knowledge gaps despite high trust in the care pathway. This qualitative analysis offers insight into patient and clinician understanding of and attitudes toward remote monitoring, and may guide future efforts to improve education and patient-centeredness of remote monitoring.

Identification of Need for Ultrasound Enhancing Agent Study (the IN-USE Study)

BACKGROUND

Ultrasound enhancing agents (UEAs) are routinely used to improve transthoracic echocardiographic (TTE) image quality, yet anticipation of UEA need is a barrier to their use.

METHODS

Structured report data from 171,509 consecutive TTE studies in 97,515 patients who underwent TTE imaging from January 26, 2000, to September 20, 2018, were analyzed. Trends in UEA use and suboptimal image quality were examined. Among outpatients (92,291 TTE examinations, n = 56,479), the data set was randomly split into a 75% derivation sample and a 25% validation sample. Logistic regression was used to model the composite of either UEA receipt or suboptimal image quality (two or more nonvisualized segments) using only variables available at the start of the TTE examination. Model performance was tested in the validation sample.

RESULTS

A total of 4,444 TTE examinations (2.6%) in 3,827 patients (3.9%) involved UEAs, and 28,468 TTE examinations (16.6%) in 21,994 patients (22.5%) were suboptimal. UEA use increased over the observation period. Among TTE studies with suboptimal image quality, UEA use was lower in women (P < .0001). Among outpatients referred for TTE imaging, older age, greater weight, and higher heart rate best predicted UEA use or suboptimal image quality. Model performance in the validation sample was excellent (C statistic = 0.74 [95% CI, 0.73-0.75]; calibration slope = 1.11 [95% CI, 1.06-1.15]).

CONCLUSIONS

In this large, single-center, retrospective study, UEA use remained substantially below rates of suboptimal image quality, despite increases over time. Among outpatients, a simple prediction rule using three routinely collected variables available before TTE image acquisition predicted potential benefit from UEAs with high accuracy. If confirmed in other cohorts, this rule may be used to identify patients who may benefit from intravenous placement for UEA administration before TTE image acquisition, thus potentially improving work-flow efficiency.

Abstract 233: Geographic Variability in the Utilization of Remote Monitoring for Pacemakers and Implantable Cardioverter-Defibrillators

Background: Remote monitoring (RM) of pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs) reduces the need for in-office visits, of particular importance to patients in rural areas. Whether adoption of RM varies by geography is unknown.

Objective: To evaluate geographic variability in the use of RM among Medicare beneficiaries.

Methods: Medicare carrier files (2012-2015) were queried for RM and in-office professional claims of PM or ICD interrogations. Patient location was identified using residence ZIP code. Geographic variability was assessed using standard deviation of county-based proportion of RM vs in-office interrogations. We also assessed the relationship between counties’ proportional use of RM and population density.

Results: Across the US, the proportion of remote to in-office interrogations increased from 2012-15 for both PMs (18.5% to 27.6%, 420,480/2,269,305 to 682,200/2,476,100) and ICDs (31.4% to 33.8%, 440,130/1,401,350 to 466,605/1,380,380) (FIGURE). However, marked variability across counties was noted, with the standard deviation of the proportion of RM ranging from 16.8-17.9% by year and device type. Significant county-to-county variability in the rate of change in proportion of RM from 2012 to 2015 was also observed (standard deviation of 2012-15 change in proportion of RM: 11.8% for PMs; 14.1% for ICDs). Population density accounted for only 1.7-4.6% of observed variability in RM utilization over time (PM: r=0.20; ICD: r=0.19; p<0.001).

Conclusion: Counties varied widely in their relative use of RM and rate of adoption over time, yet population density accounted for just a small fraction of RM use variability. These findings suggest a need to target rural populations for adoption of this technology.

Abstract 234: Remote Monitoring Utilization and Medicare Spending for Pacemakers and Implantable Cardioverter-Defibrillators

Background: Remote monitoring (RM) may improve outcomes and the value of care by reducing the need for in-person visits. No study has evaluated national trends in utilization of remote and in-office interrogation services, nor associated Medicare spending.

Objective: To assess national trends in the utilization and Medicare spending related to RM and in-office interrogations for pacemakers (PMs) and implantable cardioverter-defibrillators (ICDs).

Methods: Medicare carrier claims and outpatient files (2012-2015) were evaluated for the volume of remote vs in-person professional and facility claims submitted for the interrogation of PMs and ICDs. Payments were quantified by identifying line payments, which specify Medicare reimbursements/claim. As carrier claims represent a 20% national sample, volume and cost of services were multiplied accordingly to represent the entire population.

Results: Professional RM claims increased for PMs (420,758 to 682,345) and ICDs (440,223 to 466,733) from 2012-2015. Medicare spending on RM (professional and facility combined) also increased from $45.7 million to $57.4 million annually (FIGURE). During the same period, volume and spending for in-office interrogations decreased both in absolute numbers and proportionally compared with RM. For example, the proportion of interrogations performed in-office decreased from 81.5% (1,848,825/2,269,305) to 72.5% (1,793,905/2,476,105) for PMs and from 68.6% (964,220/1,401,350) to 66.2% (913,785/1,380,390) for ICDs.

Conclusion: Use of RM and associated Medicare spending increased from 2012-2015. Over the same period, in-office services and associated spending declined. Continued adoption of RM may further reduce the need for in-office services and associated costs.

Is an Admission for Decompensated Heart Failure Inevitable?

Given the high prevalence of heart failure (HF) and the profound impact on morbid, mortality, and health care costs, strategies to improve outcomes and reduce cost have become progressively more attractive. Reducing HF hospitalizations as a study outcome has gained traction in recent years. The basic hypothesis of these investigations is that HF hospitalizations are preventable and harmful. This article examines advancements in pharmacotherapy, medical devices, and health care delivery techniques targeting reductions in HF hospitalizations and evaluates the role and implications of hospitalization in the natural history of HF.