Development and user-testing of a digital patient decision aid to facilitate shared decision-making for people with stable angina

Background

Research shows that people with stable angina need decision support when considering elective treatments. Initial treatment is with medicines but patients may gain further benefit with invasive percutaneous coronary intervention (PCI). Choosing between these treatments can be challenging for patients because both confer similar benefits but have different risks. Patient decision aids (PtDAs) are evidence-based interventions that support shared decision-making (SDM) when making healthcare decisions. This study aimed to develop and user-test a digital patient decision aid (CONNECT) to facilitate SDM for people with stable angina considering invasive treatment with elective PCI.

Methods

A multi-phase study was conducted to develop and test CONNECT (COroNary aNgioplasty dECision Tool) using approaches recommended by the International Patient Decision Aid Standards Collaboration: (i) Steering Group assembled, (ii) review of clinical guidance, (iii) co-design workshops with patients and cardiology health professionals, (iv) first prototype developed and ‘alpha’ tested (semi-structured cognitive interviews and 12-item acceptability questionnaire) with patients, cardiologists and cardiac nurses, recruited from two hospitals in Northern England, and (v) final PtDA refined following iterative user-feedback. Quantitative data were analysed descriptively and qualitative data from the interviews analysed using deductive content analysis.

Results

CONNECT was developed and user-tested with 34 patients and 29 cardiology health professionals. Findings showed that CONNECT was generally acceptable, usable, comprehensible, and desirable. Participants suggested that CONNECT had the potential to improve care quality by personalising consultations and facilitating SDM and informed consent. Patient safety may be improved as CONNECT includes questions about symptom burden which can identify asymptomatic patients unlikely to benefit from PCI, as well as those who may need to be fast tracked because of worsening symptoms.

Conclusions

CONNECT is the first digital PtDA for people with stable angina considering elective PCI, developed in the UK using recommended processes and fulfilling international quality criteria. CONNECT shows promise as an approach to facilitate SDM and should be evaluated in a clinical trial. Further work is required to standardise the provision of probabilistic risk information for people considering elective PCI and to understand how CONNECT can be accessible to underserved communities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01882-x.

Real-world performance and accuracy of stress echocardiography: the EVAREST observational multi-centre study

Aims

Stress echocardiography is widely used to identify obstructive coronary artery disease (CAD). High accuracy is reported in expert hands but is dependent on operator training and image quality. The EVAREST study provides UK-wide data to evaluate real-world performance and accuracy of stress echocardiography.

Methods and results

Participants undergoing stress echocardiography for CAD were recruited from 31 hospitals. Participants were followed up through health records which underwent expert adjudication. Cardiac outcome was defined as anatomically or functionally significant stenosis on angiography, revascularization, medical management of ischaemia, acute coronary syndrome, or cardiac-related death within 6 months. A total of 5131 patients (55% male) participated with a median age of 65 years (interquartile range 57–74). 72.9% of studies used dobutamine and 68.5% were contrast studies. Inducible ischaemia was present in 19.3% of scans. Sensitivity and specificity for prediction of a cardiac outcome were 95.4% and 96.0%, respectively, with an accuracy of 95.9%. Sub-group analysis revealed high levels of predictive accuracy across a wide range of patient and protocol sub-groups, with the presence of a resting regional wall motion abnormalitiy significantly reducing the performance of both dobutamine (P < 0.01) and exercise (P < 0.05) stress echocardiography. Overall accuracy remained consistently high across all participating hospitals.

Conclusion

Stress echocardiography has high accuracy across UK-based hospitals and thus indicates stress echocardiography is being delivered effectively in real-world practice, reinforcing its role as a first-line investigation in the assessment of patients with stable chest pain.

Randomized comparison of percutaneous coronary intervention with coronary artery bypass grafting in diabetic patients. 1-year results of the CARDia (Coronary Artery Revascularization in Diabetes) trial

OBJECTIVES

The purpose of this study was to compare the safety and efficacy of percutaneous coronary intervention (PCI) with stenting against coronary artery bypass grafting (CABG) in patients with diabetes and symptomatic multivessel coronary artery disease.

BACKGROUND

CABG is the established method of revascularization in patients with diabetes and multivessel coronary disease, but with advances in PCI, there is uncertainty whether CABG remains the preferred method of revascularization.

METHODS

The primary outcome was a composite of all-cause mortality, myocardial infarction (MI), and stroke, and the main secondary outcome included the addition of repeat revascularization to the primary outcome events. A total of 510 diabetic patients with multivessel or complex single-vessel coronary disease from 24 centers were randomized to PCI plus stenting (and routine abciximab) or CABG. The primary comparison used a noninferiority method with the upper boundary of the 95% confidence interval (CI) not to exceed 1.3 to declare PCI noninferior. Bare-metal stents were used initially, but a switch to Cypher (sirolimus drug-eluting) stents (Cordis, Johnson & Johnson, Bridgewater, New Jersey) was made when these became available.

RESULTS

At 1 year of follow-up, the composite rate of death, MI, and stroke was 10.5% in the CABG group and 13.0% in the PCI group (hazard ratio [HR]: 1.25, 95% CI: 0.75 to 2.09; p=0.39), all-cause mortality rates were 3.2% and 3.2%, and the rates of death, MI, stroke, or repeat revascularization were 11.3% and 19.3% (HR: 1.77, 95% CI: 1.11 to 2.82; p=0.02), respectively. When the patients who underwent CABG were compared with the subset of patients who received drug-eluting stents (69% of patients), the primary outcome rates were 12.4% and 11.6% (HR: 0.93, 95% CI: 0.51 to 1.71; p=0.82), respectively.

CONCLUSIONS

The CARDia (Coronary Artery Revascularization in Diabetes) trial is the first randomized trial of coronary revascularization in diabetic patients, but the 1-year results did not show that PCI is noninferior to CABG. However, the CARDia trial did show that multivessel PCI is feasible in patients with diabetes, but longer-term follow-up and data from other trials will be needed to provide a more precise comparison of the efficacy of these 2 revascularization strategies. (The Coronary Artery Revascularisation in Diabetes trial; ISRCTN19872154).

Suicide among North Carolina women, 1989-93: information from two data sources

OBJECTIVES

To characterize the events and examine suicide precursors among women and to examine gaps in surveillance.

SETTING

A statewide study in North Carolina.

METHODS

Suicides of women age 15 and older for the time period 1989-93, as identified from the Office of the Chief Medical Examiner, were included. All case files were reviewed by hand and telephone interviews were attempted with investigating law enforcement officials for every case in 1993.

RESULTS

Altogether 882 suicides met the case definition, for an age adjusted rate that fluctuated between 5.53 and 7.26 per 100 000 women across the period. Interviews with law enforcement officials were completed for 135 of the 177 cases from 1993. White women had rates nearly three times those of racial minorities. Women under age 45 were proportionally more likely than older women to have recently experienced the breakup of an intimate relationship. Information about precursors was not as consistently reported as had been hoped. Medical examiner records were variable in completeness. Law enforcement interviews frequently did not yield information about the factors we had hoped to examine, probably because the investigations were conducted primarily to rule out homicide.

CONCLUSIONS

This study suggests somewhat different precursor patterns by age group. It also points to the need for reconsidering how suicide surveillance is accomplished as a strategy to guide intervention.

A population based study of unintentional firearm fatalities

OBJECTIVES

To describe the circumstances of fatal unintentional firearm injuries in a statewide population in a region of the United States with high firearm fatality rates and to compare to similar data from an earlier period in the same state.

METHODS

Analyses of North Carolina medical examiner database (1985-94) and review of medical examiner case reports (1990-94) and comparison to similar data from 1979-82.

RESULTS

A total of 390 unintentional shooting deaths occurred (0.59/100,000 population) between 1985-94 with the highest rate in the ages 15-24. Between 1990-94, handguns were responsible for 59% of these deaths compared to 40% in the 1979-82 period. Younger victims were more likely to be shot by family or friends, though, 53% of all deaths were self inflicted. In 45 cases, the person firing the weapon was reported to believe that the gun was unloaded or had the safety device activated.

CONCLUSIONS

This study demonstrates changes in patterns of unintentional firearm fatalities in North Carolina in two decades, particularly the increase in incidence of events involving handguns. The results highlight the need for additional attention to efforts governing access to firearms, particularly handguns; technological advances in designing safer guns, and additional emphasis on safe storage policies and practices.

Medical examiner cases associated with previously undiagnosed diabetes mellitus, North Carolina, 1994

BACKGROUND

Approximately half of the 16 million Americans with diabetes mellitus (DM) are unaware they have the disease; the epidemiology of death from previously undiagnosed DM is unclear. We report medical examiner (ME) cases of death from DM in North Carolina in 1994 to determine the number and characteristics of these cases.

METHODS

Deaths from DM ICD-9 were identified and reviewed.

RESULTS

Of the 42 cases ascertained from ME records, 6 had previously undiagnosed DM, 5 had diabetes ketoacidosis, and 1 had nonketotic hyperosmolar hyperglycemia. Mean patient age at death for all cases was 42 years (range, 35 years to 57 years). Four patients felt bad at least 24 hours before death, indicating that they are not technically "sudden deaths."

CONCLUSIONS

We provide a limited epidemiologic perspective of the phenomenon of death from undiagnosed DM. We suggest further investigation of mortality from previously undiagnosed diabetes.

Partner homicide-suicide involving female homicide victims: a population-based study in North Carolina, 1988-1992

Homicide-suicide is a form of fatal violence in which an individual commits homicide and subsequently kills him- or herself. One hundred and sixteen homicide-suicide events involving 119 female homicide victims in North Carolina from 1988-1992 were identified through state medical examiner files. Case files were reviewed retrospectively to identify event characteristics, precursors, and typologies. In 86% of cases the perpetrator was the current or former partner of the victim. During the study period, 24% of men who killed their female partners in North Carolina subsequently committed suicide and another 3% attempted suicide but survived. Victim separation from the perpetrator was the most prevalent precursor (41%), followed by a history of domestic violence (29%). In nearly half of the cases with a history of domestic violence, the victim had previously sought protection from the perpetrator in the form of an arrest warrant, restraining order, or intervention by a law enforcement officer. Children of the victim (and/or perpetrator) witnessed the homicide-suicide, were in the immediate vicinity, found their parents' bodies, or were killed, in 43% of cases. The prevalence of separation and domestic violence suggests several potential points of intervention, including stronger domestic violence legislation. Future research should place priority on assessing the impact of partner homicide-suicides on the families in which they occur. Such studies are essential for the informed development of preventive and therapeutic interventions for the families of both the victims and perpetrators of these fatal events. In addition, research focused on assisting men in coping with issues of control and separation is needed.

Educating patients at home. Community Health Rap

OBJECTIVES

The authors analyzed the impact of home health education by studying the impact of a computer service called Community Health Rap. When patients call this service, the computer records their questions and alerts an expert who records a response. Subsequently, the computer alerts the patient that the question has been addressed.

METHODS

Subjects included a group of 82 pregnant women who had used cocaine during or 1 month before pregnancy (as reported by the woman) and a group of residents of zip code areas with the lowest income in Cleveland. From the drug-using pregnant women, we collected data regarding satisfaction with Community Health Rap, usage of Community Health Rap per month, self-reported health status (using the General Health Survey), and the extent of drug use (using the Addiction Severity Index). Trained coders also classified the nature of questions posed to the Community Health Rap by either the pregnant women who abuse drugs or the members of target households. Among the pregnant women who abuse drugs, we compared the differences between those who used the service and those who did not. To control for baseline differences between the two groups, analysis of co-variance was used with exit values as the dependent variables, the baseline values as the co-variates, and participation in the Community Health Rap as the independent variable.

RESULTS

Almost half (45%) of poor, undereducated subjects who lived in inner urban areas used the computer service. Content analysis of Community Health Rap messages revealed that subjects had many questions that were of a social nature (regarding sex, relationships, etc), in addition to medical questions. Analysis showed that poor health status, more frequent drug use, lower education, and age did not affect regular use of Community Health Rap service. No health outcomes or utilization of treatment were associated with regular use of Community Health Rap. One exception, however, was that regular users of Community Health Rap reported slower improvement of their pain than those who did not use Community Health Rap.

CONCLUSIONS

These data suggest that expansion of information services to households will not leave the poor and the undereducated population groups "behind." They will use computer services, though such services may not have an impact on their health status or cost of care.

A randomized trial of a telecommunications network for pregnant women who use cocaine

OBJECTIVES

The authors describe computer services designed to make patients better informed and more motivated to participate in treatment. Patients use these services through their touch-tone telephone; access to a home computer or a modem is not needed.

METHODS

The authors tested the impact of these computer services on the management of 179 pregnant women who had used cocaine during pregnancy or 1 month before pregnancy (as reported by the woman). Patients were randomly assigned to control and experimental groups; only the experimental group had access to the computer services. Patients were enrolled during the prenatal period and followed for 6 months after the birth of a live child. Self-reported data on the subjects' participation in drug treatment programs, health status (using the SF-36), and addiction severity (using the addiction severity index) were collected. The computer collected data on the frequency of the use of the service. The dependent variables were participation in formal treatment during the course of the project, and drug and alcohol use at exit interview. Multiple and logistic regressions were used to identify the effects of the intervention after controlling for demographic and baseline variables.

RESULTS

Data showed that poor, pregnant, undereducated clients who use drugs and lived in multiple residences could use the services; about one-third of clients used the services more than three times a week. Access to the service did not lead to significant change in patients' health status, drug use, or utilization of services. Use of the services did lead to significant changes in participation in drug treatment: subjects who used the service more than three times a week were 1.5 times more likely to participate in formal drug treatment than subjects who used the service less often. Participation in formal drug treatment, however, was not effective in reducing the drug or the alcohol use.

CONCLUSIONS

Almost all patients used the computer services to some extent, but there seems to be a threshold after which the use of the services had a more positive impact.

Computer reminders improve on-time immunization rates

OBJECTIVES

This study examines the effectiveness of computer-generated telephone reminders in improving infants receiving on-time immunizations. A computer called parents at home, reminded them of their child's visit, and asked if they could keep the appointment. If parents either canceled or failed to honor the appointment, the computer called back a few days later and asked them to reschedule.

METHODS

A medical assistant recruited 124 consecutive mothers to receive automated computer reminders. These mothers' infants were younger than 6 months, were being seen at an outpatient clinic for a first visit, and were patients of three attending physicians and three nurse practitioners. These infants were compared to 89 infants from the same clinic, in the same age range, who were being seen for the first time during the same period by the same providers but not contacted by the medical assistant. Subjects were selected from mothers who brought their infants for their first visit in an outpatient urban clinic that serves predominantly minority clients. A research assistant reviewed patients' medical records and collected the infants' birthday, mothers' age, race, source of payments, and the immunization record of the infants. Immunization was considered to be late if, at the time of the first visit, it was more than 30 days past due for any of the recommended immunizations of the American Academy of Pediatrics, except for Hepatitis B vaccine which was not recommended at the time of the study. The dependent variable was on-time immunization. The independent variables were age of the mother at baseline, age of the child at baseline, and membership in either the comparison or the experimental group. Chi-square tests and logistic regression were used to analyze the data.

RESULTS

The participation rate for appointments for the experimental group was 82%, as compared to a 69% overall participation rate for the clinic providers. The on-time immunization rate for experimental subjects was 67.8%, whereas the comparison group had an on-time immunization rate of 43.4% (differences were significant at alpha levels less than 0.01).

CONCLUSIONS

Computerized reminders sent to the parents led to an increase in participation rate at the clinic and an increase in on-time immunization for their infants.

Elevated postmortem tryptase in the absence of anaphylaxis

Elevations in tryptase, a recently discovered mast cell enzyme, have been proposed as a postmortem indicator of fatal anaphylaxis. The previous studies had limited numbers of controls and thus the specificity of the test with postmortem samples was not known. Therefore, tryptase was evaluated in postmortem blood samples from 49 autopsy cases where there was no evidence of fatal anaphylaxis. The tryptase was above the normal serum threshold of 1 nanogram/mL (ng/mL) in 31 of these cases. Twenty-four cases had values in the 1 to 5 ng/mL range, two cases were between 5 and 10 ng/mL, and five were greater than 10 ng/mL. One autopsy specimen had a tryptase value of 106 ng/mL. The postmortem interval and the specimen storage condition did not appear to correlate with these elevations in tryptase. Although elevations in the postmortem tryptase remain an important supporting finding in the diagnosis of fatal anaphylaxis, it should not be used alone as the sole criterion for the postmortem diagnosis of anaphylaxis.

Practices of county medical examiners in classifying deaths as on the job

Although annual United States occupational injury fatalities range between 7,000 and 10,400, consistent rules to determine which deaths are "occupational" do not exist. Fifty-seven North Carolina county medical examiners (MEs), responsible for more than 50% of all medical examiner cases in 1990, received our questionnaire. Fifty-three (93%) responded, classifying 22 scenarios as on-the-job deaths and indicating usual classification practices and information sources. Agreement varied among the scenarios, but those involving transportation and nonpaid workers elicited particularly inconsistent responses. Fifty-six percent of medical examiners have a general rule for determining on-the-job status, but deaths associated with motor vehicles, farming, and occupations other than the decedent's usual job were classified most inconsistently. The lack of standard definitions of "job," "work," and "on-the-job" is apparent in classification decisions. Certain work situations need special consideration.

Risk factors for fatal residential fires

BACKGROUND

Residential fires are the most important cause of fire-related mortality in the United States. Previous research has concentrated on fatal fires in urban areas; considerably less is known about fatal fires in rural areas.

METHODS

We studied fatal and nonfatal residential fires in predominantly rural areas. Using a case-control design, we compared all 151 fatal fires (cases) in single-family dwellings in North Carolina during a 13-month period with a sample of nonfatal fires (controls). Case fires were identified through the medical-examiner system, and control fires that occurred within a few weeks of the case fires were chosen from the records of randomly selected fire departments statewide. For each fire, fire officials were interviewed about the dwelling, the fire, the people involved, and the fire-response system.

RESULTS

Although heating incidents were the leading cause of fires, fatal fires were more likely to have been caused by smoking (31 percent of fatal fires vs. 6 percent of nonfatal fires). Mobile homes posed a higher risk of death if a fire occurred (odds ratio, 1.7; 95 percent confidence interval, 1.1 to 2.6), as did the absence of a smoke detector (odds ratio, 3.4; 95 percent confidence interval, 2.1 to 5.6). Smoke detectors were more protective against death in fires involving young children and when no one present was impaired by alcohol or drugs or had a physical or mental disability. The presence of an alcohol-impaired person was the strongest independent risk factor for death in the case of a fire (odds ratio, 7.5; 95 percent confidence interval, 4.4 to 12.7).

CONCLUSIONS

Residential fires are most likely to be caused by heating equipment or smoking materials. The risk of death is greatest in fires in mobile homes, in those involving alcohol-impaired persons, and in those in houses without smoke detectors.

Multivariate population-based analysis of the association of county trauma centers with per capita county trauma death rates

The purpose of this study was to utilize a large population-based data base to determine the association of trauma centers with per capita county trauma death rates.

METHODS

Per capita county trauma death rate, the dependent variable in the model, was obtained from a well-validated state Medical Examiner's data base. Over 200 county demographic, prehospital, and hospital trauma care resource variables were obtained from a variety of sources for multivariate modeling. Bivariate analysis identified candidate variables for multivariate modeling, excluding highly correlated independent variables to avoid problems of collinearity. Multivariate linear regression, logistic regression, and stepwise discriminant analysis were used to determine the relative association of the candidate variables with per capita county trauma death rates.

RESULTS

Bivariate analysis identified multiple factors associated with per capita county trauma death rates. These included, among others: county rurality, percentage of unemployment, percentage nonwhite, 911 access, and ALS certified EMS. Per capita trauma death rates were significantly lower in counties with trauma centers compared with counties without trauma centers (4.0 +/- 0.5 and 5.0 +/- 1.1 deaths per 10,000 population, p = 0.0001, respectively). Multivariate analysis demonstrated that the presence of a trauma center in the county and ALS were the best medical system factors predicting decreased per capita county trauma death rates.

CONCLUSIONS

This study is unique in utilizing a regional population-based data base of all trauma deaths in a large state to analyze the association of trauma centers and trauma death rates. Multivariate modeling controlling for other county variables demonstrated that the presence of a trauma center and Advanced Life Support training were the best predictors of per capita county trauma death rates. These findings are consistent with the hypothesis that trauma centers decrease trauma death rates.

Inhibition of Lancefield group D enterococci by contamination of a commercial identification medium with paraffins

A commercially available system for the identification of streptococci was found to incorrectly identify group D enterococci due to contamination of the 6.5% NaCl medium with paraffins.