Christopher E. Knoepke

Implantable Cardioverter–Defibrillator Use in Older Adults Proceedings of a Hartford Change AGEnts Symposium

Since their initial clinical demonstration in 1980, implantable cardioverter–defibrillators (ICDs) have prolonged countless lives with successful treatment of sudden cardiac arrest.1 No other therapy has proved as effective in preventing death from ventricular arrhythmias, and important advances in ICD technology continue to improve outcomes for well-selected patients.2 Although indicated for a wide range of inherited and acquired conditions,3 ICDs are predominantly placed in older patients with left ventricular systolic dysfunction and either previous myocardial infarction or congestive heart failure.4 In the United States alone, >50 000 ICDs are placed annually in patients aged > 65 years, and nearly 500 000 more may meet current guidelines for device implantation.5nnHowever, decision making for older patients considering ICD implantation is particularly challenging. Subjects in the landmark trials had average ages in the 60s, and thus the survival benefits of ICDs in older age groups is less well-established.6 In addition, compared with the younger participants in most clinical trials, older adults have a lower ratio of arrhythmic death to nonarrhythmic death because of competing risks for mortality, resulting in a potentially lower absolute risk reduction. At the same time, living and eventually dying with an ICD introduces potential risks, including a lower quality of life (QoL), hospitalizations, and potential suffering at the end of life.7 A rigorous consideration of the benefits, risks, and ongoing care surrounding ICD use in older patients is long overdue.nnOn April 22, 2014, we convened a conference of multidisciplinary experts in cardiac electrophysiology, heart failure, geriatrics, ethics, and palliative care in Boston, supported by the Hartford Change AGEnts and Paul B. Beeson Career Development Award programs, and the Hebrew SeniorLife Institute for Aging Research. The objectives of the conference were (1) to review what is currently known about ICD use in …

Loaded Questions: Internet Commenters' Opinions on Physician-Patient Firearm Safety Conversations.

Introduction Medical and public health societies advocate that healthcare providers (HCPs) counsel at-risk patients to reduce firearm injury risk. Anonymous online media comments often contain extreme viewpoints and may therefore help in understanding challenges of firearm safety counseling. To help inform injury prevention efforts, we sought to examine commenters’ stated opinions regarding firearm safety counseling HCPs. Methods Qualitative descriptive analysis of online comments posted following news items (in May–June, 2016) about a peer-reviewed publication addressing when and how HCPs should counsel patients regarding firearms. Results Among 871 comments posted by 522 individuals, most (57%) were generally negative toward firearm discussions, 17% were positive, and 26% were neutral/unclear. Two major categories and multiple themes emerged. “Areas of agreement” included that discussions may be valuable (1) when addressing risk of harm to self or others, (2) in pediatric injury prevention, and (3) as general safety education (without direct questioning), and that (4) HCPs lack gun safety and cultural knowledge. “Areas of tension” included whether (1) firearms are a public health issue, (2) counseling is effective prevention practice, (3) suicide could/should be prevented, and (4) firearm safety counseling is within HCPs’ purview. Conclusion Among this set of commenters with likely extreme viewpoints, opinions were generally negative toward firearm safety conversations, but with some support in specific situations. Providing education, counseling, or materials without asking about firearm ownership was encouraged. Engaging firearm advocates when developing materials may enhance the acceptability of prevention activities.

Colorado Medical Students’ Attitudes and Beliefs About Marijuana

BackgroundOver the past two decades, state and local governments across the U.S. have been increasingly reforming marijuana laws. Despite growing support for marijuana as a medical treatment, little is known about medical students’ perceptions of marijuana use.ObjectiveTo assess Colorado medical students’ personal and professional opinions on current and future marijuana use in a healthcare setting.DesignA voluntary, anonymous, online cross-sectional survey.ParticipantsMedical students (nu2009=u2009624) at the University of Colorado School of Medicine between January and February 2014 were invited to participate.Main MeasuresNumerical responses were quantified using counts and percentages, and Likert scale responses were collapsed for bivariate analysis. Items were gathered thematically and additively scored for each subscale. Internal consistency reliability statistics were calculated for each subscale to ensure that items were assessing similar constructs. Unadjusted t tests and one-way analysis of variance (ANOVA) were used to calculate mean differences in subscale scores between subgroups.Key ResultsWe received 236 responses (37%). Students indicated support for marijuana legalization (64%), and few believed that physicians should be penalized for recommending marijuana to patients (6%). Nearly all (97%) believed that further marijuana research should be conducted, and believed marijuana could play a role in the treatment of various medical conditions. Seventy-seven percent reported that they believed marijuana use had the potential for psychological harm, and 68% indicated concern for potential physical harm. Only a minority of students would recommend marijuana to a patient under current law (29%), or if it were legally available (45%). Acceptability of marijuana for treatment of approved conditions was not correlated with age or gender, but was positively correlated with living in Colorado prior to medical school (pu2009<u20090.001) and with prior marijuana use (pu2009<u20090.001).ConclusionsMedical students support marijuana legal reform, medicinal uses of marijuana, and increased research, but have concerns regarding risks of marijuana use, and appear hesitant to recommend marijuana to patients.

Obviously, you cant give me medical advice over the internet, but : Quality of Medical Advice Provided Between Members of an Online Message Board for Implanted Defibrillator Patients (Preprint)

Background Patients use Web-based medical information to understand medical conditions and treatments. A number of efforts have been made to understand the quality of professionally created content; however, none have described the quality of advice being provided between anonymous members of Web-based message boards. Objective The objective of this study was to characterize the quality of medical information provided between members of an anonymous internet message board addressing treatment with an implantable cardioverter-defibrillator (ICD). Methods We quantitatively analyzed 2 years of discussions using a mixed inductive-deductive framework, first, for instances in which members provided medical advice and, then, for the quality of the advice. Results We identified 82 instances of medical advice within 127 discussions. Advice covered 6 topical areas: (1) Device information, (2) Programming, (3) Cardiovascular disease, (4) Lead management, (5) Activity restriction, and (6) Management of other conditions. Across all advice, 50% (41/82) was deemed generally appropriate, 24% (20/82) inappropriate for most patients, 6% (5/82) controversial, and 20% (16/82) without sufficient context. Proportions of quality categories varied between topical areas. We have included representative examples. Conclusions The quality of advice shared between anonymous members of a message board regarding ICDs varied considerably according to topical area and the specificity of advice. This report provides a model to describe the quality of the available Web-based patient-generated material.

‘Lock to Live’: development of a firearm storage decision aid to enhance lethal means counselling and prevent suicide

Objectives We sought to (1) clarify decision needs among suicidal adults with home firearm access; (2) identify accurate, unbiased and acceptable approaches for content and messaging; and (3) develop a tablet-delivered decision aid for firearm storage options. Methods Following international standards, we used stakeholder interviews to develop a decision aid for the decision, ‘what option(s) to choose to reduce home access to firearms for an adult at risk of suicide’. Participants were adults with personal or family history of suicidal ideation or behaviours, firearm ownership or employment in a firearm range or store, involvement in suicide prevention field, or work as emergency department or other healthcare provider. Results Through 64 interviews, we created the ‘Lock to Live’ decision aid, which includes (1) introduction specifying the decision, (2) clarification of preferences and logistics, (3) table of storage options and (4) summary with specific next steps. The final tool had high user acceptability. Conclusions Should the ‘Lock to Live’ decision aid prove useful in a pilot feasibility trial and subsequent testing, it could enhance lethal means counselling and help prevent firearm suicide.

Hospice, She Yelped: Examining the Quantity and Quality of Decision Support Available to Patient and Families Considering Hospice

CONTEXTnWhether to engage hospice is one of the most difficult medical decisions patients and families make. Meanwhile, misperceptions about hospice persist. Within this context, the breadth and depth of patient decision support materials for hospice are unknown.nnnOBJECTIVESnThe objective of this study was to identify available patient decision aids (PtDAs) relating information about hospice care and compare that information with the informational needs expressed by real-world health care consumers.nnnMETHODSnFirst, the research team conducted an environmental scan of available PtDAs that included hospice as a treatment option and met six basic criteria defined by the International Patient Decision Aid Standards. Second, laypersons conducted an organic Web search for information regarding hospice, followed by a semi-structured interview eliciting perceptions of the available information. The setting was the University of Colorado Health Care System. Participants included 20 laypersons aged 18 years or older.nnnRESULTSnThe environmental scan identified 7PtDAs that included hospice. No PtDAs were designed primarily around hospice; rather, hospice was referenced under the umbrella of another treatment option. The layperson search identified information distinct from the scan; no participant accessed any of the above 7PtDAs. Many participants found the available online material confusing and biased, while failing to provide clear information on cost and lacking desired patient and caregiver testimonials.nnnCONCLUSIONnWe found no formal PtDA designed primarily to help patients/families contemplating hospice. Furthermore, accessible online information about hospice does not appear to meet patient and caregiver decisional needs. These findings support the development and dissemination of high-quality decision support materials for hospice.

Empowering Older Adults to Make Medical Decisions: Two Solutions & A Problem

“Medical science and technology have advanced at anunprecedented rate during the past half-century. In tandem has come growing complexity of health care, which today is characterized by more to know, more to do, more to manage, more to watch, and more people involved than ever before...if the system cannot consistently deliver today’s science and technology, it is even less prepared to respond to the extraordinary advances that surely will emerge during the coming decades.”—Institute of Medicine, 2001, p 1.

Capsule Commentary on Mazer et. al., A Pilot Study of the Chronology of Present Illness: Restructuring the HPI to Improve Physician Cognition and Communication

M azer and colleagues report on a single-site trial of a new pat ient history-gathering format called the BChronology of Present Illness^ (CPI), in the hope of improving upon the more familiar BHistory of Present Illness^. According to the team’s previous work, structuring the histories in timeline format reduces the omission of critical information and facilitates ease of handoffs. Using data gathered in a cross-sectional pre–post mixed-method survey of residents and attending physicians, the goal of this study was to explore provider-reported experiences using this format. Substantial benefits are reported, especially those related to the gathering of more complete clinical data and ease of communication within the healthcare team. Challenges noted related to integrating CPI into clinical workflow, as it may increase time spent gathering information up front, and may be difficult to reconcile with existing patient histories (presumably recorded in the prose-heavy HPI format). While both benefits and challenges are contextualized with qualitative data, these findings are limited by the manner in which data were collected and the possible influence of social acquiescence among residents. In this case, participants were asked to report on the experience of using the HPI and CPI at the same time. Given that the participants knew that this study was investigating process improvements attributable to CPI, and that residents may feel obligated to report that the newer procedure was better, it is possible that they may have intentionally deflated their pre scores to allow for observable improvement at post. Indeed, reports from attending physicians—who are logically less likely to feel the need to please faculty mentors—illustrated a ceiling effect where observable improvement was not practically possible. The reported advantages of CPI remain compelling, nevertheless, and certainly warrant the application of more rigorous pragmatic trials as a next investigational step. This report illustrates the need for and application of improved patient history-taking. Methodological limitations notwithstanding, Mazer provides insight into possible quality and workflow improvements if CPI were broadly implemented and institutionalized, as well as a strong rationale to investigate the utility of CPI at other sites and with different methodologies.

Preliminary Development of an Informational Media Use Measure for Patients with Implanted Defibrillators: Toward a Model of Social–Ecological Assessment of Patient Education and Support

Social work interventions in health care, particularly those that involve working with people being treated for chronic and life-threatening conditions, frequently involve efforts to educate patients about their disease, treatment options, safety planning, medical adherence, and other associated issues. Despite an intuitive notion that patients access information about all of these issues through a variety of media-both inside and outside the clinical encounter, created by professionals and by others-there currently exists no validated means of assessing patients use of these forms of information. To address this gap, authors first created candidate item measures with input from both physicians and a small group of diverse patients who currently have an implantable cardioverter defibrillator (ICD), a sophisticated cardiac device for which a trajectory model of social work intervention was recently outlined. Authors then surveyed a group of 205 individuals who have these devices, assessing their use of various media to learn about ICDs. They then conducted factor and item analysis to refine and remove poorly performing items while delineating forms of media use by type. The resultant preliminary measure of informational media use can be further refined and adapted for use with any clinical population.