John R. Kues

Nonverbal expressions of anxiety in physician-patient interactions.

NONVERBAL expressions of anxiety were analyzed during patient presentation of conflicted emotional topics (i.e., hidden agendas) while consulting with family medicine practitioners. It was hypothesized that underlying anxiety would be revealed in higher frequencies of specific types of nonverbal behavior. As predicted, hand-to-body self-touching occurred significantly more often during presentation of anxiety-producing topics, while frequencies of speech-illustrative gestures did not differ for type of agenda presented. Applications for these findings are discussed with reference to medical and psychotherapy encounters.

Developing an Atrial Fibrillation Guideline Support Tool (AFGuST) for shared decision making

Abstract Objective: Patient values and preferences are an important component to decision making when tradeoffs exist that impact quality of life, such as tradeoffs between stroke prevention and hemorrhage in patients with atrial fibrillation (AF) contemplating anticoagulant therapy. Our objective is to describe the development of an Atrial Fibrillation Guideline Support Tool (AFGuST) to assist the process of integrating patients’ preferences into this decision. Materials and methods: CHA2DS2VASc and HAS-BLED were used to calculate risks for stroke and hemorrhage. We developed a Markov decision analytic model as a computational engine to integrate patient-specific risk for stroke and hemorrhage and individual patient values for relevant outcomes in decisions about anticoagulant therapy. Results: Individual patient preferences for health-related outcomes may have greater or lesser impact on the choice of optimal antithrombotic therapy, depending upon the balance of patient-specific risks for ischemic stroke and major bleeding. These factors have been incorporated into patient-tailored booklets which, along with an informational video, were developed through an iterative process with clinicians and patient focus groups. Key limitations: Current risk prediction models for hemorrhage, such as the HAS-BLED, used in the AFGuST, do not incorporate all potentially significant risk factors. Novel oral anticoagulant agents recently approved for use in the United States, Canada, and Europe have not been included in the AFGuST. Rather, warfarin has been used as a conservative proxy for all oral anticoagulant therapy. Conclusions: We present a proof of concept that a patient-tailored decision-support tool could bridge the gap between guidelines and practice by incorporating individual patient’s stroke and bleeding risks and their values for major bleeding events and stroke to facilitate a shared decision making process. If effective, the AFGuST could be used as an adjunct to published guidelines to enhance patient-centered conversations about the anticoagulation management.

The health beliefs of health fair participants

The motivations and health beliefs of adults who participate in community-based health promotion were studied through a survey of 303 adults attending five community health fairs. Subjects were predominately female (69.9%), over age 60 (66.8%), and had at least yearly contact with a family physician (85.3%). Obtaining laboratory testing services was the sole reason for attendance for 47% of participants, was thought to be of much greater importance than health educational materials also offered at the health fair, and identified as providing a sense of control over personal health care. Receiving their own normal test results was perceived as assuring a “healthy” future for 86% of participants and few used these results to support erroneous health beliefs. A theme of “positive health feedback”, identified through factor analysis of survey responses, may prove useful for family physicians to incorporate into more directed and useful health promotion efforts for enhanced patient participation and satisfaction.

Integrating Real-Time Clinical Information to Provide Estimates of Net Clinical Benefit of Antithrombotic Therapy for Patients With Atrial Fibrillation

Background—Guidelines for anticoagulant therapy in patients with atrial fibrillation are based on stroke risk as calculated by either the CHADS2 or the CHA2DS2VASc scores and do not integrate bleeding risk in an explicit, quantitative manner. Our objective was to quantify the net clinical benefit resulting from improved decision making about antithrombotic therapy. Methods and Results—This study is a retrospective cohort study of 1876 adults with nonvalvular atrial fibrillation or flutter seen in primary care settings of an integrated healthcare delivery system between December 2012 and January 2014. Projections for quality-adjusted life expectancy reported as quality-adjusted life-years were calculated by a decision analytic model that integrates patient-specific risk factors for stroke and hemorrhage and examines strategies of no antithrombotic therapy, aspirin, or oral anticoagulation with warfarin. Net clinical benefit was defined by the gain or loss in quality-adjusted life expectancy between current treatment and treatment recommended by an Atrial Fibrillation Decision Support Tool. Current treatment was discordant from treatment recommended by the Atrial Fibrillation Decision Support Tool in 931 patients. A clinically significant gain in quality-adjusted life expectancy (defined as ≥0.1 quality-adjusted life-years) was projected in 832 patients. Subgroups were examined. For example, oral anticoagulant therapy was recommended for 188 who currently were receiving no antithrombotic therapy. For the entire cohort, a total of 736 quality-adjusted life-years could be gained were treatment changed to that recommended by the Atrial Fibrillation Decision Support Tool. Conclusions—Use of a decision support tool that integrates patient-specific stroke and bleeding risk could result in significant gains in quality-adjusted life expectancy for a primary care population of patients with atrial fibrillation.

Impact of an Atrial Fibrillation Decision Support Tool on thromboprophylaxis for atrial fibrillation.

BACKGROUND Appropriate thromboprophylaxis for patients with atrial fibrillation (AF) remains a national challenge. METHODS We hypothesized that provision of decision support in the form of an Atrial Fibrillation Decision Support Tool (AFDST) would improve thromboprophylaxis for AF patients. We conducted a cluster randomized trial involving 15 primary care practices and 1,493 adults with nonvalvular AF in an integrated health care system between April 2014 and February 2015. Physicians in the intervention group received patient-level treatment recommendations made by the AFDST. Our primary outcome was the proportion of patients with antithrombotic therapy that was discordant from AFDST recommendation. RESULTS Treatment was discordant in 42% of 801 patients in the intervention group. Physicians reviewed reports for 240 patients. Among these patients, thromboprophylaxis was discordant in 63%, decreasing to 59% 1 year later (P = .02). In nonstratified analyses, changes in discordant care were not significantly different between the intervention group and control groups. In multivariate regression models, assignment to the intervention group resulted in a nonsignificant trend toward decreased discordance (P = .29), and being a patient of a resident physician (P = .02) and a higher HAS-BLED score predicted decreased discordance (P = .03), whereas female gender (P = .01) and a higher CHADSVASc score (P = .10) predicted increased discordance. CONCLUSIONS Among patients whose physicians reviewed recommendations of the decision support tool discordant therapy decreased significantly over 1 year. However, in nonstratified analyses, the intervention did not result in significant improvements in discordant antithrombotic therapy.

Using an Atrial Fibrillation Decision Support Tool for Thromboprophylaxis in Atrial Fibrillation: Effect of Sex and Age

To assess the appropriateness of oral anticoagulant therapy (OAT) in women and elderly adults, looking for patterns of undertreatment or unnecessary treatment.

The Development and Use of Gaming in Multidisciplinary Geriatric Education.

Many health care professionals have developed specialty training in geriatrics. Educational programs, however, are typically isolated from those of other professionals and many students in health care professions do not receive instruction in problem‐solving beyond a narrow clinical discipline. Problems that arise in the care of the elderly in long‐term institutions are complex and require problem‐solving strategies utilizing the expertise of professionals from many fields. The Game of Institutional Long‐Term Care was developed to help students from different disciplines learn how to solve patient‐management problems in nursing homes. The educational objectives of the game are (1) to teach students about the different goals and motivations of the key players in decision making, (2) to teach students how to identify and analyze problems, (3) to help students learn about the process of negotiation, compromise, and cooperation in problem‐solving, and (4) to expose students to the feelings and frustrations th...

The long-term impact of a performance improvement continuing medical education intervention on osteoporosis screening.

Introduction: The purpose of this study is to determine whether a performance improvement continuing medical education (PI CME) initiative that utilizes quality improvement (QI) principles is effective in producing sustainable change in practice to improve the screening of patients at risk for osteoporosis. Methodology: A health care center participated in a PI CME program designed to increase appropriate osteoporosis screening. There were eight 1‐hour educational sessions for this activity over a 9‐month period. Thirteen providers completed all 3 stages of the PI CME program. A variety of other clinicians, in addition to the 13 providers, participated in the educational sessions. Data were collected at the beginning and end of the PI CME activity and at three intervals during the 5 years after the completion of the activity. Results: The percentage of tests for osteoporosis ordered and performed increased significantly from Stage A to Stage C of the PI CME activity and continued to increase after the completion of the PI CME activity. Follow‐up data at 4 and 40 months (for ordering and performing osteoporosis screening) and 49 months (for performing the screening only) reflect the impact of the PI CME activity plus the continuing QI interventions. The percentage of BMD tests ordered continued to increase substantially over the post‐PI CME periods: 4 and 40 months (F(3,46) = 4.04, p < .05). Similarly, the percentage of BMD tests performed continued to increase at 4, 40, and 49 months after the conclusion of the PI CME activity (F(4,55) = 12.55, p < .0001). Discussion: The data indicate that PI CME utilizing QI principles can be effective in producing sustainable change in practice to improve the screening of patients at risk for osteoporosis. Further research is needed to determine the extent to which such changes can be directly attributed to this type of intervention.

Atrial fibrillation decision support tool: Population perspective

Background Appropriate thromboprophylaxis for patients with atrial fibrillation or atrial flutter (AF) remains a national challenge. The recent availability of direct oral anticoagulants (DOACs) with comparable efficacy and improved safety compared with warfarin alters the balance between risk factors for stroke and benefit of anticoagulation. Our objective was to examine the impact of DOACs as an alternative to warfarin on the net benefit of oral anticoagulant therapy (OAT) in a real‐world population of AF patients. Methods This is a retrospective cohort study of patients with paroxysmal or persistent nonvalvular AF. We updated an Atrial Fibrillation Decision Support Tool (AFDST) to include DOACs as treatment options. The tool generates patient‐specific recommendations based upon individual patient risk factor profiles for stroke and major bleeding using quality‐adjusted life‐years (QALYs) calculated for each treatment strategy by a decision analytic model. The setting included inpatient and ambulatory sites in an academic health center in the midwestern United States. The study involved 5,121 adults with nonvalvular AF seen for any ambulatory visit or inpatient hospitalization over the 1‐year period (January through December 2016). Outcome measure was net clinical benefit in QALYs. Results When DOACs are a therapeutic option, the AFDST recommends OAT for 4,134 (81%) patients and no antithrombotic therapy or aspirin for 489 (9%). A strong recommendation for OAT could not be made in 498 (10%) patients. When warfarin is the only option, OAT is recommended for 3,228 (63%) patients and no antithrombotic therapy or aspirin for 973 (19%). A strong recommendation for OAT could not be made in 920 (18%) patients. In total, 1,508 QALYs could be gained if treatment were changed to that recommended by the AFDST. Conclusions Availability of DOACs increases the proportion of patients for whom oral anticoagulation therapy is recommended in a real‐world cohort of AF patients and increased projected QALYs by more than 1,500 when all patients are receiving thromboprophylaxis as recommended by the AFDST compared with current treatment.

Dissemination of Evidence From Systematic Reviews Through Academic Cme Providers: A Feasibility Study

Introduction: Although systematic reviews represent a source of best evidence to support clinical decision-making, reviews are underutilized by clinicians. Barriers include lack of awareness, familiarity, and access. Efforts to promote utilization have focused on reaching practicing clinicians, leaving unexplored the roles of continuing medical education (CME) directors and faculty in promoting systematic review use. This study explored the feasibility of working with CME directors and faculty for that purpose. Methods: A convenience sample of five academic CME directors and faculty agreed to participate in a feasibility study exploring use in CME courses of systematic reviews from the Agency for Healthcare Research and Quality (AHRQ-SRs). AHRQ-SR topics addressed the comparative effectiveness of health care options. Participants received access to AHRQ-SR reports, associated summary products, and instructional resources. The feasibility study used mixed methods to assess 1) implementation of courses incorporating SR evidence, 2) identification of facilitators and barriers to integration, and 3) acceptability to CME directors, faculty, and learners. Results: Faculty implemented 14 CME courses of varying formats serving 1700 learners in urban, suburban, and rural settings. Facilitators included credibility, conciseness of messages, and availability of supporting materials; potential barriers included faculty unfamiliarity with SRs, challenges in maintaining review currency, and review scope. SR evidence and summary products proved acceptable to CME directors, course faculty, and learners by multiple measures. Discussion: This study demonstrates the feasibility of approaches to use AHRQ-SRs in CME courses/programming. Further research is needed to demonstrate generalizability to other types of CME providers and other systemic reviews.