Publications

BACKGROUND

Interprofessional health care team members consider advance care planning (ACP) to be important, yet gaps remain in systematic clinical routines to support ACP. A clearer understanding of the interprofessional team members' perspectives on ACP clinical routines in diverse settings is needed.

METHODS

One hundred eighteen health care team members from community-based clinics, long-term care facilities, academic clinics, federally qualified health centers, and hospitals participated in a 35-question, cross-sectional online survey to assess clinical routines, workflow processes, and policies relating to ACP.

RESULTS

Respondents were 53% physicians, 18% advanced practice nurses, 11% nurses, and 18% other interprofessional team members including administrators, chaplains, social workers, and others. Regarding clinical routines, respondents reported that several interprofessional team members play a role in facilitating ACP (ie, physician, social worker, nurse, others). Most (62%) settings did not have, or did not know of, policies related to ACP documentation. Only 14% of settings had a patient education program. Two-thirds of the respondents said that addressing ACP is a high priority and 85% felt that nonphysicians could have ACP conversations with appropriate training. The clinical resources needed to improve clinical routines included training for providers and staff, dedicated staff to facilitate ACP, and availability of patient/family educational materials.

CONCLUSION

Although interprofessional health care team members consider ACP a priority and several team members may be involved, clinical settings lack systematic clinical routines to support ACP. Patient educational materials, interprofessional team training, and policies to support ACP clinical workflows that do not rely solely on physicians could improve ACP across diverse clinical settings.

Over the past several years, there have been major advances in cardiovascular positron emission tomography (PET) in combination with either computed tomography (CT) or, more recently, cardiovascular magnetic resonance (CMR). These multi-modality approaches have significant potential to leverage the strengths of each modality to improve the characterization of a variety of cardiovascular diseases and to predict clinical outcomes. This review will discuss current developments and potential future uses of PET/CT and PET/CMR for cardiovascular applications, which promise to add significant incremental benefits to the data provided by each modality alone.

IMPORTANCE

The American College of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of blood cholesterol and the current European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines differ in how they identify adults in need of statin therapy; furthermore, it is unclear how this difference translates into numbers and characteristics of patients recommended for treatment.

OBJECTIVE

To determine the effect of the ACC/AHA and ESC/EAS cholesterol guidelines when applied to a population-based sample.

DESIGN, SETTING, AND PARTICIPANTS

We used nationally representative data for 3055 adults aged 40 to 65 years from the 2007-2012 National Health and Nutrition Examination Surveys (NHANES) for the United States and for 1060 adults aged 40 to 65 years from the 2011 Nadciśnięnie Tętnicze w Polsce survey for Poland. Data analysis was conducted from May 1, 2014, to December 31, 2015.

MAIN OUTCOMES AND MEASURES

The number and characteristics of adults recommended for statin therapy according to the ACC/AHA and ESC/EAS guidelines were evaluated, and characteristics were compared between adults with discordant recommendations.

RESULTS

The 3136 US adults in NHANES (2007-2012) aged 40 to 65 years represented 100.1 million adults; after excluding the 81 patients with missing data, these population estimates translate to 97.9 million adults. Similarly, the 1060 Polish adults in NATPOL (2011) aged 40 to 65 years represent 13.5 million adults. Using weighted data, in the United States, 43.8% (95% CI, 40.9%-46.7%) of adults would be recommended for statin therapy according to ACC/AHA guidelines and 39.1% (95% CI, 36.4%-41.8%) according to ESC/EAS guidelines. In Poland, 49.9% (95% CI, 46.9%-52.9%) of adults would be recommended for statin therapy under ACC/AHA guidelines compared with 47.6% (95% CI, 44.6%-50.7%) under ESC/EAS guidelines. Among individuals without cardiovascular disease and not currently taking statins, 11.0% of US and 10.5% of Polish adults had discordant guideline recommendations. Compared with individuals recommended for statin therapy by the ESC/EAS guidelines but not the ACC/AHA guidelines, those recommended for statin therapy under the ACC/AHA guidelines only had less chronic kidney disease; however, these individuals were also more likely to smoke, have lower high-density lipoprotein cholesterol levels, and have higher predicted 10-year risk of cardiovascular disease.

CONCLUSIONS AND RELEVANCE

Despite differences in the ACC/AHA and EAS/ESC guidelines, the numbers of adults aged 40 to 65 years recommended for cholesterol-lowering therapy under each guideline were similar when applied to nationwide representative samples from both the United States and Poland. Discordant recommendations were driven by differences in the risk equations used in the 2 guidelines and different recommendations for adults with chronic kidney disease.