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“New tools provide, for the first time, a mechanism for informal, self-directed just-in-time learning.”—Eugene Stead [(1)][1] The doubling time of medical knowledge has shortened dramatically—in 1950, it was 50 years; in 2010, 3.5 years; and by 2020, it is projected to be a mere 73

Patient-reported health data provide information for pragmatic trials that may not be readily available from electronic health records or administrative claims data. In this report, we present key considerations for collecting patient-reported health information in pragmatic clinical trials, which are informed by best practices from patient-reported outcome research. We focus on question design and question administration via electronic data collection platforms with respect to 3 types of patient-reported health data: medication use, utilization of health care services, and comorbid conditions. We summarize key scientific literature on the accuracy of these patient-reported data compared with electronic health record data. We discuss question design in detail, specifically defining the concept to be measured, patient understanding of the concept, recall periods of the question, and patient willingness to report. In addition, we discuss approaches for question administration and data collection platforms, which are key aspects of successful patient-reported data collection.

The Centers for Medicare and Medicaid Services (CMS) coverage with evidence development (CED) policy has significantly impacted cardiovascular services, enabling access to novel therapies like TAVR and ICDs while collecting outcome and/or facility data through clinical studies or registries. We

Background: Syncope is a common problem among older patients in the United States and national guidelines recommend a variety of tests to determine the etiology. However, few data are available regarding how tests are used nationwide and outcomes of patients presenting with syncope. Methods: Using the nationally representative 5% sample of Medicare beneficiaries 65 years or older, we identified patients who had at least 1 inpatient or 2 outpatient claims for syncope between 2001 and 2010. We excluded beneficiaries with a pacemaker or implantable cardioverter defibrillator in situ prior to the incident syncope encounter that required no prior claim of syncope in the prior 365 days. Results: The overall incidence of syncope in 2001 was 11.8 per 1000 person years and remained stable over time ranging from 10.3 to 14.6 per 1000 person years. The average age of beneficiaries with syncope was 79, with the majority being women (63.3%) and white (87.5%). Hypertension was the most common comorbid condition (84%) followed by coronary heart disease (46.5%). When considering the tests ordered within 90 days of the incident encounter, the most frequently ordered tests were CT head (57%) and echocardiogram (50%). Holter monitors were ordered for 18% of beneficiaries, implantable loop recorders for 0.2%, tilt table testing for 4% and electrophysiology study for 2.7% of beneficiaries. From 2001 to 2010, the frequency of these tests did not significantly vary. Mortality at one year was 13% overall (17% for inpatients and 6% for outpatients). All cause readmission at one year was 44% with readmissions for syncope 9% (figure). Conclusion: Syncope is a common condition and is associated with a high mortality and hospitalization within 1 year of initial presentation. Guideline recommended diagnostic tests are ordered infrequently and represent an opportunity to improve care by developing a structured approach for the evaluation of syncope.

Introduction: The use of Implantable Cardioverter-Defibrillators (ICDs) varies markedly by region of the country. One possible contributor to regional variation could be variability in physicians' attitudes towards ICDs. The objective of this study was to determine if physicians' attitudes torwards ICDs vary by region. Methods: A national sample of 10,080 members of the American College of Cardiology were surveyed regarding their attitudes towards ICDs. The survey included a hypothetical scenario asking respondents if they would recommend an ICD to an eligible patient with ischemic cardiomyopathy, followed by questions modifying the scenario by age, sex, and frailty as well as questions measuring attitudes towards ICDs and important factors in ICD decision-making. Respondents were placed into a hospital referral region (HRR) by zip code of their practice. Data were then merged with data from the National Cardiovascular Data Registry where rates of ICD implantation were determined for all Medicare beneficiaries in a given HRR. Multivariate linear and logistic regression analyses determined associations between the regional ICD utilization rate and respondents attitudes. Results: We received 1210 responses (response rate 12%) with no difference between responders and non-responders with respect to physician demographics. Physicians in regions of high and low ICD use were equally likely to recommend an ICD in the 60 yo male with ischemic cardiomyopathy scenario (~99%; p = N/A). They were also equally likely to recommend an ICD if the 60 yo patient was female (~99%; p = N/A) or if the 60 yo patient had non-ischemic cardiomyopathy (85 vs. 88% p = 0.85). Multivariate analyses determined that physicians in higher utilization regions were more likely to recommend ICD therapy if the patient was ‘frail’ (32% vs. 21%; p = 0.03) or if he had a life expectancy of less than one year (10% vs 5%; p = 0.05). Conclusions: Even when patient-level causes of regional variation are removed through alterations in hypothetical scenarios, cardiologists in regions of high ICD use are more likely to recommend ICDs in frail patients or patients with a life expectancy of less than one year. This suggests that variations in physician attitudes may contribute to regional variations in ICD use.

The management of atrial fibrillation (AF) has seen marked changes in past years, with the introduction of new oral anticoagulants, new antiarrhythmic drugs, and the emergence of catheter ablation as a common intervention for rhythm control. Furthermore, new technologies enhance our ability to detect AF. Most clinical management decisions in AF patients can be based on validated parameters that encompass type of presentation, clinical factors, electrocardiogram analysis, and cardiac imaging. Despite these advances, patients with AF are still at increased risk for death, stroke, heart failure, and hospitalizations. During the fourth Atrial Fibrillation competence NETwork/European Heart Rhythm Association (AFNET/EHRA) consensus conference, we identified the following opportunities to personalize management of AF in a better manner with a view to improve outcomes by integrating atrial morphology and damage, brain imaging, information on genetic predisposition, systemic or local inflammation, and markers for cardiac strain. Each of these promising avenues requires validation in the context of existing risk factors in patients. More importantly, a new taxonomy of AF may be needed based on the pathophysiological type of AF to allow personalized management of AF to come to full fruition. Continued translational research efforts are needed to personalize management of this prevalent disease in a better manner. All the efforts are expected to improve the management of patients with AF based on personalized therapy.