Letters
very few case reports of Chagas disease in those travelers. A diagnosis of chronic Chagas disease typically involves 2 or more serological tests for Trypanosoma cruzi because single assays do not have sufficient sensitivity and specificity to confirm infection.4 In this case, O’Brien had no signs or symptoms of chronic Chagas disease. Using extremely conservative assumptions including test reliability,4 we can calculate the posttest probability that chronic Chagas disease is present. In our analysis (available upon request from authors), the likelihood of Chagas disease remained less than 1% despite the positive serologic test for T cruzi. We sympathize with the anxiety our colleague suffered. We suspect that we each see patients each day suffering similar concerns. How many times might we order even more common tests when pretest probability of the disease in question is also low? And how often are we then left in the position of explaining abnormal tests to normal patients? We support a return to fundamental critical clinical thought; not just in treatment but also while contemplating testing. Chester B. Good, MD, MPH Mark McConnell, MD John R. Downs, MD Author Affiliations: Pittsburgh Healthcare System, Medicine, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania (Good); Oscar G Johnson Veterans Affairs Medical Clinic, Primary Care, Iron Mountain, Michigan (McConnell); University of Texas Health Sciences Center, San Antonio, Medicine, San Antonio (Downs). Corresponding Author: Chester B. Good, MD, MPH, VA Pittsburgh Healthcare System, Medicine, Center for Health Equity Research and Promotion, University Dr C, Pittsburgh, PA 15240 ([email protected]). Conflict of Interest Disclosures: None reported. 1. O’Brien M. An injudicious request—performing a test that is not indicated. JAMA Intern Med. 2015;175(10):1606-1607. 2. Centers for Disease Control and Prevention. Chagas Disease (American Trypanosomiasis). 2013. http://wwwnc.cdc.gov/travel/diseases/chagas-disease -american-trypanosomiasis. Updated August 14, 2014. Accessed September 2, 2015. 3. Office of Travel and Tourism Industries. U.S. Citizen Traffic to Overseas Regions, Canada & Mexico 2014. 2014. http://travel.trade.gov/view/m-2014-O -001/index.html. Accessed September 2, 2015. 4. Pereira GdeA, Louzada-Neto F, Barbosa VdeF, Ferreira-Silva MM, de Moraes-Souza H. Performance of six diagnostic tests to screen for Chagas disease in blood banks and prevalence of Trypanosoma cruzi infection among donors with inconclusive serology screening based on the analysis of epidemiological variables. Rev Bras Hematol Hemoter. 2012;34(4): 292-297.
In a separate response, Bydalek and Ruan explore the practical side of doing less. While I agree that the fear of both patient dissatisfaction and the legal ramifications of missed or delayed diagnosis may thwart judicious use of diagnostic tests, the shared decision–making model offers a solution rather than a barrier to these challenges. Truly shared decision making is not simply a presentation of the options and a request for the patient to choose among them. Practiced this way, the physician may shirk responsibility for the clinical and financial consequences of performing or not performing a test or intervention, underuse the years of training that honed her clinical judgment, and unduly burden a patient by shifting the responsibility for a difficult decision onto the patient. Instead, the anchors of a truly shared decision are a robust discussion of the patient’s personal beliefs, as well as an exploration of clinical rationale, the harms of doing less or more, a consideration of pretest probability, and the actionable outcomes of a test, and, given all the aforementioned, a physician’s recommendation to be considered by the patient. In my case, had my physician discussed my pretest probability of having Chagas disease and the limited options available for treatment, I would have asked her not to perform the test. I would have experienced fewer harms and would certainly have been more satisfied with the careful attention she gave to me and to my uninformed request. However, patientphysician conversations take time, a luxury few primary care physicians have under our current reimbursement structure that prioritizes procedures over counseling. Although I do not believe that tying reimbursements to patient satisfaction will be a panacea for health care reform, as we move toward this model, we should consider that evidence suggests patient satisfaction increases as appointments get longer.2 To my knowledge, there are no recent studies investigating how appointment length effects physician satisfaction, the rate of unnecessary testing, or the number of malpractice lawsuits. My suspicion is that longer appointments would allow time for important dialogue and relationship-building between physician and patients that may produce favorable outcomes on all accounts. Meghan O’Brien, MD, MBD Author Affiliation: Department of Internal Medicine, University of California-San Francisco, San Francisco. Corresponding Author: Meghan O’Brien, MD, MBD, Department of Internal Medicine, University of California-San Francisco, 1545 Divisidero St, San Francisco, CA 94143 ([email protected]). Conflict of Interest Disclosures: None reported.
In Reply I am so glad to see these responses to my previously published first-person account1 of the consequences of over-testing. Good and colleagues beautifully highlight the critical importance of considering pretest probability when deciding to order, and how to interpret, a test. As a practicing physician, I use the principle of the Bayes theorem in my decision making more than I understood how to do as a medical student, in part because its logic has allowed me to trust in the veracity of my own negative test result and quell the emotional effect of the initial (likely false-) positive result. I am grateful to Good and colleagues for the explicit reminder of this principle’s importance. jamainternalmedicine.com
1. O’Brien M. An injudicious request—performing a test that is not indicated. JAMA Intern Med. 2015;175(10):1606-1607. 2. Geraghty EM, Franks P, Kravitz RL. Primary care visit length, quality, and satisfaction for standardized patients with depression. J Gen Intern Med. 2007; 22(12):1641-1647.
Biomarkers in the Diagnosis of ST-Segment Elevation Myocardial Infarction To the Editor In a recent article published in JAMA Internal Medicine,1 Pourdjabbar et al reported 2 very interesting cases of electrocardiogram (ECG) test result misinterpretation, ow(Reprinted) JAMA Internal Medicine February 2016 Volume 176, Number 2
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of California - San Diego User on 02/02/2016
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Letters
ing to electrocardiographic artifacts.1 Pourdjabbar et al underlined that in the diagnosis process ECG testing is only 1 piece of the overall puzzle, which is correct. However, I disagree with their take-home point that biomarkers are essential in the diagnosis of ST-segment elevation myocardial infarctions and for making clinical decisions for these patients. The use of biomarkers are clearly pointed out in the American College of Cardiology Foundation guidelines2 and the European Society of Cardiology guidelines.3 It is known that biomarker (eg, troponin) elevation is delayed and can be missed in cases of early presenters. Furthermore, because the goal of STsegment elevation management is prompt reperfusion, waiting for the results of biomarkers before initiating reperfusion treatment would only worsen prognosis. Guillaume Leurent, MD Author Affiliation: Departement de Cardiologie et Maladies Vasculaires, CHU de Rennes, Rennes, France. Corresponding Author: Guillaume Leurent, MD, Departement de Cardiologie et Maladies Vasculaires, CHU de Rennes, 2 Rue Henri Le Guilloux, Rennes, France 35000 ([email protected]). Conflict of Interest Disclosures: None reported. Editorial Note: This letter was shown to the corresponding author of the original article, who declined to reply on behalf of the authors. 1. Pourdjabbar A, Green MS, Nery PB. ST-segment elevation interpretation on electrocardiogram: to cath or not to cath? JAMA Intern Med. 2015;175(10): 1695-1697. 2. O’Gara PT, Kushner FG, Ascheim DD, et al; American College of Emergency Physicians; Society for Cardiovascular Angiography and Interventions. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78-e140. 3. Steg PG, James SK, Atar D, et al; Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012; 33(20):2569-2619.
CORRECTION Incorrect Sentences in Discussion: In the Original Investigation entitled “Effect of Discontinuation of Antihypertensive Treatment in Elderly People on Cognitive Functioning—the DANTE Study Leiden: A Randomized Clinical Trial” published online August 24, 2105, and in the October 2015 issue of JAMA Internal Medicine,1 incorrect sentences appeared in the Discussion section. In the fourth paragraph of the Discussion, the last sentence, which was given as “Finally, by performing neuroimaging, we were able to assess the influence of cerebrovascular disease and CBF in a subset of participants.” should be replaced with “Finally, by performing neuroimaging in a subset of participants we were able to assess the effect of discontinuation of antihypertensive treatment in those persons with more cerebrovascular disease and/or lower cerebral blood flow at baseline.” Also, in the fifth paragraph, the fourth sentence, which was given as “Finally, by performing neuroimaging in a subset of participants we were able to assess the effect of discontinuation of
284
antihypertensive treatment in those persons with more cerebrovascular disease and/or lower cerebral blood flow at baseline.” should be replaced with “Finally, the DANTE trial investigated the effect of complete or partial discontinuation of different classes of antihypertensive treatment to achieve an increase in blood pressure.” This article was corrected online. 1. Moonen JEF, Foster-Dingley JC, de Ruijter W, et al. Effect of discontinuation of antihypertensive treatment in elderly people on cognitive functioning— the DANTE Study Leiden: a randomized clinical trial. JAMA Intern Med. 2015;175 (10):1622-1630. Error in Wording in the Abstract and Methods Section and Reworded Figure 2 Title and Caption: In the article by Sheridan et al1 titled “A Comparative Effectiveness Trial of Alternate Formats for Presenting Benefits and Harms Information for Low-Value Screening Services: A Randomized Clinical Trial,” published online on December 28, 2015, and in the January 2016 print issue, editorial errors occurred in the text in the abstract and Methods section. In the abstract (Design, Setting, and Participants and also Results), the 4 intervention arms were not described consistently as follows: words, numbers, numbers plus narrative, and numbers plus framed presentation. In the Potential Moderators of Intervention Impact subsection of the Methods section, the descriptions of the variables have been updated to aid in readability. In Figure 2, the title was updated to more accurately reflect the figure, and the Information Exposure Score information was deleted from the caption because it does not pertain to the figure. The article was corrected online on January 5, 2016. 1. Sheridan SL, Sutkowi-Hemstreet A, Barclay C, et al. A comparative effectiveness trial of alternate formats for presenting benefits and harms information for low-value screening services: a randomized clinical trial [published online December 28, 2015]. JAMA Intern Med. doi:10.1001 /jamainternmed.2015.7339. Correction to Introduction and Figure: In the Research Letter by Cullen et al1 published online December 7, 2015, the word “public” should have been deleted from the last sentence of the first paragraph of the article. In the Figure, the values in the key should have read “
very few case reports of Chagas disease in those travelers. A diagnosis of chronic Chagas disease typically involves 2 or more serological tests for Trypanosoma cruzi because single assays do not have sufficient sensitivity and specificity to confirm infection.4 In this case, O’Brien had no signs or symptoms of chronic Chagas disease. Using extremely conservative assumptions including test reliability,4 we can calculate the posttest probability that chronic Chagas disease is present. In our analysis (available upon request from authors), the likelihood of Chagas disease remained less than 1% despite the positive serologic test for T cruzi. We sympathize with the anxiety our colleague suffered. We suspect that we each see patients each day suffering similar concerns. How many times might we order even more common tests when pretest probability of the disease in question is also low? And how often are we then left in the position of explaining abnormal tests to normal patients? We support a return to fundamental critical clinical thought; not just in treatment but also while contemplating testing. Chester B. Good, MD, MPH Mark McConnell, MD John R. Downs, MD Author Affiliations: Pittsburgh Healthcare System, Medicine, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania (Good); Oscar G Johnson Veterans Affairs Medical Clinic, Primary Care, Iron Mountain, Michigan (McConnell); University of Texas Health Sciences Center, San Antonio, Medicine, San Antonio (Downs). Corresponding Author: Chester B. Good, MD, MPH, VA Pittsburgh Healthcare System, Medicine, Center for Health Equity Research and Promotion, University Dr C, Pittsburgh, PA 15240 ([email protected]). Conflict of Interest Disclosures: None reported. 1. O’Brien M. An injudicious request—performing a test that is not indicated. JAMA Intern Med. 2015;175(10):1606-1607. 2. Centers for Disease Control and Prevention. Chagas Disease (American Trypanosomiasis). 2013. http://wwwnc.cdc.gov/travel/diseases/chagas-disease -american-trypanosomiasis. Updated August 14, 2014. Accessed September 2, 2015. 3. Office of Travel and Tourism Industries. U.S. Citizen Traffic to Overseas Regions, Canada & Mexico 2014. 2014. http://travel.trade.gov/view/m-2014-O -001/index.html. Accessed September 2, 2015. 4. Pereira GdeA, Louzada-Neto F, Barbosa VdeF, Ferreira-Silva MM, de Moraes-Souza H. Performance of six diagnostic tests to screen for Chagas disease in blood banks and prevalence of Trypanosoma cruzi infection among donors with inconclusive serology screening based on the analysis of epidemiological variables. Rev Bras Hematol Hemoter. 2012;34(4): 292-297.
In a separate response, Bydalek and Ruan explore the practical side of doing less. While I agree that the fear of both patient dissatisfaction and the legal ramifications of missed or delayed diagnosis may thwart judicious use of diagnostic tests, the shared decision–making model offers a solution rather than a barrier to these challenges. Truly shared decision making is not simply a presentation of the options and a request for the patient to choose among them. Practiced this way, the physician may shirk responsibility for the clinical and financial consequences of performing or not performing a test or intervention, underuse the years of training that honed her clinical judgment, and unduly burden a patient by shifting the responsibility for a difficult decision onto the patient. Instead, the anchors of a truly shared decision are a robust discussion of the patient’s personal beliefs, as well as an exploration of clinical rationale, the harms of doing less or more, a consideration of pretest probability, and the actionable outcomes of a test, and, given all the aforementioned, a physician’s recommendation to be considered by the patient. In my case, had my physician discussed my pretest probability of having Chagas disease and the limited options available for treatment, I would have asked her not to perform the test. I would have experienced fewer harms and would certainly have been more satisfied with the careful attention she gave to me and to my uninformed request. However, patientphysician conversations take time, a luxury few primary care physicians have under our current reimbursement structure that prioritizes procedures over counseling. Although I do not believe that tying reimbursements to patient satisfaction will be a panacea for health care reform, as we move toward this model, we should consider that evidence suggests patient satisfaction increases as appointments get longer.2 To my knowledge, there are no recent studies investigating how appointment length effects physician satisfaction, the rate of unnecessary testing, or the number of malpractice lawsuits. My suspicion is that longer appointments would allow time for important dialogue and relationship-building between physician and patients that may produce favorable outcomes on all accounts. Meghan O’Brien, MD, MBD Author Affiliation: Department of Internal Medicine, University of California-San Francisco, San Francisco. Corresponding Author: Meghan O’Brien, MD, MBD, Department of Internal Medicine, University of California-San Francisco, 1545 Divisidero St, San Francisco, CA 94143 ([email protected]). Conflict of Interest Disclosures: None reported.
In Reply I am so glad to see these responses to my previously published first-person account1 of the consequences of over-testing. Good and colleagues beautifully highlight the critical importance of considering pretest probability when deciding to order, and how to interpret, a test. As a practicing physician, I use the principle of the Bayes theorem in my decision making more than I understood how to do as a medical student, in part because its logic has allowed me to trust in the veracity of my own negative test result and quell the emotional effect of the initial (likely false-) positive result. I am grateful to Good and colleagues for the explicit reminder of this principle’s importance. jamainternalmedicine.com
1. O’Brien M. An injudicious request—performing a test that is not indicated. JAMA Intern Med. 2015;175(10):1606-1607. 2. Geraghty EM, Franks P, Kravitz RL. Primary care visit length, quality, and satisfaction for standardized patients with depression. J Gen Intern Med. 2007; 22(12):1641-1647.
Biomarkers in the Diagnosis of ST-Segment Elevation Myocardial Infarction To the Editor In a recent article published in JAMA Internal Medicine,1 Pourdjabbar et al reported 2 very interesting cases of electrocardiogram (ECG) test result misinterpretation, ow(Reprinted) JAMA Internal Medicine February 2016 Volume 176, Number 2
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://archinte.jamanetwork.com/ by a University of California - San Diego User on 02/02/2016
283
Letters
ing to electrocardiographic artifacts.1 Pourdjabbar et al underlined that in the diagnosis process ECG testing is only 1 piece of the overall puzzle, which is correct. However, I disagree with their take-home point that biomarkers are essential in the diagnosis of ST-segment elevation myocardial infarctions and for making clinical decisions for these patients. The use of biomarkers are clearly pointed out in the American College of Cardiology Foundation guidelines2 and the European Society of Cardiology guidelines.3 It is known that biomarker (eg, troponin) elevation is delayed and can be missed in cases of early presenters. Furthermore, because the goal of STsegment elevation management is prompt reperfusion, waiting for the results of biomarkers before initiating reperfusion treatment would only worsen prognosis. Guillaume Leurent, MD Author Affiliation: Departement de Cardiologie et Maladies Vasculaires, CHU de Rennes, Rennes, France. Corresponding Author: Guillaume Leurent, MD, Departement de Cardiologie et Maladies Vasculaires, CHU de Rennes, 2 Rue Henri Le Guilloux, Rennes, France 35000 ([email protected]). Conflict of Interest Disclosures: None reported. Editorial Note: This letter was shown to the corresponding author of the original article, who declined to reply on behalf of the authors. 1. Pourdjabbar A, Green MS, Nery PB. ST-segment elevation interpretation on electrocardiogram: to cath or not to cath? JAMA Intern Med. 2015;175(10): 1695-1697. 2. O’Gara PT, Kushner FG, Ascheim DD, et al; American College of Emergency Physicians; Society for Cardiovascular Angiography and Interventions. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61(4):e78-e140. 3. Steg PG, James SK, Atar D, et al; Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC). ESC Guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012; 33(20):2569-2619.
CORRECTION Incorrect Sentences in Discussion: In the Original Investigation entitled “Effect of Discontinuation of Antihypertensive Treatment in Elderly People on Cognitive Functioning—the DANTE Study Leiden: A Randomized Clinical Trial” published online August 24, 2105, and in the October 2015 issue of JAMA Internal Medicine,1 incorrect sentences appeared in the Discussion section. In the fourth paragraph of the Discussion, the last sentence, which was given as “Finally, by performing neuroimaging, we were able to assess the influence of cerebrovascular disease and CBF in a subset of participants.” should be replaced with “Finally, by performing neuroimaging in a subset of participants we were able to assess the effect of discontinuation of antihypertensive treatment in those persons with more cerebrovascular disease and/or lower cerebral blood flow at baseline.” Also, in the fifth paragraph, the fourth sentence, which was given as “Finally, by performing neuroimaging in a subset of participants we were able to assess the effect of discontinuation of
284
antihypertensive treatment in those persons with more cerebrovascular disease and/or lower cerebral blood flow at baseline.” should be replaced with “Finally, the DANTE trial investigated the effect of complete or partial discontinuation of different classes of antihypertensive treatment to achieve an increase in blood pressure.” This article was corrected online. 1. Moonen JEF, Foster-Dingley JC, de Ruijter W, et al. Effect of discontinuation of antihypertensive treatment in elderly people on cognitive functioning— the DANTE Study Leiden: a randomized clinical trial. JAMA Intern Med. 2015;175 (10):1622-1630. Error in Wording in the Abstract and Methods Section and Reworded Figure 2 Title and Caption: In the article by Sheridan et al1 titled “A Comparative Effectiveness Trial of Alternate Formats for Presenting Benefits and Harms Information for Low-Value Screening Services: A Randomized Clinical Trial,” published online on December 28, 2015, and in the January 2016 print issue, editorial errors occurred in the text in the abstract and Methods section. In the abstract (Design, Setting, and Participants and also Results), the 4 intervention arms were not described consistently as follows: words, numbers, numbers plus narrative, and numbers plus framed presentation. In the Potential Moderators of Intervention Impact subsection of the Methods section, the descriptions of the variables have been updated to aid in readability. In Figure 2, the title was updated to more accurately reflect the figure, and the Information Exposure Score information was deleted from the caption because it does not pertain to the figure. The article was corrected online on January 5, 2016. 1. Sheridan SL, Sutkowi-Hemstreet A, Barclay C, et al. A comparative effectiveness trial of alternate formats for presenting benefits and harms information for low-value screening services: a randomized clinical trial [published online December 28, 2015]. JAMA Intern Med. doi:10.1001 /jamainternmed.2015.7339. Correction to Introduction and Figure: In the Research Letter by Cullen et al1 published online December 7, 2015, the word “public” should have been deleted from the last sentence of the first paragraph of the article. In the Figure, the values in the key should have read “
