Letters

Corresponding Author: Joan Y. Reede, MD, MPH, MS, Harvard Medical School, 164 Longwood, Ste 210, Boston, MA 02115 ([email protected]). Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported receiving grants from the Department of Health and Human Services Office of Minority Health, Commonwealth Fund, Josiah Macy Jr Foundation, Biomedical Science Careers Program, Health Resources and Services Administration, the National Institutes of Health (NIH), National Hispanic Medical Association, California Endowment, Novartis, Genzyme, and Merck; being the chair-elect of the Group on Diversity and Inclusion of the Association of American Medical Colleges; serving on the advisory committee and subcommittee on peer review to the NIH Director’s Working Group on Diversity; and serving on the advisory subcommittee to the deputy director for intramural research at the NIH. No other disclosures were reported. 1. Guevara JP, Adanga E, Avakame E, Carthon MB. Minority faculty development programs and underrepresented minority faculty representation at US medical schools. JAMA. 2013;310(21):2297-2304. 2. Massachusetts General Hospital Center for Faculty Development. Past events and programs. http://www2.massgeneral.org/facultydevelopment/cfd/past -events.html. Accessed December 19, 2013. 3. Ries A, Wingard D, Gamst A, Larsen C, Farrell E, Reznik V. Measuring faculty retention and success in academic medicine. Acad Med. 2012;87(8):1046-1051.

In Reply Mr Deng and Ms Chen raise concerns that the categorization of Asian faculty as nonunderrepresented minority faculty obscures barriers that Asian faculty continue to face. We concur that the underrepresentation of Asian faculty in senior leadership positions is a cause for concern. However, Asian faculty are not underrepresented among medical school faculty relative to their proportion in the general population.1 In data from the 124 eligible schools included in our study, Asian faculty accounted for 15.0% of all faculty in 2010, including 12.7% of all new faculty hires, 15.5% of all faculty promotions, and 8.6% of all full professors. The great strides in faculty representation achieved by Asian faculty in recent years are a cause for celebration, although clearly more work needs to be done at the top ranks. The focus of our study was on the more modest success in faculty representation achieved by black, Hispanic, Native American, Alaskan Native, Native Hawaiian, and Pacific Islander faculty. In 2010, these underrepresented minority faculty accounted for only 8.0% of all faculty, including 12.1% of all new faculty hires, 7.9% of all faculty promotions, and 4.3% of all full professors; all less than the proportions of Asian faculty. Dr Reede raises concerns that our study did not address institutional structure and program quality in its assessment of the association of minority faculty development programs with minority faculty representation. She relates that minority faculty development programs may affect minority representation differently in integrated health systems vs affiliated structures. She also suggests that program quality and variation may affect the results. We certainly agree. Palermo et al2 reviewed minority faculty development programs at 9 institutions and found significant heterogeneity in institutional and program structure. However, validated measures of institutional structure and program quality were lacking and development of such measures was beyond the scope of our study. We used public/private status, faculty size, and reputation ranking as proxy measures of institutional structure and for proxy measures of program quality, we used pro1158

gram duration, program components, and program intensity (duration × components). Future national studies of minority faculty development programs should develop and incorporate validated contextual measures of institutional structure and program quality into analyses. James Guevara, MD, MPH Emem Adanga, BA Margo Brooks Carthon, PhD Author Affiliations: Policylab, Center to Bridge Research, Practice, and Policy, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania (Guevara, Adanga); Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia (Carthon). Corresponding Author: James Guevara, MD, MPH, Children’s Hospital of Philadelphia, 34th and Civic Center Boulevard, Room 1531, Philadelphia, PA 19104 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. 1. Association of American Medical Colleges. Striving Toward Excellence: Faculty Diversity in Medical Education. Washington, DC: Association of American Medical Colleges; 2009. 2. Palermo AG, Soto-Greene ML, Taylor VS, et al. Diversity in academic medicine No. 5 successful programs in minority faculty development: overview. Mt Sinai J Med. 2008;75(6):523-532.

Patient Engagement Programs and Treatment of Depression To the Editor Dr Kravitz and colleagues1 reported results from a trial that compared depression outcomes among primary care patients who received a tailored interactive multimedia computer program (IMCP) on depression, a depression engagement video (DEV), or a control video unrelated to depression. Depression screening was an important component of the IMCP intervention. In the trial registration, Kravitz et al1 reported that the primary study outcomes were provision of minimally acceptable initial care, reductions in depression-related stigma, and improvement in depression symptoms. Minimally acceptable depression care included: (1) antidepressant prescription, (2) mental health referral, or (3) timely follow-up. In the published study protocol, which was submitted for review 9 months after completion of data collection2 and in the article reporting trial outcomes, Kravitz et al1 described only 1 primary outcome, provision of minimally acceptable depression care, although the definition no longer included timely follow-up. The authors reported that IMCP, but not DEV, significantly increased minimally acceptable depression care compared with control. Of the other registered primary outcomes, stigma was not discussed in the outcomes report. Depression symptoms were described as a secondary outcome, and neither IMCP nor DEV significantly reduced symptoms.1 Kravitz et al1 concluded that IMCP successfully increased appropriate depression care and that further research is needed to “determine effects on clinical outcomes and whether the benefits outweigh possible harms.” However, the depression care in this case would almost certainly have been inappro-

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priate for many of the individuals in the depressed cohort because the majority had Patient Health Questionnaire–9 (PHQ-9) scores of 5 through 9.1 Based on the true-positive screening rate among patients not already being treated for depression, fewer than half of primary care patients with scores above the standard PHQ-9 cutoff of 10 have depression, and most patients in the 5 through 9 range do not have depression that responds to antidepressant treatment.3,4 If Kravitz et al1 had reported their trial results in a manner consistent with their a priori registered trial outcomes, they would have concluded that IMCP with depression screening increased treatment without improving symptoms of depression. This is not surprising because a Cochrane Review5 found that depression screening increases recognition and treatment, but does not improve depression outcomes. The effect of changing the status of outcome variables on the interpretation of results of this study underscores the importance of leaving primary outcome variables unaltered after a trial is registered and data are collected. Brett D. Thombs, PhD Roy C. Ziegelstein, MD, MACP Author Affiliations: Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, Quebec, Canada (Thombs); Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland (Ziegelstein). Corresponding Author: Brett D. Thombs, PhD, Jewish General Hospital, 4333 Côte-Sainte-Catherine Rd, Montreal, QC H3T 1E4, Canada (brett.thombs @mcgill.ca). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Thombs reported receiving support from an investigator salary award from the Arthritis Society. Dr Ziegelstein reported receiving support from the Miller Family Scholar Program of the Johns Hopkins Center for Innovative Medicine. 1. Kravitz RL, Franks P, Feldman MD, et al. Patient engagement programs for recognition and initial treatment of depression in primary care: a randomized trial. JAMA. 2013;310(17):1818-1828. 2. Tancredi DJ, Slee CK, Jerant A, et al. Targeted versus tailored multimedia patient engagement to enhance depression recognition and treatment in primary care: randomized controlled trial protocol for the AMEP2 study. BMC Health Serv Res. 2013;13:141. 3. Thombs BD, Arthurs E, El-Baalbaki G, Meijer A, Ziegelstein RC, Steele R. Risk of bias from inclusion of patients who already have diagnosis of or are undergoing treatment for depression in diagnostic accuracy studies of screening tools for depression: a systematic review. BMJ. 2011;343:d4825. 4. Manea L, Gilbody S, McMillan D. Optimal cutoff score for diagnosing depression with the Patient Health Questionnaire (PHQ-9): a meta-analysis. CMAJ. 2012;184(3):191-196. 5. Gilbody S, Sheldon T, House A. Screening and case-finding instruments for depression: a meta-analysis. CMAJ. 2008;178(8):997-1003.

In Reply Drs Thombs and Ziegelstein note 3 differences between our study registration in May 2010 and the protocol published in BioMed Central (BMC) Health Services Research1 in April 2013 and the JAMA article. First, the follow-up interval was omitted from the primary composite process outcome due to lack of evidence for any particular follow-up interval and lack of specificity for the reason for follow-up. Subsequent reanalysis including follow-up interval in the process outcome did not materially affect the results (the results are available from the authors).

Second, stigma was omitted from the article because the complexity of the findings precluded adequate presentation within the space limitations and will be reported separately. Third, initial process outcomes and subsequent health status outcomes were presented and discussed in separate paragraphs of the article, allowing readers to discern the intervention effect on initial care and lack of effect on subsequent outcomes. Although preliminary data analysis occurred prior to submission of the trial protocol to BMC Health Services Research, changes in the operationalization of the primary outcome were made on scientific grounds (ie, not data driven). Furthermore, in the registry, we identified only 1 medication measure of potential intervention toxicity (antidepressant prescribing to nondepressed patients), whereas the article presented 2 measures: patient rec all of being recommended a prescription and physician report of prescribing an antidepressant. Had we reported only physician prescribing, we would have concluded no evidence of intervention toxicity. Patient recall of recommendations is a much more sensitive, albeit less specific, measure of the potential for toxicity. By using patient recall, we were unable to exclude potential toxicity of the interventions. We believe that reporting the findings in this way provided readers with a more complete understanding of the potential for harm. Thus, not only did we not overstate the benefits of the intervention, we did not understate the harms—indeed quite the opposite. We question the statement that depression screening was an important component of the IMCP intervention because PHQ-9 scores were not shared with the clinicians (except in instances of suicidal ideation). Rather, the IMCP used tailored motivational messages to encourage patients above a predefined symptom threshold to talk with physicians about their symptoms. Furthermore, although sample size limited power to detect a significant interaction, the IMCP effect on care process was confined to patients with more depression symptoms (PHQ-9 score ≥ 10) who are more likely to benefit from medication or counseling. Our article concluded that “a tailored IMCP increased clinician recommendations for antidepressant drugs, a mental health referral, or both among depressed patients but had no effect on mental health at the 12-week follow-up,” a more specific version of the conclusion than Thombs and Ziegelstein propose. We appreciate the importance of published trial registries and the need to document deviations, but we believe that slavish adherence to an original, flawed registry entry does not necessarily serve the interests of readers or science. Richard L. Kravitz, MD, MSPH Anthony Jerant, MD Daniel J. Tancredi, PhD Author Affiliations: Division of General Medicine, University of California Davis, Sacramento (Kravitz); Department of Family and Community Medicine, University of California Davis, Sacramento (Jerant); Center for Healthcare Policy and Research, University of California Davis, Sacramento (Tancredi). Corresponding Author: Richard L. Kravitz, MD, MSPH, University of California Davis, 4150 V St, Ste 2400, Sacramento, CA 94817 ([email protected]).

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Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. All 3 authors reported receiving grant funding from the National Institute of Mental Health. 1. Tancredi DJ, Slee CK, Jerant A, et al. Targeted versus tailored multimedia patient engagement to enhance depression recognition and treatment in primary care: randomized controlled trial protocol for the AMEP2 study. BMC Health Serv Res. 2013;13(1):141.

Strategies to Reduce Heart Failure Readmissions To the Editor The Viewpoint by Dr Butler and colleagues1 seems to misinterpret our recent work2 by suggesting that none of the 10 widely promoted strategies for reducing readmission for patients with heart failure was effective. Our study 2 evaluated the relationship between riskstandardized readmission rates and hospital strategies to improve transitions in care. A total of 599 hospitals (91% response rate) enrolled in the Hospital-to-Home quality campaign sponsored by the American College of Cardiology completed the survey. We found several individual strategies that were associated with significantly lower risk-standardized 30-day readmission rates in multivariable analysis. These strategies included partnering with community physicians and physician groups, partnering with local hospitals, having nurses responsible for medication reconciliation, arranging for follow-up visits before discharge, having a process in place to send all discharge or electronic summaries directly to the patient’s primary care physician, and assigning staff to follow up on test results after the patient is discharged. Hospitals that implemented more strategies had lower readmission rates by a clinically significant margin, although the magnitude of effects for any single strategy was modest. Physicians and researchers may be more satisfied with a magic bullet that single-handedly reduces readmissions; however, it is prudent to recognize the complexity of these processes and accept that multiple simultaneous interventions are needed to lower readmissions. If findings such as ours are misinterpreted to conclude nothing works, the national goals for improving important patient outcomes are unlikely to be achieved. Elizabeth H. Bradley, PhD Leslie A. Curry, MPH, PhD Harlan M. Krumholz, MD, SM Author Affiliations: Department of Health Management and Policy, Yale School of Public Health, New Haven, Connecticut. Corresponding Author: Elizabeth H. Bradley, PhD, Yale School of Public Health, 60 College St, New Haven, CT 06520 ([email protected]). Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Krumholz reported that he is the recipient of a research grant from Medtronic through Yale University; serves on the board of directors for ImageCor; has received payment for educational talks from Centrix; and chairs a cardiac scientific advisory board for United Health. No other disclosures were reported. 1. Butler J, Fonarow GC, Gheorghiade M. Need for increased awareness and evidence-based therapies for patients hospitalized for heart failure. JAMA. 2013;310(19):2035-2036. 2. Bradley EH, Curry L, Horwitz LI, et al. Hospital strategies associated with 30-day readmission rates for patients with heart failure. Circ Cardiovasc Qual Outcomes. 2013;6(4):444-450. 1160

In Reply We appreciate the efforts of Dr Bradley and colleagues to discover means to reduce readmissions after hospitalizations for heart failure. Our Viewpoint attempted to highlight the multiple issues that are related to the lack of progress in this area. In reference to the study by Bradley et al,1 we had 4 concerns. First, unlike myocardial infarction, for which quality improvement efforts implemented a robust set of acute interventions proven by randomized clinical trials, there are no such known interventions for heart failure hospitalizations and those that are being implemented are generic. Second, data regarding the effectiveness of these generic interventions have been inconsistent across studies. The Institute for Healthcare Improvement’s 5 Million Lives from Harm campaign committed to a 25% reduction in readmission for heart failure from 2006 to 2008 and used many of these interventions; yet despite thousands of hospitals participating, no reductions in readmission for heart failure were observed.2 Third, it is impossible to assess the value of these interventions considering that the risk reduction is low and no data exist on costs and how much hospitals must invest to develop the infrastructures to support these efforts. Bradley et al1 reported that individually no strategy was associated with a 0.4% or greater reduction in readmission rates, and the 5 strategies together represented an absolute 2% difference in readmissions. In addition, the findings from their study were internally inconsistent. The study also reported that 4 commonly recommended strategies by quality alliances were associated with higher readmission rates, which together would account for a 2% increase in readmission rates if these associations were causal. These strategies included outpatient and inpatient prescriptions linked electronically, patients/caregivers receiving written emergency plans, outpatient physicians alerted to a patient’s discharge within 48 hours, and calling patients regularly after discharge. The inconsistencies raise concern regarding noncausal findings for the positive associations, highlighting the need for prospective evaluation of these strategies before promoting broad uptake. Heart failure is not a single disease but a manifestation of distinct cardiac abnormalities and is complex. We caution that further rigorous evaluation is needed before there is widespread acceptance that a few generic interventions represent the solution to improving outcomes for this challenging high-risk patient population. We are optimistic that with adoption of a mechanistic approach,3 increased focus and investment to better understand the disease processes, taxonomy, and the various pathophysiological subgroups within this syndrome, and development of targeted therapies, outcomes for these patients postdischarge will follow the same trajectory as those for other cardiovascular diseases (eg, acute myocardial infarction or stroke) during the last 2 decades.4 Javed Butler, MD, MPH Gregg C. Fonarow, MD Mihai Gheorghiade, MD

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