Introduction: Lung cancer is the leading cause of cancer death in the U.S. Combusted tobacco use, the primary risk factor, accounts for 90% of all lung cancers. Early detection of lung cancer improves survival, yet lung cancer screening rates are much lower than those of other cancer screening tests. Electronic health record (EHR) systems are an underutilized tool that could improve screening rates.Methods: This study was conducted in the Rutgers Robert Wood Johnson Medical Group, a university-affiliated network in New Brunswick, NJ. Two novel EHR workflow prompts were implemented on July 1, 2018. These prompts included fields to determine tobacco use and lung cancer screening eligibility and facilitated low-dose computed tomography ordering for eligible patients. The prompts were designed to improve tobacco use data entry, allowing for better lung cancer screening eligibility identification. Data were analyzed in 2022 retrospectively for the period July 1, 2017 to June 30, 2019. The analyses represented 48,704 total patient visits.Results: The adjusted odds of patient record completeness to determine eligibility for low-dose computed tomography (AOR=1.19, 95% CI=1.15, 1.23), eligibility for low-dose computed tomography (AOR=1.59, 95% CI=1.38, 1.82), and whether low-dose computed tomography was ordered (AOR=1.04, 95% CI=1.01, 1.07) all significantly increased after the electronic medical record prompts were implemented.Conclusions: These findings show the utility and benefit of EHR prompts in primary care settings to increase identification for lung cancer screening eligibility as well as increased low-dose computed tomography ordering. Am J Prev Med 2023;65(5):892-895.(c) 2023 American Journal of Preventive Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Background: Inpatient portals are online platforms that allow patients to access their personal health information and monitor their health while in the acute care setting. Despite their potential to improve quality of care and empower patients and families to participate in their treatment, adoption remains low. Outpatient portal studies have shown that physician endorsement can drive patients' adoption of these systems. Insights on physicians' perspectives on use of these platforms can help improve patient and physician satisfaction and inpatient portal uptake.Objective: The purpose of this systematic review is to better understand physicians' perspectives toward inpatient portals.Methods: A systematic literature review was conducted for studies published between 1994 and November 2021 using keywords for physicians' perspectives toward patient portals and personal health records. Databases included PubMed, MEDLINE, Web of Science, and Scopus. Articles solely focused on nonphysician clinicians or addressing only outpatient settings or shared notes were excluded from this review. Two reviewers performed title, abstract, and full-text screening independently. Bias assessment was performed using the JBI SUMARI Critical Appraisal Tool (Joanna Briggs Institute). Inductive thematic analysis was done based on themes reported by original authors. Data were synthesized using narrative synthesis and reported according to overarching themes.Results: In all, 4199 articles were collected and 9 included. All but 2 of the studies were conducted in the United States. Common themes identified were communication and privacy, portal functionality and patient use, and workflow. In studies where physicians had no prior patient portal experience, concerns were expressed about communication issues created by patients' access to laboratory results and potential impact on existing workflow. Concerns about negative communication impacts were not borne out in postimplementation studies.Conclusions: Physicians perceived inpatient portals to be beneficial to patients and saw improvement in communication as a result. This is consistent with outpatient studies and highlights the need to improve training on portal use and include physicians during the design process. Health care organizations and information technology entities can take steps to increasing clinician comfort. Physician concerns involving patient portal usage and managing patient expectations also need to be addressed. With improved clinician support, initial pessimism about communication and workload issues can be overcome. Limitations of this review include the small number of pre-and postimplementation studies found. This is also not a review of perspectives on open notes, which merits separate discussion.

BackgroundTime of day has been associated with variations in certain clinical practices such as cancer screening rates. In this study, we assessed how more general process measures of physician activity, particularly rates of diagnostic test ordering and diagnostic assessments, might be affected by time of day.MethodsWe conducted a retrospective chart review of 3,342 appointments by 20 attending physicians at five outpatient clinics, matching appointments by physician and comparing the average diagnostic tests ordered and average diagnoses assessed per appointment in the first hour of the day versus the last hour of the day. Statistical analyses used sign tests, two-sample t-tests, Wilcoxon tests, Kruskal Wallis tests, and multivariate linear regression.ResultsExamining physicians individually, four and six physicians, respectively, had statistically significant first- versus last-hour differences in the number of diagnostic tests ordered and number of diagnoses assessed per patient visit (p ≤ 0.04). As a group, 16 of 20 physicians ordered more tests on average in the first versus last hour (p = 0.012 for equal chance to order more in each time period). Substantial intra-clinic heterogeneity was found in both outcomes for four of five clinics (p < 0.01).ConclusionsThere is some statistical evidence on an individual and group level to support the presence of time-of-day effects on the number of diagnostic tests ordered per patient visit. These findings suggest that time of day may be a factor influencing fundamental physician behavior and processes. Notably, many physicians exhibited significant variation in the primary outcomes compared to same-specialty peers. Additional work is necessary to clarify temporal and inter-physician variation in the outcomes of interest.

Clinical trials are a fundamental tool in evaluating the safety and efficacy of new drugs, medical devices, and health system interventions. Clinical trial visits generally involve eligibility assessment, enrollment, intervention administration, data collection, and follow-up, with many of these steps performed during face-to-face visits between participants and the investigative team. Social distancing, which emerged as one of the mainstay strategies for reducing the spread of SARS-CoV-2, has presented a challenge to the traditional model of clinical trial conduct, causing many research teams to halt all in-person contacts except for life-saving research. Nonetheless, clinical research has continued during the pandemic because study teams adapted quickly, turning to virtual visits and other similar methods to complete critical research activities. The purpose of this special communication is to document this rapid transition to virtual methodologies at Clinical and Translational Science Awards hubs and highlight important considerations for future development. Looking beyond the pandemic, we envision that a hybrid approach, which implements remote activities when feasible but also maintains in-person activities as necessary, will be adopted more widely for clinical trials. There will always be a need for in-person aspects of clinical research, but future study designs will need to incorporate remote capabilities.

Objectives: To provide a comprehensive overview of computerinterpretable guideline (CIG) systems aimed at non-experts. The overview includes the history of efforts to develop CIGs, features of and relationships among current major CIG systems, current status of standards developments pertinent to CIGs and identification of unsolved problems and needs for future research Methods: Literature review based on PubMed, AMIA conference proceedings and key references from publications identified. Search terms included practice guidelines, decision support, controlled vocabulary and medical record systems. Papers were reviewed by both authors and summarized narratively. Results: There is a consensus that guideline delivery systems must be integrated with electronic health records (EHRs) to be most effective. Several evolving CIG formalisms have in common, use of a task network model. There is currently no dominant CIG system. The major challenge in development of interoperable CIGs, is agreement on a standard controlled vocabulary. Such standards are under development, but not widely used, particularly in commercial EHR systems. The Virtual Medical Record (VMR) concept has been proposed as a standard that would serve as an intermediary between guideline vocabulary and that used in EHR implementation. Conclusion: CIG systems are in a state of evolution. Standards efforts promise to improve interoperability without compromising innovation. The VMR concept can assist guideline development even before clinical systems routinely adhere to standards. Frontiers for future work include using the principles learned by computer implementation of guidelines to improve the guideline development process and evaluation methods that isolate the effects of specific CIG features. Haux R, Kulikowski C, editors. IMIA Yearbook of Medical Informatics 2006. Methods Inf Med 2006; 45 Suppl 1: S145-58.

Introduction: The mortality from colorectal cancer (CRC) has declined in the last several decades because screening results in earlier diagnosis and treatment. The literature documents various methods that have improved CRC screening, including mail and phone call reminders, support groups, navigation systems, spiritual groups, and office visits. There have been no studies investigating the efficacy of medical trainees in a CRC screening project. Methods: Age appropriate patients who had not received any form of CRC screening at our Internal Medicine Clinic were complied. A gastroenterology fellow, medical resident, and medical student made individual phone calls to identify the barriers and reasons for which CRC screening had not been performed. Information was then provided to clarify misunderstandings, and a colonoscopy referral or a mailed FIT test was then offered if desired.Figure: These figures depict the total numbers of phone calls completed as well as the numbers of patients who had some form of screening already completed. Out of the 27 who had been screened already, 2 had obtained FIT tests and 25 patients had obtained colonoscopies.Figure: The first bar graph shows out of the patients who were reached, how many decided to get colonoscopies, FIT tests, and were Spanish speaking and thus not able to participate. The second bar graph showed the distribution of screening in patients who were reached and already had some form of screening.Results: Out of the 200 phone calls made, 65% (n=129) were not completed, and 35% (n=71) were completed. 38% (n=27) of the patients reached already had screening performed. Of the 44 patients who were reached who did not have prior screening, 16 colonoscopy referrals were made, 3 were sent FIT tests, 13 were going to obtain a colonoscopy on their own, 9 were not interested, and 3 were Spanish speaking only. The most common reason patients had not yet gotten a screening test was that they were busy with other priorities (n= 13), and 10 of them needed a reminder to schedule their colonoscopies. Conclusion: This study shows that phone calls from training doctors are efficacious in that patients successfully take advantage of health-care provider recommendations. Almost 75% of the patients reached had decided to undergo screening, either via referrals through our office or on their own, because of the additional information provided. A limitation of this method is that a large team of professionals would be required to reach the same volume of patients as letter reminders. Future directions may include having larger research personnel, sending letter reminders to the patients that could not be reached, and having a Spanish speaking trainee assisting with calls. Another secondary outcome identified was 38% of patients already had screening performed, highlighting a deficit in our documentation.

Objective To identify challenges, lessons learned and best practices for service-oriented clinical decision support, based on the results of the Clinical Decision Support Consortium, a multi-site study which developed, implemented and evaluated clinical decision support services in a diverse range of electronic health records. Methods Ethnographic investigation using the rapid assessment process, a procedure for agile qualitative data collection and analysis, including clinical observation, system demonstrations and analysis and 91 interviews. Results We identified challenges and lessons learned in eight dimensions: (1) hardware and software computing infrastructure, (2) clinical content, (3) human-computer interface, (4) people, (5) workflow and communication, (6) internal organizational policies, procedures, environment and culture, (7) external rules, regulations, and pressures and (8) system measurement and monitoring. Key challenges included performance issues (particularly related to data retrieval), differences in terminologies used across sites, workflow variability and the need for a legal framework. Discussion Based on the challenges and lessons learned, we identified eight best practices for developers and implementers of service-oriented clinical decision support: (1) optimize performance, or make asynchronous calls, (2) be liberal in what you accept (particularly for terminology), (3) foster clinical transparency, (4) develop a legal framework, (5) support a flexible front-end, (6) dedicate human resources, (7) support peer-to-peer communication, (8) improve standards. Conclusion The Clinical Decision Support Consortium successfully developed a clinical decision support service and implemented it in four different electronic health records and four diverse clinical sites; however, the process was arduous. The lessons identified by the Consortium may be useful for other developers and implementers of clinical decision support services.

BackgroundThis guideline focuses on long-term administration of antithrombotic drugs designed for primary and secondary prevention of cardiovascular disease, including two new antiplatelet therapies.MethodsThe methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement.ResultsWe present 23 recommendations for pertinent clinical questions. For primary prevention of cardiovascular disease, we suggest low-dose aspirin (75-100 mg/d) in patients aged > 50 years over no aspirin therapy (Grade 2B). For patients with established coronary artery disease, defined as patients 1-year post-acute coronary syndrome, with prior revascularization, coronary stenoses > 50% by coronary angiogram, and/or evidence for cardiac ischemia on diagnostic testing, we recommend long-term low-dose aspirin or clopidogrel (75 mg/d) (Grade 1A). For patients with acute coronary syndromes who undergo percutaneous coronary intervention (PCI) with stent placement, we recommend for the first year dual antiplatelet therapy with low-dose aspirin in combination with ticagrelor 90 mg bid, clopidogrel 75 mg/d, or prasugrel 10 mg/d over single antiplatelet therapy (Grade 1B). For patients undergoing elective PCI with stent placement, we recommend aspirin (75-325 mg/d) and clopidogrel for a minimum duration of 1 month (bare-metal stents) or 3 to 6 months (drug-eluting stents) (Grade 1A). We suggest continuing low-dose aspirin plus clopidogrel for 12 months for all stents (Grade 2C). Thereafter, we recommend single antiplatelet therapy over continuation of dual antiplatelet therapy (Grade 1B).ConclusionsRecommendations continue to favor single antiplatelet therapy for patients with established coronary artery disease. For patients with acute coronary syndromes or undergoing elective PCI with stent placement, dual antiplatelet therapy for up to 1 year is warranted. This guideline focuses on long-term administration of antithrombotic drugs designed for primary and secondary prevention of cardiovascular disease, including two new antiplatelet therapies. The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. We present 23 recommendations for pertinent clinical questions. For primary prevention of cardiovascular disease, we suggest low-dose aspirin (75-100 mg/d) in patients aged > 50 years over no aspirin therapy (Grade 2B). For patients with established coronary artery disease, defined as patients 1-year post-acute coronary syndrome, with prior revascularization, coronary stenoses > 50% by coronary angiogram, and/or evidence for cardiac ischemia on diagnostic testing, we recommend long-term low-dose aspirin or clopidogrel (75 mg/d) (Grade 1A). For patients with acute coronary syndromes who undergo percutaneous coronary intervention (PCI) with stent placement, we recommend for the first year dual antiplatelet therapy with low-dose aspirin in combination with ticagrelor 90 mg bid, clopidogrel 75 mg/d, or prasugrel 10 mg/d over single antiplatelet therapy (Grade 1B). For patients undergoing elective PCI with stent placement, we recommend aspirin (75-325 mg/d) and clopidogrel for a minimum duration of 1 month (bare-metal stents) or 3 to 6 months (drug-eluting stents) (Grade 1A). We suggest continuing low-dose aspirin plus clopidogrel for 12 months for all stents (Grade 2C). Thereafter, we recommend single antiplatelet therapy over continuation of dual antiplatelet therapy (Grade 1B). Recommendations continue to favor single antiplatelet therapy for patients with established coronary artery disease. For patients with acute coronary syndromes or undergoing elective PCI with stent placement, dual antiplatelet therapy for up to 1 year is warranted.

BACKGROUND This guideline focuses on long-term administration of antithrombotic drugs designed for primary and secondary prevention of cardiovascular disease, including two new antiplatelet therapies. METHODS The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS We present 23 recommendations for pertinent clinical questions. For primary prevention of cardiovascular disease, we suggest low-dose aspirin (75-100 mg/d) in patients aged > 50 years over no aspirin therapy (Grade 2B). For patients with established coronary artery disease, defined as patients 1-year post-acute coronary syndrome, with prior revascularization, coronary stenoses > 50% by coronary angiogram, and/or evidence for cardiac ischemia on diagnostic testing, we recommend long-term low-dose aspirin or clopidogrel (75 mg/d) (Grade 1A). For patients with acute coronary syndromes who undergo percutaneous coronary intervention (PCI) with stent placement, we recommend for the first year dual antiplatelet therapy with low-dose aspirin in combination with ticagrelor 90 mg bid, clopidogrel 75 mg/d, or prasugrel 10 mg/d over single antiplatelet therapy (Grade 1B). For patients undergoing elective PCI with stent placement, we recommend aspirin (75-325 mg/d) and clopidogrel for a minimum duration of 1 month (bare-metal stents) or 3 to 6 months (drug-eluting stents) (Grade 1A). We suggest continuing low-dose aspirin plus clopidogrel for 12 months for all stents (Grade 2C). Thereafter, we recommend single antiplatelet therapy over continuation of dual antiplatelet therapy (Grade 1B). CONCLUSIONS Recommendations continue to favor single antiplatelet therapy for patients with established coronary artery disease. For patients with acute coronary syndromes or undergoing elective PCI with stent placement, dual antiplatelet therapy for up to 1 year is warranted.

ObjectivesThis article provides recommendations on the use of antithrombotic therapy in patients with stroke or transient ischemic attack (TIA).MethodsWe generated treatment recommendations (Grade 1) and suggestions (Grade 2) based on high (A), moderate (B), and low (C) quality evidence.ResultsIn patients with acute ischemic stroke, we recommend IV recombinant tissue plasminogen activator (r-tPA) if treatment can be initiated within 3 h (Grade 1A) or 4.5 h (Grade 2C) of symptom onset; we suggest intraarterial r-tPA in patients ineligible for IV tPA if treatment can be initiated within 6 h (Grade 2C); we suggest against the use of mechanical thrombectomy (Grade 2C) although carefully selected patients may choose this intervention; and we recommend early aspirin therapy at a dose of 160 to 325 mg (Grade 1A). In patients with acute stroke and restricted mobility, we suggest the use of prophylactic-dose heparin or intermittent pneumatic compression devices (Grade 2B) and suggest against the use of elastic compression stockings (Grade 2B). In patients with a history of noncardioembolic ischemic stroke or TIA, we recommend long-term treatment with aspirin (75-100 mg once daily), clopidogrel (75 mg once daily), aspirin/extended release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) over no antiplatelet therapy (Grade 1A), oral anticoagulants (Grade 1B), the combination of clopidogrel plus aspirin (Grade 1B), or triflusal (Grade 2B). Of the recommended antiplatelet regimens, we suggest clopidogrel or aspirin/extended-release dipyridamole over aspirin (Grade 2B) or cilostazol (Grade 2C). In patients with a history of stroke or TIA and atrial fibrillation we recommend oral anticoagulation over no antithrombotic therapy, aspirin, and combination therapy with aspirin and clopidogrel (Grade 1B).ConclusionsThese recommendations can help clinicians make evidence-based treatment decisions with their patients who have had strokes. This article provides recommendations on the use of antithrombotic therapy in patients with stroke or transient ischemic attack (TIA). We generated treatment recommendations (Grade 1) and suggestions (Grade 2) based on high (A), moderate (B), and low (C) quality evidence. In patients with acute ischemic stroke, we recommend IV recombinant tissue plasminogen activator (r-tPA) if treatment can be initiated within 3 h (Grade 1A) or 4.5 h (Grade 2C) of symptom onset; we suggest intraarterial r-tPA in patients ineligible for IV tPA if treatment can be initiated within 6 h (Grade 2C); we suggest against the use of mechanical thrombectomy (Grade 2C) although carefully selected patients may choose this intervention; and we recommend early aspirin therapy at a dose of 160 to 325 mg (Grade 1A). In patients with acute stroke and restricted mobility, we suggest the use of prophylactic-dose heparin or intermittent pneumatic compression devices (Grade 2B) and suggest against the use of elastic compression stockings (Grade 2B). In patients with a history of noncardioembolic ischemic stroke or TIA, we recommend long-term treatment with aspirin (75-100 mg once daily), clopidogrel (75 mg once daily), aspirin/extended release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) over no antiplatelet therapy (Grade 1A), oral anticoagulants (Grade 1B), the combination of clopidogrel plus aspirin (Grade 1B), or triflusal (Grade 2B). Of the recommended antiplatelet regimens, we suggest clopidogrel or aspirin/extended-release dipyridamole over aspirin (Grade 2B) or cilostazol (Grade 2C). In patients with a history of stroke or TIA and atrial fibrillation we recommend oral anticoagulation over no antithrombotic therapy, aspirin, and combination therapy with aspirin and clopidogrel (Grade 1B). These recommendations can help clinicians make evidence-based treatment decisions with their patients who have had strokes.

Representatives from a consortium of academic institutions, healthcare organisations, and commercial entities have collaborated to implement and evaluate a multi–layered representation framework targeted to promote the sharing and distribution of clinical practice guideline knowledge artefacts. Definition of a metadata model for knowledge artefacts submitted to a shared repository based on this framework proceeded through an iterative process that sought to strike a balance between the need to provide enough specification to allow for efficient indexing and retrieval and recognition of the potential burden imposed by excessive requirements.

OBJECTIVES:This article provides recommendations on the use of antithrombotic therapy in patients with stroke or transient ischemic attack (TIA). METHODS:We generated treatment recommendations (Grade 1) and suggestions (Grade 2) based on high (A), moderate (B), and low (C) quality evidence. RESULTS:In patients with acute ischemic stroke, we recommend IV recombinant tissue plasminogen activator (r-tPA) if treatment can be initiated within 3 h (Grade 1A) or 4.5 h (Grade 2C) of symptom onset; we suggest intraarterial r-tPA in patients ineligible for IV tPA if treatment can be initiated within 6 h (Grade 2C); we suggest against the use of mechanical thrombectomy (Grade 2C) although carefully selected patients may choose this intervention; and we recommend early aspirin therapy at a dose of 160 to 325 mg (Grade 1A). In patients with acute stroke and restricted mobility, we suggest the use of prophylactic-dose heparin or intermittent pneumatic compression devices (Grade 2B) and suggest against the use of elastic compression stockings (Grade 2B). In patients with a history of noncardioembolic ischemic stroke or TIA, we recommend long-term treatment with aspirin (75-100 mg once daily), clopidogrel (75 mg once daily), aspirin/extended release dipyridamole (25 mg/200 mg bid), or cilostazol (100 mg bid) over no antiplatelet therapy (Grade 1A), oral anticoagulants (Grade 1B), the combination of clopidogrel plus aspirin (Grade 1B), or triflusal (Grade 2B). Of the recommended antiplatelet regimens, we suggest clopidogrel or aspirin/extended-release dipyridamole over aspirin (Grade 2B) or cilostazol (Grade 2C). In patients with a history of stroke or TIA and atrial fibrillation we recommend oral anticoagulation over no antithrombotic therapy, aspirin, and combination therapy with aspirin and clopidogrel (Grade 1B). CONCLUSIONS:These recommendations can help clinicians make evidence-based treatment decisions with their patients who have had strokes.

BACKGROUND:Computer-based clinical decision support (CDS) systems have been shown to improve quality of care and workflow efficiency, and health care reform legislation relies on electronic health records and CDS systems to improve the cost and quality of health care in the United States; however, the heterogeneity of CDS content and infrastructure of CDS systems across sites is not well known. OBJECTIVE:We aimed to determine the scope of CDS content in diabetes care at six sites, assess the capabilities of CDS in use at these sites, characterize the scope of CDS infrastructure at these sites, and determine how the sites use CDS beyond individual patient care in order to identify characteristics of CDS systems and content that have been successfully implemented in diabetes care. METHODS:We compared CDS systems in six collaborating sites of the Clinical Decision Support Consortium. We gathered CDS content on care for patients with diabetes mellitus and surveyed institutions on characteristics of their site, the infrastructure of CDS at these sites, and the capabilities of CDS at these sites. RESULTS:The approach to CDS and the characteristics of CDS content varied among sites. Some commonalities included providing customizability by role or user, applying sophisticated exclusion criteria, and using CDS automatically at the time of decision-making. Many messages were actionable recommendations. Most sites had monitoring rules (e.g. assessing hemoglobin A1c), but few had rules to diagnose diabetes or suggest specific treatments. All sites had numerous prevention rules including reminders for providing eye examinations, influenza vaccines, lipid screenings, nephropathy screenings, and pneumococcal vaccines. CONCLUSION:Computer-based CDS systems vary widely across sites in content and scope, but both institution-created and purchased systems had many similar features and functionality, such as integration of alerts and reminders into the decision-making workflow of the provider and providing messages that are actionable recommendations.

Background: The survival benefit of heart transplantation (HT) compared to current optimal medical therapy (OMT) or Ventricular Assist Device (VAD) implantation in heart failure has never been assessed directly. Methods: We created a decision analytic model that simulates a randomized clinical trial of OMT versus HT versus VAD for New York Heart Association (NYHA) class I-IV heart failure (HF). The model simulates average life expectancy. The following assumptions were made for OMT annual mortality: class I confers no excess mortality; class II and III mortalities are based on Sudden Cardiac Death in Heart Failure Study (SCD-HeFT) and assumed to be 4.4% and 13.2% per patient year of follow-up respectively. Class IV annualized mortality for OMT is based on Scientific Registry of Transplant Recipients(SRTR) data for Status 1A and 1B patients (class 4A and 4B) listed for transplantation and assumed to be 53.6% for status 1A and 32.6% for Status 1B. HT mortality rates were based on survival curves for HT 1982–2001 from the International Society of Heart and Lung Transplantation. VAD mortality was 41% per year based on information from later enrolled Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure REMATCH trial patients. Results: Destination therapy for LVAD had an expected survival of 17 months regardless of preceding heart failure class and was not favored over OMT or HT for any class. For Classes I and II, OMT was the favored strategy with gains over HT of 108 months and 29 months respectively and with gains over LVAD of 211 months and 128 months respectively. For Classes III, IV-A and IV-B, HT was favored with gains over OMT of 31, 61 and 54 months, respectively and gains over LVAD of 58, 8 and 25 months, respectively. For Class IV-A, mortality following LVAD placement would have to decrease by 33% (to 0.028 monthly) for LVAD to equal OMT. For Class IV-B, mortality following LVAD placement would have to decrease by 67% to 0.014 monthly for LVAD to equal OMT. Conclusions: Our model predicts that currently, OMT is superior to HT or VAD for classes I & II, but HT is superior to both OMT and VAD for class III and IV. However, future advances in OMT, VAD or HT may change the relative benefits of these treatment modalities.