PURPOSE:Serious illness communication skills are essential for physicians, yet competency-based training is lacking. We address scalability barriers to competency-based communication skills training by assessing the feasibility of a multi-center, virtual simulation-based mastery learning (vSBML) curriculum on breaking bad news (BBN). METHODS:First-year emergency medicine residents at three academic medical centers participated in the virtual curriculum. Participants completed a pretest with a standardized patient (SP), a workshop with didactics and small group roleplay with SPs, a posttest with an SP, and additional deliberate practice sessions if needed to achieve the minimum passing standard (MPS). Participants were assessed using a previously published BBN assessment tool that included a checklist and scaled items. Authors compared pre- and posttests to evaluate the impact of the curriculum. RESULTS:Twenty-eight (90%) of 31 eligible residents completed the curriculum. Eighty-nine percent of participants did not meet the MPS at pretest. Post-intervention, there was a statistically significant improvement in checklist performance (Median= 93% vs. 53%, p < 0.001) and on all scaled items assessing quality of communication. All participants ultimately achieved the MPS. CONCLUSIONS:A multi-site vSBML curriculum brought all participants to mastery in the core communication skill of BBN and represents a feasible, scalable model to incorporate competency-based communication skills education in a widespread manner.

Endovascular revascularization of the superficial femoral artery (SFA) may lead to recurrent ischemic syndromes, revascularization, or amputation. The impact of these events on mortality is unknown. We followed all patients having SFA endovascular revascularization for claudication or chronic limb-threatening ischemia in 2 cardiovascular (CV) divisions in Boston, Massachusetts. Any recurrent limb event after the initial SFA revascularization included recurrent claudication (67%), limb ulceration or gangrene (13%), repeat endovascular revascularization (61%), surgical revascularization (15%), or major (9%) or minor amputation (8%). We linked data to the National Death Index to ascertain cause of death grouped into CV mortality, or non-CV mortality. Hazard ratios (HRs) and 95% confidence intervals (95% CIs) from Cox proportional hazards and subHRs from Fine-Gray competing risks analyses were clustered by patient. Overall, there were 202 patients with 253 index limb endovascular procedures. A recurrent limb event occurred in 123 limbs (49%) and 93 patients (46%). Patients with and without recurrent limb events had similar numbers of deaths over follow-up (76 [62%] vs 71 [55%], respectively). In multivariable models, recurrent limb event was not related to all-cause death (HR 0.92, 95% CI 0.64 to 1.33), CV death (HR 1.29, 95% CI 0.72 to 1.30), or non-CV death (HR 0.65, CI 0.39 to 1.07). Competing risk analyses suggested male gender and chronic limb-threatening ischemia were more strongly related to CV death, and chronic kidney more strongly related to disease to non-CV death. In conclusion, recurrent limb events, which contribute to patient morbidity, do not increase the risk of all-cause or cause -specific mortality, and should not discourage repeat revascularization to relieve symptoms or ischemia. Published by Elsevier Inc. (Am J Cardiol 2023;205:425-430)

clinicians (69 teams), consisting of nurses (52%), social workers (35%), and chaplains (13%), attended the courses.The pre-course survey revealed spiritual and cultural aspects of care as participants' least effective areas of communication across the NCP domains.Postcourse evaluations, on a scale of 1 to 5 (1=lowest), revealed the course met participants' expectations (4.8), and the spiritual (4.8) and cultural (4.8) modules were most useful to their practice.Cohort 1 and 2's 6and 12-month follow-up revealed 1,802 clinicians (1,083 nurses, 220 social workers, 87 chaplains, 176 physicians, and 236 others) have been trained.Conclusion.ICC is an effective train-the-trainer program, and the NCP guidelines serve as an effective framework for teaching communication.A 12-month follow-up on course 2 is scheduled and the third ICC course is scheduled for August

Background: We aimed to describe patient and limb outcomes in the decade after endovascular revascularization for chronic lower-extremity peripheral artery disease (PAD). Methods: We assessed outcomes in patients having endovascular revascularization of the superficial femoral artery in two centers between 2003 and 2011 and followed for a median 9.3 (25–75%: 6.8, 11.1) years. Outcomes included death, myocardial infarction, stroke, repeat limb revascularizations, and amputations. We used competing risks analysis with clustering by patient to determine the hazard ratios (HR) and 95% CI for patients, and procedural characteristics for cause of death, cardiovascular events, and major adverse limb events (MALE). Results: There were 253 index limb revascularizations in 202 patients followed for a median 9.3 years. Patients had intensive medical treatment with 90% on statins and 80% on beta-blockers. During follow up there were 57 (28%) cardiovascular deaths and 62 (31%) noncardiovascular deaths. Of the 253 limbs, 227 (90%) were free of MALE over follow up and 93 (37%) had MALE or minor repeat revascularization. In multivariable models, cardiovascular death significantly associated with critical limb ischemia (HR = 3.21, 95% CI = 1.84, 5.61) and noncardiovascular death with chronic kidney disease (HR = 2.69, 95% CI = 1.68, 4.30), and smoking (HR = 2.75, 95% CI = 1.01, 7.52). MALE or minor repeat revascularization associated with critical limb ischemia (HR = 1.43, 95% CI = 0.84, 2.43), smoking (HR = 2.49, 95% CI = 1.26, 4.90), and lesion length > 200 mm (HR = 1.51, 95% CI = 0.98, 2.33). Conclusions: Among patients with intensive medical therapy, the risk of noncardiovascular death was high and similar to cardiovascular death. Endovascular intervention can have acceptable long-term results. Future studies should evaluate strategies to reduce both cardiovascular and noncardiovascular deaths.

Introduction: Veteran Affairs (VA) patients may have higher risk factors and worse outcomes after peripheral revascularization compared to patients treated in non-VA facilities. Hypothesis: Compared to non-VA patients, VA patients have higher rates of risk factors and poorer outcomes after superficial femoral artery (SFA) endovascular revascularization. Methods: We assessed long-term outcomes in all patients having SFA endovascular revascularization between 2003-2010 in 2 regional referral institutions in Boston, one a VA hospital (VA Boston) and the other a non-VA hospital (Brigham and Women’s Hospital). Atherosclerosis risk factors, lesion characteristics, and outcomes of death, repeat revascularization, and limb amputation were assessed by review of the chart and national death indices. The hazard ratio and 95% confidence interval (HR, 95%CI) of death and adverse limb events for VA versus non-VA patients were assessed by Cox proportional hazard models. Results: Of the 203 subjects, 88 were VA patients and 115 were non-VA patients and 254 limbs were revascularized. VA and non-VA patients had a similar mean age (68 vs 68 years, p=0.74), and aspirin and statin use were over 90% in both groups. VA patients had a higher prevalence of diabetes (59% vs 41%, p=0.011) and current smoking (36% vs 18%, p=0.006). The prevalence of limbs with critical limb ischemia was similar (VA: 20% vs Non-VA: 17%, p=0.51), but limbs in VA patients were more likely to have TASC C or D lesions (57% vs 43%, p=0.028), and lesions > 200mm in length (44% vs 31%, p=0.044). Over an average 5.1 years follow-up, 96 patients died and 82 limbs required repeat revascularization. Compared to non-VA patients, VA patients had similar risks of death (HR=0.91, 95%CI=0.55, 1.49) and repeat revascularization (HR=1.1, 95%CI=0.67, 1.75). 17 limbs required subsequent surgical revascularization and 16 limbs had minor or major amputation with similar rates in both groups. Multivariable models showed similar results. Conclusion: In this comparison, VA patients having SFA endovascular revascularization had a higher prevalence of some atherosclerosis risk factors and more complex lesion characteristics, but similar long-term outcomes over an average 5 years.

Objectives: To assess the impact of stent type on the risk of death or myocardial infarction (MI) related to dual antiplatelet therapy (DAPT) more than 12 months (prolonged DAPT) versus 12 or less months after PCI for an acute coronary syndrome (ACS). Background: The recent DAPT study reported lower recurrent ischemic events from prolonged DAPT in patients treated with PCI for an ACS, but was underpowered to determine the impact of stent type. Methods: We determined clinical outcomes after PCI for an ACS (median follow-up: DES=26 months, BMS=46 months) in 18,484 patients in the Veterans Affairs system treated with first generation drug-eluting stents (DES) or bare-metal stents (BMS). We used landmark analyses starting 1 year after the index PCI to assess the risk of prolonged DAPT on the primary endpoint of death or MI. Multivariable and propensity models adjusted for confounding. Results: There was a significant interaction between stent type and prolonged DAPT for death and MI (P=0.0036), death (P=0.054), and major bleeding (P=0.0013). Patients treated with prolonged DAPT had lower risks of death or MI (HR=0.71, 95% CI=0.61, 0.82) and death (HR=0.74, 95% CI=0.62, 0.89) with DES, but not BMS, and higher risks of major bleeding, particularly with BMS (HR=1.67, P< 0.001) than DES (HR=1.24, p=0.01). Conclusions: Prolonging DAPT more than 12 months after PCI for ACS only associated with a lower risk of ischemic events in the 1-4 years after PCI in those receiving first generation DES. Stent type may influence the benefit of prolonged DAPT. (C) 2016 Wiley Periodicals, Inc.

Background: Cigarette smoking potentiates the antiplatelet effect of clopidogrel. Guidelines recommend clopidogrel for 12 months after percutaneous coronary intervention (PCI) with bare-metal (BMS) or drug-eluting (DES) stents. Whether smoking affects the risk of ischemic events related to clopidogrel use beyond 12 months after PCI is unknown Methods: We identified all PCIs performed in the Veterans Affairs (VA) health system from 2002-2006 and linked the information with the VA pharmacy database. VA and non-VA clinical outcomes were identified by ICD-9 codes from the VA National Patient Care and CMS/Medicare databases. All patients who were event-free at 12 months were followed for death, myocardial infarction (MI), or target vessel revascularization (TVR) up to 4 years following PCI. Prolonged (i.e., > 12 months) vs. clopidogrel use for < 12 months was assessed for each outcome within each stent type using propensity score adjusted inverse probability of weighting (IPW) Cox-proportional hazards analyses. Results: From 2002-2006, 28,507 patients included in the study underwent PCI and were event free at 12 months. Of these, 42% were smokers (n = 11,989) at the index PCI, 51% received a DES (n = 14, 594) and 45% were treated with prolonged clopidogrel use (n = 12,968). Following a 12-month landmark period, 2,194 deaths, 2,288 death or MIs, and 2,010 TVRs occurred. In smokers, prolonged clopidogrel use was associated with a lower risk of death and death or MI with both stent types (interaction p ≤ 0.10). In non-smokers, prolonged clopidogrel use was associated with a lower risk of death (interaction p = 0.04) and death or MI (interaction p = 0.03) in patients receiving DES only (Table). Conclusions: Prolonging clopidogrel more than 12 months after PCI may lower the risk of death or MI in smokers irrespective of stent type and in non-smokers receiving DES only. This study suggests that the duration of clopidogrel use after PCI may be tailored to smoking status and stent-type.

Introduction: Clopidogrel up to 12 months after an acute coronary syndrome (ACS) lowers the risk of major adverse coronary events. Guidelines recommend clopidogrel for 12 months after coronary intervention (PCI) with bare-metal (BMS) or drug-eluting (DES) stents. The value of prolonging clopidogrel beyond 12 months in PCI patients with ACS is unknown. Hypothesis: We hypothesize that prolonged clopidogrel differentially reduces adverse events in patients receiving DES compared with those receiving BMS for an ACS. Methods: We linked all PCIs in the national Veterans Affairs (VA) health system from 2002-2006 with the VA pharmacy database. VA and non-VA clinical outcomes were identified by ICD9 codes from the VA and CMS/Medicare databases. All patients who were event free at 12 months were followed for death, myocardial infarction (MI), and recurrent target vessel revascularization (TVR). The hazard ratio for prolonged clopidogrel use (more than 12 months) versus clopidogrel for less than or equal to 12 months was assessed for each outcome within each stent type, using Cox proportional hazards models. Multivariable models and propensity models were also used to adjust for confounding related to the propensity for prolonged clopidogrel treatment. Results: After exclusions, 28,507 patients had PCI and were event free at 12 months. Of these, 18,279 (64%) had an ACS at their index PCI including 9,336 (51%) who received a DES and 8,447 (46%) who received prolonged clopidogrel. Events occurring up to 4 years after PCI in these ACS patients included 1358 deaths, 1885 death or MIs, and 1335 TVRs. Prolonged clopidogrel was associated with lower risk of death (interaction p=0.04) and death or MI (interaction p=0.001) only in patients receiving DES (Table). Similar results were seen in multivariable and propensity models. Conclusions: Prolonging clopidogrel more than 12 months after PCI for ACS may lower the risk of death or MI in patients receiving DES but not in patients receiving BMS.