Table 1.
Vignette Wording and Results
| Recommended Test or Treatment | Proportion Responding "Always/Almost Always" or "Most of the Time" | "Intensity Weight" Given to This Item |
|---|---|---|
| Vignette 1. In your office, you are evaluating an otherwise healthy 75-year-old man who has presented with new onset of exertional substernal chest pain occurring after heavy work that is relieved by rest. An ECG done in the office is interpreted as normal. His personal medical history is positive for cigarette smoking and his father died of an acute myocardial infarction at age 58. He has adequate health insurance to cover tests and medications. At this point, for a patient presenting like this, how often would you arrange for each of the following: (Response options: always/almost always; most of the time; some of the time; rarely; never) | ||
| Standard exercise treadmill test | 25.7% | 2 |
| Stress (echo or nuclear) imaging study | 63.8% | 5 |
| Resting echocardiogram | 29.1% | 6 |
| Coronary angiography | 29.6% | 9 |
| Admit to hospital for evaluation | 6.9% | 10 |
| Vignette 2. A 75-year-old man with severe (NYHA Class IV) congestive heart failure from ischemic heart disease, is on maximal medications, and has effective disease management. His symptoms did not improve after recent angioplasty and stent placement and coronary artery bypass graft is not an option. He is uncomfortable at rest. He is noted to have frequent, asymptomatic nonsustained ventricular tachycardia on cardiac monitoring. He has adequate health insurance to cover tests and medications. At this point, for a patient presenting like this, how often would you arrange for each of the following: | ||
| Initiate or continue discussions about palliative care | 31.1% | 1 |
| Initiate antiarrhythmic therapy | 23.3% | 7 |
| Recommend an implantable cardiac defibrillator (ICD) | 64.6% | 8 |
| Recommend biventricular pacemaker for cardiac resynchronization | 47.6% | 8 |
| Repeat angiography | 5.7% | 10 |
| Vignette 3. An 85-year-old man patient has severe (NYHA Class IV) congestive heart failure from ischemic heart disease, is on maximal medications, and is not a candidate for coronary revascularization. He is on 2 L of supplemental oxygen at home. He presents to your office with worsening shortness of breath and difficulty sleeping due to orthopnea. Office chest x-ray confirms severe heart failure. Oxygen saturation was 85% and increased to 94% on 4 L and the patient is more comfortable. He has adequate health insurance to cover tests and medications. At this point, for a patient presenting like this, how often would you arrange for each of the following: | ||
| Allow the patient to return home on increased oxygen and increased diuretics | 19.1% | 1 |
| Initiate or continue discussions about palliative care | 45.8% | 1 |
| Admit to the hospital for aggressive diuresis (not to the ICU/CCU) | 56.5% | 5 |
| Admit to the ICU/CCU for intensive therapy and monitoring | 18.3% | 9 |
| Recommend biventricular pacemaker for cardiac resynchronization | 14.7% | 9 |
| Place a pulmonary artery catheter for hemodynamic optimization | 1.6% | 10 |