Faculty Bibliography

BACKGROUND:Online accessible patient education materials (PEMs) are essential for patient empowerment. However, studies have shown that these materials often exceed the recommended sixth-grade reading level, making them difficult for many patients to understand. Large language models (LLMs) have the potential to simplify PEMs into more readable educational content. OBJECTIVE:We sought to evaluate whether 3 LLMs (ChatGPT [OpenAI], Gemini [Google], and Claude [Anthropic PBC]) can optimize the readability of PEMs to the recommended reading level without compromising accuracy. METHODS:This cross-sectional study used 60 randomly selected PEMs available online from 3 websites. We prompted LLMs to simplify the reading level of online PEMs. The primary outcome was the readability of the original online PEMs compared with the LLM-simplified versions. Readability scores were calculated using 4 validated indices Flesch Reading Ease, Flesch-Kincaid Grade Level, Gunning Fog Index, and Simple Measure of Gobbledygook Index. Accuracy and understandability were also assessed as balancing measures, with understandability measured using the Patient Education Materials Assessment Tool-Understandability (PEMAT-U). RESULTS:The original readability scores for the American Heart Association (AHA), American Cancer Society (ACS), and American Stroke Association (ASA) websites were above the recommended sixth-grade level, with mean grade level scores of 10.7,10.0, and 9.6, respectively. After optimization by the LLMs, readability scores significantly improved across all 3 websites when compared with the original text. Compared with the original website, Wilcoxon signed rank test showed ChatGPT improved the readability to 7.6 from 10.1 (P<.001); Gemini, to 6.6 (P<.001); and Claude, to 5.6 (P<.001). Word counts were significantly reduced by all LLMs, with a decrease from a mean range of 410.9-953.9 words to a mean range of 201.9-248.1 words. None of the ChatGPT LLM-simplified PEMs were inaccurate, while 3.3% of Gemini and Claude LLM-simplified PEMs were inaccurate. Baseline understandability scores, as measured by PEMAT-U, were preserved across all LLM-simplified versions. CONCLUSIONS:This cross-sectional study demonstrates that LLMs have the potential to significantly enhance the readability of online PEMs while maintaining accuracy and understandability, making them more accessible to a broader audience. However, variability in model performance and demonstrated inaccuracies underscore the need for human review of LLM output. Further study is needed to explore advanced LLM techniques and models trained for medical content.

Undergraduate medical educators seek to optimize student learning, improve grading transparency and fairness, and provide useful information to residency programs. Recently, the United States Medical Licensing Examination's shift to pass/fail scoring for Step 1 disrupted curricular and assessment operations, and schools' tiered grading practices have been scrutinized. In noting that significant institutional time and energy were being expended in addressing the current levels of student grade appeals, 6 public and private medical schools in the Northeastern United States engaged in an examination of grade appeals via a root cause analysis (RCA). From November 2021 to April 2022, the authors reviewed specific instances of grading challenges that the team of educators encountered previously. From May to June 2022, the authors met for a facilitated discussion of the question, "Why are students challenging grading processes and systems or outcomes?" From July to October 2022, the authors identified root causes by analyzing results from the fishbone diagram (process, equipment, materials, people, and environment) and using the "five whys" technique. Several potential explanations for grade appeals and challenging grading systems across institutions were identified, including variability in the quality or experience of evaluators, lack of clarity about the goals and expectations of clerkships and a lack of transparency about the grading process, having a tiered grading system, technical issues with equipment, and clinical productivity demands of faculty. In proposing solutions to root causes identified in the RCA, factors were mapped to Liaison Committee on Medical Education (LCME) standards to facilitate quality and process improvements in grading. Aiming to support the learning environment and a fair and equivalent assessment process, the authors present a novel RCA and LCME method that can contribute to improving grading systems and has the potential to enhance learning and success.

DESIGN/METHODS:Retrospective database analysis. OBJECTIVE:This study aims to assess the RVU compensation model for the most common spine surgeries. BACKGROUND:Physician work is commonly valued by utilizing the relative value unit (RVU) model for compensation. Our aim in this study was to assess RVU and RVU per minute valuations of the most common spine procedures comparing cervical versus lumbar and fusion versus non-fusion cases. METHODS:The ACS-NSQIP database was utilized to identify the most commonly performed spine procedures. RVU and RVU per minute values were calculated and compared in each group. RESULTS:In all, 18,779 entries encompassing 28 CPT codes/code combinations were identified. Average RVUs were higher in cervical spine cases compared with lumbar cases (29 vs. 20 RVUs, respectively). Furthermore, cervical cases had significantly higher RVUs per minute compensation compared with lumbar cases (0.26 vs. 0.18 RVUs/min; P=0.01). Fusion cases also fared higher average RVUs compared with nonfusion cases (28 vs. 19 RVUs, respectively). However, when corrected for operative time, fusion cases did not differ significantly in RVUs per minute (P=0.13). CONCLUSIONS:Cervical spine surgery provides the best value for the surgeon in terms of RVUs per minute. We highlight key aspects of the compensation model in spine surgery. LEVEL OF EVIDENCE/METHODS:Level III-economic study.

OBJECTIVE:The Diabetes in Children, Adolescents, and Young Adults (DiCAYA) network seeks to create a nationwide electronic health record (EHR)-based diabetes surveillance system. This study aimed to develop a DiCAYA-wide EHR-based computable phenotype (CP) to identify prevalent cases of diabetes. RESEARCH DESIGN AND METHODS/METHODS:We conducted network-wide chart reviews of 2,134 youth (aged <18 years) and 2,466 young adults (aged 18 to <45 years) among people with possible diabetes. Within this population, we compared the performance of three alternative CPs, using diabetes diagnoses determined by chart review as the gold standard. CPs were evaluated based on their accuracy in identifying diabetes and its subtype. RESULTS:The final DiCAYA CP requires at least one diabetes diagnosis code from clinical encounters. Subsequently, diabetes type classification was based on the ratio of type 1 diabetes (T1D) or type 2 diabetes (T2D) diagnosis codes in the EHR. For both youth and young adults, the sensitivity, specificity, and positive and negative predictive values (PPV and NPV, respectively) in finding diabetes cases were >90%, except for the specificity and NPV in young adults, which were slightly lower at 83.8% and 80.6%, respectively. The final DiCAYA CP achieved >90% sensitivity, specificity, PPV, and NPV in classifying T1D, and demonstrated lower but robust performance in identifying T2D, consistently maintaining >80% across metrics. CONCLUSIONS:The DiCAYA CP effectively identifies overall diabetes and T1D in youth and young adults, though T2D misclassification in youth highlights areas for refinement. The simplicity of the DiCAYA CP enables broad deployment across diverse EHR systems for diabetes surveillance.

INTRODUCTION/BACKGROUND:Atopic dermatitis (AD) is a chronic, relapsing disease that can start at any age and has a significant negative impact on quality of life, including a significant itch burden. Here we report the proportion of patients in a real-world study achieving a complete/almost complete resolution of itch, as measured by the Peak Pruritus Numeric Rating Scale (PP-NRS) and improvement in overall disease severity score (ODS), in patients aged ≥ 12 years with moderate-to-severe AD up to 3 years after commencing dupilumab treatment. METHODS:PROSE is an ongoing, prospective, observational, multicenter registry in the USA and Canada, collecting real-world data from patients aged ≥ 12 years with moderate-to-severe AD who initiated dupilumab in accordance with country-specific prescribing information. Assessments include patient-reported PP-NRS (range 0-10) and clinician-measured ODS score (range 0-4). RESULTS:A total of 857 patients were enrolled, of whom 42% were male and 6.4% were adolescents aged ≥ 12 to < 18 years. The mean [standard deviation (SD)] age was 40.1 (17.9) years, and the duration of AD was 17.4 (16.2) years. The subsequent mean (SD) duration of dupilumab treatment was 23.1 (13.7) months. The proportion of patients achieving complete/almost complete itch resolution (PP-NRS score of 0 or 1) improved consistently over time, from 2.7% (17/622) of patients at baseline to 56.3% (58/103) at 3 years. Additionally, by year 3, 65.1% (54/83) of patients had an ODS score of no/minimal disease (score of 0 or 1), versus 2.2% (19/852) at baseline. CONCLUSIONS:In this real-world setting of the PROSE registry, adult and adolescent patients with moderate-to-severe AD followed up for up to 3 years after the initiation of dupilumab treatment experienced sustained and substantial improvement in pruritus and ODS, using the stringent endpoints of PP-NRS 0 or 1 and ODS 0 or 1. TRIAL REGISTRATION/BACKGROUND:ClinicalTrials.gov identifier: NCT03428646.

BACKGROUND:Myeloproliferative neoplasms (MPN) are associated with an increased cardiovascular risk including acute coronary syndrome. However, there is a lack of comprehensive data regarding the rate of percutaneous coronary intervention (PCI), as well as the in-hospital characteristics and outcomes for MPN patients. AIMS/OBJECTIVE:We aimed to evaluate the temporal trends and outcomes of PCI among patients with MPN. METHODS AND RESULTS/RESULTS:The National Inpatient Sample database from 2016 to 2020 was queried to identify all PCI hospitalizations. Temporal trends and outcomes of patients with and without MPN following PCI were analyzed. Propensity score matching (PSM) was implemented to compare outcomes between MPN and non-MPN groups. 2,237,210 PCI hospitalizations with 7560 (0.27%) patients with MPN were included in this study. Throughout the study period, the prevalence of MPN among PCI admissions remained stable (p-value for trend = 0.12). Within the MPN subgroup, essential thrombocythemia (ET) was the predominant condition (53.2). Patients with MPN had higher prevalence of cardiovascular comorbidities than non-MPN patients. Following PSM, MPNs were significantly associated with a higher risk of blood transfusions (OR: 1.66, 95% CI: 1.22-2.24, p = 0.001) and AKI (OR: 1.39, 95% CI: 1.17-1.65, p < 0.001). In contrast, the risk of in-hospital mortality (OR: 1.18, 95% CI: 0.83-1.69, p = 0.354 and bleeding (OR: 1.43, 95% CI: 0.90-2.27, p = 0.127) did not significantly differ between the two groups. CONCLUSIONS:Our study demonstrated that while the prevalence of MPN among patients undergoing PCI remained stable, those with MPN faced higher risks of bleeding, blood transfusion and acute kidney injury. Further research is warranted to explore the underlying reasons for these increased risks and to improve outcomes in this high-risk group.

BACKGROUND:The PARTNER 3 (Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low Risk Patients with Aortic Stenosis) trial compared SAPIEN 3 transcatheter aortic valve replacement (TAVR) to surgery in low-risk patients with symptomatic, severe aortic stenosis. Echocardiographic outcomes at 5 years are unknown. OBJECTIVES/OBJECTIVE:This study sought to compare 5-year echocardiographic results of TAVR and surgery in the PARTNER 3 trial. METHODS:Echocardiograms for 1,000 randomized patients were obtained at baseline, 30 days, 1 year, and annually through 5 years and were analyzed by a core lab consortium. The composite primary endpoint of death, stroke, or rehospitalization was adjudicated by a clinical events committee. RESULTS:At 5 years, ≥ mild aortic regurgitation was higher following TAVR vs surgery (24.5% vs 6.3%; P < 0.001), with low ≥ moderate aortic regurgitation in both groups. TAVR patients had higher mean transaortic gradient (12.8 ± 6.5 vs 11.7 ± 5.6 mm Hg; P < 0.001), stroke volume index (44.6 ± 9.7 vs 41.1 ± 9.2; P < 0.0001), and aortic valve area (1.87 ± 0.46 vs 1.82 ± 0.46; P = 0.895). Fewer TAVR patients had low-flow stroke volume index (P < 0.001) and left ventricular hemodynamic burden (valvulo-arterial impedance; P < 0.01). Tricuspid annular plane systolic excursion was also higher with TAVR (P < 0.001), as was right ventricular-to-pulmonary artery coupling (P < 0.0001). In the combined cohorts, 30-day moderate to severe prosthesis-patient mismatch, mild to severe aortic regurgitation, or low stroke volume index were not predictive of clinical outcomes; only low right ventricular-to-pulmonary artery coupling and high valvulo-arterial impedance at 30 days were associated with increased risk of the 5-year composite primary endpoint. CONCLUSIONS:In low-risk patients with severe aortic stenosis, TAVR, compared to surgery, was associated with similar, stable valve hemodynamics at 5 years with less frequent low-flow state, lower valvulo-arterial impedance, and better right ventricular function. (PARTNER 3 Trial: Safety and Effectiveness of the SAPIEN 3 Transcatheter Heart Valve in Low Risk Patients with Aortic Stenosis [P3]; NCT02675114).

[This corrects the article DOI: 10.1016/j.jscai.2024.102399.].