Publications

BACKGROUND

Small drifts in intracoronary pressure measurements (±2 mm Hg) can affect stenosis categorization using pressure indices. This has not previously been assessed for fractional flow reserve (FFR), instantaneous wave-free ratio (iFR), and whole-cycle distal pressure/proximal pressure (Pd/Pa) indices.

METHODS AND RESULTS

Four hundred forty-seven stenoses were assessed with FFR, iFR, and whole-cycle Pd/Pa. Cut point values for significance were predefined as ≤0.8, <0.90, and <0.93, respectively. Pressure wire drift was simulated by offsetting the distal coronary pressure trace by ±2 mm Hg. FFR, iFR, and whole-cycle Pd/Pa indices were recalculated and stenosis misclassification quantified. Median (±median absolute deviation) values for FFR, iFR, and whole-cycle Pd/Pa were 0.81 (±0.11), 0.90 (±0.07), and 0.93 (±0.06), respectively. For the cut point of FFR, iFR, and whole-cycle Pd/Pa, 34.6% (155), 50.1% (224), and 62.2% (278) of values, respectively, lay within ±0.05 U. With ±2 mm Hg pressure wire drift, 21% (94), 25% (110), and 33% (148) of the study population were misclassified with FFR, iFR, and whole-cycle Pd/Pa, respectively. Both FFR and iFR had significantly lower misclassification than whole-cycle Pd/Pa (P<0.001). There was no statistically significant difference between the diagnostic performance of FFR and iFR (P=0.125).

CONCLUSIONS

In a substantial proportion of cases, small amounts of pressure wire drift are enough to cause stenoses to change classification. Whole-cycle Pd/Pa is more vulnerable to such reclassification than FFR and iFR.

Target lesion revascularization (TLR) for BRS failure is burdened with a high rate of adverse events. DES implantation appears to be the safest treatment option following BRS failure. A real world observational study with a minimum of 2-year follow-up would be required to investigate the long-term clinical outcomes in patients with a BRS failure and to assess the best treatment option in case of TLR.

CONTEXT

For health care reform to succeed, health care systems need a professionally satisfied primary care workforce. Evidence suggests that primary care physicians are less satisfied than those in other medical specialties.

OBJECTIVE

To assess three domains of physician satisfaction by area of clinical practice among physicians practicing in an established integrated health system.

DESIGN

Cross-sectional online survey of all Southern California Permanente Medical Group (SCPMG) partner and associate physicians (N = 1034) who were primarily providing clinic-based care in 1 of 4 geographically and operationally distinct Kaiser Permanente Southern California Medical Centers.

MAIN OUTCOME MEASURES

Primary measure was satisfaction with one's day-to-day professional life as a physician. Secondary measures were satisfaction with quality of care and income.

RESULTS

Of the 636 physicians responding to the survey (61.5% response rate), on average, 8 in 10 SCPMG physicians reported satisfaction with their day-to-day professional life as a physician. Primary care physicians were only minimally less likely to report being satisfied (difference of 8.2-9.5 percentage points; p < 0.05) than were other physicians. Nearly all physicians (98.2%) were satisfied with the quality of care they are able to provide. Roughly 8 in 10 physicians reported satisfaction with their income. No differences were found between primary care physicians and those in other clinical practice areas regarding satisfaction with quality of care or income.

CONCLUSION

It is possible to create practice settings, such as SCPMG, in which most physicians, including those in primary care, experience high levels of professional satisfaction.