IMPORTANCE Shared decision-making (SDM) is widely advocated for patients with valvular heart disease yet is not integrated into the heart team model for patients with symptomatic aortic stenosis. Decision aids (DAs) have been shown to improve patient-centered outcomes and may facilitate SDM.OBJECTIVE To determine whether the repeated use of a DA by heart teams is associated with greater SDM, along with improved patient-centered outcomes and clinician attitudes about DAs. DESIGN, SETTING, AND PARTICIPANTSThis mixed-methods study included a nonrandomized pre-post intervention and clinician interviews. It was conducted between April 30, 2015, and December 7, 2017, with quantitative analysis performed between January 12, 2017, and May 26, 2017, within 2 academic medical centers in northern New England among 35 patients with symptomatic aortic stenosis who were at high to prohibitive risk for surgery. The qualitative analysis was performed between August 6, 2018, and May 7, 2019. The Severe Aortic Stenosis Decision Aid was delivered by 6 clinicians, with patients choosing between transcatheter aortic valve replacement and medical management.MAIN OUTCOMES AND MEASURES Clinician SDM performance was measured using the Observer OPTION 5 scale with dual-independent coding of audiotaped clinic visits. Previsit and postvisit surveys measured the patient's knowledge, satisfaction, and decisional conflict. Audiotaped clinician interviews were coded, and qualitative thematic analysis was performed.RESULTS Six male clinicians and 35 patients (19 of 34 women [55.9%; 1 survey was missing]; mean [SD] age, 85.8 [7.8] years) participated in the study. Shared decision-making increased stepwise with repeated use of the DA (mean [SD] Observer OPTION 5 scores: usual care, 17.9 [7.6]; first use of a DA, 60.5 [30.9]; fifth use of a DA, 79.0 [8.4]; P < .001 for comparison between usual care and fifth use of DA). Multiple uses of the DA were associated with increased patient knowledge (mean difference, 18.0%; 95% CI, 1.2%-34.8%; P = .04) and satisfaction (mean difference, 6.7%; 95% CI, 2.5%-10.8%; P = .01) but not decisional conflict (mean [SD]: usual care, 96.0% [9.4%]; first use of DA, 93.8% [12.5%]; fifth use of DA, 95.0% [11.2%]; P = .60). Qualitative analysis of clinicians' interviews revealed that clinicians perceived that they used an SDM approach without DAs and that the DA was not well understood by elderly patients. There was infrequent values clarification or discussion of stroke risk. CONCLUSION AND RELEVANCEIn a mixed-methods pilot study, use of a DA for severe aortic stenosis by heart team clinicians was associated with improved SDM and patient-centered outcomes. However, in qualitative interviews, heart team clinicians did not perceive a significant benefit of the DA, and therefore sustained implementation is unlikely. This pilot study of SDM clarifies new research directions for heart teams.

Introduction. Evidence suggests that early-life antibiotic use can alter gut microbiome, predisposing children to obesity. The obesity epidemic has a disproportionate effect on individuals from lower socioeconomic status (SES). Thus, this study aims to explore the link between SES and antibiotic use. Design. We performed a retrospective cohort study of all babies born at and receiving 2 or more outpatient visits at a large, suburban health system in Illinois (United States) between 2007 and 2017. We collected data on zip code as a proxy for SES and antibiotic use in the first year of life. We also obtained comorbid diagnosis codes, race/ethnicity, gender, and number of inpatient, outpatient, and emergency department visits. Results. A total of 7224 patients met our study criteria. Children from low-poverty areas received a lifetime average of 4.28 prescriptions, while those from high-poverty neighborhoods received an average of 3.31 prescriptions. This was statistically significant in our unadjusted analysis but not after adjusting for covariates. Children from high-poverty areas were significantly more likely to receive more antibiotics at 48 hours, 1 week, and 1 month of life in our unadjusted analysis, but not after adjusting for covariates. In our unadjusted and adjusted analyses, children from high-poverty areas were significantly more likely to have received antibiotics at 1 week of life. Conclusion. The relationship between SES and antibiotic use warrants further investigation to help elucidate possible causes of the disproportionate impact obesity has in low-income communities.

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Objective: We previously demonstrated that racial disparities exist in limb salvage outcomes in patients with peripheral artery disease (PAD), with blacks noted to have a twofold higher risk for major amputation than whites. We sought to evaluate the accuracy of the Wound, Ischemia, and foot Infection (WIfI) score in predicting amputation risk among racial groups. To better understand modifiable factors associated with poorer outcomes in the black population, we sought to investigate whether the WIfI score at initial presentation with chronic limb-threatening ischemia (CLTI) varied among racial groups.Methods: A single-center academic institution's electronic medical record database was queried to identify all patients presenting with an initial diagnosis of CLTI from 2007 to 2018. Data were collected on race, age, sex, socioeconomic status, medical comorbidities, and outcomes including major amputation and mortality. Chart review gathered information on wound characteristics, ischemia severity, and extent of