John B Wong

Tufts Medical Center, Boston, Massachusetts, United States

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Publications (146)1413.45 Total impact

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    ABSTRACT: Background: Solid tumor chemotherapy regimens pose a risk for hepatitis B virus (HBV) reactivation, but screening and antiviral prophylaxis remains controversial because of insufficient evidence. Purpose: To determine the risk for HBV reactivation with and without antiviral prophylaxis and the effectiveness of prophylaxis in adults with solid tumors and chronic or resolved HBV infection. Data sources: MEDLINE through 1 July 2015 and Web of Science, Cochrane Central Register of Controlled Trials, TOXNET, and Scopus through 1 March 2015. Study selection: 26 English-language observational studies and randomized, controlled trials in patients with chronic or resolved HBV receiving chemotherapy for solid tumors. Data extraction: Study characteristics, quality, and risk of bias were assessed by 1 researcher and verified by another independent researcher. Data synthesis: Random-effects model meta-analyses were used to estimate the risk and odds ratio (OR) of reactivation with versus without antiviral prophylaxis. Reactivation in chronic HBV without prophylaxis ranged from 4% to 68% (median, 25%) with substantial heterogeneity. Prophylaxis reduced the risk for HBV reactivation (OR, 0.12 [95% CI, 0.06 to 0.22]), HBV-related hepatitis (OR, 0.18 [CI, 0.10 to 0.32]), and chemotherapy interruption (OR, 0.10 [CI, 0.04 to 0.27]). In 3 studies of patients with resolved HBV infection, none received HBV prophylaxis and reactivation risk ranged from 0.3% to 9.0. Limitations: Significant heterogeneity in underlying study populations and treatment regimens, incomplete baseline data, possibility of publication bias, and limited study quality. Most studies were observational and from Asia. Conclusion: In patients with chronic HBV receiving solid tumor chemotherapy, the risk for HBV reactivation is similar to the risk with other types of immunosuppressive therapy. Results support HBV screening and antiviral prophylaxis before initiation of chemotherapy for solid tumors. Primary funding source: National Center for Advancing Translational Sciences and National Institutes of Health.
    Annals of internal medicine 11/2015; DOI:10.7326/M15-1121 · 17.81 Impact Factor
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    ABSTRACT: Conclusion: Most of the current literature focuses on the immune active phases of chronic HBV infection; decision-making in other commonly encountered and challenging clinical settings depends on indirect evidence. (Hepatology 2015).
    Hepatology 11/2015; DOI:10.1002/hep.28280 · 11.06 Impact Factor
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    ABSTRACT: Conclusion: In children with chronic HBV infection, antivirals compared to no antiviral therapy improve HBV DNA suppression and frequency of alanine aminotransferase normalization and HBeAg seroconversion. (Hepatology 2015).
    Hepatology 11/2015; DOI:10.1002/hep.28278 · 11.06 Impact Factor
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    ABSTRACT: Conclusions: Antiviral therapy improves HBV suppression and reduces MTCT in women with chronic HBV infection with high viral load compared to the use of hepatitis B immunoglobulin and vaccination alone; the use of telbivudine, lamivudine, and tenofovir appears to be safe in pregnancy with no increased adverse maternal or fetal outcome. (Hepatology 2015).
    Hepatology 11/2015; DOI:10.1002/hep.28302 · 11.06 Impact Factor
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    ABSTRACT: Placebo controls are essential in evaluating the effectiveness of medical treatments. Although it is unclear whether different placebo interventions for osteoarthritis vary in efficacy, systematic differences would substantially affect interpretation of the results of placebo-controlled trials. To evaluate the effects of alternative placebo types on pain outcomes in knee osteoarthritis. MEDLINE, EMBASE, Web of Science, Google Scholar, and Cochrane Database from inception through 1 June 2015 and unpublished data. 149 randomized trials of adults with knee osteoarthritis that reported pain outcomes and compared widely used pharmaceuticals against the following 4 placebos: oral, intra-articular, topical, and oral plus topical. Study data were independently double-extracted; study quality was assessed by using the Cochrane risk of bias tool. Placebo effects that were evaluated by using a network meta-analysis with 4 separate placebo nodes (differential model) showed that intra-articular placebo (effect size [95% credible interval], 0.29 [0.09 to 0.49]) and topical placebo (effect size, 0.20 [credible interval, 0.02 to 0.38]) had significantly greater effect sizes than did oral placebo. This differential model showed marked differences in the relative efficacies and hierarchy of the active treatments compared with a network model that considered all placebos equivalent. In the model accounting for differential effects, intra-articular and topical therapies were superior to oral treatments in reducing pain. When these differential effects were ignored, oral nonsteroidal anti-inflammatory drugs were superior. Few studies compared different placebos directly. The study could not decisively conclude whether disease severity and co-interventions systematically differed between trials evaluating different placebos. All placebos are not equal, and some can trigger clinically relevant responses. Differential placebo effects can substantially alter estimates of the relative efficacies of active treatments, an important consideration for the design of clinical trials and interpretation of the results. Agency for Healthcare Research and Quality.
    Annals of internal medicine 07/2015; 163(5). DOI:10.7326/M15-0623 · 17.81 Impact Factor
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    ABSTRACT: Methadone is an effective treatment for opioid dependence. When people who are receiving methadone maintenance treatment for opioid dependence are incarcerated in prison or jail, most US correctional facilities discontinue their methadone treatment, either gradually, or more often, abruptly. This discontinuation can cause uncomfortable symptoms of withdrawal and renders prisoners susceptible to relapse and overdose on release. We aimed to study the effect of forced withdrawal from methadone upon incarceration on individuals' risk behaviours and engagement with post-release treatment programmes.
    The Lancet 05/2015; 386(9991). DOI:10.1016/S0140-6736(14)62338-2 · 45.22 Impact Factor
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    ABSTRACT: Eliciting patient preferences within the context of shared decision making has been advocated for colorectal cancer screening. Risk stratification for advanced colorectal neoplasia (ACN) might facilitate more effective shared decision making when selecting an appropriate screening option. Our objective was to develop and validate a clinical index for estimating the probability of ACN at screening colonoscopy. We conducted a cross-sectional analysis of 3,543 asymptomatic, mostly average-risk patients 50-79 years of age undergoing screening colonoscopy at two urban safety net hospitals. Predictors of ACN were identified using multiple logistic regression. Model performance was internally validated using bootstrapping methods. The final index consisted of five independent predictors of risk (age, smoking, alcohol intake, height, and a combined sex/race/ethnicity variable). Smoking was the strongest predictor (net reclassification improvement (NRI), 8.4%) and height the weakest (NRI, 1.5%). Using a simplified weighted scoring system based on 0.5 increments of the adjusted odds ratio, the risk of ACN ranged from 3.2% (95% confidence interval (CI), 2.6-3.9) for the low-risk group (score ≤2) to 8.6% (95% CI, 7.4-9.7) for the intermediate/high-risk group (score 3-11). The model had moderate to good overall discrimination (C-statistic, 0.69; 95% CI, 0.66-0.72) and good calibration (P=0.73-0.93). A simple 5-item risk index based on readily available clinical data accurately stratifies average-risk patients into low- and intermediate/high-risk categories for ACN at screening colonoscopy. Uptake into clinical practice could facilitate more effective shared decision-making for CRC screening, particularly in situations where patient and provider test preferences differ.Am J Gastroenterol advance online publication, 26 May 2015; doi:10.1038/ajg.2015.146.
    The American Journal of Gastroenterology 05/2015; 110(7). DOI:10.1038/ajg.2015.146 · 10.76 Impact Factor
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    ABSTRACT: Health care practitioners who care for adolescents transitioning to adulthood often face incongruent recommendations from pediatric and adult guidelines for treatment of lipid levels. To compare the proportion of young people aged 17 to 21 years who meet criteria for pharmacologic treatment of elevated low-density lipoprotein cholesterol (LDL-C) levels under pediatric vs adult guidelines. We performed a cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES) population. Surveys were administered from January 1, 1999, through December 31, 2012, and the analysis was performed from June through December 2014. Participants included 6338 individuals aged 17 to 21 years in the United States. To estimate the number and proportion of individuals aged 17 to 21 years in the NHANES population who were eligible for statin therapy, we applied treatment algorithms from the 2011 Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents of the National Heart, Lung, and Blood Institute and the 2013 Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults from the American College of Cardiology and American Heart Association. After imputing missing data and applying NHANES sampling weights, we extrapolated the results to 20.4 million noninstitutionalized young people aged 17 to 21 years living in the United States. Of the 6338 young people aged 17 to 21 years in the NHANES population, 2.5% (95% CI, 1.8%-3.2%) would qualify for statin treatment under the pediatric guidelines compared with 0.4% (95% CI, 0.1%-0.8%) under the adult guidelines. Participants who met pediatric criteria had lower mean (SD) LDL-C levels (167.3 [3.8] vs 210.0 [7.1] mg/dL) but higher proportions of other cardiovascular risk factors, including hypertension (10.8% vs 8.4%), smoking (55.0% vs 23.9%), and obesity (67.7% vs 18.2%) compared with those who met the adult guidelines. Extrapolating to the US population of individuals aged 17 to 21 years represented by the NHANES sample, 483 500 (95% CI, 482 100-484 800) young people would be eligible for treatment of LDL-C levels if the pediatric guidelines were applied compared with only 78 200 (95% CI, 77 600-78 700) if the adult guidelines were applied. Application of pediatric vs adult guidelines for lipid levels, which consider additional cardiovascular risk factors beyond age and LDL-C concentration, might result in statin treatment for more than 400 000 additional adolescents and young adults.
    04/2015; 169(6). DOI:10.1001/jamapediatrics.2015.0168
  • Akriti P. Saxena · John B. Wong ·

    Gastroenterology 04/2015; 148(4):S-785. DOI:10.1016/S0016-5085(15)32678-0 · 16.72 Impact Factor

  • Gastroenterology 04/2015; 148(4):S-993. DOI:10.1016/S0016-5085(15)33392-8 · 16.72 Impact Factor
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    ABSTRACT: The relative efficacy of available treatments of knee osteoarthritis (OA) must be determined for rational treatment algorithms to be formulated. To examine the efficacy of treatments of primary knee OA using a network meta-analysis design, which estimates relative effects of all treatments against each other. MEDLINE, EMBASE, Web of Science, Google Scholar, Cochrane Central Register of Controlled Trials from inception through 15 August 2014, and unpublished data. Randomized trials of adults with knee OA comparing 2 or more of the following: acetaminophen, diclofenac, ibuprofen, naproxen, celecoxib, intra-articular (IA) corticosteroids, IA hyaluronic acid, oral placebo, and IA placebo. Two reviewers independently abstracted study data and assessed study quality. Standardized mean differences were calculated for pain, function, and stiffness at 3-month follow-up. Network meta-analysis was performed using a Bayesian random-effects model; 137 studies comprising 33 243 participants were identified. For pain, all interventions significantly outperformed oral placebo, with effect sizes from 0.63 (95% credible interval [CrI], 0.39 to 0.88) for the most efficacious treatment (hyaluronic acid) to 0.18 (CrI, 0.04 to 0.33) for the least efficacious treatment (acetaminophen). For function, all interventions except IA corticosteroids were significantly superior to oral placebo. For stiffness, most of the treatments did not significantly differ from one another. Lack of long-term data, inadequate reporting of safety data, possible publication bias, and few head-to-head comparisons. This method allowed comparison of common treatments of knee OA according to their relative efficacy. Intra-articular treatments were superior to nonsteroidal anti-inflammatory drugs, possibly because of the integrated IA placebo effect. Small but robust differences were observed between active treatments. All treatments except acetaminophen showed clinically significant improvement from baseline pain. This information, along with the safety profiles and relative costs of included treatments, will be helpful for individualized patient care decisions. Agency for Healthcare Research and Quality.
    Annals of internal medicine 01/2015; 162(1):46-54. DOI:10.7326/M14-1231 · 17.81 Impact Factor
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    ABSTRACT: The potential for academic community partnerships are challenged in places where there is a history of conflict and mistrust. Addressing Disparities in Asian Populations through Translational Research (ADAPT) represents an academic community partnership between researchers and clinicians from Tufts Medical Center and Tufts University and community partners from Boston Chinatown. Based in principles of community-based participatory research and partnership research, this partnership is seeking to build a trusting relationship between Tufts and Boston Chinatown. This case study aims to provides a narrative story of the development and formation of ADAPT as well as discuss challenges to its future viability. Using case study research tools, this study draws upon a variety of data sources including interviews, program evaluation data and documents. Several contextual factors laid the foundation for ADAPT. Weaving these factors together helped to create synergy and led to ADAPT's formation. In its first year, ADAPT has conducted formative research, piloted an educational program for community partners and held stakeholder forums to build a broad base of support. ADAPT recognizes that long term sustainability requires bringing multiple stakeholders to the table even before a funding opportunity is released and attempting to build a diversified funding base.
    Progress in Community Health Partnerships Research Education and Action 12/2014; 8(3):353-63. DOI:10.1353/cpr.2014.0046
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    ABSTRACT: Purpose: The U.S. Agency for Healthcare Research and Quality (AHRQ) solicited the development of guidance for decision and simulation modeling in the context of systematic reviews. Method: We updated and expanded existing systematic reviews of recommendations for the conduct and reporting of decision and simulation modeling with input from a multidisciplinary team of clinical, policy, and decision analysis experts. The results of the systematic review were discussed in-person with a panel of 28 stakeholders including patient representatives, providers of care, purchasers of care, payers, policy makers, and principal investigators. Stakeholders commented on existing recommendations from various sources and identified gaps, limitations and areas for elaboration. We subsequently reviewed the websites of 126 international health technology assessment organizations providing guidance on the conduct and reporting of decision and simulation models. We solicited further input from senior researchers with experience in decision and simulation modeling from AHRQ and its Evidence-based Practice Centers. Result: We developed a list of principles and good practice recommendations for modeling conducted to enhance and contextualize findings of systematic reviews. The guidance applies to structural mathematical models, including declarative, functional, and spatial models. We categorized recommendations by whether they pertain to the model structure, model data, or consistency, and reporting. We provide the rationale for each recommendation, evidence supporting the recommendation, or best judgment where adequate evidence was lacking. Conclusion: We used a systematic approach to develop guidance for decision and simulation modeling in the context of systematic reviews. We are optimistic that this work will contribute to increased use of modeling in systematic reviews.
    The 36th Annual Meeting of the Society for Medical Decision Making; 10/2014
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    ABSTRACT: BackgroundKnee osteoarthritis (OA) causes pain and long-term disability with annual healthcare costs exceeding $185 billion in the United States. Few medical remedies effectively influence the course of the disease. Finding effective treatments to maintain function and quality of life in patients with knee OA is one of the national priorities identified by the Institute of Medicine. We are currently conducting the first comparative effectiveness and cost-effectiveness randomized trial of Tai Chi versus a physical-therapy regimen in a sample of patients with symptomatic and radiographically confirmed knee OA. This article describes the design and conduct of this trial.Methods/DesignA single-center, 52-week, comparative effectiveness randomized controlled trial of Tai Chi versus a standardized physical-therapy regimen is being conducted at an urban tertiary medical center in Boston, Massachusetts. The study population consists of adults ≥ 40 years of age with symptomatic and radiographic knee OA (American College of Rheumatology criteria). Participants are randomly allocated to either 12 weeks of Tai Chi (2x/week) or Physical Therapy (2x/week for 6 weeks, followed by 6 weeks of rigorously monitored home exercise). The primary outcome measure is pain (Western Ontario and McMaster Universities WOMAC) subscale at 12 weeks. Secondary outcomes include WOMAC stkiffness and function domain scores, lower extremity strength and power, functional balance, physical performance tests, psychological and psychosocial functioning, durability effects, health related quality of life, and healthcare utilization at 12, 24 and 52 weeks.DiscussionThis study will be the first randomized comparative-effectiveness and cost-effectiveness trial of Tai Chi versus Physical Therapy in a large symptomatic knee OA population with long-term follow up. We present here a robust and well-designed randomized comparative-effectiveness trial that also explores multiple outcomes to elucidate the potential mechanisms of mind-body effect for a major disabling disease with substantial health burdens and economic costs. Results of this study are expected to have important public health implications for the large and growing population with knee OA.Trial identifier: NCT01258985Electronic supplementary materialThe online version of this article (doi:10.1186/1472-6882-14-333) contains supplementary material, which is available to authorized users.
    BMC Complementary and Alternative Medicine 09/2014; 14(1):333. DOI:10.1186/1472-6882-14-333 · 2.02 Impact Factor
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    ABSTRACT: The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party to develop a consensus cost-effectiveness model for treatment of Hepatitis B in Asia Pacific countries in March 2010. The working party consisted of expert hepatologists, virologists and epidemiologists from 11 representative countries in the Asia Pacific region. Meetings were conducted at the 20th APASL Annual Meeting in 2010 to determine consensus estimates for modeling and at the 21st and 22nd APASL meetings in 2011 and 2012, respectively to review and approve the models. The consensus cost-effectiveness model used Singapore as base case analysis and was validated using actual data from the Singapore Cancer, Diseases and Death Registries. Simulation for Singapore, China, Thailand, Pakistan, Taiwan and Korea were performed. Antivirals with high resistance barriers like entecavir and tenofovir had the highest retail cost but were the most cost-effective therapy in developed countries such as Singapore, Taiwan and Korea while generic tenofovir was most cost effective in Thailand and Pakistan. The cost effectiveness of different treatment strategies varied significantly between countries and was affected by medication cost, economic affordability, access to liver transplantation and the prevailing health of the general population. Choosing treatment strategies for hepatitis B based on low retail drug cost can be misleading because more expensive drugs may be more cost effective when considering long-term health outcomes and costs. Cost-effectiveness data should be individualized to countries based on their unique socio-economic conditions. Governmental policies which subsidize more costly drugs that have lower risk of drug resistance can benefit more patients.
    Hepatology International 07/2014; 8(3):382-394. DOI:10.1007/s12072-014-9549-1 · 1.78 Impact Factor
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    ABSTRACT: Objective: Seizure frequency represents a commonly assessed epilepsy status, but in the context of the growing trend toward patient-centered care, we examined the adequacy of seizure frequency as a measure of epilepsy status as perceived by the patient. Methods: Between 2006 and 2008, we assessed seizure frequency, mood, and preference-based health-related quality of life (HRQOL) measured with the visual analog scale metric in 182 adult patients sampled consecutively. Using nonparametric tests and Monte Carlo computer simulations, we analyzed the relationship between preference-based HRQOL and seizure frequency, and using regression analyses, we tested for significant predictors of preference-based HRQOL. Results: Only patients who had been seizure-free for >1 year had significantly higher preference-based HRQOL (p < 0.0001) than those who experienced any recurrent seizure, regardless of their seizure frequency. Among patients with recurrent seizures, preference-based HRQOL and seizure frequency were not monotonically, linearly related. For patients with similar seizure frequency, preference-based HRQOL varied substantially with large overlaps in preference-based HRQOL across different seizure frequency categories. The Monte Carlo simulation found that seizure frequency was a poor predictor of preference-based HRQOL about one third of the time. The presence of depressive symptoms was an independent predictor of preference-based HRQOL measure, accounting for 33.5% of the variation in scores between patients. Significance: Our findings highlight the importance of attaining complete seizure freedom and the substantial variation in preference-based HRQOL among patients with similar seizure frequencies. To improve assessment of patient-centered outcomes in epilepsy, we encourage adding direct measurement of preference-based HRQOL into clinical care.
    Epilepsia 06/2014; 55(8). DOI:10.1111/epi.12672 · 4.57 Impact Factor
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    ABSTRACT: OBJECTIVES We conducted a review of the peer-reviewed literature since 2003 to catalogue reported methods of stakeholder engagement in comparative effectiveness research and patient-centered outcomes research. METHODS AND RESULTS We worked with stakeholders before, during and after the review was conducted to: define the primary and key research questions; conduct the literature search; screen titles, abstracts and articles; abstract data from the articles; and analyze the data. The literature search yielded 2,062 abstracts. The review was conducted on 70 articles that reported on stakeholder engagement in individual research projects or programs. FINDINGS Reports of stakeholder engagement are highly variable in content and quality. We found frequent engagement with patients, modestly frequent engagement with clinicians, and infrequent engagement with stakeholders in other key decision-making groups across the healthcare system. Stakeholder engagement was more common in earlier (prioritization) than in later (implementation and dissemination) stages of research. The roles and activities of stakeholders were highly variable across research and program reports. RECOMMENDATIONS To improve on the quality and content of reporting, we developed a 7-Item Stakeholder Engagement Reporting Questionnaire. We recommend three directions for future research: 1) descriptive research on stakeholder-engagement in research; 2) evaluative research on the impact of stakeholder engagement on the relevance, transparency and adoption of research; and 3) development and validation of tools that can be used to support stakeholder engagement in future work.
    Journal of General Internal Medicine 06/2014; 29(12). DOI:10.1007/s11606-014-2878-x · 3.45 Impact Factor
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    ABSTRACT: The Chicago Area Patient-Centered Outcomes Research Network (CAPriCORN) represents an unprecedented collaboration across diverse healthcare institutions including private, county, and state hospitals and health systems, a consortium of Federally Qualified Health Centers, and two Department of Veterans Affairs hospitals. CAPriCORN builds on the strengths of our institutions to develop a cross-cutting infrastructure for sustainable and patient-centered comparative effectiveness research in Chicago. Unique aspects include collaboration with the University HealthSystem Consortium to aggregate data across sites, a centralized communication center to integrate patient recruitment with the data infrastructure, and a centralized institutional review board to ensure a strong and efficient human subject protection program. With coordination by the Chicago Community Trust and the Illinois Medical District Commission, CAPriCORN will model how healthcare institutions can overcome barriers of data integration, marketplace competition, and care fragmentation to develop, test, and implement strategies to improve care for diverse populations and reduce health disparities.
    Journal of the American Medical Informatics Association 05/2014; 21(4). DOI:10.1136/amiajnl-2014-002827 · 3.50 Impact Factor
  • John B Wong ·

    Annals of internal medicine 02/2014; 160(4). DOI:10.7326/M14-0040 · 17.81 Impact Factor
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    ABSTRACT: The American College of Cardiology Foundation along with key specialty and subspecialty societies, conducted an appropriate use review of common clinical presentations for stable ischemic heart disease (SIHD) to consider use of stress testing and anatomic diagnostic procedures. This document reflects an updating of the prior Appropriate Use Criteria (AUC) published for radionuclide imaging (RNI), stress echocardiography (Echo), calcium scoring, coronary computed tomography angiography (CCTA), stress cardiac magnetic resonance (CMR), and invasive coronary angiography for SIHD. This is in keeping with the commitment to revise and refine the AUC on a frequent basis. A major innovation in this document is the rating of tests side by side for the same indication. The side-byside rating removes any concerns about differences in indication or interpretation stemming from prior use of separate documents for each test. However, the ratings were explicitly not competitive rankings due to the limited availability of comparative evidence, patient variability, and range of capabilities available in any given local setting. The indications for this review are limited to the detection and risk assessment of SIHD and were drawn from common applications or anticipated uses, as well as from current clinical practice guidelines. Eighty clinical scenarios were developed by a writing committee and scored by a separate rating panel on a scale of 1 to 9, to designate Appropriate, May Be Appropriate, or Rarely Appropriate use following a modified Delphi process following the recently updated AUC development methodology. The use of some modalities of testing in the initial evaluation of patients with symptoms representing ischemic equivalents, newly diagnosed heart failure, arrhythmias, and syncope was generally found to be Appropriate or May Be Appropriate, except in cases where low pre-test probability or low risk limited the benefit of most testing except exercise electrocardiogram(ECG). Testing for the evaluation of newor worsening symptoms following a prior test or procedure was found to be Appropriate. In addition, testing was found to be Appropriate or May Be Appropriate for patients within 90 days of an abnormal or uncertain prior result. Pre-operative testing was rated Appropriate or May Be Appropriate only for patientswho had poor functional capacity and were undergoing vascular or intermediate risk surgery with 1 or more clinical risk factors or an organ transplant. The exercise ECGwas suggested as an Appropriate test for cardiac rehabilitation clearance or for exercise prescription purposes. Testing in asymptomatic patients was generally found to be Rarely Appropriate, except for calcium scoring and exercise testing in intermediate and high-risk individuals and either stress or anatomic imaging in higher-risk individuals, which were all rated as May Be Appropriate. All modalities of follow-up testing after a prior test or percutaneous coronary intervention (PCI) within 2 years and within 5 years after coronary artery bypass graft (CABG) in the absence of new symptoms were rated Rarely Appropriate. Pre-operative testing for patients with good functional capacity, prior normal testing within 1 year, or prior to low-risk surgery also were found to be Rarely Appropriate. Imaging for an exercise prescription or prior to the initiation of cardiac rehabilitation was Rarely Appropriate except for cardiac rehabilitation clearance for heart failure patients.

Publication Stats

9k Citations
1,413.45 Total Impact Points


  • 1993-2015
    • Tufts Medical Center
      • • Institute for Clinical Research and Health Policy Studies
      • • Division of Clinical Decision Making, Informatics and Telemedicine
      • • Department of Medicine
      Boston, Massachusetts, United States
  • 1995-2014
    • University of Massachusetts Boston
      Boston, Massachusetts, United States
  • 1992-2014
    • Tufts University
      • • Institute for Clinical Research and Health Policy Studies
      • • Department of Medicine
      • • Division of Clinical Decision Making, Informatics and Telemedicine
      • • Division of Rheumatology
      Бостон, Georgia, United States
  • 2011-2013
    • Boston Children's Hospital
      Boston, Massachusetts, United States
  • 2012
    • American College of Cardiology
      Washington, Washington, D.C., United States
  • 2009
    • Private Universität für Gesundheitswissenschaften, Medizinische Informatik und Technik
      Solbad Hall in Tirol, Tyrol, Austria
  • 2004
    • Harvard University
      • Department of Nutrition
      Cambridge, Massachusetts, United States
  • 2002
    • University of Greifswald
      Griefswald, Mecklenburg-Vorpommern, Germany
  • 1998-2001
    • New England Baptist Hospital
      Boston, Massachusetts, United States
  • 1994
    • Louis Stokes Cleveland VA Medical Center
      Cleveland, Ohio, United States
    • University of Groningen
      • Department of Health Sciences
      Groningen, Groningen, Netherlands

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