S45T he morbidity and mortality of acute type B aortic dissection (ABAD) are strongly related to the clinical presentation. 1,2 In contrast to patients with ascending involvement, medical treatment is the preferred therapy in all uncomplicated type B dissection patients, because current randomized controlled trials have failed to demonstrate a beneficial outcome of prophylactic endovascular repair in the shortterm.3,4 Surgical and endovascular approaches are reserved for patients presenting with complications such as shock, periaortic bleeding, organ malperfusion, limb ischemia, and rapidly expanding false lumen. However, these procedures are still associated with high mortality rates between 20% and 30% for surgery and 10% and 20% for endovascular repair in the acute setting, especially in the elderly.3-5 Because of the various clinical features of ABAD, the progress and outcome of individual patients with ABAD admitted to the emergency department remain unpredictable.6-8 Therefore, more insights into the early prognosis of ABAD based on patient characteristics and presenting symptoms are needed to optimize treatment strategies and inform patients and their family. A Background-The outcome of patients with acute type B aortic dissection (ABAD) is strongly related to their clinical presentation. The purpose of this study was to investigate predictors for mortality among patients presenting with ABAD and to create a predictive model to estimate individual risk of in-hospital mortality using the International Registry of Acute Aortic Dissection (IRAD). Methods and Results-All patients with ABAD enrolled in IRAD between 1996 and 2013 were included for analysis.Multivariable logistic regression analysis was used to investigate predictors of in-hospital mortality. Significant risk factors for in-hospital death were used to develop a prediction model. A total of 1034 patients with ABAD were included for analysis (673 men; mean age, 63.5±14.0 years), with an overall in-hospital mortality of 10.6%. In multivariable analysis, the following variables at admission were independently associated with increased in-hospital mortality: increasing age (odds ratio

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IMPORTANCE Much of health care involves established, routine use of medical services for chronic conditions or prevention. Stopping these services when the evidence changes or if the benefits no longer outweigh the risks is essential. Yet, most guidelines focus on escalating care and provide few explicit recommendations to stop or scale back (ie, deintensify) treatment and testing.OBJECTIVE To develop a systematic, transparent, and reproducible approach for identifying, specifying, and validating deintensification recommendations associated with routine adult primary care. DESIGN, SETTING, AND PARTICIPANTSA focused review of existing guidelines and recommendations was completed to identify and prioritize potential deintensification indications. Then, 2 modified virtual Delphi expert panels examined the synthesized evidence, suggested ways that the candidate recommendations could be improved, and assessed the validity of the recommendations using the RAND/UCLA Appropriateness Method. Twenty-five physicians from Veterans Affairs and US academic institutions with knowledge in relevant clinical areas (eg, geriatrics, primary care, women's health, cardiology, and endocrinology) served as panel members. MAIN OUTCOMES AND MEASURESValidity of the recommendations, defined as high-quality evidence that deintensification is likely to improve patient outcomes, evidence that intense testing and/or treatment could cause harm in some patients, absence of evidence on the benefit of continued or repeated intense treatment or testing, and evidence that deintensification is consistent with high-quality care.RESULTS A total of 409 individual recommendations were identified representing 178 unique opportunities to stop or scale back routine services (eg, stopping population-based screening for vitamin D deficiency and decreasing concurrent use of opioids and benzodiazepines). Thirty-seven recommendations were prioritized and forwarded to the expert panels. Panelists reviewed the evidence and suggested modifications, resulting in 44 recommendations being rated. Overall, 37 recommendations (84%) were considered to be valid, as assessed by the RAND/UCLA Appropriateness Method. CONCLUSIONS AND RELEVANCEIn this study, a total of 178 unique opportunities to deintensify routine primary care services were identified, and 37 of these were validated as high-priority deintensification recommendations. To date, this is the first study to develop a model for identifying, specifying, and validating deintensification recommendations that can be implemented and tracked in clinical practice.

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