Faculty Bibliography

Importance:Hip and knee arthroplasty are the most common inpatient surgical procedures for Medicare beneficiaries in the US, with substantial variation in cost and quality. Whether remote monitoring incorporating insights from behavioral science might help improve outcomes and increase value of care remains unknown. Objective:To evaluate the effect of activity monitoring and bidirectional text messaging on the rate of discharge to home and clinical outcomes in patients receiving hip or knee arthroplasty. Design, Setting, and Participants:Randomized clinical trial conducted between February 7, 2018, and April 15, 2019. The setting was 2 urban hospitals at an academic health system. Participants were patients aged 18 to 85 years scheduled to undergo hip or knee arthroplasty with a Risk Assessment and Prediction Tool score of 6 to 8. Interventions:Eligible patients were randomized evenly to receive usual care (n = 153) or remote monitoring (n = 147). Those in the intervention arm who agreed received a wearable activity monitor to track step count, messaging about postoperative goals and milestones, pain score tracking, and connection to clinicians as needed. Patients assigned to receive monitoring were further randomized evenly to remote monitoring alone or remote monitoring with gamification and social support. Remote monitoring was offered before surgery, began at hospital discharge, and continued for 45 days postdischarge. Main Outcomes and Measures:The primary outcome was discharge status (home vs skilled nursing facility or inpatient rehabilitation). Prespecified secondary outcomes included change in average daily step count and rehospitalizations. Results:A total of 242 patients were analyzed (124 usual care, 118 intervention); median age was 66 years (interquartile range, 58-73 years); 78.1% were women, 45.5% were White, 43.4% were Black; and 81.4% in the intervention arm agreed to receive monitoring. There was no significant difference in the rate of discharge to home between the usual care arm (57.3%; 95% CI, 48.5%-65.9%) and the intervention arm (56.8%; 95% CI, 47.9%-65.7%) and no significant increase in step count in those receiving remote monitoring plus gamification and social support compared with remote monitoring alone. There was a statistically significant reduction in rehospitalization rate in the intervention arm (3.4%; 95% CI, 0.1%-6.7%) compared with the usual care arm (12.2%; 95% CI, 6.4%-18.0%) (P = .01). Conclusions and Relevance:In this study, the remote monitoring program did not increase rate of discharge to home after hip or knee arthroplasty, and gamification and social support did not increase activity levels. There was a significant reduction in rehospitalizations among those receiving the intervention, which may have resulted from goal setting and connection to the care team. Trial Registration:ClinicalTrials.gov Identifier: NCT03435549.

INTRODUCTION: Revascularization is an important strategy for reducing stroke risk in patients with severe carotid atherosclerosis. Magnetic resonance angiography (MRA) and/or carotid ultrasound have traditionally been used as the only diagnostic modalities prior to revascularization. Patients undergoing CEA frequently have no further assessments of carotid anatomy prior to surgery. Evaluation with carotid ultrasound and MRA can often overestimate the degree of stenosis. We sought to determine if noninvasive imaging was sufficient for determining whether a patient should be referred for carotid intervention. METHODS: We performed an analysis of 101 patients referred for carotid artery stenting (CAS). All patients had previously been evaluated with carotid ultrasound and 94% had undergone MRA as well. We sought to determine if noninvasive diagnostic imaging for carotid stenosis was sufficient to determine the necessity for endovascular intervention. RESULTS: Of the 101 patients referred for carotid intervention, 36 (36%) were shown to have <70% stenoses and did not require intervention. Of those who had significant disease, 49 (75%) underwent successful CAS, 15 (23%) underwent CEA, and 1 patient was treated medically for a total occlusion. Three of the 36 patients not requiring carotid intervention were found to have subclavian stenosis. Two (4%) of the patients undergoing CAS and 4 (27%) of the patients undergoing CEA had minor complications. No patients suffered a major stroke, MI, or death at follow-up. CONCLUSION: This analysis demonstrates that 36% of patients referred for endovascular intervention based on noninvasive imaging did not meet criteria by angiography. This emphasizes the need for carotid angiography prior to carotid intervention

The Concussion Resolution Index (CRI) is an online assessment tool designed to track resolution of symptoms following sports-related concussion. The CRI is composed of six subtests measuring reaction time, visual recognition, and speed of information processing. Three factors are derived from the subtests: Simple Reaction Time (SRT), Complex Reaction Time (CRT), and Processing Speed (PS). Multiple alternate forms within subtests afford simple, reliable, assessment of change, relative to a baseline test completed by an athlete. The test also assesses self-reported neurophysiological symptoms at the time of injury and tracks resolution of these symptoms. The data demonstrate the CRI is a valid and reliable measure of cognitive performance in a relatively heterogeneous group of athletes aged 13-35. Two methods of statistical analysis for assessing change from baseline were compared to establish a psychometric basis for return-to-play decision-making: the Reliable Change Index (RCI) and multiple regression. Multiple regression was more accurate than the RCI in determining a decline in performance relative to the baseline

OBJECTIVES: We acquired normative data for an Internet neurocognitive screening tool, the Cognitive Stability Index (CSI), and investigated its validity both for initial assessment and for detecting significant change. PARTICIPANTS: Normative data on a nationally representative sample of 284 individuals aged 18 to 89. Validity data was obtained for outpatient groups of mild-to-moderate TBI, attention deficit/hyperactivity disorder (AD/HD), and Alzheimer's disease. RESULTS: The CSI subtests resolve to four factors: attention, processing speed, motor speed, and memory with acceptable psychometric properties. Patterns of scores obtained by three groups of patient-participants provided reasonable evidence of clinical validity for screening and monitoring change. CONCLUSIONS: An Internet-based system holds promise for applying complex statistical models for routine monitoring of cognitive function