Faculty Bibliography

BACKGROUND: Educational and computerized interventions have been shown to reduce red blood cell (RBC) transfusion rates, yet controversy remains surrounding the optimal strategy needed to achieve sustained reductions in liberal transfusions. STUDY DESIGN AND METHODS: The purpose of this study was to assess the impact of clinician decision support (CDS) along with targeted education on liberal RBC utilization to four high-utilizing service lines compared with no education to control service lines across an academic medical center. Clinical data along with associated hemoglobin levels at the time of all transfusion orders between April 2014 and December 2015 were obtained via retrospective chart review. The primary outcome was the change in the rate of liberal RBC transfusion orders (defined as any RBC transfusion when the hemoglobin level is >7.0 g/dL). Secondary outcomes included the annual projected reduction in the number of transfusions and the associated decrease in cost due to these changes as well as length of stay (LOS) and death index. These measures were compared between the 12 months prior to the initiative and the 9-month postintervention period. RESULTS: Liberal RBC utilization decreased from 13.4 to 10.0 units per 100 patient discharges (p = 0.002) across the institution, resulting in a projected 12-month savings of $720,360. The mean LOS and the death index did not differ significantly in the postintervention period. CONCLUSION: Targeted education combined with the incorporation of CDS at the time of order entry resulted in significant reductions in the incidence of liberal RBC utilization without adversely impacting inpatient care, whereas control service lines exposed only to CDS had no change in transfusion habits.

This article discusses the current state of value in the United States health care system, and the unsustainable growth trend of health care spending. Also discussed is the role of waste and its subcategories as the drivers of that cost. The key differences in the cost drivers for governmental and commercial payers are discussed. The patient-level outcomes of low-value care are addressed. In addition, hospitalists are provided with an overview of the tools that exist to help improve the value of their current practices as well as for teaching value and leading value-based projects.

PURPOSE: To decrease overutilization of laboratory testing by eliminating a feature of the electronic ordering system that allowed providers to order laboratory tests to occur daily without review. METHODS: We collected rates of utilization of a group of commonly ordered laboratory tests (number of tests per patient per day) throughout the entire hospital from June 10th, 2013 through June 10th, 2015. Our intervention which eliminated the ability to order daily recurring tests was implemented on June 11th, 2014. We compared pre and post-intervention rates in order to assess the impact and surveyed providers about their experience with the intervention. RESULTS: We examined 1,296,742 laboratory tests performed on 92,799 unique patients over 434,059 patient days. Prior to the intervention, the target tests were ordered using this daily recurring mechanism 33% of the time. After the intervention we observed between an 8.5% (p <0.001) to 20.9% (p <0.001) reduction in tests per patient per day. The reduction in rate for some of the target tests persisted during the study period but not for the two most commonly ordered tests. We estimated an approximate reduction in hospital costs of $300,000 due to the intervention. CONCLUSION: A simple modification to the order entry system significantly and immediately altered provider practices throughout a large tertiary care academic center. This strategy is replicable by the many hospitals that use the same electronic health record system and possibly by users of other systems. Future areas of study include evaluating the additive effects of education and real-time decision support.

Rationale: Novel approaches for faculty development and assessment of procedural teaching skills are needed to improve the procedural education of trainees. The Objective Structured Teaching Exercise entails a simulated encounter in which faculty are observed teaching a standardized student and has been used to evaluate teaching skills. Use of an Objective Structured Teaching Exercise to assess the teaching of central venous catheterization has not been reported. Objectives: The purpose of this study was to develop a Procedural Objective Structured Teaching Exercise for subclavian central venous catheter insertion and to determine specific aspects of procedural teaching associated with improved skills in novices. Methods: Critical Care faculty/fellows taught a standardized student to insert a central venous catheter in a simulator. We assessed the instructor's teaching skills using rating scales to generate a procedural teaching score. Following this encounter, the instructor taught novice medical students to place central venous catheters in simulators. Novices then independently placed catheters in simulators and were evaluated by trained observers using a checklist. Generalized estimating equations were used to examine the correlation between specific teaching behaviors and the novices' skills in central venous catheter placement. Measurements and Main Results: We recruited 10 participants to serve as teachers and 30 pre-clinical medical students to serve as novice learners. The overall mean procedural teaching score was 85.5 (+/-15.4). Improved student performance was directly related to the degree to which the teacher 'Provided Positive Feedback' (beta=1.53, SE=0.44, p=0.001), 'Offered Learner Suggestions for Improvement' (beta=1.40, SE=0.35, p<0.001), and 'Demonstrated the Procedure in a Step-by-Step Manner' (beta=2.50, SE=0.45, p<0.001). There was no significant correlation between total scores and student skills (beta =0.06, [SE]=0.46, p=0.18). Conclusions: The Objective Structured Teaching Exercise is a standardized method to assess procedural teaching skills. Our findings suggest that specific aspects of procedural teaching should be emphasized to ensure effective transfer of psychomotor skills to trainees.

A 49-year-old woman with cholangiocarcinoma metastatic to the lungs presented with new-onset unrelenting headaches. A lumbar puncture revealed malignant cells consistent with leptomeningeal metastasis from her cholangiocarcinoma. Magnetic resonance imaging (MRI) of the brain revealed leptomeningeal enhancement. An intrathecal (IT) catheter was placed and IT chemotherapy was initiated with methotrexate. Her case is notable for the rarity of cholangiocarcinoma spread to the leptomeninges, the use of IT chemotherapy with cytologic and potentially symptomatic response, and a possible survival benefit in comparison to previously reported cases of leptomeningeal carcinomatosis secondary to cholangiocarcinoma.

Rationale: Posttranslational phosphorylation of connexin43 (Cx43) has been proposed as a key regulatory event in normal cardiac gap junction expression and pathological gap junction remodeling. Nonetheless, the role of Cx43 phosphorylation in the context of the intact organism is poorly understood. Objective: To establish whether specific Cx43 phosphorylation events influence gap junction expression and pathological remodeling. Methods and Results: We generated Cx43 germline knock-in mice in which serines 325/328/330 were replaced with phosphomimetic glutamic acids (S3E) or nonphosphorylatable alanines (S3A). The S3E mice were resistant to acute and chronic pathological gap junction remodeling and displayed diminished susceptibility to the induction of ventricular arrhythmias. Conversely, the S3A mice showed deleterious effects on cardiac gap junction formation and function, developed electric remodeling, and were highly susceptible to inducible arrhythmias. Conclusions: These data demonstrate a mechanistic link between posttranslational phosphorylation of Cx43 and gap junction formation, remodeling, and arrhythmic susceptibility

Pressure overload is a common pathological insult to the heart and the resulting hypertrophy is an independent risk factor for sudden cardiac death. Gap junction remodeling (GJR) has been described in hypertrophied hearts; however, a detailed understanding of the remodeling process and its effects on impulse propagation is lacking. Moreover, there has been little progress developing therapeutic strategies to diminish GJR. Accordingly, transverse aortic banding (TAC) was performed in mice to determine the effects of progressive pathological hypertrophy on connexin (Cx)43 expression, posttranslational phosphorylation, gap junction assembly, and impulse propagation. Within 2 weeks after TAC, total and phospho-Cx43 abundance was reduced and incorporation of Cx43 into gap junctional plaques was markedly diminished. These molecular changes were associated with progressive slowing of impulse propagation, as determined by optical mapping with voltage-sensitive dyes. Treatment with the aldosterone receptor antagonist spironolactone, which has been shown to diminish sudden arrhythmic death in clinical trials, was examined for its effects on GJR. We found that spironolactone blunted the development of GJR and also potently reversed established GJR, both at the molecular and functional levels, without diminishing the extent of hypertrophy. These data suggest a potential mechanism for some of the salutary electrophysiological and clinical effects of mineralocorticoid antagonists in myopathic hearts