Faculty Bibliography

INTRODUCTION: Orthopaedic care is shifting to alternative payment models. We examined whether New York University Langone Medical Center achieved savings under the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement initiative. METHODS: This study was a difference-in-differences study of Medicare fee-for-service patients hospitalized from April 2011 to June 2012 and October 2013 to December 2014 for lower extremity joint arthroplasty, cardiac valve procedures, or spine surgery (intervention groups), or for congestive heart failure, major bowel procedures, medical peripheral vascular disorders, medical noninfectious orthopaedic care, or stroke (control group). We examined total episode costs and costs by service category. RESULTS: We included 2,940 intervention episodes and 1,474 control episodes. Relative to the trend in the control group, lower extremity joint arthroplasty episodes achieved the greatest savings: adjusted average episode cost during the intervention period decreased by $3,017 (95% confidence interval [CI], -$6,066 to $31). For cardiac procedures, the adjusted average episode cost decreased by $2,999 (95% CI, -$8,103 to $2,105), and for spinal fusion, it increased by $8,291 (95% CI, $2,879 to $13,703). Savings were driven predominantly by shifting postdischarge care from inpatient rehabilitation facilities to home. Spinal fusion index admission costs increased because of changes in surgical technique. DISCUSSION: Under bundled payment, New York University Langone Medical Center decreased total episode costs in patients undergoing lower extremity joint arthroplasty. For patients undergoing cardiac valve procedures, evidence of savings was not as strong, and for patients undergoing spinal fusion, total episode costs increased. For all three conditions, the proportion of patients referred to inpatient rehabilitation facilities upon discharge decreased. These changes were not associated with an increase in index hospital length of stay or readmission rate. CONCLUSION: Opportunities for savings under bundled payment may be greater for lower extremity joint arthroplasty than for other conditions.

BACKGROUND: In 2012 The Joint Commission implemented new Tobacco Treatment (TOB) performance measures for hospitals. A study evaluated the impact of a hospital-based electronic health record (EHR) intervention on adherence to the revised TOB measures. METHODS: The study was conducted in two acute care hospitals in New York City. Data abstracted from the EHR were analyzed retrospectively from 4,871 smokers discharged between December 2012 and March 2015 to evaluate the impact of two interventions: an order set to prompt clinicians to prescribe pharmacotherapy and a nurse-delivered counseling module that automatically populated the nursing care plan for all smokers. The study estimated the relative odds of a patient being prescribed medication and/or receiving smoking cessation counseling in the intervention period compared to the baseline time period. RESULTS: There was a modest increase in medication orders (odds ratio [OR], 1.35). In contrast, rates of counseling increased 10-fold (OR, 10.54). Patients admitted through surgery were less likely to receive both counseling and medication compared with the medicine service. CONCLUSION: Hospitalization presents an important opportunity to engage smokers in treatment for primary and secondary prevention of tobacco-related illnesses. EHRs can be leveraged to facilitate integration of TOB measure requirements into routine inpatient care; however, the smaller effect on prescribing patterns suggests limitations in this approach alone in changing clinician behavior to meet this measure. The success of the nurse-focused EHR-driven intervention suggests an effective tool for integrating the cessation counseling component of the new measures and the importance of nursing's role in achieving the Joint Commission measure targets.

BACKGROUND: Diabetic medications are approved by the Food and Drug Administration (FDA) based on efficacy in controlled clinical settings. Real world effectiveness may often vary from the results of clinical trials. We attempted to quantify the "efficacy versus effectiveness" gap at our institution. METHODS: We performed a retrospective analysis of all patients prescribed oral diabetic medications at New York University Langone Medical Center, a large urban tertiary care center, using data extracted from our electronic health record from October 2009 to September 2014. We limited the dataset to include newly diagnosed diabetic patients who were started on monotherapy or a combination pill. We excluded patients who were prescribed insulin or multiple diabetic agents. We used two-tailed Welch's t-tests to compare the initial Hemoglobin A1c (HbA1c), final HbA1c, and total HbA1c reduction to clinical trial data used for FDA approval, with statistical significance defined as p<0.05. RESULTS: Among the 566 of the 2452 patients who met our inclusion criteria, the mean age was 62.9 +/- 12.2 years, the majority of whom were male (51.1%), white (61.1%), non-Hispanic (80.4%), and prescribed metformin monotherapy (70.3%). The mean treatment time for each drug class ranged from 32-39 weeks. The mean initial HbA1c for all groups was 8.95%, the mean final HbA1c was 7.44%, and the mean HbA1c reduction was 0.51%. For almost all drug classes, the initial HbA1c was lower than the initial HbA1c from efficacy trials. For most drug classes, effectiveness was about half of the expected value from efficacy trials. Most patients achieved their goal HbA1c levels [Table]. CONCLUSIONS: In our study population, real world effectiveness did not reflect measures of efficacy from controlled clinical settings. The results highlight the need for clinicians to realize that a medication may not perform as well as it does in a controlled setting and they may need to increase the intensity of treatment more quickly than expected. Also, replicating the results of clinical trials in an actual clinical setting is challenging, both from the perspective of data availability and clinical practice patterns. (Table Presented)

BACKGROUND: National surveys indicate high rates of burnout, particularly among primary care physicians. Despite concerns about the impact of burnout on health outcomes, this relationship is not well studied. HealthyHearts NYC, funded through the EvidenceNOW initiative of the Agency for Healthcare Research and Quality is evaluating the effectiveness of practice facilitation to improve adoption of Million Hearts' evidence-based ABCS guidelines (Aspirin, Blood pressure control (BP), Cholesterol management, and Smoking cessation) in small-to-medium size primary care practices. This study examined the association between site characteristics and physicians' burnout, as well as the relationship with the ABCS outcomes. METHODS: We present data on 99 small practices working with the NYCDOHMH Primary Care Information Project, and 8 Federally Qualified Health Centers (FQHC) from the Community Health Care Association of New York State. Each provider from participating practice sites completed a survey that included a validated question assessing burnout that used a 5-point scale ranging from 1- no symptoms of burnout to 5- completely burned out. For sites with multiple providers, we calculated a site burnout score by extracting the maximum score within each site. The burnout level was dichotomously coded as 1- burned out, and 0- not burned out. Each site completed a practice survey to report site characteristics, including the number of providers (1 vs. 2 or more), Patient Centered Medical Home (PCMH) status (recognized vs. not recognized), average number of patient visits per week, and total number of support staff. We used logistic regression analysis to assess the association of practice site characteristics and burnout. We also calculated a composite measure for patients with multiple CVD risk factors to capture the extent to which targets are met across three of the outcome measures (ABC). We used ttests to assess the difference in ABCS and composite measures by burnout status. RESULTS: Overall, 19% of physicians reported burnout. A significant difference was detected for all ABCS measures by the sites' burnout status. Sites reporting burnout had higher rates of meeting aspirin, smoking, and composite measure targets, but lower rates of meeting BP and cholesterol target measures and were more likely to have achieved PCMH recognition. FQHCs reported higher rates of burnout compared with small practices. CONCLUSIONS: The overall rates of burnout were lower than reported in previous surveys. Lower burnout rates among small independent practices compared with FQHCs may be related to small practice providers' greater level autonomy. We will present additional data exploring organizational factors that may explain variation in burnout across these different practice settings. Finally, previous research has similarly found inconsistent associations between quality and burnout. Further studies are required to determine whether healthier workplaces also result in higher quality care

BACKGROUND: Buprenorphine maintenance for opioid dependence remains of limited availability among underserved populations, despite increases in US opioid misuse and overdose deaths. Low threshold primary care treatment models including the use of unobserved, "home," buprenorphine induction may simplify initiation of care and improve access. Unobserved induction and long-term treatment outcomes have not been reported recently among large, naturalistic cohorts treated in low threshold safety net primary care settings. METHODS: This prospective clinical registry cohort design estimated rates of induction-related adverse events, treatment retention, and urine opioid results for opioid dependent adults offered buprenorphine maintenance in a New York City public hospital primary care office-based practice from 2006 to 2013. This clinic relied on typical ambulatory care individual provider-patient visits, prescribed unobserved induction exclusively, saw patients no more than weekly, and did not require additional psychosocial treatment. Unobserved induction consisted of an in-person screening and diagnostic visit followed by a 1-week buprenorphine written prescription, with pamphlet, and telephone support. Primary outcomes analyzed were rates of induction-related adverse events (AE), week 1 drop-out, and long-term treatment retention. Factors associated with treatment retention were examined using a Cox proportional hazard model among inductions and all patients. Secondary outcomes included overall clinic retention, buprenorphine dosages, and urine sample results. RESULTS: Of the 485 total patients in our registry, 306 were inducted, and 179 were transfers already on buprenorphine. Post-induction (n = 306), week 1 drop-out was 17%. Rates of any induction-related AE were 12%; serious adverse events, 0%; precipitated withdrawal, 3%; prolonged withdrawal, 4%. Treatment retention was a median 38 weeks (range 0-320) for inductions, compared to 110 (0-354) weeks for transfers and 57 for the entire clinic population. Older age, later years of first clinic visit (vs. 2006-2007), and baseline heroin abstinence were associated with increased treatment retention overall. CONCLUSIONS: Unobserved "home" buprenorphine induction in a public sector primary care setting appeared a feasible and safe clinical practice. Post-induction treatment retention of a median 38 weeks was in line with previous naturalistic studies of real-world office-based opioid treatment. Low threshold treatment protocols, as compared to national guidelines, may compliment recently increased prescriber patient limits and expand access to buprenorphine among public sector opioid use disorder patients.

Importance: Low-income minority children living in urban neighborhoods are at high risk for mental health problems and underachievement. ParentCorps, a family-centered, school-based intervention in prekindergarten, improves parenting and school readiness (ie, self-regulation and preacademic skills) in 2 randomized clinical trials. The longer-term effect on child mental health and academic performance is not known. Objective: To examine whether ParentCorps delivered as an enhancement to prekindergarten programs in high-poverty urban schools leads to fewer mental health problems and increased academic performance in the early elementary school years. Design, Setting, and Participants: This is a 3-year follow-up study of a cluster randomized clinical trial of ParentCorps in public schools with prekindergarten programs in New York City. Ten elementary schools serving a primarily low-income, black student population were randomized in 2005, and 4 consecutive cohorts of prekindergarten students were enrolled from September 12, 2005, through December 31, 2008. We report follow-up for the 3 cohorts enrolled after the initial year of implementation. Data analysis was performed from September 1, 2014, to December 31, 2015. Interventions: ParentCorps included professional development for prekindergarten and kindergarten teachers and a program for parents and prekindergarten students (13 two-hour group sessions delivered after school by teachers and mental health professionals). Main Outcomes and Measures: Annual teacher ratings of mental health problems and academic performance and standardized tests of academic achievement in kindergarten and second grade by testers masked to the intervention or control group randomization. Results: A total of 1050 children (4 years old; 518 boys [49.3%] and 532 girls [50.7%]) in 99 prekindergarten classrooms participated in the trial (88.1% of the prekindergarten population), with 792 students enrolled from 2006 to 2008. Most families in the follow-up study (421 [69.6%]) were low income; 680 (85.9%) identified as non-Latino black, 78 (9.8%) as Latino, and 34 (4.3%) as other. Relative to their peers in prekindergarten programs, children in ParentCorps-enhanced prekindergarten programs had lower levels of mental health problems (Cohen d = 0.44; 95% CI, 0.08-0.81) and higher teacher-rated academic performance (Cohen d = 0.21; 95% CI, 0.02-0.39) in second grade. Conclusions and Relevance: Intervention in prekindergarten led to better mental health and academic performance 3 years later. Family-centered early intervention has the potential to prevent problems and reduce disparities for low-income minority children. Trial Registration: clinicaltrials.gov Identifier: NCT01670227.

BACKGROUND: HealthyHearts NYC (HHNYC) will evaluate the effectiveness of practice facilitation as a quality improvement strategy for implementing the Million Hearts' ABCS treatment guidelines for reducing cardiovascular disease (CVD) among high-risk patients who receive care in primary care practices in New York City. ABCS refers to (A) aspirin in high-risk individuals; (B) blood pressure control; (C) cholesterol management; and (S) smoking cessation. The long-term goal is to create a robust infrastructure for implementing and disseminating evidence-based practice guidelines (EBPG) in primary care practices. METHODS/DESIGN: We are using a stepped-wedge cluster randomized controlled trial design to evaluate the implementation process and the impact of practice facilitation (PF) versus usual care on ABCS outcomes in 250 small primary care practices. Randomization is at the practice site level, all of which begin as part of the control condition. The intervention consists of one year of PF that includes a combination of one-on-one onsite visits and shared learning across practice sites. PFs will focus on helping sites implement evidence-based components of patient-centered medical home (PCMH) and the chronic care model (CCM), which include decision support, provider feedback, self-management tools and resources, and linkages to community-based services. DISCUSSION: We hypothesize that practice facilitation will result in superior clinical outcomes compared to usual care; that the effects of practice facilitation will be mediated by greater adoption of system changes in accord with PCMH and CCM; and that there will be increased adaptive reserve and change capacity. TRIAL REGISTRATION: NCT02646488.

BACKGROUND: Extended-release naltrexone (XR-NTX) is an injectable monthly sustained-release mu opioid receptor antagonist, which blocks the typical effects of heroin and other opioid agonists. Use of XR-NTX among opioid dependent persons leaving jails and prisons is increasing despite scant high-quality evidence regarding XR-NTX's effectiveness at re-entry. METHODS: This 24-week, open-label randomized controlled trial examines the effectiveness of XR-NTX as opioid relapse prevention at release from jail (N=85) compared to enhanced treatment as usual (ETAU, N=85). A third, non-randomized, quasi-experimental naturalistic arm of participants who have newly initiated a jail-to-community methadone treatment program (MTP, N=85) allows for comparisons to a methadone standard-of-care. RESULTS: We describe the rationale, design, and primary and secondary outcomes of the study. The primary outcome is an opioid relapse event; the primary contrast is a time-to-relapse comparison of XR-NTX and ETAU over a 24-week treatment phase. Secondary outcomes are rates of: (a) post-release opioid treatment participation, (b) opioid, alcohol, and cocaine use, (c) injection drug use and HIV sexual risk behaviors, (d) overdose (fatal and non-fatal) and all-cause mortality, and, (e) re-incarceration. CONCLUSIONS: XR-NTX is a potentially important, effective treatment and relapse prevention option for a large US population of persons with opioid use disorders leaving jails. This study will estimate XR-NTX's effectiveness relative to existing standards of care, including counseling-only treatment-as-usual and methadone maintenance.