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Validation of parsimonious prognostic models for patients infected with COVID-19

Harish, Keerthi; Zhang, Ben; Stella, Peter; Hauck, Kevin; Moussa, Marwa M; Adler, Nicole M; Horwitz, Leora I; Aphinyanaphongs, Yindalon
OBJECTIVES/OBJECTIVE:Predictive studies play important roles in the development of models informing care for patients with COVID-19. Our concern is that studies producing ill-performing models may lead to inappropriate clinical decision-making. Thus, our objective is to summarise and characterise performance of prognostic models for COVID-19 on external data. METHODS:We performed a validation of parsimonious prognostic models for patients with COVID-19 from a literature search for published and preprint articles. Ten models meeting inclusion criteria were either (a) externally validated with our data against the model variables and weights or (b) rebuilt using original features if no weights were provided. Nine studies had internally or externally validated models on cohorts of between 18 and 320 inpatients with COVID-19. One model used cross-validation. Our external validation cohort consisted of 4444 patients with COVID-19 hospitalised between 1 March and 27 May 2020. RESULTS:Most models failed validation when applied to our institution's data. Included studies reported an average validation area under the receiver-operator curve (AUROC) of 0.828. Models applied with reported features averaged an AUROC of 0.66 when validated on our data. Models rebuilt with the same features averaged an AUROC of 0.755 when validated on our data. In both cases, models did not validate against their studies' reported AUROC values. DISCUSSION/CONCLUSIONS:Published and preprint prognostic models for patients infected with COVID-19 performed substantially worse when applied to external data. Further inquiry is required to elucidate mechanisms underlying performance deviations. CONCLUSIONS:Clinicians should employ caution when applying models for clinical prediction without careful validation on local data.
PMID: 34479962
ISSN: 2632-1009
CID: 5000192

Continuous care: Implementation of a virtual and in person transitional care management(TCM) clinicby internal medicine residents [Meeting Abstract]

Li, P; Kassapidis, V; Pandey, A; Bharadwaj, K; Moussa, M; Hayes, R; Sartori, D; Jervis, R
STATEMENT OF PROBLEM OR QUESTION (ONE SENTENCE): The transition between hospital and home is a vulnerable time for patients, who are at risk for readmission, medication reconciliation errors, and lack of follow up. LEARNING OBJECTIVES 1: Introduce a new type of visit to improve continuity of care for patients recently discharged from acute care LEARNING OBJECTIVES 2: Apply data from TCMvisits to identify areas for improvement in the hospital discharge process DESCRIPTION OF PROGRAM/INTERVENTION, INCLUDING ORGANIZATIONAL CONTEXT (E.G. INPATIENT VS. OUTPATIENT, PRACTICE OR COMMUNITY CHARACTERISTICS): The time between hospital discharge and primary care follow-up has historically been a vulnerable period for patients. The COVID-19 pandemic has exacerbated this transitional period, as patients have been forgoing their routine healthcare visits, losing touch with their primary care providers (PCPs), and not having a point of contact for their health needs after they leave the hospital. We launched a new resident-led virtual and in-person post-discharge clinic at an urban academic hospital connected in order to address the increasing need for follow-up care after hospital discharge. Patients admitted to the hospital who did not have a PCP or could not schedule a PCP visit within 10 days after being discharged were given the option of either an in-person or video TCM visit with an internal medicine resident. Each visit consisted of a templated set of questions, including whether medications were reconciled, and if follow-up appointments were scheduled. MEASURES OF SUCCESS (DISCUSS QUALITATIVE AND/OR QUANTITATIVEMETRICSWHICHWILL BE USEDTOEVALUATE PROGRAM/INTERVENTION): The primary endpoint for this pilot program was the total number of completed TCM visits. Secondary endpoints included the number of visits where there was a discrepancy in medications or follow-up appointments after hospital discharge. FINDINGS TO DATE (IT IS NOT SUFFICIENT TO STATE FINDINGS WILL BE DISCUSSED): Between October and December 2020, there were a total of 79 scheduled TCM visits (28 virtual visits and 51 in-person visits) and 51 (67%) completed visits. For the virtual visits, there was a 86% (24/28) completion rate. For in-person visits, there was a 53% (27/51) completion rate. In 31% (16/51) of the visits, subspecialty appointments were not scheduled at the time of discharge. In 12% (6/51) of the visits, there was a discrepancy with the medications patients were discharged with, with 50% (3/6) due to misprescribed antihyperglycemic agents. KEY LESSONS FOR DISSEMINATION (WHAT CAN OTHERS TAKE AWAY FOR IMPLEMENTATION TO THEIR PRACTICE OR COMMUNITY): The increased completion rate of virtual visits as compared to in-person visits (86%vs. 57%, respectively) suggests virtual visits may be a more convenient and preferable mode of follow-up for patients after hospital discharge. This pilot also shows how TCMvisit data can offer insights about the hospital discharge process that would otherwise go unnoticed. The data on discrepancies in medications reveals antihyperglycemic medication reconciliation may be a potential area of focus to improve the hospital discharge process. More data is needed to determine the effectiveness of this resident-led TCMinitiative, including its effects on hospital readmission rates. The preliminary data suggests that TCM visits, especially virtual visits, may effectively bridge gaps in care from the time patients leave the hospital until they establish more permanent care
ISSN: 1525-1497
CID: 4986522

A case of late-onset hemoptysis in a COVID19 patient [Meeting Abstract]

Tsui, C; Roca-Nelson, L; Ibarra, S; Moussa, M
LEARNING OBJECTIVE #1: Recognize hemoptysis as a symptom of alveolar hemorrhage in COVID19 LEARNING OBJECTIVE #2: Recognize the complexity of managing simultaneous pulmonary embolism and hemoptysis in worsening COVID19 pneumonia CASE: A 69-year-old man with hypertension, mild emphysema and gastritis presented for a week of fatigue, dyspnea and fever. On arrival to ED, T 100.4F, tachycardic, hypoxic to 86% on room air and improved to 94% on nasal cannula (NC). No cough, anosmia/ageusia or gastrointestinal (GI) symptoms. Nasopharyngeal swab detected SARS-CoV-2. Chest xray showed bilateral multifocal patchy airspace opacities and prominent interstitial markings. Ddimer was 470. 'Do not intubate (DNI)' status was affirmed. The next day, he required 100% fraction of inspired oxygen with high-flow NC despite initiation of high-dose dexamethasone and remdesivir. Twice-daily proton pump inhibitor (PPI) was begun in tandem with steroid. Procalcitonin of 0.31 prompted addition of ceftriaxone and azithromycin. On day 4, Ddimer jump from 861 to 3099 raised suspicion for pulmonary embolism (PE). CT confirmed bilateral PE. Heparin drip was started and later changed to apixaban. On day 18, he had a large episode of hemoptysis. No hemoglobin (Hgb) drop. Repeat CT showed decreased clot burden but increased bilateral airspace opacity consistent with atypical pneumonia, ARDS and hemorrhage. Interventional Radiology (IR) did not intervene due to lack of target on CT. Once hemodynamically stable with no further bleed, heparin drip was restarted. On day 22, he had another episode of moderate hemoptysis with an isolated episode of melena. Repeat Hgb was again stable, but a unit of packed red blood cells was given preemptively. IMPACT/DISCUSSION: COVID19 is associated with hypercoagulability and increased risk for thrombotic events such as PE. Hemoptysis occurs in 13% of PE cases but has so far rarely been reported in COVID19. There are a few case reports of COVID19 pneumonia, acute PE and underlying emphysema that developed hemoptysis and had worse outcomes. Our case is unique in that his hemoptyses were on hospital days 18 and 22 after starting therapeutic anticoagulation. So, his hemoptysis was unlikely to be caused by PE. Upper GI bleed (GIB) was also less likely; he was on a PPI, and Hgb was low but stable throughout. The most likely etiology was alveolar hemorrhage and ARDS secondary to COVID19. Concurrence of venous thromboembolism and alveolar hemorrhage can create a therapeutic dilemma. Our patient's DNI status precluded procedures requiring general anesthesia, e.g. endoscopy to visualize GIB or bronchoscopy to identify vessels for IR embolization. Apixaban reversal with andexanet alfa was deferred given his known PE. IVC filter was considered in case he could not tolerate anticoagulation. Heparin drip was restarted for easier anticoagulant reversal.
CONCLUSION(S): Hemoptysis can present as a late-onset complication of COVID19 in the hospitalized patient. Heparin drip for pulmonary embolism in COVID19 can be easily discontinued if hemoptysis develops
ISSN: 1525-1497
CID: 4986732

Incorporating outcomes data from large registries and administrative databases to improve appropriateness criteria for total knee replacement [Meeting Abstract]

Ghomrawi, H; Riddle, D; Hasan, M; Song, J; Kang, R; Mandl, L; Parks, M; Moussa, M; Beal, M; Russell, L; Mathias, J; Semanik, P; Dunlop, D; Franklin, P; Chang, R
Purpose: Appropriateness criteria (AC) are important tools that could help inform decision making for elective surgical procedures. Available AC for elective total knee replacement (TKR) focus on pre-operative factors only. With recent availability of longitudinal outcome data on thousands of patients from patient registries and administrative databases, we aimed to develop new AC that also included predicted outcomes.
Method(s): To update the AC, we expanded these 16 hypothetical scenarios of the validated modified Escobar AC to include 3 predicted outcome factors: risk of serious complications (0%, 1-2%, 3-5%), time to revision (<5, 5-15, >15 years), and improvement in pain and function 2 years after surgery (little, some, a lot). The modified Escobar AC are based on 5 clinical factors: age, osteoarthritis radiographic severity, knee stability, symptoms severity, and number of knee compartments with osteoarthritis). A panel of clinician experts (3 orthopedic surgeons, 2 rheumatologists, 2 internists, 1 physical therapist, 1 experienced nurse practitioner) rated 432 written clinical scenarios for appropriateness on a 1-9 scale (1 being least appropriate and 9 being most appropriate), and the median score for each scenario was classified into one of 3 categories: inappropriate 1-3, maybe appropriate 4-6, and appropriate 7-9. Classification and Regression Tree (CART) analysis was applied to the TKR AC appropriateness categories to determine the contribution of the predicted outcomes variables to appropriateness classification.
Result(s): After orthopedic surgeons ruled out clinically implausible scenarios, the remaining 279 scenarios were classified as 71 inappropriate, 112 maybe appropriate, and 96 appropriate. Figure below shows the results of the CART analyses classification tree with the branches labeled with the key variables that discriminated among the classifications. The terminal nodes of each branch (highlighted in grey) indicate the final distribution of the ratings of appropriate (App), may be appropriate ( Maybe App) and inappropriate (Inapp). CART analyses showed that all 3 predicted outcome factors and 2 of the clinical presentation factors (knee symptom severity and X-ray findings) were the variables that discriminated among the classifications.
Conclusion(s): Our Results showed that predicted outcomes were utilized by clinicians when determining appropriateness for TKR. How these data influence the decision making of patients contemplating TKR should be investigated further. [Formula presented]
ISSN: 1063-4584
CID: 4373922

Ouch! Addressing Microaggressions on the Interdisciplinary Team [Meeting Abstract]

Reiff, Stefanie; Moussa, Marwa; Ha, Jung-Eun; Manfield, Laura; Lee-Riley, Lorna; Duran, Deserie; Volpicelli, Frank; Trivedi, Shreya P
ISSN: 1525-1497
CID: 4610372

Can Appreciative Inquiry Improve Interdisciplinary Experiences [Meeting Abstract]

Trivedi, Shreya P; Reiff, Stefanie; Ha, Jung-Eun; Moussa, Marwa; Boardman, Davis; Altshuler, Lisa; Duran, Deserie; Lee-Riley, Lorna; Mansfield, Laura; Volpicelli, Frank
ISSN: 1525-1497
CID: 4610362

Transfusion in acute coronary syndrome: A retrospective case-control series [Meeting Abstract]

Rosenthal, J A; Castellano, A J; Vidaurrazaga, M M; Kovacs, B M; Huynh, H -L C; Weerahandi, H M; Moussa, M M
Objective: To compare morbidity and mortality of Acute Coronary Syndrome (ACS) patients, with hemoglobin level above 7g/dl in transfused or not transfused groups.
Method(s): We conducted a retrospective cohort study of patients admitted with ACS to both campuses of NYU Langone Hospital. Of 1080 patients screened in, 82 met inclusion criteria and were included in our analysis. Patients with hemoglobin less than 7 g/dL or greater than 10 g/dL during their ischemic event were excluded. The outcomes of interest were length of stay (LOS) and negative clinical events as ascertained by physician chart review. The Mann-Whitney U test, was used to compare continuous variables, and the chi-squared test compared categorical variables.
Result(s): 54 patients were transfused, and 28 were not transfused. Mean age (72.5 vs 74.4 years), and race did not differ significantly between groups. Proportion with heart failure, known anemia and mean baseline hemoglobin of anemic patients prior to admission were similar between both groups. ACS diagnosis and proportion of patients receiving medical management were similar between groups as well. However, transfused patients were more likely to be male, have Chronic Kidney Disease (51.9% vs 28.6%), have known Coronary Artery Disease (77.8 vs 42.6%) and those with Congestive Heart Failure had a lower baseline ejection fraction (34.5 vs 57.5%). For outcomes, blood transfusion was associated with a longer LOS (mean 11.48 vs 6.36 days, p=0.002). Furthermore, transfusion was associated with a higher likelihood to have a combined negative outcome which included new or worsening respiratory distress, hypoxia, volume overload, upgrade to the Intensive Care Unit and death (79% vs 24%, RR=3.29, P<0.001), driven by a significant increase in volume overload (40.7 vs 4.0% P<0.001) and a non-significant tendency towards increased mortality (16.7 vs 4.0%, p=0.12).
Conclusion(s): ACS patients who underwent blood transfusion had worse outcomes, namely longer LOS, increased risk for volume overload and a pronounced but not significant trend towards increased mortality. This effect was confounded by more severe comorbidities in the transfused group. However, given the size and significance of this harmful association, it is possible or perhaps even likely that transfusion itself was a factor in the worsened outcomes in the transfused group. Though transfusion for a hemoglobin > 7g/dl and even > 8g/dl is common in ACS patients, the harms associated with blood transfusions may outweigh the possible risk of worsened myocardial ischemia in the setting of lower oxygen carrying capacity
ISSN: 1526-7598
CID: 4101912

Implementing a daily medicine rounding tool to promote patient safety and improve communication between physician and nurse during hospital-ization [Meeting Abstract]

Moussa, M; Schwartz, L; Mansfield, L; Knight, T -A; Renaud, J; Ferrauiola, M; Thompson, S; Okamura, C; Volpicelli, F
Statement of Problem Or Question (One Sentence): As communication among patient care team members is often dangerously fragmented and effective collaboration becomes essential to provide safe hospital care for patients, we implemented the Daily Medicine Rounding Tool (DMeRT) that improved collaboration between the physician and nurse. Objectives of Program/Intervention (No More Than Three Objectives): 1. We aimed to promote a patient-centered, highly reliable rounding tool to reduce hospital adverse events by streamlining real time communication between nurses and physicians. 2. We hypothesize that this tool will decrease the need for frequent calls throughout the day, ultimately improving team productivity and overall staff satisfaction. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): In our institution, the Epic's default patient dashboard columns included patient name, venous thromboemboli (VTE) prophylaxis, Medical Orders for Life Sustaining Treatment (MOLST) completion, glycemic control, and medication reconciliation completion. Expanding upon these prior default columns, we partnered with information technology and nursing to create a customized dashboard that included additional informational columns extracted from the documentation in the charts, to include the administration of intravenous fluids, oxygen supplementation, last bowel movement recorded and high risk medications (anti-coagulants, anti-epileptics, furosemide, opioids, and benzo-diazepines). We then trained the physicians and nurses to discuss each patient using the customized DMeRT dashboard during interdisciplinary rounds. The average time spent on the DMeRT is 15 minutes for a total 10 patients. This helps as a reminder and the identification of potential pitfalls and safety concerns. The DMeRT was instituted on a 30 bed medical unit (5500) on June 1, 2018 with iterative improvements to content. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): We will analyze data pre and post intervention to assess for impact on reducing medication errors during hospitalization, hospital acquired VTE events and improvement in glycemic control. Finally we will track MOLST completion, medication reconciliation compliance, constipation and fluid overload events added to the patient's problem list 48 hours prior to discharge. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): To date, the unit which implemented the intervention had an improvement in the Quality Hyperglycemia Scores (method used to evaluate inpatient glycemic management) from 56 in 4/2018 to 95 in 12/2018. There was an improved MOLST completion from 14% in 4/2018 to 83% in 12/2018. A Preliminary survey of 15 nurses on unit 5500 showed that 80% reported that they rarely need to call house staff within 2 hours of completing the rounding tool and 66% of nurses were satisfied with the DMeRT. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): During hospitalization, multiple aspects of patient care are overlooked while we focus on the admitting diagnosis, necessary diagnostics and treatments. Medication errors during hospitalization are commonly caused by breakdowns in communication and associated with substantial risk. This is a simple tool that utilizes information technology to efficiently and systematically review standardized aspects of care
ISSN: 1525-1497
CID: 4052702

Promoting high-value practice by standardizing communication between the hospitalist and primary care provider during hospitalization [Meeting Abstract]

Moussa, M; Mahowald, C; Okamura, C; Ksovreli, O; Aye, M; Weerahandi, H
Statement of Problem Or Question (One Sentence): The increasing complexity of admitted patients, shorter hospital stays and post-acute care adverse events demand a more sophisticated and effective coordination of care between hospitalists and Primary care providers (PCPS). Objectives of Program/Intervention (No More Than Three Objectives): 1. Standardizing communication between Hospitalist and PCP during hospitalization will lower the rate of readmission due to lack of PCP follow up and post-acute care adverse events. 2. Implementing this practice into our daily workflow will improve PCP satisfaction and increase referrals to our institution. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): We reviewed a root-cause survey of 30 day readmissions between 1/2018-4/2018 as well as readmission rates for each of our hospitalists. We surveyed our PCPS' satisfaction with communication experiences with our hospitalist group. Finally, we conducted a semi-structured interview of the hospitalist with the lowest readmission (8% vs 12% average for other hospitalists) and highest PCP satisfaction rates, Dr. A, to develop best practices for closed loop communication. Based on this data, we designed a protocol and piloted on 5/1/2018, where the hospitalist contacts the PCP via phone call on admission and delivers a discharge narrative to the PCP via our EMR's routing capability. We used a trackable smart phrase to document the communication. For the prospective phase, we will operationalize these best practices in a study group, Family Health Center PCPS. A control group (community PCPS) will receive usual practice. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): We will compare readmission rates between the study group and control group, monitoring the proportion and absolute number of readmissions attributed to no PCP follow up or medication errors. Follow up satisfaction surveys will be sent to the PCPS 6 months after our revised communication practice. Finally, we will monitor the hospitalists' compliance with the smart phrase. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): A review of our institution's 30 day readmissions between 1/2018-4/2018 found that 19% were attributed to lack of PCP/outpatient provider follow-up. Surveys of our community PCPS showed 70% reported being contacted by the hospitalist group in less than 25% of the time. Results from Dr. A's interview revealed that after her encounter with the patient, she calls the patient's PCP highlighting the admitting diagnosis, significant events, pertinent labs, imaging and medications. Dr. A then delivers a discharge narrative to the PCP on the day of discharge highlighting any medication changes, incidental findings and follow up. On a random audit of 100 charts between 5/1/2018-10/30/2018 our preliminary data show that there was 88% compliance with using the smart phrase by the hospitalists. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): Using a "positive deviance" approach, we identified best practices for hospitalist-PCP closed loop communication to develop an intervention to improve this aspect of care. If we are successful in reducing readmission rates and improving PCP satisfaction, we will expand to all of our PCPS and ultimately expand to other services to implement this program as best practice
ISSN: 1525-1497
CID: 4052712

Bedside rounds improve patient satisfaction and care transitions [Meeting Abstract]

Moussa, M; Renaud, J; Okamura, C; Brown, Y; Volpicelli, F
Statement of Problem Or Question (One Sentence): As the lack of a 'face-to-face' interaction between the full team and the patient led to a downtrend in patient experience scores, we were inspired to design a patient centered communication tool that standardizes the multi-disciplinary bedside rounds. Objectives of Program/Intervention (No More Than Three Objectives): 1. To improve our patients' hospital experience in regards to care transitions and discharge planning by implementing standard bedside rounds that center around the patient's health care needs. 2. To create a daily scheduled opportunity for the patient to be involved in medical decisions and discharge planning which enhances patients' understanding of their own care plan. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): Our medical-surgical units did not have a standardized approach to ensure clear communication from a patient's multidisciplinary team, comprised of physicians, nurses, case managers and social workers. To this end, we implemented a communication plan based on the acronym "WE CARE" 1) Who was present (who was at bedside in addition to the patient); 2) Everyone on same page (language and literacy barriers); 3) Connect with patient and family (promote patient-centeredness and compassionate care through eye contact, introducing the full team); 4) Assessing understanding (explanation of changes to medications, key lab and test Results, and post-discharge plans); 5) Response from patient and/or caregivers (ensuring understanding); 6) Educate/empathy/end of conversation. Centered on the WE CARE model, we gathered all members of the care team and visited each patient at a standardized time every day. The intervention was started on one medical-surgical, unit 5600 on July 2018. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): HCAPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores for care transitions and discharge information pre and post intervention will be evaluated for the study group (unit 5600). We will also compare these scores to med/surg units who did not receive the intervention. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): We compared our pre-intervention 1/1/2018-4/31/2018 (approximately 54 surveys) and post-intervention (approximately 42 surveys) scores. In the domain of care transitions, e. g., patient had a good understanding of things patient was responsible for in managing his/her health; patient had a good understanding of purpose of each medication; staff consideration of patient and caregiver preferences post-discharge, there was an increase from 28% in our top-box (an answer of always) composite HCAHPS score to 58%. Scores for "discharge information delivered" remained high with a top-box response above 85% both pre-and post-intervention. In addition, during the post-intervention time, the study group unit had the highest "care transition" and "discharge information" top box responses compared to all control units. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): A focused, structured communication tool WE CARE, implemented as a part of daily standardized multidisciplinary bedside rounds led to an improvement in patient satisfaction scores around care transitions and discharge information delivered
ISSN: 1525-1497
CID: 4052912