Faculty Bibliography
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department:Medicine. General Internal Medicine
recentyears:2
school:SOM
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14488
Graduate level health professions education: how do previous work experiences influence perspectives about interprofessional collaboration?
Understanding how previous experiences with interprofessional education and collaboration inform health care provider perspectives is important for developing interprofessional interventions at the graduate level. The purpose of this study was to examine how previous work experiences of graduate level health professions students inform perspectives about interprofessional education and collaboration. Drawing from program evaluation data of two separate graduate level interprofessional education interventions based in primary care and home health care, we conducted a qualitative secondary data analysis of 75 interviews generated by focus groups and individual interviews with graduate students from 4 health professions cadres. Using directed content analysis, the team coded to capture descriptions of interprofessional education or collaboration generated from participants' previous work experiences. Coding revealed 173 discrete descriptions related to previous experiences of interprofessional education or collaboration. Three themes were identified from the analysis that informed participant perspectives: Previous educational experiences (including work-based training); previous work experiences; and organizational factors and interprofessional collaboration. Experiences varied little between professions except when aspects of professional training created unique circumstances. The study reveals important differences between graduate and undergraduate learners in health professions programs that can inform interprofessional education and collaboration intervention design.
PMID: 32506976
ISSN: 1469-9567
CID: 4486232
Using Focus Group Feedback to Identify Patient-Centered Initiatives for Older Persons with HIV
OBJECTIVES/OBJECTIVE:This study assessed how few community-based programs target older people living with HIV. METHODS:We conducted four focus groups comprised of people 50 and older with HIV (NÂ =Â 32; gay/bisexual men, heterosexual men, women, and Spanish-speakers) to inform HIV program development by exploring the services in which participants were actively involved, along with the services they wanted to receive. RESULTS:Using inductive thematic qualitative analysis, four themes were identified pertaining to program development: (a) types of currently utilized HIV service organizations; (b) dissatisfaction with HIV programming and services; (c) participants' preferred programming, courses, groups, or activities; and (d) desire to serve as peer mentors. CONCLUSIONS:Results highlight the need for community-based organizations to address social engagement and isolation among older people living with HIV. CLINICAL IMPLICATIONS/CONCLUSIONS:These findings exemplify the need for programs to be specifically designed for OPH, and created with the primary goals of socialization and helping develop social support networks.
PMID: 32497461
ISSN: 1545-2301
CID: 4469312
Development and Validation of a Survival Calculator for Hospitalized Patients with COVID-19
BACKGROUND:Chinese studies reported predictors of severe disease and mortality associated with coronavirus disease 2019 (COVID-19). A generalizable and simple survival calculator based on data from US patients hospitalized with COVID-19 has not yet been introduced. OBJECTIVE:Develop and validate a clinical tool to predict 7-day survival in patients hospitalized with COVID-19. DESIGN/METHODS:Retrospective and prospective cohort study. SETTING/METHODS:Thirteen acute care hospitals in the New York City area. PARTICIPANTS/METHODS:Adult patients hospitalized with a confirmed diagnosis of COVID-19. The development and internal validation cohort included patients hospitalized between March 1 and May 6, 2020. The external validation cohort included patients hospitalized between March 1 and May 5, 2020. MEASUREMENTS/METHODS:Demographic, laboratory, clinical, and outcome data were extracted from the electronic health record. Optimal predictors and performance were identified using least absolute shrinkage and selection operator (LASSO) regression with receiver operating characteristic curves and measurements of area under the curve (AUC). RESULTS:The development and internal validation cohort included 11 095 patients with a median age of 65 years [interquartile range (IQR) 54-77]. Overall 7-day survival was 89%. Serum blood urea nitrogen, age, absolute neutrophil count, red cell distribution width, oxygen saturation, and serum sodium were identified as the 6 optimal of 42 possible predictors of survival. These factors constitute the NOCOS (Northwell COVID-19 Survival) Calculator. Performance in the internal validation, prospective validation, and external validation were marked by AUCs of 0.86, 0.82, and 0.82, respectively. LIMITATIONS/CONCLUSIONS:All participants were hospitalized within the New York City area. CONCLUSIONS:The NOCOS Calculator uses 6 factors routinely available at hospital admission to predict 7-day survival for patients hospitalized with COVID-19. The calculator is publicly available at https://feinstein.northwell.edu/NOCOS.
PMCID:7276996
PMID: 32511640
ISSN: n/a
CID: 4996192
Journal of thoracic & cardiovascular surgery. 2020:159(6):2230-2240.e15.DOI: 10.1016/j.jtcvs.2019.06.040
Cost-effectiveness of coronary artery bypass grafting plus mitral valve repair versus coronary artery bypass grafting alone for moderate ischemic mitral regurgitation
OBJECTIVE:The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. METHODS:We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. RESULTS:In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; -0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [-3866 to 56,826]) and quality-adjusted life years showed no difference (-0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. CONCLUSIONS:The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.
PMID: 31375378
ISSN: 1097-685x
CID: 5451272
Impact of the Centers for Disease Control and Prevention Recommendation and State Law on Birth Cohort Hepatitis C Screening of New York City Medicaid Recipients
INTRODUCTION:The Centers for Disease Control and Prevention estimated that, during 1999-2008, people born in 1945-1965 (the baby boomer generation) represented approximately 75% of people infected with hepatitis C virus and 73% of hepatitis C virus-associated deaths and are at greatest risk for hepatocellular carcinoma and liver disease. In 2012, the Centers for Disease Control and Prevention recommended one-time hepatitis C virus screening for people born during 1945-1965. In addition, New York State enacted a Hepatitis C Virus Testing Law in 2014. This analysis assesses the impacts of the 2012 recommendation and 2014 New York State Testing Law on hepatitis C virus screening rates among New York City Medicaid-enrolled recipients born during 1945-1965. METHODS:The eligible population was determined quarterly as the number of Medicaid recipients continuously enrolled for 12 months with neither a prior hepatitis C virus diagnosis nor antibody test since 2005. Quarterly screening rates during 2010-2017 were examined using interrupted time series analysis. Data were analyzed in 2018-2019. RESULTS:In 2010-2017, the highest screening rate occurred in the quarter immediately after the law (33.64 per 1,000 Medicaid recipients). There was no change in screening rates after the Centers for Disease Control and Prevention recommendation and a significant increase after the New York State Law, which was not sustained. CONCLUSIONS:Hepatitis C virus screening rates increased in the quarter after the 2014 New York State Hepatitis C Virus Testing Law became effective. Additional efforts are needed to screen baby boomers and people who were recently infected with hepatitis C virus related to opioid use.
PMID: 32444001
ISSN: 1873-2607
CID: 5325062
Slow-pathway visualization by using voltage-time relationship: a novel technique for identification and fluoroless ablation of atrioventricular nodal reentrant tachycardia
BACKGROUND:Atrioventricular nodal reentrant tachycardia (AVNRT) is treatable by catheter ablation. Advances in mapping-system technology permit fluoroless workflow during ablations. As national practice trends toward fluoroless approaches, easily obtained, reproducible methods of slow-pathway identification and ablation become increasingly important. We present a novel method of slow-pathway identification and initial ablation results from this method. METHODS AND RESULTS/RESULTS:We examined AVNRT ablations performed at our institution over a 12-month period. In these cases, the site of the slow pathway was predicted by latest activation in the inferior triangle of Koch during sinus rhythm. Ablation was performed in this region. Proximity of the predicted site to the successful ablation location, complication rates, and patient outcomes were recorded. Junctional rhythm was seen in 40/41 ablations (98%) at the predicted site (mean, 1.3 lesions and median, 1 lesion per case). One lesion was defined as 5mm of ablation. The initial ablation was successful in 39/41 cases (95%); in 2 cases, ≥2 echo beats were detected after the initial ablation, necessitating further lesion expansion. In 8/41 cases (20%), >1 lesion was placed during initial ablation before attempted reinduction. Complications included 1 transient heart block and 1 transient PR prolongation. During follow up (median, day 51), 1 patient had lower-extremity deep-vein thrombosis and pulmonary embolus, and 1 had a lower-extremity superficial venous thrombosis. There was 1 tachycardia recurrence, which prompted a redo ablation. CONCLUSIONS:Mapping-system detection of late-activation, low-amplitude voltage during sinus rhythm provides an objective, fluoroless means of identifying the slow pathway in typical AVNRT. This article is protected by copyright. All rights reserved.
PMID: 32270564
ISSN: 1540-8167
CID: 4377552
Molecular and clinical epidemiology of carbapenem-resistant Enterobacterales in the USA (CRACKLE-2): a prospective cohort study
BACKGROUND:Carbapenem-resistant Enterobacterales (CRE) are a global threat. We aimed to describe the clinical and molecular characteristics of Centers for Disease Control and Prevention (CDC)-defined CRE in the USA. METHODS:CRACKLE-2 is a prospective, multicentre, cohort study. Patients hospitalised in 49 US hospitals, with clinical cultures positive for CDC-defined CRE between April 30, 2016, and Aug 31, 2017, were included. There was no age exclusion. The primary outcome was desirability of outcome ranking (DOOR) at 30 days after index culture. Clinical data and bacteria were collected, and whole genome sequencing was done. This trial is registered with ClinicalTrials.gov, number NCT03646227. FINDINGS/RESULTS:1040 patients with unique isolates were included, 449 (43%) with infection and 591 (57%) with colonisation. The CDC-defined CRE admission rate was 57 per 100 000 admissions (95% CI 45-71). Three subsets of CDC-defined CRE were identified: carbapenemase-producing Enterobacterales (618 [59%] of 1040), non-carbapenemase-producing Enterobacterales (194 [19%]), and unconfirmed CRE (228 [22%]; initially reported as CRE, but susceptible to carbapenems in two central laboratories). Klebsiella pneumoniae carbapenemase-producing clonal group 258 K pneumoniae was the most common carbapenemase-producing Enterobacterales. In 449 patients with CDC-defined CRE infections, DOOR outcomes were not significantly different in patients with carbapenemase-producing Enterobacterales, non-carbapenemase-producing Enterobacterales, and unconfirmed CRE. At 30 days 107 (24%, 95% CI 20-28) of these patients had died. INTERPRETATION/CONCLUSIONS:Among patients with CDC-defined CRE, similar outcomes were observed among three subgroups, including the novel unconfirmed CRE group. CDC-defined CRE represent diverse bacteria, whose spread might not respond to interventions directed to carbapenemase-producing Enterobacterales. FUNDING/BACKGROUND:National Institutes of Health.
PMID: 32151332
ISSN: 1474-4457
CID: 4348732
Confirming pericardial access by using impedance measurements from a micropuncture needle
BACKGROUND:Pericardial access is complicated by two difficulties: confirming when the needle tip is in the pericardial space, and avoiding complications during access, such as inadvertently puncturing other organs. Conventional imaging tools are inadequate for addressing these difficulties, as they lack soft-tissue markers that could be used as guidance during access. A system that can both confirm access and avoid inadvertent organ injury is needed. METHODS:A 21G micropuncture needle was modified to include two small electrodes at the needle tip. With continuous bioimpedance monitoring from the electrodes, the needle was used to access the pericardium in porcine models (n =  4). The needle was also visualized in vivo by using an electroanatomical map (n =  2). Bioimpedance data from different tissues were analyzed retrospectively. RESULTS:Bioimpedance data collected from the subcutaneous space (992.8±13.1 Ω), anterior mediastinum (972.2±14.2 Ω), pericardial space (323.2±17.1 Ω), mid-myocardium (349.7±87.6 Ω), right ventricular cavity (235.0±9.7 Ω), lung (1142.0±172.0 Ω), liver (575.0±52.6 Ω), and blood (177.5±1.9 Ω) differed significantly by tissue type (P < .01). Phase data in the frequency domain correlated well with the needle being in the pericardial space. A simple threshold analysis effectively separated lung (threshold =  1120.0 Ω) and blood (threshold =  305.9 Ω) tissues from the other tissue types. CONCLUSIONS:Continuous bioimpedance monitoring from a modified micropuncture needle during pericardial access can be used to clearly differentiate tissues. Combined with traditional imaging modalities, this system allows for confirming access to the pericardial space while avoiding inadvertent puncture of other organs, creating a safer and more efficient needle-access procedure. This article is protected by copyright. All rights reserved.
PMID: 32333406
ISSN: 1540-8159
CID: 4411612
Swimming With Sharks: Teaching Residents Value-Based Medicine and Quality Improvement Through Resident-Pitched Projects
Background/UNASSIGNED:To create meaningful quality improvement (QI) curricula for graduate medical education (GME) trainees, institutions strive to improve coordination of QI curricula with hospital improvement infrastructure. Objective/UNASSIGNED:We created a curriculum to teach residents about QI and value-based medicine (VBM) and assessed curricular effectiveness. Methods/UNASSIGNED:We designed a 2-week required curriculum for internal medicine residents at a large academic program. After participating in basic skills workshops, trainees developed QI/VBM project ideas with faculty and nonclinical support and pitched them to hospital leaders at the end of the rotation. Pre-post and 1-year follow-up surveys were conducted for residents to self-assess knowledge, attitudes, and skills, participation in QI/VBM projects, and career intentions. We tracked QI/VBM project implementation. Results/UNASSIGNED: < .01). Four of 19 projects have been implemented. At 1 year, 95% of residents had presented a quality/value poster presentation, 44% were involved in QI/VBM beyond required rotations, and 26% plan to pursue careers focused on improving quality, safety, or value. Conclusions/UNASSIGNED:Our project-based curriculum culminating in a project pitch to hospital leadership was acceptable to GME trainees, improved self-assessed skills sustained at 1 year, and resulted in successfully implemented QI/VBM projects.
PMCID:7301934
PMID: 32595852
ISSN: 1949-8357
CID: 5000202
When Predictive Models Collide
PMID: 32543898
ISSN: 2473-4276
CID: 4517842
