Faculty Bibliography

Statement of Problem Or Question (One Sentence): Can a home visit complex care management program successfully identify and engage high risk patients in a FQHC? Objectives of Program/Intervention (No More Than Three Objectives): 1. Identify patients at an FQHC who are at risk for preventable hospitalization 2. Enroll and engage patients in a home visit based complex care management program. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): The Primary Care Plus program (PCP+) is a home visit based program established to address the needs of patients at risk for preventable hospitalizations within the Family Health Centers at NYU Langone. The program staff-a physician, a nurse practitioner, a social worker and 2 community health workers-coordinate as a team to identify and address the biopsychosocial needs of high risk patients. A key intervention is the home visit lead by a physician or nurse practitioner to perform the medical assessment, medication reconciliation, and identification of both medical and social impediments to optimal health. The program is not intended to replace the patient's primary care provider, but to function as an addition to the patient's care team, identifying and mitigating risk drivers, and handing off to the primary team and care management resources once the risk drivers have been addressed. Patients are referred into the program by either their primary care doctors or care management. The program is restricted to those patients who have a continuity relationship in the Federally Qualified Health Center, and who are identified as being at risk for a preventable hospitalization. Latitude is given to the referral source in how patients are identified; guidance is given to focus on patients with a history of preventable hospitalizations (as defined by PQI) or patients with advanced disease and potential palliative care needs. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): The primary measure of success is patient engagement. Patient engagement is defined by both consent to the program and successful home visit by the medical provider. Other outcome metrics are patient characteristics, number of emergency department visits and number of inpatient hospitalizations in the 12 months before program enrollment. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): Since program inception in August 2018 through December 31, 2018, 75 patients have been identified by care management or primary care providers as potential candidates for the program and who met criteria as defined above. Of the 75 patients, 6 (8%) declined the program, and another 10 (13.3%) could not be found. The remaining 59 patients were seen at home and assessed. Total engagement was 78.7%. Patients identified represent a cohort of patients with an average of 2.0 inpatient admissions and 3.2 emergency department visits in the preceding 12 months prior to enrollment. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): Identification of a high-risk patient population in a federally qualified health center and referral into a home visit based care management program is associated with high acceptance and engagement. Future study will determine if patients enrolled in the program have an impact on risk drivers and preventable hospitalizations

Learning Objective #1: Identify non-HACEK gram-negative endocarditis early in its clinical course. Learning Objective #2: Recognize the morbidity and mortality of Escherichia coli endocarditis. CASE: A 54 year-old Hispanic man with no known past medical history presented with one month of constitutional symptoms: unintentional weight loss, anorexia, fatigue, and arthralgias. On admission, he was febrile, tachycardic, and breathing comfortably on room air. The exam was otherwise significant for a thin stature with temporal wasting, thrush, a lateral tongue ulcer, a raised non-blanching erythematous macular rash on sun-exposed areas of the extremities, and erythematous papules on the hands. There were no murmurs detected on cardiac auscultation. Initial labs were significant for anemia and leukopenia. A broad differential diagnosis initially included malignancy, rheumatologic disease, and systemic infection. Work-up revealed positive anti-Smith and anti ds-DNA antibodies, C3/C4 hypocomplementemia, and a pericardial effusion on transthoracic echocardiogram (TTE). He was diagnosed with systemic lupus erythematous (SLE), and started on hydroxychloroquine and steroids with improvement. On hospital day three, blood cultures grew Escherichia coli (E. coli) in four bottles, with an unclear source with aseptic urine and no localizing symptoms. CT scans of the head, chest, abdomen, and pelvis were notable for multiple peripherally located pulmonary airspace opacities concerning for septic emboli. A TTE was negative for vegetation, but given the high clinical suspicion for endocarditis, notwithstanding the rarity of E. coli as a pathologic organism, transesophageal echocardiogram (TEE) was pursued. TEE revealed a mobile echodensity on the aortic valve consistent with vegetation. The patient completed four weeks of ceftriaxone to treat E. coli endocarditis. IMPACT/DISCUSSION: E. coli bacteremia is common; however, due to decreased adherence of the organism to the endocardium, infective endocarditis from E. coli is rare, accounting for 0.51% of cases. Risk factors include immunocompromised states. Our patient was leukopenic from SLE. Sources of infection are often gastrointestinal and urinary. However, as in our patient, initial source is unclear in approximately half of cases. Murmur is often absent, and the disease is more common in native valves than prosthetic or degenerative valves. For these reasons, diagnosis is difficult. One study reported at least one month from onset to clinical diagnosis in 90% of patients with non-HACEK gram-negative endocarditis. However, given its high surgical intervention rate (42%), high complication rate (including heart failure and abscess), and high mortality rate of 21% (drastically higher than the 4% from HACEK gram-negative endocarditis), clinicians should maintain a high degree of suspicion to make this diagnosis early.
Conclusion(s): E. coli endocarditis is rare, occurs in immunocompro-mised patients, and is difficult to diagnose. However, given its high morbidity and mortality, timely recognition is critical

Background: Electronic health record (EHR) documentation may contribute to burnout, especially for those with substantial clinical effort. We assessed whether clinical effort is associated with working in the EHR after work hours.
Method(s): We included all ambulatory physicians in a medicine specialty continuously practicing at any NYU Langone Health Faculty Group Practice site between May 1 and October 31, 2018. We quantified minutes logged into the EHR on days without scheduled appointments, and minutes logged into the EHR 30 minutes before and after appointments on days with scheduled appointments. We termed this time " work after work." We categorized physicians by their average number of days with appointments per week. Data were analyzed using SAS 9.4 (SAS Institute, Cary, NC). We calculated least squares means of fixed effects to account for heterogeneous variances, and compared means using Tukey's multiple comparison test. This study met institutional review board criteria for quality improvement work.
Result(s): We included 300 physicians, of whom 28.6% were general internists. The average physician had 3 days/week with scheduled appointments, spent 114.9 min in the EHR on days without appointments, and spent 21.7 min in the EHR after work hours on days with appointments. Time spent in the EHR on days without appointments increased with the number of appointment days per week (14.7 min/unscheduled day for 1 day/week vs. 193.8 min/unscheduled day for > 4 days/week, p< 0.001). Time spent in the EHR after hours on days with scheduled appointments did not significantly differ (Table 1).
Conclusion(s): All ambulatory physicians spend a substantial amount of time working in the EHR after hours and on unscheduled days (including weekends), but physicians with more clinical time were disproportionately burdened. The most clinically active spent an average of 2.8 hours in the EHR each unscheduled day. These findings add to concerns about EHR usability and documentation burden, particularly for busier clinicians. Our institution is now building dashboards to track work after work, offloading tasks to ancillary team members to reduce physician work burden, and exploring whether outliers would benefit from personalized technical assistance and training. Work after work analyses could be employed elsewhere to motivate similar improvements

Background: Clinical decision support (CDS) systems can be valuable resources in chronic disease management, but provider utilization of these tools and their integration into workflow remains suboptimal. We used a user-centered design approach to build a CDS recommending evidence-based therapy for heart failure in an inpatient setting. We implemented two versions of the CDS: an interruptive (pop-up) alert and a non-interruptive alert displayed in a provider checklist activity. In a prior study, we found that the interruptive alert was more effective than the non-interruptive alert but suffered from a high dismissal rate. The purpose of this study was to understand provider's perceptions of factors impacting CDS utilization following its implementation.
Method(s): We performed a qualitative study following implementation of two versions of a CDS at an academic medical center. We recruited providers who had either version of the CDS triggered in the prior 24 hours and obtained feedback through semi-structured interviews. Interviews were recorded, transcribed, and double-coded. We performed a constant comparative analysis of the transcripts and developed a coding scheme informed by the Five Rights of CDS combined with Proctor's outcomes for implementation research framework. We recruited participants until thematic saturation was achieved.
Result(s): Fourteen providers participated in interviews. In general, providers found the CDS triggered for appropriate patients, provided the right information to determine appropriateness of recommendations, and had good usability. At least four providers believed they were not the right person to receive the alert, reporting that they primarily participated in cross-coverage, worked in a setting where these medications were typically contraindicated, or were already fully compliant with evidence-based medications. Providers complained that the interruptive alert led to workflow disruption and that frequently they would "just need to click through all of this." Nonetheless, many providers still preferred the interruptive version of the alert because they were either: 1) unaware of the non-interruptive alert in the checklist; 2) "don't use the provider checklist" where the non-interruptive alert resided; or 3) were unaware of the provider checklist.
Conclusion(s): We found that CDS was generally found to be acceptable, although the interruptive version of the alert was limited by disruptions in workflow. The interruptive alert was ultimately more successful as providers were unaware of the existence of the non-interruptive alert. Furthermore, they infrequently used the provider checklist, a native EHR feature for non-interruptive alerts and messages. Our findings suggest that incorporating user-centered design features can lead to success of an interruptive alert. Furthermore, future efforts to implement non-interruptive alerts must incorporate approaches to increase awareness of the alert and encourage changes in workflow to monitor alert lists

Background: Newly recruited clinicians have heterogeneous Backgrounds and experiences and need a substantive introduction to their new institution's patient communication expectations and safety culture and standards for clinician performance. We describe a unique onboarding program designed to ensure that newly hired clinicians receive actionable, behaviorally specific feedback from the patients' perspective to support a satisfying transition to the new work environment, enhance patient experience and reduce the need to punitively react to complaints once they have started.
Method(s): During the 2-hour onboarding, participants complete 3, 10-minute Objective Structured Clinical Exam cases designed to assess how they address a medical error, manage the patient's discharge goals of care, and respond to an impaired learner. During each encounter, participants interact with highly trained Standardized Patients (SPs) or Standardized Learners (SLs) who use behaviorally-anchored checklists to evaluate provider performance on communication and case-specific skills. Following each encounter, participants complete a self-assessment while the SPs/SLs complete a behavior-specific checklist, after which the two discuss the encounter and the SL/SP provides confidential and actionable feedback. At the end, participants are encouraged to set individual learning goals to implement in their daily work, complete a program evaluation, and engage in a debrief with experienced facilitators. Participants also receive their SP checklists in addition to an institutional guide containing relevant resources and contacts.
Result(s): Over 2 years, 57 faculty members representing 6 clinical sites participated in the onboarding program. They are heterogeneous with respect to general and case specific performance on these SP/SL cases. For example, 86% adequately elicited the SP/SLs story during the discharge case compared to 66% in the other two cases, 77% addressed pain management (a key patient goal), while 44% did not discuss important medication side effects. Participants have universally found this onboarding to be useful and relevant; 98% agreed/strongly agreed that the program was an effective way to reinforce good habits in patient and learner communication, 96% felt it enhanced confidence about their ability to communicate effectively, and 96% felt it reinforced the institutional culture of safety. All 56 participants who completed the evaluation agreed/strongly agreed that the event was engaging and well-designed, and 93% felt it was a good use of their time and would recommend the program.
Conclusion(s): Traditional orientations are not well recalled and do not address knowledge and skills in real-time. Although it requires additional resources, participants are enthusiastic about our low-stakes introduction to the institution's expectations. This program sets high standards and introduces a new model for skills-based onboarding which may lead to measurably improved patient outcomes

BACKGROUND:Cardiovascular disease accounts for more than half of all deaths in the hemodialysis (HD) population. Although much of this mortality is associated with fluid overload (FO), FO is difficult to measure, and many HD patients have significant pulmonary congestion despite the absence of clinical presentation. Cohort studies have observed that FO, as measured by bioimpedance spectroscopy (BIS), correlates with mortality. Other studies have observed that lower sodium intake is associated with less fluid-related weight gain, improved hypertension, and survival. Whether sodium intake influences FO in HD patients as measured by BIS is not known. OBJECTIVE:The aims of the study were to determine the feasibility of assessing the impact of sodium restriction on body fluid composition as measured by BIS among patients with three levels of sodium intake and to determine if there are statistical and/or clinical differences in BIS measures across sodium intake groups. METHODS:We used a double-blinded randomized controlled trial design with three levels of sodium restriction, 2,400 mg per day, 1,500 mg per day, and unrestricted (control group), to test our aims. Forty-two HD patients from a tertiary acute care academic institution associated with three urban DaVita dialysis centers were enrolled. Participants remained in the inpatient center for 5 days and 4 nights and were randomly assigned to sodium intake groups. Body fluid composition was measured with BIS. RESULTS:Recruitment, enrollment, and retention statistics supported the feasibility of the study design. Regression analyses showed that there were no statistically significant differences among sodium intake groups on any of the outcomes. DISCUSSION/CONCLUSIONS:Our data suggest the need for additional research into the effects of sodium restriction on body fluid composition.

Learning Objective #1: Diagnose West Nile Virus (WNV) encephalitis Learning Objective #2: Recognize neurologic symptoms seen in Neuro-invasive WNV CASE: A 79 year old male with a past medical history of CAD s/p CABG, hypertension and hyperlipidemia presented with a 4 day history of generalized weakness, fevers, decreased oral intake, and confusion. He was accompanied by his wife, who denied any respiratory, skin or urologic changes, and reported the patient had been at baseline, tending his garden a couple of days prior. He had no recent travel, but had a sick contact in a grandchild who was diagnosed with an unknown virus. Upon admission, he was febrile to 39.5C, hypotensive to 95/43 with otherwise normal vital signs. Exam was notable for lethargy and proximal muscle weakness with diffuse hyporeflexia. CT scan of the head, chest X-Ray and urinalysis did not show acute abnormalities. He was started on antibiotics to cover for meningitis with improvement in his vitals, but not his mental status. The following day, a lumbar puncture was performed and cell count was notable for a white blood cell count of 344 with 76% neutrophils, 97 protein and 53 glucose, and negative gram stain. His course was complicated by an aspiration event that resulted in hypoxia and he was subsequently intubated. Additional CSF studies were then sent to the state lab, returning positive for WNV IgM the following week. The patient's hospital course was again complicated by a second aspiration event post extubation and required reintubation and eventually a tracheostomy and PEG placement. He continued to exhibit proximal and distal muscle weakness and an EMG was performed, which showed axonal and demyelination sensorimotor polyneuropathy. MRI of the spine showed enhancement of cauda equina consistent with Guillain Barre syndrome (GBS). Patient was started on plasmapheresis with improvement in his weakness. IMPACT/DISCUSSION: The key aspect of this case was the atypical appearance of acute flaccid paralysis, a Guillain Barre-like picture, that developed in a case of confirmed West Nile Virus infection. Prior to 1996, WNV was associated with typical B symptoms. Following the NYC outbreak, neurological complications, including muscle weakness, became common. Another key point is the presentation difference between normal GBS and the flaccid paralysis seen in WNV infection. In standard GBS, weakness typically begins weeks after infection, while weakness in WNV occurs in the acute to subacute phase. As was present in this case, leukocytosis and elevated protein in CSF are both characteristic of WNV infection while typical GBS CSF shows elevated protein without leuko-cytosis, the classic albuminocytologic dissociation. While WNV-associated paralysis is a well-described phenomenon, it has not become commonplace knowledge in general medicine.
Conclusion(s): WNV often presents as a non-specific encephalitis that may be misdiagnosed as a bacterial pneumonia. It is imperative that WNV be part of the differential in an acutely ill patient presenting with muscle weakness

Background: The core Entrustable Professional Activities medical school graduates should be able to perform on day 1 of residency provides a framework for readiness for residency. Communication skills are an essential foundation for these core EPAs and yet there have been few studies that describe communication competence across the UME-GME continuum. We report on our OSCE-based assessment of communication skills from the first few weeks of medical school to the first year of medicine residency.
Method(s): Assessment of communication is consistent in our OSCE program across UME and GME. Domains include Information Gathering (5 items), Relationship Development (6 items), and Patient Education (3 items) and these are assessed via a behaviorally anchored checklist (scores=% well done) that has strong reliability and validity evidence. In this study, we report on 3 multi-station OSCEs: the Introductory Clinical Experience (ICE) OSCE that occurs within the first weeks of medical school; the high-stakes, pass/fail Comprehensive Clinical Skills Examination (CCSE) OSCE that is fielded after clerkship year; and the Medicine Residency Program's PGY 1 OSCE. Across 3 classes of medical school (2014-2016) we have complete data for the 24 students who continued on in our Medicine Residency (and who provided consent to include their educational data in an IRB-approved registry). Analyses focus on differences in communication skills over time and between cohorts and the relationship between communication skills measured in medical school and those assessed in residency.
Result(s): Communication scores show significant improvement through medical school (but not into residency) in Information gathering (ICE mean=56%; CCSE mean=76%; PGY1 mean=77%) (F=11.54, p<.001, ICE< CCSE) and in relationship development (ICE=59%; CCSE=78%; PGY1= 74% (F=10.68, p<.001, ICE < CCSE). Mean patient education skills, however, increase significantly across all 3 time points (32% to 50% to 65%; F=31.00, p<.001). Patterns are similar across cohorts except that the Class of 2016 means increase from CCSE to PGY1. Regression analyses show that CCSE information gathering scores are more strongly associated with PGY performance than ICE scores (Std Beta=.32 vs.06), while for relationship development, it is the ICE scores that are more strongly associated (Std Beta=.40 vs.24). ICE and CCSE patient education skills have associations with PGY1 skill of similar size (Std Beta=.30 and.28).
Conclusion(s): Findings, despite the small sample, suggest a clear developmental trajectory for communication skills development and that information gathering and patient education skills may be more influenced by medical school than relationship development. That communication skills seem to level out in PGY1 highlights need for re-consolidation as clinical complexity increases. Results can inform theory development on how communication skills develop and point to transitions where skills practice/feedback may be particularly important

Statement of Problem Or Question (One Sentence): Does actionable feedback on patient safety indicators and responses to disclosed social determinants of health (SDOH) impact clinical behavior? Objectives of Program/Intervention (No More Than Three Objectives): (1) Develop/disseminate quarterly audit-feedback reports on SDoH practice behavior, focusing on elicitation of patient information. (2) Enhance our understanding of factors related to disparities in safety/quality of care. (3) Increase rates of SDoH documentation and referral. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): We sent Unannounced Standardized Patients (USPs) with SDoH-related needs to care teams in two urban, safety-net clinics. Data collected on practice behaviors were used for cycles of audit and feedback on the quality of electronic health record (EHR) documentation, team level information sharing, and appropriate service referral. Reports contained an evolving educational component (e.g. how to recognize, refer, and document SDoH). We disseminated reports to teams (doctors, nurses, physician's assistants, medical assistants, and staff) at routine meetings and via email. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): Three audit feedback reports have been distributed to date. Survey data was collected at two time points, 2017 (n=77) and 2018 (n=81), to assess provider attitude changes and integration of feedback into clinical practice. Measures included change in team knowledge and attitudes towards SDoH, and response to/documentation of presented SDoH (measured via post-visit checklist and EMR). Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): Preliminary data shows no change or improvement in documentation of SDoH and limited variation between firm-level responses. (1) Only 7% of providers reported feeling strongly confident in knowing how to make referrals for social needs in 2018; no improvement since 2017. (2) Despite regular report distribution, 58% of providers reported having received no formalized feedback on responding to SDoH. 24% reported maybe or not sure. (3) 86% of 2018 survey participants self-reported having referred a patient to appropriate services when a social need was identified. Our referral data says otherwise, referrals occur for less than 30% of visits with SDoH-related needs. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): Results suggest disconnect between team data and individual reporting: most report they refer but data suggests few do. Deeper integration of reports into team processes, attachment of feedback to curricula, and increased frequency of regular feedback may be needed for accountability. These preliminary Results help refine audit feedback methodology but research is needed to understand motivation and systems barriers to referral and documentation. Future research will look at provider attitudes toward referral processes