Faculty Bibliography

Inappropriate daily lab testing can have adverse effects on patients, including anemia, pain, and interruption of sleep. We implemented a student-led, multifaceted intervention featuring clinician education, publicity campaign, gamification, and system changes, including a novel nurse-driven protocol to reduce unnecessary daily lab testing in a teaching hospital. We applied a quasi-experimental interrupted time series design with a segmented regression analysis to estimate changes before and after our 14-month intervention with a comparison to a control surgical unit. There was an increasing trend in the baseline period, which was mitigated by the intervention (postintervention effect estimate -0.04 labs per patient day/month, p < .05), which was not seen in the control unit. Estimated cost savings was $94,269 ($6,734/month). A student-led, multidisciplinary campaign involving nurse-driven pathway, education, publicity, gamification, and system changes was effective in reducing daily lab testing.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

OBJECTIVES/OBJECTIVE:Minimally invasive aortic valve replacement (MIAVR) can be technically demanding and may lead to prolonged operative time. We evaluated the intraoperative and postoperative patient outcomes following implementation of 2 facilitating technologies (FT) in MIAVR: the Cor-Knot titanium fastener and Custodiol-histidine-tryptophan-ketoglutarate solution. METHODS:A total of 299 patients underwent MIAVR from 2008 to 2016; 172 (57.5%) patients were included in the FT group and 127 (42.5%) patients in the control group (No-FT). We performed a propensity score analysis, matching 94 pairs. Primary end-points were cardiopulmonary bypass and cross-clamp times. Secondary end-points were blood product utilization, postoperative ejection fraction, intensive care unit and hospital lengths of stay, the in-hospital mortality rate and the incidence of stroke, sepsis, renal failure, atrial fibrillation, pulmonary embolism, pneumonia and prolonged mechanical ventilator support. RESULTS:The 2 matched groups had similar baseline characteristics. Significant reductions in cardiopulmonary bypass (104 ± 22 vs 118 ± 30 min, P < 0.001) and cross-clamp times (78 ± 17 vs 90 ± 21 min, P < 0.001) were noted in the FT group. Intraoperative red blood cell and cryoprecipitate transfusions (P < 0.001), prolonged mechanical ventilator support (P = 0.013), postoperative renal failure (P = 0.031) and hospital length of stay (P = 0.002) were all significantly decreased. There was insufficient evidence to detect a difference in postoperative ejection fraction, stroke, sepsis, pneumonia, pulmonary embolism or atrial fibrillation (P > 0.49). CONCLUSIONS:FT decreased intraoperative times, intraoperative red blood cell and cryoprecipitate transfusions, the need for prolonged mechanical ventilator support, renal failure and hospital length of stay. Using FT in MIAVR will allow for more reproducible, widespread adoption of minimally invasive approaches for aortic valve replacement.

BACKGROUND:In high-resource settings, the HIV-attributable risk of myocardial infarction (MI) is higher among women than among men. The extent to which unique mechanisms contribute to MI risk among women vs. men with HIV remains unclear. METHODS:Subclinical coronary atherosclerotic plaque characteristics - including high-risk morphology plaque features - were compared among 48 HIV-infected women (48 [41, 54] years) and 97 HIV-infected men (48 [42, 52] years) on stable antiretroviral therapy (ART) without known cardiovascular disease. These individuals had previously completed coronary computed tomography angiography and metabolic/immune phenotyping as part of a prospective study. RESULTS:Extending prior analyses, now focusing exclusively on ART-treated participants, we found that HIV-infected women had a lower prevalence of any subclinical coronary atherosclerotic plaque (35% vs. 62%, P=0.003) and a lower number of segments with plaque (P=0.01), compared to HIV-infected men. We also report for the first time that ART-treated HIV-infected women had a lower prevalence of high-risk positively remodeled plaque (25% vs. 51%, P=0.003) and a lower number of positively remodeled plaque segments (P=0.002). In models adjusting for cardiovascular risk factors, we further showed that male sex remained associated with any coronary plaque (OR 3.8, 95%CI [1.4, 11.4]) and with positively remodeled plaque (OR 3.7, 95%CI [1.4, 10.9]). CONCLUSIONS:ART-treated HIV-infected women (vs. HIV-infected men) had a lower prevalence and burden of subclinical coronary plaque and high-risk morphology plaque. Thus, unique sex-specific mechanisms beyond subclinical plaque may drive the higher HIV-attributable risk of MI among women vs. men.

Importance/UNASSIGNED:Prior studies report lower birth rates for women with epilepsy (WWE) but have been unable to differentiate between biological and social contributions. To our knowledge, we do not have data to inform WWE seeking pregnancy if their likelihood of achieving pregnancy is biologically reduced compared with their peers. Objective/UNASSIGNED:To determine if WWE without a prior diagnosis of infertility or related disorders are as likely to achieve pregnancy within 12 months as their peers without epilepsy. Design, Setting, and Participants/UNASSIGNED:The Women With Epilepsy: Pregnancy Outcomes and Deliveries study is an observational cohort study comparing fertility in WWE with fertility in control women (CW) without epilepsy. Participants were enrolled at 4 academic medical centers and observed up to 21 months from November 2010 to May 2015. Women seeking pregnancy aged 18 to 40 years were enrolled within 6 months of discontinuing contraception. Exclusion criteria included tobacco use and a prior diagnosis of infertility or disorders that lower fertility. Eighteen WWE and 47 CW declined the study, and 40 WWE and 170 CW did not meet study criteria. The Women With Epilepsy: Pregnancy Outcomes and Deliveries electronic diary app was used to capture data on medications, seizures, sexual activity, and menses. Data were analyzed from November 2015 to June 2017. Main Outcomes and Measures/UNASSIGNED:The primary outcome was proportion of women who achieved pregnancy within 12 months after enrollment. Secondary outcomes were time to pregnancy using a proportional hazard model, pregnancy outcomes, sexual activity, ovulatory rates, and analysis of epilepsy factors in WWE. All outcomes were planned prior to data collection except for time to pregnancy. Results/UNASSIGNED:Of the 197 women included in the study, 142 (72.1%) were white, and the mean (SD) age was 31.9 (3.5) years among the 89 WWE and 31.1 (4.2) among the 108 CW. Among 89 WWE, 54 (60.7%) achieved pregnancy vs 65 (60.2%) among 108 CW. Median time to pregnancy was no different between the groups after controlling for key covariates (WWE: median, 6.0 months; 95% CI, 3.8-10.1; CW: median, 9.0 months; 95% CI, 6.5-11.2; P = .30). Sexual activity and ovulatory rates were similar in WWE and CW. Forty-four of 54 pregnancies (81.5%) in WWE and 53 of 65 pregnancies (81.5%) in CW resulted in live births. No epilepsy factors were significant. Conclusions and Relevance/UNASSIGNED:Women with epilepsy seeking pregnancy without prior known infertility or related disorders have similar likelihood of achieving pregnancy, time to pregnancy, and live birth rates compared with their peers without epilepsy.

Importance:The US Food and Drug Administration (FDA) is increasing its pace of approvals for novel cancer therapeutics, including for immune checkpoint inhibitors of programmed cell death 1 protein (anti-PD-1 agents). However, little is known about how quickly anti-PD-1 agents agents reach eligible patients in practice or whether such patients differ from those studied in clinical trials that lead to FDA approval (pivotal clinical trials). Objectives:To assess the speed with which anti-PD-1 agents agents reached eligible patients in practice and to compare the ages of patients treated in clinical practice with the ages of those treated in pivotal clinical trials. Design, Setting, and Participants:This retrospective cohort study, performed from January 1, 2011, through August 31, 2016, included patients from the Flatiron Health Network who were eligible for anti-PD-1 agents treatment of selected cancer types, which included melanoma, non-small cell lung cancer (NSCLC), and renal cell carcinoma (RCC). Main Outcomes and Measures:Cumulative proportions of eligible patients receiving anti-PD-1 agents treatment and their age distributions. Results:The study identified 3089 patients who were eligible for anti-PD-1 agents treatment (median age, 66 [interquartile range, 56-75] years for patients with melanoma, 66 [interquartile range, 58-72] years for patients with RCC, and 67 [interquartile range, 59-74] years for patients with NSCLC; 1742 male [56.4%] and 1347 [43.6%] female; 2066 [66.9%] white). Of these patients, 2123 (68.7%) received anti-PD-1 agents treatment, including 439 eligible patients with melanoma (79.1%), 1417 eligible patients with NSCLC (65.6%), and 267 eligible patients with RCC (71.2%). Within 4 months after FDA approval, greater than 60% of eligible patients in each cohort had received anti-PD-1 agents treatment. Overall, similar proportions of older and younger patients received anti-PD-1 agents treatment during the first 9 months after FDA approval. However, there were significant differences in age between clinical trial participants and patients receiving anti-PD-1 agents treatment in clinical practice, with more patients being older than 65 years in clinical practice (range, 327 of 1365 [60.6%] to 46 of 72 [63.9%]) than in pivotal clinical trials (range, 38 of 120 [31.7%] to 223 of 544 [41.0%]; all P < .001). Conclusions and Relevance:Anti-PD-1 agents rapidly reached patients in clinical practice, and patients treated in clinical practice differed significantly from patients treated in pivotal clinical trials. Future actions are needed to ensure that rapid adoption occurs on the basis of representative trial evidence.

PURPOSE:Access to comparative information on hospitals' quality of cancer care is limited. Patients' interest in using this information when selecting a hospital for cancer surgery and the specific data they would desire are unknown. This study gauges patients' demand for comparative information on hospitals' quality of cancer surgery. METHODS:We conducted a cross-sectional, national survey of 3,334 US residents who had received cancer surgery. The outcomes were patients' reported likelihood of using a list of best hospitals for cancer surgery and patients' reported interest in information about specific clinical outcomes, including 4-year survival after surgery, 30-day mortality after surgery, and rate of complications from surgery. RESULTS:Two thirds of patients (68%) reported being actively involved in selecting a hospital for their surgery, and two thirds (65%) reported that their physician was involved in or made this decision. When asked what information might have helped them to choose a hospital, participants identified the hospital's reputation (55%), patient satisfaction (44%), and the number of cancer surgeries performed at the hospital (36%). Approximately three quarters (73%) reported being likely to use a list of best hospitals for cancer surgery when selecting a hospital. Approximately 40% expressed interest in having information on at least one clinical outcome. CONCLUSION:Widespread interest exists among patients with cancer for comparative information on hospital quality as well as on clinical outcomes and hospitals' reputation for cancer surgery. Policy reforms and additional research should address the unmet need for transparent, comprehensive data on the quality of hospitals' cancer care.