Faculty Bibliography

This article discusses the current state of value in the United States health care system, and the unsustainable growth trend of health care spending. Also discussed is the role of waste and its subcategories as the drivers of that cost. The key differences in the cost drivers for governmental and commercial payers are discussed. The patient-level outcomes of low-value care are addressed. In addition, hospitalists are provided with an overview of the tools that exist to help improve the value of their current practices as well as for teaching value and leading value-based projects.

Big data, that is, data that are byproducts of our lives rather than designed for research purposes, are the newest of the information highway innovations. One of the important challenges to social and behavioral science data collection, curation, and dissemination for the foreseeable future is to link diverse forms of data in a way that is cumulative, representative, meaningful, and accessible to a broad range of researchers. It is critical to explore the new questions these data can address and to develop new methods to address them, including linking persons and information about them and their environments across different data platforms while maintaining confidentiality and privacy. Linking a broad array of information-from administrative data (local and state and regional), to social media (Twitter, Facebook), to census and other surveys, to ethnographic data, and data from experiments such as randomized controlled trials-to address how humans and their communities make decisions is challenging. This issue was addressed by papers presented at a conference on New Data Linkages convened by the Social Observatories Coordinating Network in 2016; those articles are brought together in this volume.

Purpose: The purpose of this paper is to argue that police research has reached a level of acceptance such that executive management has an ethical obligation to their communities to use evidence-based practices. Design/methodology/approach: Using an Evidence-Based Medicine (EBM) framework the authors apply an ethical-based decision-making model to policing decisions. EBM does not allow physicians to ignore research when giving guidance to patients. The authors compare the two professional approaches to decision making and argue policing has reached a level of research that if ignored, just like medicine, should be considered unethical. Police interventions can potentially be harmful. Rather than do no harm, the authors argue that police managers should implement practices that are the least harmful based on the current research. Findings: The authors found policing has a substantial amount of research showing what works, what does not, and what looks promising to allow police executives to make decisions based on evidence rather than tradition, culture, or best practice. There is a deep enough fund of knowledge to enable law enforcement leadership to evaluate policies on how well the policies and procedures they enforce prevent crime with a minimum of harm to the communities they are sworn to protect and serve. Originality/value: Policing has yet to view community interventions as potentially harmful. Realigning police ethics from a lying, cheating, stealing, lens to a "doing the least harm" lens can alter the practitioner"™s view of why evidence-based policing is important. Viewing executive decision from an evidence-based ethical platform is the future of evaluating police executive decisions.

Program/Project Purpose: Teaching medicine in English in non-English-speaking countries is increasingly common. IMGs receive less communication skills training and tend to perform less well on communication skills assessments. This project's purpose was to create the first Objective Structured Clinical Examination (OSCE) program in English with standardized patients at one medical school in Turkey. Structure/Method/Design: All 48 medical students in the fourth year M.D. class (of six years) at Koc University School of Medicine, Istanbul, Turkey, were separated into two internal medicine blocks in 2015-16, and were given a single station, pass/fail, end-of-block OSCE in English. Palpitations and abdominal pain OSCE cases were adapted with permission from New York University. Six American teachers from the KU English Learning Center and five faculty from KUSOM were recruited and trained as SPs and faculty assessors, respectively, in 3 training sessions per OSCE. NYU's competency-based assessment checklists were used. To prepare students, specific bedside teaching sessions were delivered during the clinical block. Data was analyzed in REDCap and ethical approval was obtained at KUSOM. Outcome & Evaluation: For each block, 58-100% students passed the OSCE. SPs gave well done marks to 50-88% for eliciting the story with appropriate questions, 8-20% for providing clear explanations about diagnosis and treatment, 58-76% for managing the physical exam respectfully, 66-80% for using clear and easy to understand English, and 50-64% of students would be recommended or highly recommended to a friend, respectively (N=48 divided into two blocks). Students who failed scored poorly on medical English anchors (N=10). Students most strongly agreed that the OSCE helped them identify strengths and weaknesses and stimulated them to learn more (3.24 and 2.96 averages, Likert scale 1=strongly disagree, 4=strongly agree). Going Forward: KUSOM's OSCE pilot program exceeded expectations. Education and counseling was more challenging than information gathering or conducting physical examination. The second block performed better than the first block. The large increase in performance between blocks is likely explained by better attendance at bedside sessions. Offering OSCEs in both English and Turkish next year will help clarify whether their performance reflected clinical skills or English language alone. These findings inform expansion of curriculum and faculty development in bedside teaching at KUSOM

BACKGROUND:Although coronary artery calcium (CAC) has been investigated for over two decades, there is very limited data on the association of CAC with cause of death. The CAC Consortium is a large ongoing multi-center observational cohort of individuals who underwent non-contrast cardiac-gated CAC testing and systematic, prospective, long-term follow-up for mortality with ascertainment of cause of death. METHODS:Four participating institutions from three states within the US (California, Minnesota, and Ohio) have contributed individual-level patient data to the CAC Consortium (spanning years 1991-2010). All CAC scans were clinically indicated and physician-referred in patients without a known history of coronary heart disease. Using strict inclusion and exclusion criteria to minimize missing data and to eliminate non-dedicated CAC scans (i.e. concomitant CT angiography), a sharply defined and well-characterized cohort of 66,636 patients was assembled. Mortality status was ascertained using the Social Security Administration Death Master File and a validated algorithm. In addition, death certificates were obtained from the National Death Index and categorized using ICD (International Classification of Diseases) codes into common causes of death. RESULTS:Mean patient age was 54 ± 11 years and the majority were male (67%). Prevalence of CVD risk factors was similar across sites and 55% had a <5% estimated 10-year atherosclerotic cardiovascular disease (ASCVD) risk. Approximately 45% had a Calcium score of 0 and 11% had an Agatston Score ≥400. Over a mean follow-up of 12 ± 4 years, there were 3158 deaths (4.15 per 1000 person-years). The majority of deaths were due to cancer (37%) and CVD (32%). Most CVD deaths were due to CHD (54%) followed by stroke (17%). In general, CAC score distributions were similar across sites, and there were similar cause of death patterns. CONCLUSIONS:The CAC Consortium is large and highly generalizable data set that is uniquely positioned to expand the understanding of CAC as a predictor of mortality risk across the spectrum of disease states, allowing innovative modeling of the competing risks of cardiovascular and non-cardiovascular death.

The widespread dissemination of carbapenem-resistant Acinetobacter spp. has created significant therapeutic challenges. At present, rapid molecular diagnostics (RMDs) that can identify this phenotype are not commercially available. Two RMD platforms, PCR combined with electrospray ionization mass spectrometry (PCR/ESI-MS) and molecular beacons (MB), for detecting genes conferring resistance/susceptibility to carbapenems in Acinetobacter spp. were evaluated. An archived collection of 200 clinical Acinetobacter sp. isolates was tested. Predictive values for susceptibility and resistance were estimated as a function of susceptibility prevalence and were based on the absence or presence of beta-lactamase (bla) NDM, VIM, IMP, KPC, and OXA carbapenemase genes (e.g., bla_OXA-23, bla_OXA-24/40, and bla_OXA-58 found in this study) against the reference standard of MIC determinations. According to the interpretation of MICs, 49% (n = 98) of the isolates were carbapenem resistant (as defined by either resistance or intermediate resistance to imipenem). The susceptibility sensitivities (95% confidence interval [CI]) for imipenem were 82% (74%, 89%) and 92% (85%, 97%) for PCR/ESI-MS and MB, respectively. Resistance sensitivities (95% CI) for imipenem were 95% (88%, 98%) and 88% (80%, 94%) for PCR/ESI-MS and MB, respectively. PRIMERS III establishes that RMDs can discriminate between carbapenem resistance and susceptibility in Acinetobacter spp. In the context of a known prevalence of resistance, SPVs and RPVs can inform clinicians regarding the best choice for empiric antimicrobial therapy against this multidrug-resistant pathogen.