MedStar Health Blog

Jessica E. Galarraga, MD, MPH, has been awarded an Early Career Research Development Grant from the Emergency Medicine Foundation (EMF) to continue her research evaluating the health care delivery effects of a population-based global budget revenue model. The grant will fund a two-year research project “Impact of Global Budgeting & Pay-for-Performance Incentives on Emergency Care Delivery.”

In 2014, the state of Maryland implemented the global budget revenue (GBR) program to align with the following aims as defined by the Centers for Medicare and Medicaid Services: (1) reduce per capita costs, (2) enhance quality, and (3) improve population health. “Historically, MD has been the testing ground for new payment models in the United States. Maryland’s GBR program is among the most far-reaching alternative payment models using hospital settings as leaders for health care system improvement,” said Dr. Galarraga.

This grant will continue Dr. Galarraga’s research into the effects of GBR on emergency care delivery, utilization, and outcomes. This research will serve to fill a gap in knowledge on the impact of GBR, as CMS has recently approved the renewal of Maryland’s GBR program effective 2019 and started to implement similar programs in other states beginning in 2017.

This research with look specifically at the effects of GBR on the utilization and quality of hospital-based emergency care. It will also address issues related to transitions of care in emergency departments.

 “The findings from this research will generate implications for health care practice leaders and policymakers on the effects of population-based health care payment reform on emergency care delivery. This will hopefully provide guidance on the continual evolution and advancement of payment reform efforts with global budgeting,” said Dr. Galarraga.

The EMF has awarded more than $16 million in research grants since its founding in 1972 by visionary leaders of the American College of Emergency Physicians. The mission of the EMF is to promote education and research that improve patient care, provide the basis for effective health policy, and develop career emergency medicine researchers.

Dr. Galarraga is a physician Investigator at the MedStar Health Research Institute, an attending physician with MedStar Emergency Physicians, and Instructor of Emergency Medicine at the Georgetown University. She was also the recipient of a grant from the EMF in 2016, along with funding from the MedStar Health New Investigators Grant fund in 2016 and 2017.

Congratulations to all MedStar researchers who had articles published in July 2018. The selected articles and link to PubMed provided below represent the body of work completed by MedStar Health investigators, physicians, and associates and published in peer-reviewed journals last month. The list is compiled from PubMed for any author using “MedStar” in the author affiliation.

Congratulations to this month’s authors! We look forward to seeing your future research.

View the full list of publications on PubMed.gov here.

Selected research:

1. Redesigning Hospital Diabetes Education: A Qualitative Evaluation With Nursing Teams.
   Journal of Nursing Care Quality. DOI: 1097/NCQ.0000000000000349
   Smith KM, Baker KM, Bardsley JK, McCartney P, Magee M
2. A Hospital-Based Initiative to Reduce Postdischarge Sudden Unexpected Infant Deaths.
   Hospital Pediatrics. DOI: 1542/hpeds.2017-0211
   Krugman SD, Cumpsty-Fowler CJ
3. Baricitinib, a Janus kinase inhibitor, in the treatment of rheumatoid arthritis: a systematic literature review and meta-analysis of randomized controlled trials.
   Clinical Rheumatology. DOI: 1007/s10067-018-4199-7
   Kunwar S, Collins CE, Constantinescu F
4. A usability and safety analysis of electronic health records: a multi-center study.
   Journal of the American Medical Informatics Association. DOI: 1093/jamia/ocy088
   Ratwani RM, Savage E, Will A, Arnold R, Khairat S, Miller K, Fairbanks RJ, Hodgkins M, Hettinger AZ
5. Medication Allergy and Adverse Drug Reaction Documentation Discrepancies in an Urban, Academic Emergency Department.
   Journal of Medical Toxicology. DOI: 10.1007/s13181-018-0671-7
   Kiechle ES, McKenna CM, Carter H, Zeymo A, Gelfand BW, DeGeorge LM, Sauter DA, Mazer-Amirshahi M

MedStar Health policies require that all individuals engaged in the conduct of research complete the annual conflict of interest disclosure. The annual research conflicts of interest disclosure process is designed to manage financial and nonfinancial research interests. As you probably know, MedStar Health Research Institute is required to manage conflicts of interests as a condition of receiving federal funding for research.

If you have completed the questionnaire as a researcher during the fiscal year 2018, a link to the conflict of interest disclosure was sent to you in July. If you held a research role at MedStar in FY18, you may have already entered data into the COISmart system during the fiscal year. Please follow the instructions in the email you received to certify your previous disclosure. You are required to certify your previously completed disclosure to ensure that it accurately reflects a full fiscal year of reporting (July 1, 2017, through June 30, 2018). Please make sure you confirm the information in the FY 2018 Questionnaire is accurate and resubmit it. As a researcher, the FY 2019 questionnaire is also open for your use between July 1, 2017, and June 30, 2018.

You can access the system at https://medstar.coi-smart.com/.

If you have any questions about the conflict of interest policy or accessing the COISmart system to make disclosures, contact the Research Compliance Program at researchcompliance@medstar.net.

Mark your calendars now to connect with other MHRI and MedStar associates by participating in one of these upcoming events to support the health of our communities.

Race to Beat Cancer

Saturday, September 15

Four Seasons Hotel Washington, D.C., is proud to host the 38th annual Four Seasons Hotel Washington, D.C., Race to Beat Cancer 5K. This charitable event is one of the premier 5K races in Washington, D.C., The proceeds from this event are donated to the Washington Cancer Institute at MedStar Washington Hospital Center. In 2017, the event raised more than $300,000 for cancer research!

Where: Four Seasons Hotel Washington, D.C.,
Check-In: 7:00 am
Starts: 8:00 am
Length of Walk/Run: 5K
To learn more and register, visit https://www.racetobeatcancer5k.com/home. 

2018 Step Out: Washington, D.C.,

Saturday, September 22

Participating in the Step Out Walk is an experience you will never forget. You will be joining your community members along the beautiful route who share your passion to fight diabetes. You will be helping people in your own community who live with this disease every day. Bring your friends, family, and co-workers to walk with thousands of people from across the country and help us change the future of diabetes. This walk is hosted by the American Diabetes Association. 

Where: Washington Monument Grounds, Washington, D.C.,
Check-In: 8:00 am
Event starts: 9:30 am
Learn more about the walk here.

Super H 5K Run, Walk & Wheel

Sunday, September 23

Help support the Adaptive Sports Programs at MedStar National Rehabilitation Network and participate in the Super H 5K Run, Walk & Wheel in Tysons Corner, VA. This race is open to all able-bodied and disabled athletes who can run, walk or roll through the course. All proceeds benefit Adaptive Sports Programs at MedStar National Rehabilitation Network, which helps children and adults with physical disabilities to pursue healthy, active lifestyles through recreational and competitive sports.

Where: Sport & Health Club, Tysons Corner, VA
Check-In: 7:00 am
Event starts: 9:00 am
Length of Walk: 5K
Learn more and register at SuperH5K.com.

2018 Step Out: Baltimore, MD

Sunday, October 7

The Step Out Walk to Stop Diabetes gives everyone in our community a chance to gather together to raise funds for diabetes research, advocacy, and education. Dollars raised through Step Out help to support those affected by diabetes in Maryland, and beyond. When you register for the Step Out Walk to Stop Diabetes, you become a part of the American Diabetes Association’s team. Joining you will be thousands of participants from around the country who come together and directly impact the lives of people facing the daily challenges of diabetes. This walk is hosted by the American Diabetes Association. 

Where: Canton Waterfront, Baltimore, MD
Event starts: 9:00 am
Length of Walk 3.15 mile walk
Learn more here.

2018 Greater Washington Heart Walk

Saturday, November 3

Hosted by the American Heart Association and the American Stroke Association, this event includes 1- and 3-mile routes. Join walkers from across our community as they step out to have fun, get inspired and support a meaningful cause.

Where: The National Mall, Washington, D.C.,
Check-In: 8:30 am
Event starts: 10:00 am
Length of Walk: 1-mile or 3-mile walk

Learn more on the website.

Hernias are common, and you likely know someone who has had one at some point in their life. So, perhaps it’s no surprise that the most common esophageal condition I treat is paraesophageal hernia, which is when the stomach bulges into the chest through diaphragm—the primary muscle located along the lower ribs that is used in the process of breathing. Hernia occurs when the small opening connecting the esophagus and the stomach in the diaphragm weakens over time, allowing the stomach to move up into their chest.

Anyone can develop a paraesophageal hernia. People who are overweight are at greater risk because they have increased abdominal pressure. Women who have had multiple babies sometimes have diaphragm weakening over time, which can result in a hernia, and genetic factors can contribute as well.

Symptoms range from none to severely limiting one’s ability to eat, sleep, or do daily activities. Symptoms can include:

• Acid reflux
• Bloating and early fullness after eating
• Cough
• Dysphagia, or difficulty swallowing
• Shortness of breath from the stomach pushing on the diaphragm or compressing the lungs
• Retching up undigested food
• Weight loss
• Fear of food due to severe symptoms

Some patients rely on over-the-counter antacids to try to manage their symptoms. But if left untreated, in extreme cases, a paraesophageal hernia can cause the stomach to twist along the esophagus and cut off the blood supply. Thankfully, paraesophageal hernias can be treated with medication from a doctor or even cured through advanced, minimally invasive robotic surgery.

LISTEN: Dr. John Lazar discusses paraesophageal hernia treatment in the Medical Intel podcast.

Diagnosis and treatment of paraesophageal hernia

The only way to know for sure whether you have a paraesophageal hernia is to see a doctor and undergo:

• A CT scan of the chest
• Esophagogram, which is an X-ray to determine if liquids go down the esophagus properly
• Esophageal manometry, which tests how well the esophagus squeezes food down the length of the esophagus
• Esophagogastroduodenoscopy (EGD), which is a fiberoptic scope like a colonoscope that can be inserted into the esophagus and stomach to see any abnormalities

Based on the findings of your tests, the doctor can recommend a variety of treatment options.

Medications

Patients can use antacids such as Rolaids or Tums to neutralize minor stomach acid symptoms. Proton pump inhibitors (PPIs) like Prilosec, meanwhile, are stronger acid-blocking medications. There’s a growing debate regarding long-term injury from using PPIs. This had led many patients to ask whether surgery is right for them.

Surgery

We can cure paraesophageal hernias at MedStar Washington Hospital Center through minimally invasive robotic surgery. We use a robotic system that is completely controlled by the surgeon to help enhance the surgeon’s vision and ability to handle delicate tissues of the abdomen. The surgery entails releasing the hernia scar tissue, which allows the stomach to return to its proper place in the abdomen. Then, the opening in the diaphragm where the stomach herniated through is closed with sutures. Patients are usually back home two to three days after surgery.

I urge you to see your doctor if you experience symptoms of a paraesophageal hernia. What might seem like acid reflux or difficulty swallowing could lead to serious health problems down the road.

The number of first-time total knee replacements, also known as arthroplasties, is expected to grow by 673 percent, reaching 3.48 million procedures by 2030, according to a study published by the Journal of Bone and Joint Surgery. The primary reasons that we feel contribute to this huge increase are the growing rates of baby boomers living longer and desiring to maintain youthful active lifestyles.

Historically, knee arthritis patients undergo full knee replacement to relieve arthritis pain, stay active, and maintain their quality of life. However, many patients could achieve these goals with partial knee replacements, which keep more of the original knee intact for a more natural-feeling joint. This procedure usually results in shorter recovery times and longer-lasting outcomes than traditional procedures.

LISTEN: Orthopedic surgeon Evan Argintar discusses joint replacement bioplasty in the Medical Intel podcast.

When should you choose partial knee replacement?

This search for long-term relief leads many people with arthritis of the knee to opt for a full knee replacement. A full knee replacement replaces the inside portion, outside portion, and underneath the kneecap. This is great if all three parts of the knee are diseased or arthritic. The problem with a full knee replacement is that you must sacrifice the ligaments on the inside of the knee, often changing how the knee feels. This results in a knee that feels artificial and is limited in the activities it can perform.

In addition, sometimes the inner or outer portion of the knee is worse than the rest of the joint. In this case, a full knee replacement might not be necessary, and a patient can opt for a partial knee replacement—allowing them to maintain their youth and activity, plus avoid some of the limitations inherent with a more major surgery.

We incorporate technologies of partial knee replacements with some of the isolated treatments we have done in the sports world, such as cartilage restoration or ligament reconstruction. In years past, if you had medial isolated arthritis on the inside of your knee without an ACL (anterior cruciate ligament) injury, you had no option but to have a full knee replacement. Now, you can do a partial knee replacement with an ACL reconstruction. This is an exciting prospect for patients who want to get back to physical activity.

Who is a candidate for partial knee replacement?

Every person with arthritis likely has had a meniscal tear. These patients might be better off receiving a partial knee replacement in combination with some other cartilage-restorative procedure rather than arthroscopy alone. Arthroscopy will not predictably cure or relieve pain from arthritis.

Other candidates include those with knee pain who have been diagnosed with a degenerative disease in only one or two parts of their knee. If arthritis is found only underneath the knee, then a partial replacement can be performed to preserve as much normal anatomy as possible. The more we can preserve the ligaments, cartilage, and meniscus, the better the knee will feel. The term we use for this is bioplasty, which combines arthroplasty with biology, or your normal body.

Our patients benefit from a team approach. We have many experts who specialize in joint procedures, including:

• Partial knee replacement surgeries: Dr. Evan Argintar and Dr. Savyasachi Thakkar
• ACL reconstruction and cartilage preserving procedures: Dr. Evan Argintar and Dr. Wiemi Douoguih

Get back to being you

A partial knee replacement procedure is not only more comfortable and natural, but it also allows for a shorter recovery time compared to traditional surgery. With a full knee replacement, you would look at a minimum recovery time of six months. However, with new technological advances, a partial knee replacement requires only a four-month recovery period. This is huge for someone who is physically active. Moreover, there is less inflammation and pain, plus more mobility.

This approach worked out great for a patient who was in her 40s and had undergone a full knee meniscectomy (removal of meniscus from the knee) a decade earlier. At the time, she was working and continually active with her young children, but she was experiencing knee pain due to arthritis. She wanted to combat the pain, but the last thing she wanted to do was sacrifice two-thirds of her knee and restrict her mobility. To treat her, we did an ACL reconstruction, which allowed us to perform a successful partial knee replacement. Today, she’s back at work, exercising, and able to chase her children around.

If you’ve been experiencing knee pain from arthritis or a sports injury, don’t ignore it! You could be suffering from arthritis or a tear in one of your knee ligaments. Treating your condition early might mean you can spare more of your natural knee tissue, which can result in less pain and better function for years to come.