MedStar Educators Investigate the Impact of Training Statement on Cardiology Fellowships

Recent research from MedStar Health investigators and educators sought to understand the impact and perception of a newly implemented training statement for cardiovascular education. The research was the first to collect data from program directors in cardiology fellowships on how they understand and implement the new training guidelines.

The research as published in Journal of the American College of Cardiology. The research team was led by Gaby Weissman, MD, and included Alex J. Auseon, DO; James A. Arrighi, MD; Lisa A. Mendes, MD; Paul Theriot, BSBA; Marty C. Tam, MD; and Julie B. Damp, MD.

American College of Cardiology wanted to address the rapid advancement of knowledge for treating cardiovascular disease. Initially developed in 1995, the Core Cardiovascular Training Statement (COCATS), provided a uniform set of curricular recommendations for training in cardiovascular disease. The most recent iteration, COCATS4, differs from previous versions in that it added elements of competency-based medical education as well as adding new domains of knowledge such as critical care cardiology and it changed the duration of training that needed to be devoted to gaining clinical skills and knowledge. 

Of the 229 cardiovascular disease training programs based in the United States, 130 (57%) responded to the survey over a month-long period. Each program self-reported their size based on fellows (small to large, one through 18+) and program type (university hospital-based, community hospital/university-affiliated, community-based, or military hospital).

Half of the program directors found the guidelines to be helpful in assessing competency, with an additional 30% finding it somewhat useful. Many program directors (57%) found the COCATS4 guidelines to be extremely useful, with an additional 35% finding it somewhat useful. The majority of program directors (69%) found that the COCATS4 guidelines are better aligned with the needs of today’s job market.

Despite the new guidelines, almost one-half (45%) of programs had made no significant changes since the release of COCATS4, however 22% of programs increased the number of clinical months, 8% decreased the number of clinical months, and 11% increased the number of required echocardiography months. 57% of responding programs indicated that resource limitations impacted the lack of direct clinical experience. This included lack of subspecialty programs within their institutions. Another important finding was that over half of programs reported that they lacked the ability to deliver direct clinical experience in at least one domain of cardiovascular care. 

This research helped to identify gaps in training programs based on the guidelines, finding that programs may need to utilize alternative educational experiences to ensure that their fellows are meeting the guidelines. This data can be used as a comparison for future research, as it can create a benchmark of training programs. Importantly, it should serve as a call for national organizations to help fill in the educational gaps that cardiology training programs may have.

Journal of the American College of Cardiology, 2019. DOI: 10.1016/j.jacc.2019.03.488

MedStar Researchers Investigate Cardiovascular Testing

Researchers from MedStar Heart & Vascular Institute, MedStar Washington Hospital Center, MedStar Georgetown University Hospital and National Institute of Health have recently sought to identify pre-transplantation cardiac testing practices and to report post-transplant cardiac outcomes in patients receiving renal allografts.

“Pre-Operative Cardiovascular Testing and Post-Renal Transplant Clinical Outcomes” was published in Cardiovascular Revascularization Medicine. Chronic kidney disease and end-stage renal disease are closely linked to coronary artery disease. This retrospective analysis examined demographics and medical data for patients undergoing first renal transportation. Pre-transplant workup included echocardiograms, cardiac stress testing, coronary computed tomography, left heart catherization and any revascularization.

The research included 235 patients and the mean length of follow-up was 1.63 years. Patients were reviewed for use of antiplatelet, HMG-CoA reductase inhibitors (statins), insulin, beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, mineralocorticoid receptor antagonists, and diuretics over a 6-month period before transplant. 219 (93%) patients had non-invasive functional testing before transplant. The most common co-morbidity was hypertension (88.1%), and the most common pre-transplant medication class was beta blockers (59.6%). The most common cause of chronic kidney disease/end-stage renal disease was hypertension (36.7%) and diabetes mellitus (26.2%). There were 3 deaths, 2 that were cardiac-specific. Of those patients with a 30-day post-operative troponin, 30 (13%) patients had an elevation due to a type II NSTEMI or myocardial injury.

The results of the study show that cardiovascular testing remains an ever-present practice in pre-transplant evaluation, with an ongoing low rate of adverse cardiac outcomes for those patients who are ultimately deemed suitable for kidney transplant. In conclusion, this study demonstrates low mortality despite the relative frequency of post-operative troponin elevation. “There is no clear pattern of pre-cardiac testing results or revascularization inpatients who develop post-transplant major adverse cardiac outcomes.”

The research team included Michael Yang, Patrick Miller, PT, DPT; Brian C. Case, MD; Alexander J. Gilbert, MD; Jared K. Widell, MD; Toby Rogers, MD; Lowell F. Satler, MD; Ron Waksman, MD; and Itsik Ben-Dor, MD.

Cardiovascular Revascularization Medicine, 2019. DOI: 10.1016/j.carrev.2019.04.017

New! MedStar Study Information Portal Live

We are pleased to announce the release of a new tool to broaden public awareness of open clinical trials happening across MedStar Health and MedStar Health Research Institute.

We have launched the Study Information Portal on the MedStar Health Research Institute website, on the webpage that currently displays our open clinical trials. The Study Information Portal references real-time data from enrolling studies in OnCore to help patients and providers identify active clinical trials that meet their needs and interests. Users can browse our active clinical trials by site or by principal investigator, or they may search for a study by key words, such as a disease or diagnosis.

Informational WebEx sessions will be available August 5th, 6th, and 7th at both 8:30am and 12:30pm daily to showcase the Study Information Portal and address any questions. Subsequent announcements will be made via Twitter, the MedConnect Minute, and MedStar Patient Portal to further share the tool with the MedStar Health community.

The Study Information Portal is publicly accessible on the MedStar Health Research Institute website here.

If you have any questions, please contact Allie Moses at [email protected]

July Peer-Reviewed Publications from MedStar Health

Congratulations to all MedStar researchers who had articles published in July 2019. 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 here.

Selected research:

  1. Fresh and Savory: Integrating Teaching Kitchens with Shared Medical Appointments
    The Journal of Alternative and Complementary Medicine, 2019. DOI: 10.1089/acm.2019.0091
    Kakareka R, Stone TA, Plsek P, Imamura A, Hwang E.
  1. The Effects of Medicaid Expansion on Triage and Regional Transfer After Upper-Extremity Trauma
    The Journal of Hand Surgery, 2019. DOI: 1016/j.jhsa.2019.05.020
    Daly CA, Cho BH, Desale S, Aliu O, Mete M, Giladi AM.

  2. Clinical, Pathological and Molecular Profiling of Radioactive Iodine Refractory Differentiated Thyroid Cancer
    Thyroid, 2019. DOI: 10.1089/thy.2019.0075
    Shobab L, Gomes-Lima CJ, Zeymo A, Feldman R, Jonklaas J, Wartofsky L, Burman KD.
  1. Intravascular Ultrasound-Guided Drug-Eluting Stent Implantation
    Minerva Cardioangiologica, 2019. DOI: 10.23736/S0026-4725.19.04895-3
    Shlofmitz E, Kuku KO, Waksman R, Garcia-Garcia HM.
  1. Improved Survival After Multimodal Approach with 131I Treatment in Patients with Bone Metastases Secondary to Differentiated Thyroid Cancer
    Thyroid, 2019. DOI: 10.1089/thy.2018.0582
    Wu D, Gomes Lima CJ, Moreau SL, Kulkarni K, Zeymo A, Burman KD, Wartofsky L, Van Nostrand D.

MedStar Honored for Work on Health Equity by the AAMC

In 2017, MedStar Health joined a group of eight institutions, brought together by the Association of American Medical Colleges (AAMC), to plan and evaluate strategies to produce coordinated systems for community health.  Over three years, members participated in a series of workshops titled Building a Systems Approach to Community Health and Health Equity for Academic Medical Centers. This topic is closely tied to MedStar Health Research Institute’s mission to advance the health of our community through research.

With collaborators from Georgetown University, the team investigated medical-legal partnerships as a method to address issues of health equity and community health. A medical-legal partnership is an inter-professional healthcare delivery model that adds legal services to health care to help doctors address “health-harming legal needs”, which encompass social determinants of health that contribute to poor health and health disparities. The research included qualitative and quantitative data centered around patients at MedStar Franklin Square Medical Center (MFSMC) and its Family Health Center (FHC) in Baltimore, Maryland. Some risk factors for health-harming legal needs include low socioeconomic status, caring for young children, homeless, and elderly. Legal issues that arise from these social determinants of health include custody, domestic violence, health insurance, and eviction.

At the end of June, the entire team received an award for their participation at a dinner and the work was presented at the final meeting for participating sites by Deliya Wesley, PhD, MPH (Health Equity investigator),  Angela D. Thomas, DrPH, MPH, MBA (Assistant Vice President, Healthcare Delivery Research, MHRI) and Vicki W. Girard, JD (Founding Co-Director, Georgetown University Health Justice Alliance and a Professor of Law, Legal Practice).

The team presented their research at the 2019 MedStar Health-Georgetown University Research Symposium. The poster, “An Empirical Approach to Planning for Medical-Legal Partnerships (MLPs): Initial Findings from the MedStar Franklin Square Service Area,” can be viewed here.

While the work the team is conducting under the oversight of AAMC is completed, they will be continuing their work into identifying costs that would be associated with implementing a medical-legal partnership, including potential savings for the system.

Dr. Weissman Recognized with 2019 Mentorship Award from ASE

Join us in congratulating Neil J. Weissman, MD, FASE, Chief Scientific Officer, MedStar Health and President, MedStar Health Research Institute, on his 2019 Mentorship Award from the American Society of Echocardiography (ASE).

This award recognizes a senior physician or sonographer who has demonstrated exceptional mentorship within ASE. Unlike other awards, the Mentorship Award specifically acknowledges individuals who helped younger members advance within the Society and thus cultivated ASE’s future leaders.

Dr. Weissman uses his unique leadership skills to develop mentoring programs that benefit both individuals and organizations. He conceived of, and implemented, the ASE Leadership Academy as a way of growing the future leadership of the Society and assuring that they develop the necessary skills to be effective leaders.

Improving Patient Safety: MedStar Research Team Highlights the Work of the CANDOR Program

Patient safety remains a top priority for all healthcare systems. One method that systems use to provide an organized approach for responding to unintended patient harm is a Communication and Resolution Program. MedStar has a been a leader in this field by making it an active area of research.  

“Lessons Learned from Implementing a Principled Approach to Resolution Following Patient Harm” describes lessons learned after implementing the resolution component of Communication and Optimal Resolution, a comprehensive contemporary communication and resolution program at MedStar Health.  Some healthcare systems have struggled with implementing Communication and Resolution Programs, mainly around the components to resolving events that have caused serious patient harm. The recent research publication sought to share the findings from an implementation science study that helps support other systems.

MedStar Health initiated a five-year strategic plan to improve patient safety at our 10 acute care hospitals and 250 ambulatory care sites in 2012. In 2013, MedStar collaborated with leaders from around the US to develop and pilot test a Communication and Optimal Resolution (CANDOR) toolkit. MedStar piloted the toolkit in eight hospitals in partnership with the Agency for Healthcare Research and Quality (AHRQ). In 2015, MedStar extended its CANDOR implementation to all 10 MedStar hospitals and has since expanded its implementation to all ambulatory care sites and diversified business units.

At MedStar, CANDOR is initiated when a serious patient harm event is reported. This is followed by starting an immediate investigation at the local care site, a discussion with the patient safety and local care team, early communication to the patient and family, and activation of the health system’s critical incident response process including care for the care teams and notification of leadership and claims and risk management.

The authors formed seven strategies to support the resolution process at MedStar Health. These included processes to:

  1. provide immediate support to patients and families,
  2. hold and waive bills,
  3. activate event review processes early to inform resolution,
  4. embrace a paradigm shift in legally defensible cases,
  5. develop a communication and resolution program legal community,
  6. accept sacrifices with a principled resolution, and
  7. commit to address challenges with open medical staffs.

While the CANDOR program is still quite new, the research team has found that the resolution process is complex, and improvements can be made in support of organizational transparency. MedStar is committed to patient safety and recognizes the importance of partnering with patients and/or families to prevent serious patient harm from happening to others.

The authors for this publication are: Kelly M. Smith, PhD (MedStar Institute for Quality and Safety); Larry L. Smith (Risk Management for MedStar Health; Greenspring Financial Insurance Limited, Inc. of Cayman); John C. (Jack) Gentry (MedStar Health System Patient and Family Advisory Council for Quality and Safety); and David B. Mayer (MedStar Institute for Quality and Safety).

This research received funding from the Association of American Medical Colleges, Learning Health Systems Award. The demonstration project for CANDOR was funded by the Agency for Healthcare Research and Quality under an ACTION II contract to the Health Research and Educational Trust.

Journal of Patient Safety and Risk Management, 2019. DOI: 10.1177/2516043518813814

June Peer-Reviewed Publications from MedStar Health

Congratulations to all MedStar researchers who had articles published in June 2019. 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 here.

Selected research:

  1. Lateral Transfer of the Flexor Digitorum Longus for Peroneal Tendinopathy
    Foot & Ankle International, 2019. DOI: 10.1177/1071100719853297
    Sherman TI, Koury K, Orapin J, Schon LC.
  1. The Impact of Institutional Factors On Physician Burnout: A National Study of Urology Trainees
    Urology, 2019. DOI: 1016/j.urology.2019.04.042
    Marchalik D, Brems J, Rodriguez A, Lynch JH, Padmore J, Stamatakis L, Krasnow R.

  2. Protecting the Kidneys
    Catheretization and Cardiovascular Interventions, 2019. DOI:10.1002/ccd.28355
    Satler LF.
  1. Techniques to Optimize the Use of Optical Coherence Tomography: Insights from the Manufacturer and User Facility Device Experience (MAUDE) Database
    Cardiovascular Revascularization Medicine, 2019.
    DOI: 10.1016/j.carrev.2019.03.009
    Shlofmitz E, Garcia-Garcia HM, Rogers T, Khalid N, Chen Y, Kajita AH, Khan JM, Iantorno M, Gallino RA, Bernardo NL, Hashim H, Torguson R, Waksman R.
  1. Perceptions and Utilization of the U.S. Core Cardiovascular Training Statement
    JACC, 2019. DOI: 10.1016/j.jacc.2019.03.488
    Weissman G, Auseon AJ, Arrighi JA, Mendes LA, Theriot P, Tam MC, Damp JB.

Proteomic Alterations of HDL in Youth with Type 1 Diabetes: Outstanding Research at the Symposium

At the 2019 MedStar Health-Georgetown University Research Symposium, three abstracts were recognized as outstanding abstracts from among all of our submissions. These research studies were the three highest scored out of the over 450 submissions to the Research Symposium by the Scientific Review committee and exemplifies the caliber of work presented by the MedStar-Georgetown research community.

“Proteomic Alterations of HDL in Youth with Type 1 Diabetes and their Associations with Glycemic Control: A Case-Control Study” presented a cross-sectional case-control study, comparing the high-density lipoprotein (HDL) cholesterol proteomes of youth with type 1 diabetes and healthy controls. It sought to evaluate the influence of glycemic control on HDL protein composition.

Led by Jenny (Evgenia) Gourgari, MD, the research team included Junfeng Ma, PhD; Martin Playford, PhD; Nehal Mehta, MD; Radoslav Goldman, PhD; Alan Remaley, MD, PhD; and Scott Gordon. This research was presented in the basic/translational science category.

Patients with type 1 diabetes typically have normal or even elevated plasma HDL cholesterol concentrations. However, HDL protein composition can be altered without a change in cholesterol content. Alteration of the HDL proteome can result in dysfunctional HDL particles which reduced the ability of the body to protect against cardiovascular disease.

Blood samples were obtained from 26 patients with type 1 diabetes and 13 healthy controls. HDL was isolated from plasma by size-exclusion chromatography and further purified using a lipid binding resin. The HDL proteome was analyzed by mass spectrometry using label-free SWATH peptide quantification.

The samples were analyzed and 78 HDL-bound proteins were measured. The results showed that youth with type 1 diabetes had significantly increased amounts of complement factor H related protein compared to the healthy controls. When patients were analyzed based on glucose control, several trends emerged. Some proteins were altered in type 1 diabetes and not influenced by glycemic control, while others were partially or completely corrected with optimal glucose control. Some proteins including complement component C3  and albumin were significantly different only in type 1 diabetes patients with optimal glucose control, suggesting a possible effect of exogenous insulin.

The research concluded that youth with type 1 diabetes have proteomic alterations of their HDL compared to healthy controls, despite a similar concentration of HDL cholesterol. The influence of these compositional changes on HDL function are not yet known.

The authors suggested that future efforts should focus on investigating further the role of these HDL associated proteins in regards to HDL function and their role in cardiovascular disease risk in patients with type 1 diabetes. 

Congratulations to the research team for their outstanding research! You can read about the other winners here and here.

Multi-Modal Sepsis Performance Improvement Initiative: Outstanding Research at the Symposium

At the 2019 MedStar Health-Georgetown University Research Symposium, three abstracts were recognized as outstanding abstracts from among all of our submissions. These research studies were the three highest scored out of the over 450 submissions to the Research Symposium by the Scientific Review committee and exemplifies the caliber of work presented by the MedStar-Georgetown research community.

"Multi-Modal Sepsis Performance Improvement Initiative Improves Early and Appropriate Treatment, Reduces Sepsis-Related Readmissions, and Reduces Overall Mortality" analyzed patient outcomes before and after implementation of the Centers for Medicare and Medicaid Services (CMS) SEP-1 Core Measure. The SEP-1 Core Measure mandates that hospitals implement quality improvement initiatives to improve sepsis outcomes. The team looked at data before and after the implementation of the multi-modal sepsis performance initiative launched in 2016 at MedStar Washington Hospital Center (MWHC).

Led by Seife Yohannes, MD, the research team included Sean Huang, PhD, Andrea Ryan, and Muhtadi Alnababteh.

The multi-modal sepsis performance initiative at MWHC had multiple components as part of the process, including:

  • a hospital-wide educational campaign about sepsis
  • 24-7 electronic warning system (EWS) of patients at risk for sepsis
  • a rapid response nursing team that monitors the EWS and implements bundled treatments
  • 24-7 mid-level provider team that evaluates patients identified by the EWS
  • quality improvement initiatives in sepsis documentation and coding.

The study used coding data for over 4,00 patients with a diagnosis of sepsis as reported to CMS. The study compared patient outcomes six months before the launch of the initiative and 13 months after full implementation.

The study found that based on an average of 2000 sepsis cases at our hospital, this amounted to 90 lives saved per year. Post-intervention, hospital length of stay was reduced by 1.8 days and re-admission rate was reduced by 1.6%.

Regression analysis showed age, admission through the emergency department, and severity of illness as independent risk factors for increased mortality. Adjusted for these risk factors, the incidence of severe sepsis and septicemia was reduced by 5.3% and 6.9% in the post-intervention period, while the incidence of simple sepsis increased by 12%.

The study concluded that the “multi-modal sepsis performance improvement initiative improved quality of care and patient outcomes.”

Congratulations to the research team for their outstanding research! You can read about the other winners here and here.