Collaborative Research from MedStar Investigators Evaluate On-Demand Telehealth COVID Screening

A collaborative team of researchers from across MedStar Health recently published research evaluating the performance of on-demand telehealth as an approach to respond to COVID-19. The team included investigators from MedStar Health National Center for Human Factors in Healthcare, MedStar Telehealth Innovation Center and the MedStar Institute for Innovation.

“A Descriptive Analysis of an On-Demand Telehealth Approach for Remote COVID-19 Patient Screening” was published in Journal of Telemedicine and Telecare. The analysis presented by the investigators covers telehealth patient characteristics, measures of patient wait time and visit duration, technical success of the telehealth request and the post-visit trajectory of these patients.

The study evaluated 9,270 on-demand telehealth requests from 7,112 unique patients from March to April 2020.  Each telehealth request was categorized as either a completed encounter in which the patient successfully saw the provider and was given clinical guidance, or an incomplete request in which the patient did not complete an encounter with the provider. For completed encounters, additional analyses were performed, and the patient was provided a survey and asked what they would have done if on-demand telehealth was unavailable.

The results show that out of the over 7,000 unique patients with on-demand telehealth requests, the average patient age was around 38 years old, 4,511 were female and 2,601 were male. Most requests (61.6%) had a visit reason categorized as likely COVID-19 related. The majority (79%) of likely COVID-19 related requests were completed encounters and of these, 19% were referred for in-person care or testing. The average completed encounter wait time was 26 minutes. In addition, there were 1194 requests that were categorized as left without being seen. The average wait time for patients that left without being seen was 19 minutes.

The post-encounter survey, for patients who had a completed visit, indicated that 26% of patients would have gone to an urgent care or retail clinic if on-demand telehealth was unavailable. There were 482 patients (10.7%) who said they would go to their doctor’s office and 267 (5.9%) would go to the ER. The survey showed 9.1% of patients would not have done anything.  There was no response from 48% of completed encounters.

The research concluded that on-demand telehealth service can serve an important public health need in response to the COVID-19 pandemic. According to the survey, 1935 (42.8% of the 4518 COVID-19 related requests) patients would have sought in-person care had they not had access to on-demand telehealth.  There were several patients who stated they would have done nothing about their concerns. On-demand telehealth helps to decrease personal exposure and demonstrates a low-barrier approach to screening patients for COVID-19.

The research team included MedStar Health’s Raj Ratwani, PhD; David Brennan; Bill Sheahan; Allan Fong; Katharine Adams; Allyson Gordon; Mary Calabrese; Elizabeth Hwang; Mark Smith, MD; and Ethan Booker, MD.

Journal of Telemedicine and Telecare, 2020. DOI: 10.1177/1357633X20943339

MedStar Researchers Evaluate Outcomes in Patients Undergoing ACL Repair

Researchers at MedStar Health sought to assess failure rate, outcomes, and patient satisfaction in patients who underwent anterior cruciate ligament (ACL) repair with suture augmentation for clinical instability and proximal avulsion of the ACL. ACL avulsion fractures have a high incidence in most injuries around the knee joint. Improved surgical technology, rehabilitation principles, and minimally invasive surgical techniques have led to renewed interest in primary ACL repair.

“Anterior Cruciate Ligament Repair with Suture Augmentation for Proximal Avulsion Injurieswas recently published in Arthroscopy, Sports Medicine, and Rehabilitation. The research team retrospectively reviewed suture-augmented ACL repairs performed by a single surgeon between January 2014 and June 2016 for proximal ACL avulsion. Patients were followed in the office until they were released to return to unrestricted activity. All patients were contacted by phone to collect data such as recurrent clinical instability, number of reoperations, reason for reoperation, and return to sport or previous activity level. An automated database was used to collect functional and clinical outcomes scores. 

The team hypothesized they would find significantly improved functional outcome and a high percentage of patients who exceeded the minimum clinically important difference (MCID) and patient acceptable symptom state (PASS) threshold for ACL surgery. The PASS threshold for Knee Injury and Osteoarthritis Outcome Score (KOOS) components in patients who underwent ACL reconstruction has been reported as pain, 88.9%; symptoms, 57.1%; activities of daily living (ADL), 100%; sport/recreation, 75%; and quality of life (QoL), 62.5%.

Of 172 patients who underwent ACL surgery during the study period, 28 (16%) underwent ACL repair with suture augmentation. One patient was unavailable for follow-up.   Of these 27 patients, 17 were diagnosed with Sherman type I tear and 10 were diagnosed with Sherman type II tear. All 27 patients available for follow-up had post-operative scores, and 14 patients had preoperative scores. Of the 27 patients, 4 recurrent ACL injuries required revision to reconstruction. The remaining 23 patients had successful ACL repair with no clinical instability and no subjective complaints at final follow-up. The results include 11 patients with baseline data, demonstrating significant improvements in KOOS score and final follow-up score in relation to the MCID for that instrument: pain (73%), symptoms (100%), ADL (64%), sport and recreation (80%), and quality of life (45%).

The research concludes that patients with proximal ACL avulsion, ACL repair with suture augmentation demonstrated high functional outcome and improved patient-reported outcomes at 2-year follow-up. This procedure shows promise for treating patients with clinical instability from proximal ACL avulsion.

The study team included Wiemi A. Douoguih, M.D.; Ralph T. Zade, M.D.; Blake M. Bodendorfer, M.D.; Yalda Siddiqui, B.S.; and Andrew E. Lincoln, D.P.H.

August Peer-Reviewed Publications from MedStar Health

Congratulations to all MedStar researchers who had articles published in August 2020. 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.

  1. Epidemiology, Treatment, and Performance-Based Outcomes in American Professional Baseball Players With Symptomatic Spondylolysis and Isthmic Spondylolisthesis
    The American Journal of Sports Medicine, 2020. DOI: 10.1177/0363546520945727
    Gould HP, Winkelman RD, Tanenbaum JE, Hu E, Haines CM, Hsu WK, Kalfas IH, Savage JW, Schickendantz MS, Mroz TE.

  2. Ethnicity and insurance status predict metastatic disease presentation in prostate, breast, and non-small cell lung cancer
    Cancer Medicine, 2020. DOI: 10.1002/cam4.3109
    Aghdam N, McGunigal M, Wang H, Repka MC, Mete M, Fernandez S, Dash C, Al-Refaie WB, Unger KR.

  3. The IMPact on Revascularization Outcomes of intraVascular ultrasound-guided treatment of complex lesions and Economic impact (IMPROVE) trial: Study design and rationale
    American Heart Journal, 2020. DOI: 10.1016/j.ahj.2020.08.002
    Shlofmitz E, Torguson R, Mintz GS, Zhang C, Sharp A, Hodgson JM, Shah B, Kumar G, Singh J, Inderbitzen B, Weintraub WS, Garcia-Garcia HM, Di Mario C, Waksman R.

  4. Lessons Learned from Caring for Patients with COVID-19 at the End of Life
    Journal of  Palliative Medicine, 2020. DOI: 10.1089/jpm.2020.0251
    Rao A, Kelemen A.

MedStar Researchers Use Visualization Dashboards to Enhance Situation Awareness of COVID-19 Telehealth Initiatives

A collaborative team of researchers from across MedStar Health published a case report which examined the need for improved situation awareness of all telehealth operations to effectively monitor and proactively manage patient experience, healthcare provider experience, and platform performance.  The team included investigators from MedStar Health National Center for Human Factors in Healthcare, MedStar Health Research Institute, MedStar Simulation Training and Education Lab, MedStar Telehealth Innovation Center, and Georgetown University School of Medicine.

“Rapid Development of Visualization Dashboards to Enhance Situation Awareness of COVID-19 Telehealth Initiatives at a Multi-Hospital Healthcare System” was published in Journal of the American Medical Informatics Association.  The COVID-19 pandemic has required the need for prompt acceleration of telehealth programs to lessen community spread while providing safe patient care.  The researchers used a situation awareness model and five-step process to identify operational end-user needs, along with design and develop visualizations to meet those needs.  Three stakeholder groups (healthcare system executives, telehealth leaders, and telehealth managers) were identified and provided with visualization dashboards to seek their relative needs.

The multidisciplinary visualization team used a five-step process to support the launch and ongoing development of the telehealth program. The five steps were:

  • Subject Matter Expert Interviews to Increase Domain Knowledge
  • User Needs Analysis and Feature Identification
  • Processing Telehealth Data Sources
  • Visualization Design, Development, and Testing
  • Dissemination and Iterative Refinement

The results show that executive stakeholders needed weekly awareness of high-level metrics and trends to convey telehealth activity across the MedStar Health system. Telehealth leaders requested daily awareness of key operational indicators to monitor telehealth operations.  Telehealth managers and team members needed detailed information about their respective areas with the ability to diagnose where issues such as increased patient volumes, poor patient experiences, or dropped calls were occurring.

User feedback suggests the visualizations improved situational awareness and may have provided valuable information to better inform operational decisions. In the future, the researchers plan to improve data accessibility and gather more feedback from end-users for dashboard optimization.

The study team included Raj M. Ratwani, PhD; Ethan Booker, M.D; Ram A. Dixit, M.S; Stephen Hurst, Katharine T. Adams, Christian Boxley, Kristi Lysen-Hendershot, and Sonita S. Bennett, M.S.

Journal of the American Medical Informatics Association, DOI: 10.1093/jamia/ocaa161/5866982

July Peer-Reviewed Publications from MedStar Health

Congratulations to all MedStar researchers who had articles published in July 2020. 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. Functional mitral regurgitation
    Current Opinion in Cardiology, 2020. DOI: 10.1097/HCO.0000000000000770
    Asch FM, Medvedofsky D.

  2. Infections in Burn Patients: Innovations in Infection Prevention and Treatment
    Surgical Infections, 2020. DOI: 1089/sur.2020.202
    Tejiram S, Shupp JW.

  3. Lymphoma survivors have an increased long-term risk of chronic kidney disease
    Leukemia & Lymphoma, 2020. DOI: 10.1080/10428194.2020.1786555
    Desai SH, Al-Shbool G, Desale S, Veis J, Malkovska V.

  4. Head Repositioning during Neurointerventional Procedures to Optimize Biplanar Imaging
    Journal of Neuroimaging, 2020. DOI: 1111/jon.12750
    Dowlati E, Zhou T, Stewart J, Felbaum DR, Liu AH, Mai JC, Armonda RA.

  5. Food Insecurity and Insulin Use in Hyperglycemic Patients Presenting to the Emergency Department
    Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 2020. DOI: 10.5811/westjem.2020.4.45918
    Nhoung HK, Goyal M, Cacciapuoti M, Day H, Hashemzadeh T, Magee M, Jarris YS.

MedStar Investigators Report on Myocardial Injury from COVID-19

MedStar Health researchers published a report highlighting two cases of COVID-19 infection with myocardial involvement with distinct mechanistic pathways and outcomes. The cases discussed the important decision strategies for these critically ill patients, such as the timing of cardiac catheterization (when indicated) and requirement of early hemodynamic support. “COVID-19 (SARS-Cov-2) and the heart – An ominous association” was published in Cardiovascular Revascularization Medicine.

Cardiovascular manifestations of COVID-19 can be diverse and complex, including myocardial injury, infarction, myocarditis simulating ST-segment elevation myocardial infarction, non-ischemic cardiomyopathy, coronary vasospasm, pericarditis, or stress(takotsubo) cardiomyopathy.  The publication discussed that based on the initial experience from Wuhan, China, that approximately 27.8% (52/187) of patients with COVID-19 exhibited myocardial injury. Myocardial injury was associated with worse out-comes of COVID-19, whereas the prognosis of patients with underlying cardiovascular disease but without myocardial injury was comparatively favorable.

The cases described in this report are patients with COVID-19 infection and myocardial involvement. The authors indicated that during the COVID-19 pandemic, management of patients with acute coronary syndrome and COVID-19 remains critically important.  Underlying cardiovascular disease and associated risk factors such as hypertension, coronary heart disease, and cardiomyopathy put patients at higher risk of developing myocardial injury during the course of their COVID-19 infection.

The team included Nauman Khalid, MD; Yuefeng Chen MD, PhD; Brian C. Case, MD; Evan Shlofmitz, DO; Jason P. Wermers, Toby Rogers, MD, PhD; Itsik Ben-Dor, MD; and Ron Waksman, MD.

Cardiovascular Revascularization Medicine, 2020, DOI: 10.1016/j.carrev.2020.05.009

Collaborative Research from MedStar Investigators Evaluates Racial Variations in Takotsubo Cardiomyopathy Outcomes

A collaborative team of researchers from across MedStar Health and partners published their work to assess the effect of race on in-hospital outcomes of takotsubo cardiomyopathy (TC) in a large nationwide sample. The team included investigators from MedStar Washington Hospital Center, MedStar Health Research Institute, MedStar Heart and Vascular Institute, Georgetown University, and National Heart, Lung and Blood Institute.

“Racial Differences in Takotsubo Cardiomyopathy Outcomes in a Large Nationwide Sample” was published in ESC Heart Failure. Takotsubo Cardiomyopathy or stress-induced cardiomyopathy is characterized by transient ventricular impairment, often preceded by emotional or physical stressors. Gender, racial, and ethnic differences have been reported with respect to incidence and prognosis of cardiovascular diseases including heart failure and acute myocardial infarction, in part due to variability in genetic, biological and socio-economic factors. Studies have reported increased in-hospital complications in African American patients presenting with TC; however, the effect of race on TC remains unknown

The research included data obtained from the National Inpatient Sample (NIS) database. Of 97, 650 patients included: 83,807 were women; 89, 624 identified as Caucasian; 8,026 identified as African American. Between the two races, demographic characteristics and insurance variables were significantly different.  African American patients were younger, having a higher percentage of men and lower median household income. The rate of TC hospitalizations increased in both races. Mortality rates initially increased from 50 cases (1–2%) to 340 cases (5–6%) and subsequently remained stable around 5–7% with fluctuations but with no overall significant difference between races.  Multivariate regression models were created to adjust for potential confounders.

In unadjusted analysis, African American patients had more cardiac arrests, invasive mechanical ventilation, tracheostomies, acute kidney injuries, and longer hospital stays compared with Caucasians.  After the adjustment for differences in age, gender, comorbidities, hospital location/teaching status, and socio-economic factors, all differences were significantly reduced or eliminated. The adjusted risk was lower in African Americans compared with Caucasians, for cardiogenic shock, mechanical ventilation and intra-aortic balloon pump insertion.

The research concluded that African American patients overall have worse outcomes including longer hospitalizations, higher rates of cardiac arrests, invasive mechanical ventilation, tracheostomies, and acute kidney injury compared with Caucasians. Overall, African American patients have more in-hospital complications; however, the differences are driven by racial disparities in demographics, comorbidities, and socio-economic factors.

The team included Raja Zaghlol,MD; Ana Barac, MD; Amit K. Dey; and Sameer Desale.

ESC Heart Failure, 2020.  DOI: 10.1002/ehf2.12664

June Peer-Reviewed Publications from MedStar Health

Congratulations to all MedStar researchers who had articles published in June 2020. 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. Sex-Associated Differences in Cardiac Reverse Remodeling in Patients Supported by Contemporary Left Ventricular Assist Devices
      Journal of Cardiac Failure, 2020. DOI: 10.1016/j.cardfail.2020.03.005
      Mehta N, Mazer-Amirshahi M, Schulman C, O'Connell F, Pourmand A.
    2. Differentiated Thyroid Cancer and Hashimoto Thyroiditis: Utility of the Afirma Gene Expression Classifier
      Journal of  Surgical Oncology, 2020.
      DOI: 10.1002/jso.25875
      Papoian V, Rosen JE, Lee W, Wartofsky L, Felger EA.

    3. Varying Rates of Patient Identity Verification When Using Computerized Provider Order Entry
      Journal of the American Medical Informatics Association, 2020. DOI: 10.1093/jamia/ocaa047
      Fortman E, Hettinger AZ, Howe JL, Fong A, Pruitt Z, Miller K, Ratwani RM.

    4. Racial Disparity in Postpartum Readmission Due to Hypertension Among Women With Pregnancy-Associated Hypertension
      American Journal of Perinatology, 2020. DOI: 10.1055/s-0040-1712530
      Chornock R, Iqbal SN, Kawakita T.

MedStar Investigates Point of Care Lung Ultrasound for COVID-19 Patients

Recently published research evaluated lung ultrasound findings in patients admitted to the internal medicine ward with COVID-19. “Point-of-Care Lung Ultrasound Findings in Patients with Novel Coronavirus Disease (COVID-19) Pneumonia” was published in The American Journal of Tropical Medicine and Hygiene. The study sought to diagnose and monitor patients who received point-of-care ultrasound and assess the findings.

The research was led by Kosuke Yasukawa from the Department of Medicine at MedStar Washington Hospital Center, in collaboration with Taro Minami from Care New England Medical Group and The Warren Alpert Medical School of Brown University.

Patients with COVID-19 typically present with bilateral multilobar ground-glass characteristics. Chest CT has been used in the diagnosis and management of patients with COVID-19. However, CT is not always readily available and the disinfection of CT machine after the use of a patient with COVID-19 may result in a delay of care for other patients requiring CT examination. While the utility of point-of-care ultrasound has been suggested, detailed descriptions of lung ultrasound findings are not available.

The research team retrospectively evaluated lung ultrasound images of 10 patients who received point-of-care ultrasound and were diagnosed with COVID-19. The images were stored and reviewed to determine demographics, comorbidities, laboratory, and radiographic findings. The findings showed that characteristic glass rockets with or without the Birolleau variant (white lung) were present in all 10 patients. One patient required transfer to intermediate care unit, and another patient required transfer to intensive care unit. Four of the patients required administration of oxygen via a non-rebreather mask. Abnormal lung ultrasound findings were detected in all of the patients. Two patients had septal rockets and small subpleural consolidations were detected in five patients. Although glass rockets and the Birolleau variant can be seen in patients with cardiogenic pulmonary edema, none of the patients were diagnosed with decompensated congestive heart failure.

The results found confluent B lines and thick, irregular pleural lines present in all patients evaluated. The glass rockets, confluent B lines, thick irregular pleural lines, and subpleural consolidations are likely not specific to COVID-19. However, these findings can be an aid for diagnosis during the COVID-19 pandemic when pretest probability is high.

The American Journal of Tropical Medicine and Hygiene, 2020. DOI: 10.4269/ajtmh.20-0280

Collaborative Research from MedStar Investigators Evaluates Surgical Outcomes of Minimally Invasive Surgery for Colorectal Cancer

Recently published collaborative research examined temporal trends and surgical outcomes of minimally invasive surgery approaches for colorectal cancer by hospital type. “Minimally Invasive Surgery for Colorectal Cancer: Hospital Type Drives Utilization and Outcomes” was published in the Journal of Surgical Research. The study sought to assess these relationships to improve access to high-quality surgical care for CRC patients.

The study collected data from the National Cancer Database which organizes oncology data from more than 1500 accredited cancer facilities across the United States and Puerto Rico. The main outcome variable was the performance of minimally invasive surgery for the associated cancer type. Secondary outcome variables included surgical margin, conversion to open, length of stay, 30-day unanticipated readmission rate, 30-day mortality, 90-day mortality, and overall survival. The main independent variable was hospital type and facility-level variables included location by US region, center type, and average center volume.

The results of the study found that of 234, 935 cases, 48.5% of colorectal cancer surgeries were performed in comprehensive community hospitals, 28% in academic, 12.5% in community, and 11.1% in integrated networks. Many procedures performed in community hospitals were open, while all other hospital types primarily performed minimally invasive surgery. The percentage of robotic surgeries was highest in academic hospitals (7.9%) and lowest in community centers (3.3%).

The study findings showed rates of MIS utilization overall (40.1%), as well as for laparoscopic (36.8%) and robotic (3.3%) procedures specifically, were lowest in community hospitals compared with comprehensive community (46.2% laparoscopic; 5.7% robotic), integrated network (47.7% laparoscopic; 6.8% robotic), and academic (46.3% laparoscopic; 7.9% robotic) centers.

MIS utilization rates varied substantially by hospital type for both the laparoscopic and robotic approaches however were generally lower at community centers for both cancer types. Also, compared with laparoscopic colon surgery at academic centers, community centers treated lower grade tumors with higher 30-day and 90-day mortality. In conclusion, “Future research and healthcare policy must address these trends at the community level to facilitate safe, effective access to these techniques across the US.”

This research was supported by a grant from the Georgetown Howard Universities Center for Clinical and Translational Science and The Lee Folger Foundation.

The research team included researchers from the MedStar-Georgetown Surgical Outcomes Research Center, MedStar Health Research Institute, and MedStar-Georgetown University Hospital: Anthony M. Villano MD, Alexander Zeymo MS, Brenna K. Houlihan MD, Mohammed Bayasi MD, Waddah B. Al-Refaie MD, FACS and Kitty S. Chan PhD.

Journal of Surgical Research, 2020. DOI: 10.1093/jbcr/irz168