MedStar Investigators Examine Computed Tomography Pulmonary Angiography in the Emergency Department

Recently published collaborative research examined utilization patterns and predictors of computed tomography pulmonary angiography (CTPA) results in the emergency department. “High Scan Volume with Low Positive Scan Rate in Highest Utilizers: Computed Tomography Pulmonary Angiography in the Emergency Department” was published in The Journal of Emergency Medicine. This publication was the result of the Summer Research Student program with MedStar Health investigators mentoring rising second-year medical students from the Georgetown University School of Medicine. The team included investigators from MedStar Good Samaritan Hospital, MedStar Union Memorial Hospital, MedStar Washington Hospital Center and Georgetown University.

The overutilization of CTPA is a serious concern in the emergency department because the potential of increased risk for radiation exposure, cost, and over diagnosis bias may occur. This study reviewed all CTPA studies performed in one year across a multisite medical system and focused on data for emergency department attendings and positive CTPA scan rates (PSR). The team manually reviewed all applicable scans and classified them as positive, negative, or indeterminate.

The results show there were 10,032 total scans from the emergency department and 6,168 of those were ordered by 153 emergency department attendings. Most attendings (123/153; 80%) ordered 60 or fewer scans, with relatively high PSR (259/2927, PSR 8.8%; 95% confidence interval 7.8–9.9%). Of the emergency department attendings, 13 (3%) ordered more than 100 scans each (1981 scans; 32% of all scans), with PSR of 5.5% (95% confidence interval 4.5–6.5%).

Overall, the study found that most emergency department attendings were low-to mid-volume utilizers of CTPA and had a relatively high PSR. However, the small percentage of attendings who ordered more than 100 scans each accounted for a large percentage of the total number of scans and had a relatively low PSR. These findings suggest that mentoring and/or sharing of performance feedback and best practices in the highest utilizers could help to improve CTPA PSR in the emergency department. 

Dr. David Weisman, a mentor for the Scholars program and senior author for the publication shared his thoughts on the students and the program.  “I’ve have been extremely fortunate to have had the opportunity to work with so many wonderful Georgetown medical students for the past 4 years. Each student brings to the table their individual uniqueness and talents. I’ve been thankful and impressed by the dedication of MedStar Health and Georgetown University leadership to support this program which is so vital to introduce students to research early in their career. I look forward too many more years of collaboration and mentorship.”

The research team included Himanshu Rawal, MD; Oluwatoyosi Ipaye, MS; Amit D. Kalaria, MD; Radhika Vij, MD, FACP; Jeffrey S. Dubin, MD, MBA; Lyn Camire, MA, ELS; and David S. Weisman, DO, FACP.

The Journal of Emergency Medicine, 2020. DOI: 10.1016/j.jemermed.2020.04.008

September Peer-Reviewed Publications from MedStar Health

Congratulations to all MedStar researchers who had articles published in September 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 PubMed.gov here.

Selected research:

  1. Diabetes Education for Behavioral Health Inpatients: Challenges and Opportunities
    Journal of the American Psychiatric Nurses Association, 2020. DOI: 10.1177/1078390319878781
    Bardsley JK, Baker KM, Smith KM, Magee MF.
  2. Measurement of Outlet Pressures Favors Rib Resection for Decompression of Thoracic Outlet Syndrome
    Annals of Thoracic Surgery, 2020. DOI: 10.1016/j.athoracsur.2019.12.059
    Assi PE, Hui-Chou HG, Giladi AM, Segalman KA.

  3. Biomechanical Analysis of Zone 2 Flexor Tendon Repair With a Coupler Device Versus Locking Cruciate Core Suture
    Journal of Hand Surgery, 2020. DOI: 10.1016/j.jhsa.2020.02.015
    Irwin CS, Parks BG, Means KR Jr.
  4. Bulla Formation and Tension Pneumothorax in a Patient with COVID-19
    The American Society of Tropical Medicine and Hygiene, 2020. DOI: 10.4269/ajtmh.20-0736
    Yasukawa K, Vamadevan A, Rollins R.

Honoring SPIRIT at MHRI

Grant Gonzalez was awarded the SPIRIT of Excellence Award during the MHRI Virtual Town Hall.  Grant is the Director of Finance Operations for the Office of Financial Management. Nominated by Ron Migues, Executive Director, MedStar Health Research Institute, the award was presented by Tina Stanger, Assistant Vice President of Research Administration.

Grant was recognized for his willingness to work with anyone and his infectious smile.  Grant is a problem solver and is dedicated to gather all the necessary components to make something more efficient.

“Wanted to give you a huge thank you for taking the time to work with me and my team to ensure our finances are up to date and as accurate as possible,” said Ron Migues. “Given we encompass so many areas and have the most diverse areas of research, it usually takes a small village to accomplish anything, but you have stepped forward and are leading us to become financially sound.  We really see all you do and are extremely appreciative for the support!”

The SPIRIT Award is given to recognize and reward one associate (management or non-management) each quarter, who excels in Service, Patient First, Integrity, Respect, Innovation, and Teamwork. 

Nominations are based on submission to the MHRI Kudos program. Each quarter, the MHRI Executive Team will review the KUDOS submissions and select an associate or manager who best exemplifies all our SPIRIT values.

Sorting out Single IRB Review: What Investigators Need to Know at MHRI

In recent years, there has been an increasing trend toward the use of a single IRB (sIRB) review for multi-site HSR projects funded through other sources.  Specifically, many commercial sponsors prefer single IRB review for their multi-site projects.

The revised common rule includes a requirement for single IRB review of most federally funded multi-site non-exempt human subjects research projects. Initially, the Office of Human Research Protections (OHRP) indicated that compliance with this common rule requirement was required starting on January 20, 2020. Later, OHRP clarified that although sIRB review is required for all federally funded multi-site non-exempt HSR projects, the agency has granted an exemption for all projects approved prior to January 20, 2020. This eliminates the need to transition currently approve projects from review by multiple IRBs to sIRB review.

For all future federally funded projects, it is strongly suggested that investigators include IRB review fees in the budget for their grant proposals. In most cases it is assumed that sIRB review will be conducted by a commercial IRB (such as WIRB or Advarra) or a larger academic/medical institution IRB. In some limited cases, the MHRI IRB may agree to serve as the IRB of record for a multi-site HSR project but this will not be the norm.

In all cases (regardless of funding) for which a MedStar investigator intends to request the MHRI IRB serve as the IRB of record, they must submit a request to the ORI office. The request must be submitted before the investigator commits the MHRI IRB to the responsibility of serving as IRB of record for other sites and before discussing reliance with any outside institution. The request should include a copy of the research protocol, an indication of the source of funding (if any), a list of all sites that may be engaged in the project, and the scope of involvement for each site. The ORI Director will evaluate the request and in consultation with the Institutional Official determine if the request will be approved or should be declined.

This process is similar to that for investigators requesting reliance on an external IRB. When an investigator would like to rely on an external IRB for review of their non-exempt HSR project, a request to cede review must be submitted to ORI in advance. In the case of the commercial IRBs for which there is a master reliance agreement (currently WIRB and Advarra), the investigator may simply submit an external IRB application through the Huron system. For other IRBs, a reliance agreement must be executed for each individual project. In the event that MedStar has not previously had an agreement with the intended external IRB, a request should be submitted to the ORI by email. The ORI Director will evaluate the request and in consultation with the Institutional Official determine if the request may be approved or should be declined. If approved the organization will be added to the Huron system and the investigator may submit the external IRB application for the project.

Please note that in most cases request for reliance involving exempt HSR projects will not be approved. Generally speaking, it is more efficient for these projects to be reviewed individually by each institution and most institutions have not been willing to enter into a reliance agreement for these projects.

In all cases, requests for reliance (either for the MHRI IRB to serve as the IRB of record or for MedStar to rely on an external IRB) will be considered with regard to the need for reliance, the feasibility of the arraignment and nature of the project. Ultimately the determination of reliance is left to the discretion of the ORI Director and the Institutional Official.

If you have any questions regarding this process, please contact MHRI’s ORI Director, Jim Boscoe, at [email protected].

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 PubMed.gov 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 Health 2020-2021 Mandatory Influenza Vaccinations

The 2020-2021 influenza season will coincide with the COVID-19 pandemic. This inevitable combination will present unique challenges affecting MedStar Health associates and physicians, as well as the communities we serve. This year, more than ever, compliance with our mandatory influenza (flu) vaccination program is essential to achieving our patient and associate safety priorities.

As a reminder, all MedStar Health associates, physicians, residents, students, volunteers, contracted staff, and vendors are required to receive the influenza (flu) vaccination. The vaccination period is Thursday, Oct. 1, 2020 through Wednesday, Dec. 9, 2020. While flu vaccine clinics will be scheduled at a variety of locations across the system, eligible associates and physicians may also receive their vaccination at Occupational Health offices, unit rounds in high-volume patient care areas, and from peer immunizers. New infection prevention protocols, including appropriate Personal Protective Equipment (PPE), frequent disinfection of clipboards, pens and other tools, and physical distancing, will be in place in all flu vaccine clinic locations.

We will continue to provide the vaccine at MedStar Health entities free of cost for associates, physicians, residents, and volunteers. Locations, dates and times for entity clinics will be posted on StarPort (starport.medstar.net/go/EveryoneCounts) by Sept. 14, 2020. If individuals choose to be vaccinated at non-MedStar facilities or a MedStar Health Urgent Care location, they must complete and submit official documentation to Occupational Health (letterhead, prescription form, printed receipt, etc.) from the provider administering the vaccine. Documentation must include:

  • Associate's name
  • Date of vaccination
  • Name, dose and lot number of vaccine
  • Name, address and phone number of provider

We recognize that a small percentage of individuals may not be able to receive the flu vaccination due to medical contra-indications and/or religious exemptions. The Influenza Vaccine Exemption Form will need to be obtained from, completed and returned to Occupational Health by Oct. 31, 2020.

While the Centers for Medicare & Medicaid Services (CMS) announced it will not require the typical vaccine compliance data reporting this year, MedStar Health will continue to require all associates, physicians, residents/fellows, volunteers, students, contracted staff, and vendors to receive a flu vaccine before the end of the vaccination period or document exemption by the deadline.

Please share this information with your appropriate stakeholders as a priority topic at town hall meetings, staff meetings, rounds, and other communication touch points.

By collectively vaccinating ourselves against influenza, we enhance patient and associate safety across our organization and communities. Remember, an individual with no flu symptoms may still be a carrier and unknowingly spread it to patients, coworkers, visitors, and family members.

Thank you for your commitment to patient and associate safety through flu vaccination.

Ongoing Cybersecurity Risks – Phishing

Throughout the COVID-19 pandemic, criminals have used the crisis as a basis for increased attacks on computer systems, including phishing campaigns. These attacks are organized and often specifically target healthcare systems or individuals to collect sensitive business or personal information.  

Phishing is a constant threat, but there is also a seasonality to cyberattacks, with more coming during traditional vacation times, when criminals assume defenses are lowered and staffing may vary due to time off. As organizations, including MedStar Health, navigate a new normal, experts anticipate new email phishing attacks attempting to exploit changes, such as adjustments to revised workflows and remote working arrangements.

Associate vigilance is among our best defense strategies for savvy attackers who prompt associates to provide personal information or passwords, click on or open malicious links or attachments, or transfer money. Attacks can come through phishing emails, texts or voice calls to a workstation, smartphone or other device.

Malicious senders may spoof a known source for COVID-19 information, such as the Centers for Disease Control and Prevention (CDC), MedStar Human Resources, or a local school district or government office. Phishing attempts may also come from from vendors purporting to have or sell Personal Protective Equipment (PPE). 

To avoid these risks, always follow these important recommendations: 

  • Take your time when reviewing email or text messages. Use caution before you click!
  • Be alert for phishing messages in your email inbox. Since phishing emails arrive from outside of the network, determine whether the email is legitimate. All external emails include a tag of [EXTERNAL] in the email subject line and a banner:

** ATTENTION: This email originated from outside the MedStar network.
** DO NOT CLICK links or attachments unless you recognize the sender and know the content is safe.

  • If you don’t know the sender and it looks suspicious, delete the email. Do not click on any attachments or links within the body of the email.
  • Look for spoofed addresses. For example, if an email appears to come from an associate and the sender’s address is not @medstar.net, it is not a legitmate email.
  • If you receive a text message from a number you do not know, delete the text message. Do not click on any links within the text message.
  • Report suspicious emails to [email protected]. Call the IS Service Desk at 877-777-8787 with any questions.

Thank you for your efforts to protect our network, data, systems, and organization.

Research Billing Compliance at MedStar Health

Research compliance encompasses a wide variety of issues including research billing. Billing compliance ensures all services in a trial are paid for by helping to reduce double billing and preventing billing for services that are not covered by the trial or are not medically necessary for the research subject. Accurate billing in research is a complex and challenging process that requires a diverse group of professionals across MedStar Health to work cohesively and collaboratively with one another. We at the Research Institute seek to ensure that we have an efficient and compliant approach to billing compliance.

The research coordinators have the most critical step in the clinical research revenue cycle process. Research subject visit tracking directly drives financial management and compliance. This is the first line of defense against erroneous billing. Subject visits must be logged in OnCore within one business day to ensure timely review by the MHRI revenue cycle team for MedStar Health to maintain compliance with the Centers for Medicare and Medicaid Services (CMS) Clinical Trial Policy.

MHRI strives for efficient, compliant and transparent research billing by providing monthly metrics and encourages internal audits. In FY20, MedStar Health completed two internal research billing compliance audits which were favorable. In addition, Research Operations provides monthly metrics showing corrections made to a subject’s account before a bill is automatically sent to Medicare or a commercial payor. 

Thank you to the research coordinators and the Research Institute research revenue cycle team for all the hard work you put in daily! Know that it is recognized and greatly appreciated.

If you have any questions about research billing compliance or the process within OnCore, please contact [email protected].