Download Abstracts from the 2014 CHA Academic Poster Session

CHA Academic Poster Session – April 2014
Abstracts from the Internal Medicine Residency Program
CASE REPORTS ABSTRACTS
Author(s): Clarke, MD, Camille*; McCormick, Danny; Cohen, Pieter; Thatai, Deepak
Title: An Unexpected Case of bigeminy and non-sustained ventricular tachycardia
Department(s): Medicine
Learning Objective 1: Recognize ventricular arrhythmias as an atypical
presentation of pericardial effusion and cardiac tamponade.
Learning Objective 2: Appreciate the utility of echocardiogram in elucidating
etiologies of non-sustained ventricular tachycardia
A 68 year old Latino male with coronary artery disease and coronary artery
bypass graft surgery eight years prior presented with symptoms of progressive
exertional shortness of breath for the past three months with acute worsening in the
preceding three days. He endorsed mild palpitations during these episodes but denied
any accompanying chest pain, orthopnea, dizziness, syncope or abnormal constitutional
symptoms. On arrival, he was noted to have persistent bigeminy with a 5 beat run of
ventricular tachycardia. Vitals signs were within normal and electrocardiogram revealed
sinus rhythm with persistent bigeminy but no ST-T segment changes. His basic
metabolic panel was unremarkable, troponin negative and hematocrit 38. Chest x-ray
showed minimal enlarged heart with no lung pathology. Physical exam revealed jugular
venous distention to the angle of his mandible, lungs were clear and cardiac exam
normal. On the night of admission patient had persistent bigeminy with significant
couplets and a 40 beat run of ventricular tachycardia. He remained hemodynamically
stable throughout. Echocardiogram was performed and showed inferoapical wall
akinecity and two pockets of pericardial effusion behind the left atrium as well as a
compressed right ventricle. He was transferred for cardiac catheterization, which
revealed a patent cardiac graft but transudative pericardial fluid causing tamponade,
which resolved after drainage.
Ventricular arrhythmias have been reported as a presenting manifestation of
metastatic or infectious cardiac arrhythmias, however, it is an uncommon presenting
symptom of transudative pericardial effusion. Our patient had a pocket of pericardial
fluid that accumulated and compressed his right ventricle, leading to cardiac tamponade
with resultant ventricular arrhythmias. Though ischemia was an appropriate initial
suspicion given his history of CABG and cardiac risk factors, timely echocardiogram was
imperative and played a key role in confirming the diagnosis of pericardial disease.
CLINICAL & RESEARCH ADVANCES ABSTRACTS
Author(s): Pham, MD, Christina B.*; Kratz, MD, Johannes R.*; McCormick, MD, Danny
Title: Children: A Barrier to Maternal Health Care Utilization?
Department(s): Internal Medicine, Surgery, Massachusetts General Hospital
Background: Prior studies have demonstrated that women with children are at
higher risk for illness, such as cardiovascular disease and all-cause mortality than
women without children. No prior studies have examined the impact of having a young
child on a mother’s utilization of health care that could mediate these disparities.
Methods: We analyzed cumulative data from 5 years (2008-2012) of the National
Health Interview Survey (NHIS), which included 57,746 women age 60 or younger. The
* Internal Medicine trainee
CHA Academic Poster Session – April 2014
Abstracts from the Internal Medicine Residency Program
primary outcome was having a visit to a primary care physician in the preceding year.
The primary predictor was having one or more children under the age of 18 in the home.
Results: When adjusted for confounders, patients who had children under the
age of 18 had a 12% lower odds of having a PCP visit in the preceding year and a 27%
lower odds of having seen a medical specialist in the past year. These patients also had
a lower odds of receiving basic health screening such as blood pressure checks,
cholesterol checks, tetanus shots, and mammograms.
Conclusions: Women with children younger than 18 years old are less likely to
engage in their own primary care and receive important preventive care than women
without young children. Current health care delivery system models may not be optimally
structured to meet the needs of women with children.
HEALTH PROFESSIONS EDUCATION ABSTRACTS
Author(s): Clarke, MD, Camille*; Edshteyn, Ingrid; Zhu, Colin
Title: Students Lead the Way for Lifestyle Medicine Integration into Medical Education
Department(s): Medicine
Lifestyle practices profoundly influence health and quality of life. Practice
guidelines for chronic disease prevention and management recommend that treatment
begin with evidence-based lifestyle medicine interventions as the primary modality.
Physicians, however, cite inadequate confidence and lack of knowledge and skill as
major barriers to counseling patients about lifestyle interventions. The past three years
has seen a rise in student-led interest groups for lifestyle medicine as medical students
take initiative to address the current gap in medical school curricula. The purpose of this
study was to explore the motivation, goals, and impediments for these developments,
while highlighting the impressive accomplishments of these student led interest groups.
Author(s): Hathaway, MD, Rachel*; Jain, MD, Priyank; Batalden, MD, Maren; Clark,
RN, Kathleen; Lantieri, RN, Martin
Title: Residents Join the Huddle: Resident participation in a quality improvement project
on RN-MD communication develops several ACGME resident competencies.
Department(s): Medicine, Nursing
Goals/Objectives: Recently there has been institution of a daily, structured, and
brief “huddle” between residents and nurses at the beginning of the day shift on 4W, our
Med/Surg unit. The intent of this resident-led huddle is to address early in the shift any
nursing or patient concerns, and to clearly communicate the patient care plan for the day
to all providers. These huddles are being run without any formalized structure or
feedback process.
We are running weekly meetings to elicit real-time feedback from both residents
and nurses in order to rapidly improve these huddles. We anticipate that it is in this way
that residents will learn more about quality improvement and how to practice it
effectively.
Methods: We have been running a short meeting (20 minutes) at the end of each
week with the two current residents on the wards and two nurses who have been
participating in the huddle. We act as facilitators to the residents and nurses as they
identify ways to improve the huddle process. The suggestions made at these meetings
* Internal Medicine trainee
CHA Academic Poster Session – April 2014
Abstracts from the Internal Medicine Residency Program
are then instituted the following week in the huddles. In this way, the huddle process has
been rapidly changed via continuous feedback loops.
The evaluation of this pilot project is occurring via a qualitative resident survey.
Their interviews have been recorded, transcribed, and then various themes coded to
identify collective opinions. This project is IRB approved.
Results/ Conclusions: We are interested in how resident participation in this
process improves their competency in the realm of quality improvement, a major
ACGME milestone. Through participating in these quality improvement meetings,
residents learn firsthand how to practice quality improvement in a meaningful way. We
are also evaluating changes observed in other secondary outcomes like RN-MD
communication, teamwork, and satisfaction with work environment.
Author(s): Pasternack, MD, Amy*; Lupton, MD, Katherine
Title: Longitudinal Resident-Student Patient Care Collaboration in Primary Care
Department(s): Medicine
Given the structure of the Cambridge Integrated Clerkship, CHA internal
medicine residents have fewer opportunities to teach medical students than do residents
at many other medicine training programs.
We are currently piloting a collaborative patient care experience in which CIC
students pair with senior resident PCPs to longitudinally co-follow complex medical
patients. The student and resident see the patient together: the student primarily runs
the visits while the resident directly observes and helps guide the encounter. The
student presents to the resident – who acts as preceptor for the visit – in the presence of
an experienced faculty preceptor who ensures the quality of patient care while observing
and providing feedback on the resident’s teaching skills.
An initial pilot by one resident and two medical students has shown the project to
be feasible despite scheduling complexities, and other residents and medical students
have expressed interest in participating. Defining appropriate patients – who are
medically and psychosocially complex enough to require frequent visits and would
benefit from continuity with a medical student, but not so complex as to overwhelm the
resident or student – has been an early challenge and is a main focus of program
development for the remainder of the pilot year.
Author(s): Pham, MD, Christina B.*; Huang, MD, Jennifer*; Bothamley, MD, Dylan*;
Lee, MD, Patrick T.; Saravanan, MD, Yamini
Title: Innovation in shared medical appointments (SMAs) for diabetes management:
engaging residents in interdisciplinary leadership and self-directed curriculum
development.
Department(s): Internal Medicine
Objective: We developed and implemented a structure for internal medicine
resident-led shared medical appointments (SMAs) for diabetic patients to provide
trainees an opportunity to develop interdisciplinary leadership skills, quality improvement
experience, and training in non-traditional health care delivery.
Methods: Residents lead the planning, execution, and de-brief of an
interdisciplinary team. During an SMA, the resident examines patients, engages them in
active management of their diabetes, and goes through a patient-directed educational
curriculum. The resident fosters an environment of peer mentorship, which patients cite
* Internal Medicine trainee
CHA Academic Poster Session – April 2014
Abstracts from the Internal Medicine Residency Program
as the overarching value that keeps attendance high. The resident then runs a post-SMA
de-brief and enters ideas for process improvements into a change log that feeds into
future plan-do-study-act (PDSA) cycles.
Results: Improved patient satisfaction with self-management of diabetes based
on formal exit interviews, Hands-on resident training in SMA implementation, a new
format for many physicians, Development of resident skill set in leading SMAs and
designing curriculum based on patient needs and quality improvement metrics
Conclusions: Our process can be replicated at other internal medicine
residencies, to not only produce a cadre of physicians with evidence-based training and
experience with SMAs, but to offer more patients an effective way to manage their
diabetes.
QUALITY/SYSTEMS IMPROVEMENTS ABSTRACTS
Author(s): Bedard, MD, Rachael*; Rapoport, MD, Alison*; Batalden MD, MPH, Maren
Title: Not Too Much, Not Too Little, but Just Right: Goldilocks Rounds at the Cambridge
Health Alliance.
Department(s): Medicine
Needs and objectives: The AGCME identifies “Systems-Based Practice” (SBP)
as a core competency for internal medicine residents, with sub-competencies including
providing cost-effective care, recognizing system errors and advocating for systems
improvement. “Goldilocks Rounds” provides an innovative, structured forum for
residents to discuss cases involving the overuse, underuse and misuse of healthcare
resources and to design and implement small tests of change.
Setting and participants: The internal medicine residency has 8 residents in each
of the PGY-1, 2 and 3 years; there are an additional 8 psychiatry interns and 7
transitional-year interns. All residents are invited to monthly Goldilocks Rounds. The two
chief medical residents facilitate rounds.
Description: Goldilocks Rounds are scheduled at regular intervals throughout the
year. Housestaff are expected to come prepared with recent stories that exemplify:
overuse or misuse of medical resources, clinical error or system failures. Participants
select 1-2 pressing problems raised in the discussion, brainstorm interventions, and
commit to individual or group action.
Evaluation: Prior to the first Goldilocks Rounds all house officers were invited to
complete a survey on attitudes and perceived self-efficacy regarding SBP. 60% of
residents responded. The same survey will be administered at the end of this academic
year.
Discussion: Baseline survey results revealed that 43% of respondents feel “very
comfortable” discussing a medical error with a fellow housestaff. Only 21% feel “very
comfortable” filing a formal occurrence report; 30% of respondents reported not knowing
how to file a formal occurrence report. Despite this, 72% of respondents “strongly agree”
with the statement “My role as a physician includes a responsibility to improve the
system of care in which I practice”. The Goldilocks Rounds are a promising, easily
replicated strategy for bringing SBP into the residency.
* Internal Medicine trainee
CHA Academic Poster Session – April 2014
Abstracts from the Internal Medicine Residency Program
Author(s): Koulouris, MD, Carolyn*; Huang, MD, Jennifer*; Bothemly, MD, Dylan*;
Lueras, MD, Pauls*; Pasternack, MD, Amy*; Phillips, MD, Christina*; Kwok, MD, Judy*;
Shah, MD, Neil*; Rogers, MD, Rebecca*; Basu, MD, Gaurab; McCormick, MD, Danny
Title: Prevalence and Causes of Delayed Hospital Discharge from a Safety-Net Hospital
Department(s): Medicine
Background: Patients often stay in acute care hospitals longer than is medically
necessary. Such delays in hospital discharge often have negative impacts on the
patients (increased risk of nosocomial infections and deconditioning, e.g.) and the
hospital (lack of reimbursement for care provided and inability to fill beds with new
patients).
Methods: We conducted a study to examine the prevalence of non-medically
necessary hospital stays and the causes of delayed days at a safety net hospital. The
prospective observational study was conducted at the second largest safety net hospital
in Massachusetts during the period of October 2013 to February 2014. For each day of
hospitalization, a research team member recorded if the day was medically appropriate
for the acute hospital, and the cause of discharge delay as determined by the primary
clinical team. This information was gathered during multidisciplinary rounds and with
direct interaction with the physician.
Results: A total of 624 hospital admissions (representing 1,749 hospital days)
were observed. The average length of stay was 2.8 days. The share of admissions that
the patient experienced any delay in discharge was 12.5%. The share of hospital days
that were not medically necessary was 9.4%. The most common reasons for delay
included: skilled nursing facility bed not available (34%), patient not safe to discharge to
home (17%), psychiatric bed not available (10%), awaiting guardianship determination
(9%), and for Medicare patients, a requirement to keep the patient for 3 days prior to
transfer to another care facility.
Discussion: Despite increasing efforts to decrease non-medically necessary days
of hospitalization, at this safety net hospital, a substantial number of patients experience
such a delay. Efforts to decrease this rate are warranted.
Author(s): Phillips, MD, Christina*; Wang, Winnie*; Saravanan, MD, Yamini; Lee, MD,
Patrick
Title: Why do our patients go to the Emergency Department? Designing a staff-led
process to target inappropriate ED utilization
Department(s): Primary Care Center, Harvard School of Public Health
Background: Causes of inappropriate Emergency Room(ED) use vary in the
literature, ranging from inadequate after hour coverage to poor patient understanding of
when to access the ED,but exact reasons for inappropriate ED utilization at the
Cambridge Hospital Primary Care Center (PCC) have yet to be described.
Objectives:
1.
Quantify the number of inappropriate ED visits among a randomized
sample of high risk patients at the PCC.
2.
Educate clinical staff about the reasons why patients go to the ED
inappropriately.
3.
Design a staff-led process that improves upon pre-existing workflows to
decrease inappropriate ED utilization.
Methods: Thirty(30) high risk patients were randomly selected from each of the
three PCC care-teams who visited the ED between February 2013 and July 2013(90
* Internal Medicine trainee
CHA Academic Poster Session – April 2014
Abstracts from the Internal Medicine Residency Program
total patients). Demographic data, information on their ED visit including time of day
and day of week, ED diagnosis, and whether the patient attempted to call his/her PCP
prior to the ED visit was collected. Each ED visit was categorized as either appropriate
or inappropriate based on a previously validated algorith.
Results: Of the 90 ED visits, 52(58%) met criteria for inappropriate use. There
was no difference between inappropriate and appropriate visits with regard to age, time
of day, day of week, payment source, or month. Of the 90 patients who went to the ED,
74(82%) did not call their PCP. A significantly higher number of patients who did not call
their PCP had inappropriate ED visits.
Conclusions: The percentage of inappropriate ED visits(58%) is higher than
previously published values and not calling the PCP is associated with a higher numbers
of inappropriate visits. Understanding why patients don’t contact their PCP prior to an
ED visit is our next step.
SOCIAL & COMMUNITY HEALTH ABSTRACTS
Author(s): Green, MD, Brian; McCaughan, RN, MS, Fiona; Stark, MD, MPH, Rachel;
Marshall, MD, Jeffrey*; Rogers, MD, Rebecca*
Title: Smoking Cessation in Primary Care
Department(s): Primary Care, Primary Care
Somerville Hospital Primary Care has implemented several strategies to increase
our identification and counseling of smokers and use patient-centered interactions.
Smoking rates are higher in our high risk populations.
Goal: Identify 100% of our smokers and provide appropriate counseling.
Objectives: Increase our assessment of patient’s smoking status at every PCP
visit. Improve our smoking cessation counseling documentation. Include patient self
management and motivational interviewing to identify readiness to change.
Results: Educating staff has increased our rate of correctly assessing patients
from 50% to 80% and improved our counseling rates from 60-84%. The residents have
supported the smoking cessation counseling classes, by attending the classes and
prescribing medication support as appropriate. We have continued to provide an
environment where patients have a positive experience.
Conclusions: We have achieved improvement in our rates of correctly
documenting a patient’s smoking status and providing counseling. We create a shared
agenda for the primary care visit and highlight patients who have identified a readiness
for change. There are several other strategies we will try to improve our patients health
including using standing orders, improve our motivational interviewing and patient self
management. We will continue this work with a focus on our asthmatic patients.
Author(s): Rogers, MD, Rebecca*; Phillips, MD, Christina*; Pauls Lueras, MD, Pauls*;
Pasternack, MD, Amy*; Shah, MD, Neil*; Huang, MD, Jennifer*; Kwok, MD, Judy*;
Koulouris, MD, Carolyn*; Bothemly, MD, Dylan*; Basu, MD, Gaurab; McCormick, MD,
Danny
Title: Prevalence and Consequences of Lapses in Public Insurance in Massachusetts
after Health Reform
Department(s): Medicine
* Internal Medicine trainee
CHA Academic Poster Session – April 2014
Abstracts from the Internal Medicine Residency Program
Background: Lapses in health insurance coverage can lead to can lead to
inability to access care and high out of pocket medical spending when medical care
needs arise during the lapse.
While MA health reform decreased the proportion of the population that lacks health
insurance from about 10% to 5%, the ability of individuals with either publicly subsidized
or private insurance post reform is not known.
Methods: We conducted face-to-face structured interviews with 770 patients with
publicly subsidized insurance (Medicaid or Commonwealth care plans purchased
through a health care exchange and 301 with private insurance who presented to three
emergency departments at a large integrated safety net health care system in the
greater Boston area. We included patients aged 18-64, who spoke English, Portuguese,
Spanish or Haitian Creole. We excluded severely ill patients. The survey assessed
whether patients experienced lapses in current insurance coverage and whether care
was needed but forgone or delayed due to this lapse.
Results: Among 770 publicly insured patients, 24.9% had a lapse of their current
insurance, compared with only 4% of privately insured. Among publicly insured patients
who experienced a lapse in coverage, 40% needed but did not received medical care
due to the lapse. Experiencing a lapse in insurance coverage did not vary by age,
gender, arace, language the survey was conducted in or level of aducation. However,
experiencing a lapse was more common among immigrants (29 vs 21%; p<0.01) and
those reporting having to submit additional paperwork to maintain eligibility for insurance
(34 vs 19%; p<0.001) and those reporting having difficulty with this task (42 vs 29%;
p<0.04)
Discussion: Following Massachusetts health reform a substantial proportion of
patients with public insurance experienced a lapse in coverage with many of those
unable to received needed care due to the lapse.
Author(s): Torres, MD, MPH, Hugo*; Yelin, PhD, Ed
Title: Among Medicaid patients in California, usual source of care is not associated with
lower hospitalization rates for ambulatory-care sensitive conditions.
Department(s): Medicine, UCSF
Background: Prior research links primary care access, often measured by usual
source of care (USOC), with lower rates of hospitalizations for many chronic diseases,
called ambulatory care sensitive Conditions (ACSC). This study aims to determine if the
difference in ACS hospitalizations between Medicaid beneficiaries and low-income
privately-insured individuals can be explained by the presence of a USOC.
Methods: This is a cross-sectional study utilizing the 2009 and 2011 California
Health Interview Survey (CHIS). The population studied is respondents to the CHIS,
aged 18-64, earning less than 300% of the Federal Poverty Level (N=7564). The
principal independent variable is Medicaid vs. Private insurance. The outcome is an ED
visit or hospitalization for an ACSC. The analysis determines if Medicaid insurance was
associated with rates of ED use or hospitalization; USOC was added to the model, first
as an independent variable, then as an interaction term.
Results: The unadjusted rates of ED use and hospitalization for ACS conditions
were 46.8% vs. 30.9% for privately insured patients (OR: 1.96, 95% CI 1.60-2.41,
p<0.0001). The OR adjusted for confounders was lower but still significant at 1.54 (95%
CI 1.2-2.0, p<0.0001). The association remained after controlling for USOC (OR 1.55,
p<0.0001). An interaction term for USOC and Medicaid was positive and significant (OR
* Internal Medicine trainee
CHA Academic Poster Session – April 2014
Abstracts from the Internal Medicine Residency Program
1.79, p=0.05), indicating an increased effect of Medicaid on ED use/hospitalization for
ACS conditions.
Conclusions: This analysis demonstrates a correlation between Medicaid (vs.
private) insurance and ED use/hospitalization among people with ACSC, and that
possession of primary care access in the form of having a usual source of care did not
affect this relationship in the expected pattern. The explanation for this relationship is
likely multifactorial, and highlights the need for expanded efforts to understand and treat
the causes of poor chronic disease outcomes in Medicaid patients.
Author(s): Torres, MD, MPH, Hugo*; Yelin, PhD, Ed
Title: Health Access Indicators and ER Use among Latino Medicaid Beneficiaries
Department(s): Medicine, UCSF
Background: The Medicaid program has been shown to increase healthcare
utilization for low-income adults who would be otherwise uninsured. The purpose of this
study is to measure the association between health access indicators and insurance
type in the Latino population, comparing Medicaid to private insurance. The second is to
measure differences in ER and hospital usage for ambulatory-care-sensitive conditions
(ACSC) between Medicaid and privately-insured Latinos.
Methods: This is a cross-sectional study utilizing the 2009 California Health
Interview Survey (CHIS). The population studied is California adult Latino respondents
to the CHIS survey. The independent variable is health coverage (Medicaid vs. private
insurance). For the first objective, the outcome variable is presence of a usual source of
care (USOC) and interruption in health insurance in the past year. For the second
objective, the analysis was limited to ACSC; the outcome variable is ED visit or
hospitalization.
Results: After adjustment with logistic regression, there were continued
significant differences in usual source of care and uninsured in the past year: Medicaid
recipients were half as likely to report having a usual source of care (OR=0.52, 95%CI
0.37-0.73, p<0.0001) and three times more likely to report having been uninsured in the
past year (OR 3.0, 95%CI 2.0-4.5, p<0.0001). Among patients with ACSC, there was an
association between Medicaid and ER use/hospitalization after adjustment for the
covariates (OR=2.2, p=0.03).
Conclusions: Results of this study demonstrate that Latinos with Medicaid report
worse health access and have a greater chance of going to the emergency room with a
chronic condition than those with private insurance. In light of the importance of having a
usual source of care and continuous insurance in the prevention of adverse health
outcomes, these findings point to a need to ensure that a robust primary care system
and education on how to access it support Medicaid patients.
* Internal Medicine trainee