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2015 - MPH Clinical Effectiveness

Organization Practice Abstract

Brigham and Women's Hospital, Department of Medicine

1) evaluated whether medical home transformation was associated with breast cancer screening performance in primary care practices at the Brigham and Women's Hospital /

Department of Population Medicine, Harvard Medical School / Harvard Pilgrim Health Care Institute

My work during fellowship has focused on studying trends in sepsis burden and improving surveillance of this important disease. I was first author on a Perspective article in the New England Journal of Medicine where we suggested that the apparent surge in sepsis rates may actually be an artifact of increasingly aggressive diagnosis and coding practices rather than a true increase in the burden of disease. We used the Nationwide Inpatient Sample to show that the incidence of sepsis as a principal diagnosis almost tripled from 2000-2008 whereas the incidence of pneumonia, intraabdominal infections, urinary tract infections, and bacteremia (the infections that most commonly cause sepsis) were stable or decreasing. We urged caution on implementing mandates for sepsis care and public reporting in light of our current deficiencies in surveillance, and proposed that surveillance should be conducted using objective clinical data instead of claims data. I subsequently published a first-author Major Article in Clinical Infectious Diseases showing that trends in sepsis incidence imputed from administrative data differed markedly from those suggested by objective clinical markers (positive blood cultures) at Massachusetts General Hospital (MGH) and Brigham and Women’s Hospital (BWH). We also demonstrated steadily rising sensitivity of sepsis codes for capturing patients with unequivocal markers of severe sepsis, positive blood cultures with concurrent vasopressors or lactic acidosis. My next project compared the accuracy of surveillance definitions based on clinical data stored in electronic health records versus claims data to identify true severe sepsis cases. I validated the surveillance definitions with 1000 chart reviews. We found that a surveillance definition based on clinical data (blood culture orders and antibiotics and various organ dysfunction markers) has superior sensitivity to claims and stable sensitivity over time. Importantly, we showed that rising trends in incidence and declining mortality was exaggerated with claims data when compared to clinical data. This manuscript is now under review. /

Boston Children's Hospital, Division of Endocrinology

We examined relationships between autistic traits in children, mothers, and fathers and recalled gender nonconformity (GNC) in children using data from the Nurses' Health Study II (NHSII) and the Growing Up Today Study 1 (GUTS1). Autistic traits of mothers, fathers and children were measured using the Social Responsiveness Scale (SRS). GNC in children was measured using questions from the Recalled Childhood Gender Identity/Gender Role Questionnaire. In multivariable analyses increase in child’s SRS score was associated with increased odds (OR 1.35; p=0.03) of being in a higher GNC category. Increase in maternal SRS score was also associated with increased odds (OR 1.46; p=0.005) of the child being in a higher GNC category. Paternal SRS scores were not related to child's GNC category. These results call for further exploration into the etiology of these associations and suggest the importance of being sensitive to the diversity of gender expression in children with ASD.



Boston Children's Hospital, Department of Surgery

The purpose of this study was to identify which conditions are responsible for the majority of hospital cost and cost variation within the scope of pediatric surgical practice. We described the variation in cost of these procedures in the context of a public health focused prioritization framework. We retrospectively reviewed administrative data from over 60,000 encounters where a proedure was performed at a children's hospital and found that a relatively small number of conditions account for the majority of cost and cost variation burden in general pediatric surgery. The prioritization of these conditions for value-focused comparative effectiveness research may provide a high-yield strategy to improve care from a broad public health perspective. This should segway nicely into more sophisticated analyses of drivers of cost for these high priority conditions. /

Obesity Prevention Program, Department of Population Medicine

Background: Insufficient sleep is a risk factor for obesity, cancer, and other chronic disease. Maternal antenatal stress is associated with child depression and ADHD, perhaps via the hypothalamic-pituitary-adrenal axis, and thus may affect child sleep. / / Objective: To determine the relationship between maternal antenatal stress and child sleep duration and efficiency. / / Methods: In 2007-2010, we recruited pregnant women at a Mexico City hospital and followed their children to 4 years. In mid-pregnancy (median X weeks gestation) mothers reported stress in the previous month with the Prenatal Stress Scale (PSS) and total lifetime stressful events with the Negative Life Events subscale of the Crisis in Family Systems scale. They also provided 5 salivary cortisol samples over 24 hours from which we derived area under the curve, daytime slope, and cortisol awakening response, which is the difference between the first two cortisol measurements of the day. At 4 years, we measured total sleep time (minutes) and sleep efficiency (% of in-bed time asleep) in children using 7-day wrist actigraphy for up to 7 days. We examined associations of maternal stress with child sleep outcomes in 408 pairs using linear regression analysis, adjusted for maternal age, prenatal body mass index (BMI), socio-economic status, and child sex, gestational age, and birth weight. / / / Results: mean (SD) maternal age was 27.7 (5.5) years, with 216 (53%) of mothers in the lowest 2 of 6 SES categories, 239 (59%) mothers ever having smoked, and 106 (29%) mothers reporting a victim of violence in the family. Mean (SD) PSS score was 5.2 (2.8) out of 16 and Negative Life Events score was 3.1 (2) out of 11. Half 51%) of children were male, mean (SD) age was 58 (5) months, BMI z-score was 0.19 (1.1), physical activity was 3.1 (0.4) hours per day, hours of sleep per night was 8.0 (0.7), and sleep efficiency was 79% (6). In unadjusted linear regression models, greater cortisol slope was associated with longer sleep duration (effect estimate 9.6, 95% CI 1.7-17.5), but this relationship fell out of significance after adjustment (5.6, 95% CI -5.9, 17.3) each additional point on the NEGATIVE LIFE EVENTS subscale was associated with -1.2 (95% CI -3.6, 1.2) minutes sleep, and -4.2 (95% CI -7.8, -0.6) minutes sleep after adjustment. No predictors were associated with sleep efficiency, before or after adjustment. / / Conclusions: Higher maternal lifetime stress, as measured by second trimester Negative Life Events score, was associated with less child sleep, though other measures of maternal antenatal stress were not associated with child sleep outcomes. /



University of Wisconsin Department of Surgery

Our aim is to evaluate the effectiveness of breast MRI on time to breast cancer recurrence and survival in stage II and III breast cancer patients after curative intent therapy with the objective of optimizing surveillance strategies in women with stage II and III breast cancer. Using the National Cancer Database (NCDB) in addition to primary data abstraction, we will evaluate receipt of routine surveillance breast MRI compared to symptom driven imaging and compare primary outcome of time to a second breast event defined as locoregional recurrence, new cancer in the ipsilateral or contralateral breast and secondary outcome of comparing overall survival between these cohorts. We will also assess patterns of MRI use within this cohort including quantity and frequency. We will also examine frequency of subsequent imaging, biopsy rate and results. In addition, we will assess variation in recurrence patterns based on patient and tumor characteristics.

SaveLife Foundation, New DelhiTrauma and injuries are rising in incidence in LMICs. Western style EMS systems are expensive and are not always optimized to the challenges of overcrowding and road conditions. We worked with SaveLife Foundation, an Indian NGO training police officers in trauma response.

Brigham and Women's Hospital, Department of OB/GYN

Many studies have evaluated pain control options for intrauterine device (IUD) insertion, though few interventions have shown efficacy. Prior studies of naproxen sodium suggest effective pain relief. However, it is unclear if those results apply to modern IUDs utilized in the United States. We hypothesize that administering 550 mg of naproxen sodium orally, 1 hour prior to IUD insertion, will lead to a clinically significant reduction in pain scores compared to placebo. Our primary outcome is pain score with IUD insertion as measured on a 10cm visual analogue scale (VAS). Secondary outcomes will include VAS pain scores for tenaculum placement, uterine sounding, and 5 and 15 minutes post-procedure. We will also evaluate subjective reports of pain and need for additional pain medication. This will be a double-blind, randomized, placebo-controlled trial. Recruitment will take place at Planned Parenthood League of Massachusetts in Boston, MA (PPLM-Boston). Eligible women will be 18 years or older, premenopausal, at least 4 weeks postabortion or postpartum, and presenting for IUD insertion of any type. Women will be ineligible if they have a chronic pain diagnosis or any contraindications to IUD insertion or non-steroidal anti-inflammatory drugs. Given known differences in IUD insertion pain between nulliparous and parous women, we will stratify by parity. Separate sample size calculations were done with different standard deviations for each strata based on published data. Both sample size calculations are based on a clinically significant difference of 1.5cm on a 10 cm VAS. To achieve 80% power with a 5% alpha error rate and allowing for 10% subject discontinuation and/or missing data, 76 parous and 84 nulliparous participants will be required, for a total recruitment of 160 participants. Given the large volume of interval IUD insertions at PPLM-Boston (approximately 970 in 2014) we anticipate recruitment to take approximately 9 months. We plan to establish whether prophylactic naproxen sodium leads to a clinically significant decrease in pain and warrants routine use prior to IUD insertion. /



Division of Preventive Medicine - Brigham and Women's Hospital

It is uncertain whether subclinical hypothyroidism (SCH) is associated with lipid abnormalities. Therefore, we examined a range of lipid and lipoprotein subclasses across the spectrum of euthyroid, SCH, and overt hypothyroidism (HT) in apparently healthy women free of CVD. A random sample of 3914 individuals from the Women’s Health Study was selected for thyroid function analysis. From this sample, 3321 individuals were not on lipid lowering therapy and had thyroid profiles compatible with euthyroid, 2571 (77.4%); SCH, 573 (17.3%); and HT, 177 (5.3%). Lipids were measured directly, and lipoprotein subclasses were measured by nuclear magnetic resonance spectroscopy. Statistical comparison was performed by ANOVA, after adjusting for age, BMI, menopausal status, HRT, blood pressure, anti-hypertensive medication, diabetes, and current smoking. Compared with euthyroid individuals, those with SCH and HT were older, had higher BMI, greater prevalence of post-menopausal status and metabolic syndrome, and lower prevalence of smoking. They also had higher triglycerides and lower HDL-C, but similar LDL-C (Table ). More detailed lipoprotein phenotyping showed that SCH and HT were associated with an insulin resistant lipoprotein subclass profile. Going from euthyroid to SCH to HT, there was a graded increase in concentrations of VLDL particles (mainly due to large and medium VLDL), reflected by larger VLDL size; higher concentration of LDL particles as well as apolipoprotein B concentration despite no difference in LDL-C; and higher concentration of small HDL particles. Similarly, the lipoprotein insulin resistance score of SCH and HT was worse than euthyroid. In this large population of apparently healthy women, individuals with SCH had differences in the lipid and lipoprotein subclass profile that indicated worsening insulin resistance compared with euthyroid individuals, despite having similar LDL-C and total cholesterol. /



Institue for Aging Research, Hebrew SeniorLife

OBJECTIVES: To examine baseline (preoperative) neuro- / psychological test performance in a cohort of elderly indi- / viduals undergoing elective surgery and the association / between specific neuropsychological domains and postop- / erative delirium. / SETTING: Successful Aging after Elective Surgery Study. / PARTICIPANTS: Elderly adults (N = 300) scheduled for / elective (noncardiac) surgery. / MEASUREMENTS: Neuropsychological testing, including / standardized assessments of memory, divided and sus- / tained attention, speed of mental processing, verbal flu- / ency, working memory, language, and an overall measure / of premorbid cognitive functioning, was performed 2 to / 4 weeks before surgery. The relationship between the indi- / vidual neuropsychological tests and delirium status was / examined using linear regression, adjusting for age, sex, / and education. / RESULTS: Study participants were generally highly edu- / cated (mean years of education 15.0 2.9), with minimal / or no cognitive impairment (mean Modified Mini-Mental / State Examination score 93.2 out of 100). After adjust- / ment, participants who developed postoperative delirium / had performed significantly lower preoperatively on mea- / sures of speed of mental processing and divided attention / (Trail-Making Test Part B, mean difference 17.55, / P = .02), category fluency (animal naming, mean differ- / ence 1.94, P = .01), sustained visual attention (Visual / Search and Attention, mean difference 3.19, P < .001), / and working memory with new learning and recall (Hop- / kins Verbal Learning Test—Revised Total mean difference / 0.53 to 0.79, P < .01). / CONCLUSION: Individuals who later develop delirium / have lower scores on tests evaluating the areas of complex / attention, executive functioning, and rapid access to verbal / knowledge or semantic networks at baseline. Future stud- / ies to better understand how the cognitive profiles identi- / fied may predispose individuals to developing delirium / may help pave the way to greater understanding of the / mechanisms of delirium. J Am Geriatr Soc 2015.

Dana-Farber Cancer Institute, Division of Population Sciences

We performed a case control study to identify predictors of chemotherapy-related hospitalization. The study population included patients treated for advanced solid tumor cancers at the North Shore Cancer Center between 2003 and 2011. 292 case patients who experienced chemotherapy-related hospitalization were identified from a parent cohort of 1579 patients receiving chemotherapy. Case patients were matched to controls in a 2:1 ratio. Age, Charlson comorbidity score, creatinine clearance, calcium, below-normal white blood cell or platelet count, polychemotherapy, and camptothecin chemotherapy were identified as independent predictors of chemotherapy-related hospitalization. The final model exhibited a bootstrap adjusted c-statistic of 0.71 with acceptable calibration. Among patients with a hospitalization risk of 15% or more, the model exhibited a sensitivity of 49% and a specificity of 85% for predicting chemotherapy-related hospitalization.



Brigham and Women's Hospital, Department of medicine and Division of Pharmacoepidemiology and Pharmacoeconomics

Abstract / Background / Physicians’ financial relationships with pharmaceutical companies have long been controversial. These relationships can consist of receipt of industry-sponsored meals, money for continuing medical education (CME) activities, reimbursements for consulting and participation on speaking bureaus, grants, and payments for education and training. Numerous small studies and surveys suggest that these financial relationships affect prescribing practices, but many physicians and policymakers remain unconvinced. Using a comprehensive Massachusetts medical conflicts of interest database and a prescription claims database, we sought to evaluate the association between physicians’ financial relationships and their prescribing of brand-name versus generic cholesterol-lowering medications. / / Methodology / We manually linked Medicare prescription claims data prepared by the Centers for Medicare and Medicaid Services relating to Massachusetts physicians with the Massachusetts physician open-payment database from 2011. The exposure variable was the listing of physicians’ financial relationship and outcome measurement was physicians’ prescribing of any brand-name-only cholesterol-lowering medication. The analysis was limited to physicians who had at least 50 claims of a particular drug. We used chi-square and ANOVA tests to analyze the association between the intensity of physician-industry relationships (determined by monetary value of payments) and physicians’ prescribing practices. We used logistic regression model to determine the relationship between the types of physician-industry relationships and their brand-name prescribing behavior. / / Results / Our analysis included 2444 physicians. Approximately one-third (899, 37%) had some sort of financial relationship with a pharmaceutical company, while 63% (1546) had no industry payments in 2011. The most common payment type was for company-sponsored meals (639, 71%), followed by grants (458, 51%), consulting and speaking bureau (236, 26%), and educational training grants (95, 11%). Compared to physicians without pharmaceutical company payments, physicians in the top quartile of total value of payments (>$1188) had higher rates of brand-name cholesterol-lowering medication prescriptions (21% versus 18%, p<0.01). When physicians were categorized by quartiles based on their rates of brand-name prescribing, there was a significant positive relationship between the average total monetary value of drug company payments ($3696, $1419, $701, and $542, p<0.01) and brand-name prescribing percentage (39%, 19%, 10%, and 4%, p<0.01), respectively. Among physicians who received pharmaceutical company payments, educational training payments were significantly associated with increased brand-name prescribing (18% versus 22%, p<0.01), but the other payment types were not. / / Conclusion / Physicians who have financial relationships with pharmaceutical companies have higher brand-name cholesterol-lowering medication prescribing than physicians who do not have such relationships. The rate of brand-name prescribing was associated with the intensity of physician-industry relationships measured by the total value of monetary payments. The receipt of educational training payments may be a significant predictor of brand-name prescribing. The study findings only apply to physicians prescribing substantial numbers of cholesterol-lowering medication each year and may be limited by the integrity of pharmaceutical companies’ self-reporting of physician payments. /



Harvard Wide Pediatric Health Services Fellowship

Objective: To examine if proximity to a supermarket modified the effects of an obesity intervention. We hypothesized that children living closer to a supermarket would have larger improvements in diet quality and weight status than those living further away. / Methods: We examined 498 children ages 6-12 with a BMI ≥ 95th percentile, participating in an obesity trial from 2011-2013. The main exposure was the intervention. Outcomes were 1-year change in BMI z-score, sugar-sweetened beverage intake and fruit/vegetable intake. Distance to the closest supermarket was examined as an effect modifier. / Results: Distance to supermarkets was an effect modifier of 1-year change in BMI z-score and fruit/vegetable intake but not sugar-sweetened beverage intake. With each 1-mile shorter distance to a supermarket intervention participants increased their fruit/vegetable intake by 0.31 servings/day and decreased their BMI z-score by -0.04 units relative to controls. / Conclusions: Living closer to a supermarket was associated with greater improvements in fruit/vegetable intake and weight status in an obesity intervention. Future public health efforts should examine children’s environments and seek ways to help families who do not have readily-available supermarkets. /

Dana-Farber/Brigham and Women's Cancer Centre

Background: The objective of this study was to examine the effect of Paget disease on axillary node metastases and survival in female patients with invasive ductal carcinoma. / Methods: We identified women diagnosed as Paget disease with IDC (PD-IDC) or IDC alone between 2000-2011 using the Surveillance, Epidemiology and End Results database. We compared baseline patient demographic and tumor characteristics between the PD-IDC and IDC alone groups. We used multivariable logistic regression to examine the potential association of PD-IDC with axillary lymph node metastasis, and used the Kaplan-Meier method and Cox proportional hazards regression to model survival distributions. / Results: The study cohort consisted of 1,102 patients with PD-IDC, and 302,242 controls with IDC alone. The groups were similar with respect to patient demographics such as age (mean age 58.9 years PD-IDC vs. 58.6 years IDC, p=0.46) and race distribution (p=0.12). On analysis comparing characteristics of PD-IDC to IDC alone, tumors were more likely to be centrally located (26.9 vs. 5.5%, p<0.001), high grade (63.5 vs. 40.3%, p<0.001), larger than 2 cm (47.1 vs. 35.7%, p<0.001), and estrogen/progesterone receptor-negative (45.2 vs. 22.1%, p<0.001). In adjusted analysis controlling for patient age, tumor size, location, histologic grade, and hormone receptor status, PD-IDC had higher odds of axillary node metastasis (OR 1.83, p<0.001) than IDC alone patients. Conclusions: In the context of invasive ductal carcinoma, the presence of Paget disease is independently associated with an increased risk of axillary lymph node metastasis compared with IDC alone. /

Program in Global Surgery and Social Change, Boston children's Hospital, Department of Plastic & Oral Surgery

Earlier reports have shown that incidence of osteomyelitis is very high in African countries. Studies have proven that early diagnosis and treatment of open fracture can significantly reduce the incidence of osteomyelitis and amputation, thus, lower the burden for the patient and hospital, potentially avoiding long-term antibiotic use, and dramatically improving the outcome. Therefore, we would like to conduct this study to identify the risk factors of patients in Liberia developing osteomyelitis, and the barriers that prevent them from early presentation to the hospital and getting timely treatments. With this information, we could provide data to advocate early presentation and determine the population that carries high risk of developing osteomyelitis, optimize resource allocation in that limited-resource setting.



Medicine/Gastroenterology

Background: Care of patients with inflammatory bowel disease (IBD) poses a significant burden to the healthcare system. Repeat hospitalization in subgroups of IBD patients appears to be a large part of this issue, however there is limited data examining the characteristics of IBD patients associated with frequent hospitalizations. / Aim: To characterize admission patterns in patients with IBD at a tertiary care center, and identify preventable risk factors of 90-day readmission after an index IBD admission. / Methods: Retrospective analysis was performed extracting data from an electronic medical record using ICD-9 codes over a 2-year period. All patients who had an index IBD related admission during the study period were included. / Results: 356 patients were admitted at least once during the 2-year study period for an unplanned, IBD-related reason. Of these, 48.9% were admitted once, 38.2% were admitted 2-4 times, and 12.9% were admitted 5 or more times during the study period. 125 patients had experienced a re-admission by 90 days after index admission. Numerous demographic and medical factors were examined for association with readmission. The final Cox model included four variables: depression (HR=2.06, 1.42-2.98), chronic pain (HR=1.87,1.19-2.94) ETOH use (HR=1.31,1.03-4.9) and steroid use in the prior 6 months (HR=1.31, 0.91-1.88). / Conclusion: Our findings suggest that patients with depression, chronic pain, and who abuse alcohol are at greatest risk for a re-admission within 90 days after an initial IBD admission. Disease activity, represented by steroid use in the prior 6 months was not related to re-admission. Addressing these problems in the outpatient setting may reduce future hospitalizations /

Dana Farber Cancer Institute

The magnitude of risk associated with 9/10 mismatched unrelated donor (MMURD) hematopoietic stem cell transplantation and that of mismatches at the individual HLA loci remain unclear. We performed a meta-analysis to assess the difference in clinical outcomes between matched unrelated donor (MUD) and MMURD transplantation. A comprehensive search of Medline and Embase for manuscripts regarding transplantation outcomes in adult patients with hematologic malignancies was performed. The pooled effect estimates were calculated using DerSimonian-Laird random effects models. A total of 13 studies were included, representing 24,644 transplants. 9/10 MMURD transplantation was associated with worse overall survival compared to 10/10 MUD transplantation (pooled HR 1.24, 95% CI 1.12–1.37; n = 6 studies). The pooled effect estimates for impaired disease-free survival and excess grade II–IV acute GVHD were 1.16 (95% CI 1.04–1.30; n=3) and 1.45 (95% CI 0.97–2.17; n = 2), respectively. Mismatch at HLA-A, -B, or -C was associated with significantly worse overall survival compared to MUD transplantation, while there was no difference associated with HLA-DR, -DQ or -DPB1 mismatch. MMURD transplantation outcomes in hematologic malignancies are inferior to MUD transplantation. While the number of studies was small, we observed inferior survival with HLA-A, -B, and –C mismatch, but not with HLA-DR, -DQ or -DPB1 mismatches.

Harvard wide pediatric health services research fellowship

Using a prospectively collected national database I analyzed outcomes for a complex pediatric urologic surgery and built a multi variate model looking at patient level and procedure level characteristics associated with 30 day morbidity.



Urology Section, Deparment of Surgery, Brigham and Women's Hospital

INTRODUCTION: / Nephroureterectomy (NU) is the standard treatment for upper tract urothelial carcinoma (UTUC). Minimally invasive (MI) laparoscopic or robotic-assisted approaches have been introduced in an effort to reduce morbidity. We performed a population-based study to evaluate contemporary utilization trends, morbidity, and costs associated with NUs in the US. / / METHODS: / Using the Premier Hospital Database (Premier, Inc., Charlotte, NC), a nationally representative discharge database with data from over 600 non-federal hospitals in the US, we captured patients undergoing a NU (ICD9 55.51) with diagnoses of renal pelvis (189.1) or ureteral (189.2) neoplasms from 2004 to 2013. We fitted regression models, adjusting for clustering by hospitals and survey weighting to evaluate 90-day postoperative complications, length of stay (LOS), operating room time (OT), and direct hospital costs among open (ONU), laparoscopic (LNU), and robotic (RNU) approaches. / / RESULTS: / Approximately 17,245 ONU, 13298 LNU, and 3745 RNU were performed in the United States between 2004 and 2013 for the management of UTUC. MI surgeries increased from 36% to 54% from 2004 to 2013 while the total number of NUs decreased by nearly 20% (p=0.004) during the same period. No statistically significant differences were noted in the overall 90-day mortality and major (Clavien 3-5) complication rates between the three surgical approaches based on adjusted logistic regression, including when the analysis was restricted to the highest volume hospitals (≥7 annual cases) and highest volume surgeons (≥3 annual cases). OT was 10.77 (p<0.05) and 57.46 (p<0.001) minutes longer for LNU and RNU respectively. The LOS was decreased for LNU (Incidence Risk Ratio [IRR]: 0.87, 95% CI: 0.82-0.92, p <0.001) and RNU (IRR: 0.76, 95% CI: 0.7-0.83, p <0.001) compared to ONU. Adjusted 90-day median direct hospital costs were $1253 and $3534 higher for laparoscopic and robotic NU, respectively (p<0.001). This difference appears to be driven by increased operative and supply costs. However when adjusting for the highest volume groups, this difference disappears except in RNUs performed by high volume surgeons (+$1688, p<0.001). / / CONCLUSION: / During this contemporary 10-year study, the proportion of MI NUs increased to over half of procedures with a recent surge in robotic NUs, along with a concurrent reduction in total NUs performed in the US. Comparable perioperative outcomes suggest that the morbidity profile may be driven primarily by patient-specific characteristics as opposed to surgical approach. Higher surgical volumes suggest a potential cost containment strategy when performing MI NUs. /

Boston Children's Hospital, Divisions of General Pediatrics and Patient Safety and Quality

Medication errors result in significant patient morbidity and mortality, and medical malpractice claims. Boston Children’s Hospital has reduced medication errors through computerized order entry (CPOE) and bar code medication administration (BCMA). To further optimize clinical decision support systems (CDS) we plan to evaluate alerts in place for drug-drug interactions (DDI). This study intends to investigate the current DDI alert system and optimize it to reduce alert fatigue, improve cognitive load for providers to decrease errors and improve efficiency

Massachusetts Eye and Ear Infirmary

The Massachusetts Group Insurance Commission currently utilizes various quality metrics to tier physicians in high, mid, and low quality tiers. One of the primary metrics for otolaryngology is the obtainment of preoperative audiograms prior to tube placement. In order to test whether or not this metric is valid, we are conducting a study to compare postoperative audiometric outcomes in children undergo tube placement for recurrent ear infections who receive both preoperative and postoperative audiograms with those who received postoperative audiograms only. By doing so, we can determine if the preoperative audiogram is actually necessary and cost-effective in affecting surgical decision making for this population.



Joslin Diabetes Center

We developed a risk score for predicting the progression from advanced chronic kidney disease (20<= eGFR <60) to end stage renal disease. The derivation cohort was obtained from the Joslin Proteinuria Cohort, a group of 285 individuals with type 1 diabetes followed for 7-18 years. The risk score was validated in a second Joslin cohort, which includes 353 patients who have been followed for 7-10 years. Using a split sample approach and bootstrapping, 4 dichotomous variables were chosen for inclusion in the risk score: CKD4, age <=45, albumin/creatinine ratio >300, and HbA1c >9.0. Performance of the risk model was examined in the validation cohort and models were compared using C-statistic. The model which included all 4 variables had the highest c-statistic (0.787) and was chosen for the risk score.

Harvard Radiation Oncology Program

Importance Active surveillance (AS), per the National Comprehensive Cancer Network (NCCN) guidelines, is considered for patients with low-risk prostate cancer (PC) and a life expectancy of at least 10 years. However, given the grade migration following the 2005 International Society of Urologic Pathology consensus conference, AS may be appropriate for men presenting with favorable intermediate-risk PC. / / Objective To estimate and compare the risk of PC-specific mortality (PCSM) and all-cause mortality (ACM) following brachytherapy among men with low and favorable intermediate-risk PC. / / Design, Setting, and Participants Prospective cohort study of 5580 consecutively treated men (median age, 68 years) with localized adenocarcinoma of the prostate treated with brachytherapy at the Prostate Cancer Foundation of Chicago between October 16, 1997, and May 28, 2013. / / Intervention Standard of practice per the NCCN guidelines. / / Main Outcomes and Measures Fine and Gray competing risks regression and Cox regression analyses were used to assess whether the risks of PCSM and ACM, respectively, were increased in men with favorable intermediate-risk vs low-risk PC. Analyses were adjusted for age at brachytherapy, year of treatment, and known PC prognostic factors. / / Results After median follow-up of 7.69 years, 605 men had died (10.84% of total cohort), 34 of PC (5.62% of total deaths). Men with favorable intermediate-risk PC did not have significantly increased risk of PCSM and ACM compared with men with low-risk PC (adjusted hazard ratio [HR], 1.64; 95% CI, 0.76-3.53; P = .21 for PCSM; adjusted HR, 1.11; 95% CI, 0.88-1.39; P = .38 for ACM). Eight-year adjusted point estimates for PCSM were low: 0.48% (95% CI, 0.23%-0.93%) and 0.33% (95% CI, 0.19%-0.56%) for men with favorable intermediate-risk PC and low-risk PC, respectively. The respective estimates for ACM were 10.45% (95% CI, 8.91%-12.12%) and 8.68% (95% CI, 7.80%-9.61%). / / Conclusions and Relevance Men with low-risk PC and favorable intermediate-risk PC have similarly low estimates of PCSM and ACM during the first decade following brachytherapy. While awaiting the results of ProtecT, the randomized trial of AS vs treatment, our results provide evidence to support AS as an initial approach for men with favorable intermediate-risk PC.

BIDMC and BWH

Approximately 70% of babies born before 34 weeks of gestation have clinically significant apnea, bradycardia, or O2 desaturation during their hospital stay, known as apnea of prematurity. Apnea in infants born after 34 weeks of gestation may also have apnea due to immature breathing control, apnea of immaturity (AOI). While risk of apnea decreases with increasing gestational age at birth, AOI is a very common diagnosis in both late preterm and full term infants, and often is the sole reason for prolonged hospitalization for hundreds of thousands of such infants in the United States. The goal of this project is to describe the prevalence of apnea in late preterm to term infants in two large tertiary care neonatal intensive care units.



Division of Gastroenterology, Massachusetts General Hospital

We retrospectively analyzed all admissions to a tertiary care center with a heart failure exacerbation to determine the effect of constipation prophylaxis (i.e. laxatives) on length of stay and incidence of constipation in the hospital.

Boston Children's Hospital; Pediatric Health Services

Background: Use of unnecessary tests and treatments contributes to healthcare waste. The Choosing Wisely campaign charges medical societies with identifying such items. This report describes the identification of five tests and treatments in newborn medicine. / Methods: A national survey identified candidate tests and treatments. An expert panel of 51 individuals representing 28 perinatal care organizations narrowed the list over three rounds of a modified Delphi process. In the final round, the panel was provided with Grading of Recommendation, Assessment, Development and Evaluation literature summaries of the top 12. / Results: A total of 1648 candidate tests and 1222 treatments were suggested by 1,047 survey respondents. After three Delphi rounds, the expert panel achieved consensus on the following Top Five items: 1. Avoid routine use of anti-reflux medications for treatment of symptomatic gastroesophageal reflux disease or for treatment of apnea and desaturation in preterm infants; 2. Avoid routine continuation of antibiotic therapy beyond 48 hours for initially asymptomatic infants without evidence of bacterial infection; 3. Avoid routine use of pneumograms for pre-discharge assessment of ongoing and/or prolonged apnea of prematurity; 4. Avoid routine daily chest radiographs without an indication for intubated infants; 5. Avoid routine screening term-equivalent or discharge brain MRIs in preterm infants. / Conclusion: The Choosing Wisely Top Five for newborn medicine highlights tests and treatments that cannot be adequately justified on the basis of efficacy, safety, or cost. This list serves as a starting point for quality improvement efforts to optimize both clinical outcomes and resource utilization in newborn care. /

Brigham and Women's Hospital, Division of Gastroenterology, Hepatology, and Endoscopy

Chronic hepatitis B virus (HBV) infection affects an estimated 2.2 million people in the United States (U.S.) and 350 million people globally, resulting in approximately 1 million deaths annually. Prophylaxis to prevent vertical transmission from mothers to infants is standard of care and highly effective. Yet, despite nearly universal mandatory HBV screening of pregnant women in the U.S., there have been limited efforts in evaluating postpartum maternal outcomes and factors associated with poor follow-up. The overall goal of this study is to address the current knowledge gap in postpartum maternal HBV outcomes in a multi-disciplinary collaboration between the Brigham and Women’s Hospital (BWH) Division of Gastroenterology, BWH Department of Obstetrics and Gynecology, Harvard Medical School Department of Population Medicine, and Massachusetts Department of Public Health (MDPH). As current guidelines recommend that HBV patients be referred to physicians experienced in the management of chronic liver disease, we will use local, state, and national data sources to determine referral rates to HBV specialists and identify potential risk factors associated with poor follow-up.

Massachusetts General Hospital, Center for Quality and Safety

Patient tracers are a method used to evaluate care delivery. For my project I assembled a interdisciplinary team of health care experts to survey hospital units and shadow patients. Care assessments were made using direct observation, interviews and medical record review.



MGH Center for Quality and Safety, MGH Heart Center

Background –PCI is the most commonly performed revascularization modality for chronic stable angina, but does not provide survival benefit or reduction in MACE. PCI is performed in this population primarily for symptomatic benefit; therefore symptom reduction is an important marker of quality. Patient-reported outcome measures (PROMs) have been developed for chest pain and dyspnea which are valid and responsive to treatment, however they are not widely used in routine care. We present a model for use of PROMs in routine care. / Methods and Results – Partners Health System funded a tablet computer software platform to collect PROMs and include them in the medical record. We implemented this platform in the catheterization laboratory at Massachusetts General Hospital, targeting patients presenting for coronary angiography. Patients are assessed using the SAQ-7, the Rose dyspnea scale, the PHQ-2, and the PROMIS-10. We used a phased implementation, with the final program including pre-procedure measurement, presentation of data to clinical providers, and follow-up using an e-mail platform. We successfully captured measures from 474 patients, 57.9% of outpatient visits. Key success factors included high-level leadership support and resources, a user-friendly interface for patients and staff, easily interpretable measures, and clinical relevance. / Conclusions – We have demonstrated that routine capture of patient-reported symptom severity is technically feasible in a real-world care environment. We share our experiences to provide others with a model for similar programs, and to accelerate implementation nationwide by helping others avoid pitfalls. We believe expansion of similar programs nationally may lead to a more robust quality infrastructure. /

Brigham and Women's Hospital, Department of Gastroenterology

Idiopathic pulmonary fibrosis (IPF) is a chronic progressive lung disease with a median survival of 2-4 years and unpredictable natural history. It is often fatal without lung transplant. One of the putative risk factors for this disease is gastroesophageal reflux disease (GERD). The underlying mechanism for this association remains unclear, as both microaspiration of refluxate and increased transdiaphragmatic pressure gradient due to fibrosis have been implicated. Hypothesis: Comparing the GER profile in IPF patients to those with non-fibrotic lung disease of similar severity may help delineate the role of GER in pulmonary fibrosis. Multichannel intra-luminal impedance and pH study (MII-pH) might be a more sensitive measure of reflux as it measures both acid and nonacid reflux. This study was a cross-sectional/retrospective study of all patients from 2008-2014 who underwent lung transplant evaluation at Brigham and Women's Hospital and underwent MII-pH study as part of their evaluation. We found that patients with IPF have increased MII-pH parameters of GER compared to pts with COPD on both univariate and multivariate analyses. /



BIDMC Dept of Medicine, Division of Infectious Diseases

Background: Few published studies have made a comparison of the bloodstream infection (BSI) rate / / attributable to various catheter types within the same population. The National Healthcare Safety Network / / (NHSN) surveillance definition for central line-associated bloodstream infections (CLABSI) may have / / insufficient discrimination to capture nuances of BSI truly attributed to a intravascular catheter due to / / misattribution or underestimation. In this study, we sought to make a qualitative comparison of the / / incidence of catheter-attributable BSI when calculated using a less restrictive BSI definition. / / Methods: In this retrospective observational study, institutional databases were used to analyze all / / unique patient first ICU admissions from 4/2009 through 3/2014. The insertion and removal date/time / / were recorded for all catheter types except peripheral intravenous catheters. Catheter duration was / / counted using status at midnight until ICU discharge or BSI outcome, whichever came first. All-cause / / nosocomial BSI (inclusive of CLABSI), all-cause CLABSI, and specific catheter-attributable CLABSI were / / included if occurring within 14 days of ICU discharge. CLABSI definition followed NHSN protocol. The / / incidence of all-cause BSI, all-cause CLABSI, and specific catheter-attributable CLABSI were calculated / / in serial for the subpopulation of patients with a specific catheter type, including per 1,000 patient ICU / / admissions and per 1,000 catheter days. / / Results: 22,803 unique patient first ICU admissions were analyzed, during which there occurred 260 all- / / cause nosocomial BSI including 101 CLABSI. 12,953 (56.8%) of patients had ≥1 qualifying intravascular / / catheter placed during the ICU stay (Figure 1). The incidence of all-cause BSI, all-cause CLABSI, and / / specific catheter-attributable CLABSI among subpopulations with each catheter type are shown in Figure / / 2. / / Conclusions: Data from this observational study suggest there is possible misattribution, including / / underestimation of CLABSI using the current surveillance definition. Further studies may consider how to / / attribute BSI in the setting of multiple intravascular catheters and among different catheter types.

Brigham and Women's Hospital, Department of Quality and Safety

In 2010, a survey was conducted to better understand the inpatient mortality review process across different divisions and departments within the hospital. Some divisions/departments had very thorough mortality review processes in place while others did not. An inpatient mortality review tool was launched to capture frontline clinicians' perspectives on inpatient deaths. When a patient died in the hospital, an email containing a link to a peer-protected survey asking questions about infections, complications, delays in care, communication issues and end of life issues is sent to the responding clinician and the attending at the time of the patient's death. The tool has response rate over 95% and captures a lot of information that is often not cited in the medical record. Clinicians also assign a subjective preventability rating to the death from 1 to 5, 5 being most preventable and 1 being not preventable at all (an expected death). For the deaths rated 3, 4 or 5 or for deaths with suggestions or free text comments from reviewers, I conduct a thorough investigation and present these deaths on a monthly basis to our mortality review committee which consists of representation from clinical leadership, nursing quality and risk management. This committee then determines where the case should be sent for further review and what follow-up action is needed. I then circle back with the different departments to find out what was learned. We are in the process of figuring out how I might write this up as a quality improvement project.



The Program for Cancer Outcomes Research Training Fellowship, MGH Department of Surgery, and Ariadne Labs

There is increasing emphasis on the appropriateness and quality of acute surgical care for patients with serious illness, and at the end-of-life. This multi-institutional, retrospective cohort study seeks to characterize adverse outcomes and to identify factors independently associated with 30-day mortality among patients with disseminated cancer who undergo emergent abdominal surgery for intestinal obstruction or perforation using multivariate logistic regression. Between 2005 and 2012, 499 disseminated cancer patients undergoing emergency surgery for perforation were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Among patients who underwent surgery for perforation, 30-day mortality was 34%, 67% had complications and 52% were discharged to an institution. Renal failure, septic shock, ascites, dyspnea at rest, and dependent functional status were independent preoperative predictors of death at 30 days. When complications were considered, postoperative respiratory complications and age (75-84 years) were also predictors of mortality. Emergency abdominal operations in patients with disseminated cancer are highly morbid and many patients die within 30-days of their operation. High rates of morbidity and low rates of pre-existing DNR orders highlight the need for targeted interventions to reduce complications and integrate palliative approaches into the care of these patients.

Rheumatology Evaluation of environmental risk factors for lupus in NHS cohorts

Brigham and Women's Hospital, Department of Surgery, Section of Colon and Rectal Surgery

We perfromed a 12 year (2002-2012) retrospective review of all patients with stage IV CRC at DFCI to assess the morbidity and mortality with resection of the primary tumor. In contradistinction to the literature we found that extirpation of the primary lesion can be done as safely with same morbidity and mortality as in pateints with curable colon cancer. We then created a risk risk using multivaqriable logistic regression and cox proportional hazards model to help identify patients who would benefit from resetion of the primary tumor. We found that patients with low grade tumors, younger than 60, and 1 or fewer sites of metastatic disease had a median survival of 30.8 months when compared to the litterature for patients that received chemotherapy alone had a median survival of 19 months.

Integrative Medicine Research Fellowship/Gen Med

This is a pragmatic, randomized, controlled pilot study of pregnant women who either attend a weekly prenatal yoga class for at least 12 weeks or a time-matched educational control group (n=20 per group). It investigates the ability of prenatal yoga to prevent/attenuate the disabiliy due to back-pain. Its happening at BIDMC.

BIDMC Medicine/Infectious Diseases

My project is working on a quality improvement project for the BIDMC Outpatient Antibiotic Therapy program, which I serve as the medical director for. I'm performing a chart review of all of our enrollments in the academic year 2013-2014. In an early review of this data we discovered that fewer than 40% of our patients leave the hospital with lab orders that match the ID consult recommendations. Based on this finding, I performed a review of the process for the communication of ID consult recommendations, entry of orders by the primary team and the relaying of this information to Home Infusion companies. We have now created a standard process for the communication of ID consult OPAT order recommendations including medication specific lab order recommendations and I've developed an intake sheet for the home infusion companies to utilize to confirm our order recommendations. I will be trialing this new process this year and reviewing data from our ongoing enrollments to assess for improvement in adherence to recommendations as well as rates of adverse events including readmissions.



Global Women's Health Program, Connors Center for Women's Health and Gender Biology, Brigham and Women's Hospital

Drawing from similar programs that have improved maternal and neonatal outcomes, we designed a group antenatal care (ANC) program that creates social support and incorporates participatory action to engage women in rural Nepal in overcoming barriers to healthcare access. Women receive ANC in 2-hour group sessions co-facilitated by government midwives and community health workers (CHWs). Our program aims to increase institutional birth via improving health knowledge, self-efficacy, social support, and birth planning.

Cambridge Health Alliance, Department of Medicine

Little is known about persistent cost-barriers to seeing a physician among the insured after Massachusetts’ 2006 healthcare reform. We analyzed Behavioral Risk Factor Surveillance System data on insured adults age 18-64 in Massachusetts and control states. We examined the prevalence of cost-barriers to seeing a physician post-reform (2009-2010) by race/ethnicity and income and compared the pre (2004-2005) and post-reform prevalence in Massachusetts to control states using a difference-in-differences analysis. We also examined associations between being unable to see a physician and receiving preventive services.

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