NorthShore University HealthSystem Research Articles

Sprint-inspired One-on-One Post-Go-Live Training Session (Mini-Sprint) Improves Provider Electronic Health Record Efficiency and Satisfaction.

Inefficient electronic health record (EHR) usage increases the documentation burden on physicians and other providers, which increases cognitive load and contributes to provider burnout. Studies show that EHR efficiency sessions, optimization sprints, reduce burnout using a resource-intense five-person team. We implemented sprint-inspired one-on-one post-go-live efficiency training sessions (mini-sprints) as a more economical training option directed at providers. We evaluated a post-go-live mini-sprint intervention to assess provider satisfaction and efficiency. NorthShore University HealthSystem implemented one-on-one provider-to-provider mini-sprint sessions to optimize provider workflow within the EHR platform. The physician informaticist completed a 9-point checklist of efficiency tips with physician trainees covering schedule organization, chart review, speed buttons, billing, note personalization/optimization, preference lists, quick actions, and quick tips. We collected postsession survey data assessing for net promoter score (NPS) and open-ended feedback. We conducted financial analysis of pre- and post-mini-sprint efficiency levels and financial data. Seventy-six sessions were conducted with 32 primary care physicians, 28 specialty physicians, and 16 nonphysician providers within primary care and other areas. Thirty-seven physicians completed the postsession survey. The average NPS for the completed mini-sprint sessions was 97. The proficiency score had a median of 6.12 (Interquartile range (IQR): 4.71-7.64) before training, and a median of 7.10 (IQR: 6.25-8.49) after training. Financial data analysis indicates that higher level billing codes were used at a greater frequency post-mini-sprint. The revenue increase 12 months post-mini-sprint was $213,234, leading to a return of $75,559.50 for 40 providers, or $1,888.98 per provider in a 12-month period. Our data show that mini-sprint sessions were effective in optimizing efficiency within the EHR platform. Financial analysis demonstrates that this type of training program is sustainable and pays for itself. There was high satisfaction with the mini-sprint training modality, and feedback indicated an interest in further mini-sprint training sessions for physicians and nonphysician staff.

Personalized medicine in a community health system: the NorthShore experience.

Genomic and personalized medicine implementation efforts have largely centered on specialty care in tertiary health systems. There are few examples of fully integrated care systems that span the healthcare continuum. In 2014, NorthShore University HealthSystem launched the Center for Personalized Medicine to catalyze the delivery of personalized medicine. Successful implementation required the development of a scalable family history collection tool, the Genetic and Wellness Assessment (GWA) and Breast Health Assessment (BHA) tools; integrated pharmacogenomics programming; educational programming; electronic medical record integration; and robust clinical decision support tools. To date, more than 225,000 patients have been screened for increased hereditary conditions, such as cancer risk, through these tools in primary care. More than 35,000 patients completed clinical genetic testing following GWA or BHA completion. An innovative program trained more than 100 primary care providers in genomic medicine, activated with clinical decision support and access to patient genetic counseling services and digital healthcare tools. The development of a novel bioinformatics platform (FLYPE) enabled the incorporation of genomics data into electronic medical records. To date, over 4,000 patients have been identified to have a pathogenic or likely pathogenic variant in a gene with medical management implications. Over 33,000 patients have clinical pharmacogenomics data incorporated into the electronic health record supported by clinical decision support tools. This manuscript describes the evolution, strategy, and successful multispecialty partnerships aligned with health system leadership that enabled the implementation of a comprehensive personalized medicine program with measurable patient outcomes through a genomics-enabled learning health system model that utilizes implementation science frameworks.

FRI619 Kidney Magnetic Resonance Imaging Reveals Altered Tissue Architecture In Young Persons With Type 1 And 2 Diabetes

Abstract Disclosure: S. Poon: None. K. Nash: None. Y. Choi: None. L. Li: None. P. Prasad: None. D. Raalte: Other; Self; consulting relationships with Boehringer Ingelheim, Eli Lilly, Merck and Sanofi, and receives research operating funding from AstraZeneca, Boehringer Ingelheim-Eli Lilly Diabetes Alliance, MSD. A. Karihaloo: Employee; Self; Novo Nordisk. A. Sawyer: None. P. Bjornstad: Advisory Board Member; Self; AstraZeneca, Bayer, Lilly, Boehringer Ingelheim, Novo Nordisk, and XORTX. Other; Self; PB reports serving or having served as a consultant for AstraZeneca, Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Eli Lilly, LG Chemistry, Sanofi, Novo Nordisk, and Horizon Pharma. Background: Apparent diffusion coefficient (ADC) by magnetic resonance imaging (MRI) provides information about the microstructure and cellular organization of the kidney, and has been linked with kidney function decline in adults with chronic kidney disease. However, it is unclear whether alterations in tissue architecture or cellular density are also present in young persons with type 1 and 2 diabetes. Accordingly, the objective of this analysis was to determine early changes in ADC among young persons with and without diabetes. Materials and Method: Kidney MRIs were performed in 37 lean controls (age: 18±6 years, 54% female, eGFR: 106±19 ml/min/1.73m2), 28 participants with youth-onset T1D (age: 20±4 years, 50% female, diabetes duration: 9±6 years, HbA1c: 8.3±1.3%, eGFR: 110±19 ml/min/1.73m2) and 30 participants with youth-onset T2D (age: 17±4 years, 62% female, diabetes duration: 2±2 years, HbA1c: 7.4±2.2%, eGFR: 127±24 ml/min/1.73m2). All scans were performed on 3T whole-body scanners. A single reader at The NorthShore University HealthSystem analyzed all images while blinded to participants’ clinical information. Lower values of cortical ADC on diffusion-weighted MRI may indicate increased cellular density and are often used to estimate fibrosis. Estimated GFR (eGFR) were calculated by Full Age Spectrum serum creatinine equation. We performed multivariable linear regression models adjusted for age and sex. Results: Compared to lean controls (age and sex-adjusted means ± standard errors (SE): (1722±22 × 10−6 mm2/s), young persons with T1D (1636±28 × 10−6 mm2/s, p=0.02) and T2D (1612±27 × 10−6 mm2/s, p=0.002) exhibited lower cortical ADC. Despite younger age and shorter diabetes duration, young persons with T2D had numerically lower cortical ADC compared to those with T1D, although the difference did not reach statistical significance. Higher age and male sex were associated with lower cortical ADC (β±SE: −7.5±2.8 x 10−6 mm2/s per 1 year of age, p=0.009; β±SE: −71.1±28.5 x 10−6 mm2/s per 1 year for male sex, p=0.008) in multivariable models. Lower eGFR was associated with lower cortical ADC (β±SE: 2.3±0.8 x 10−6 mm2/s per 1 ml/min/1.73m2 increment eGFR, p=0.005). HbA1c and urine albumin-to-creatinine ratio did not associate significantly with cortical ADC in multivariable models. Conclusion: Young persons with diabetes exhibit lower cortical ADC compared to healthy lean controls, suggesting alternations in microstructure and cellular density and potentially early signs of fibrosis. Additionally, despite shorter duration of disease and younger age, participants with T2D had the lowest cortical ADC values among the 3 groups. Further research is needed to investigate the role of cortical ADC in predicting kidney function decline in young individuals with diabetes, as well as molecular determinants of the alterations in microstructure and cellular density. Presentation: Friday, June 16, 2023

Trial of a Patient-Directed eHealth Program to Ameliorate Perinatal Depression: The MomMoodBooster2 Practical Effectiveness Study

ABSTRACT Perinatal depression and postpartum depression represent a significant burden for those who experience them and are associated with preterm birth, low birth weight, postpartum hospitalization, diminished mother-child relationships, offspring developmental delay, and other important markers of health and well-being. Perinatal depression, in particular, is underidentified and thus undertreated. This study was designed to assess the MMB eHealth program (MomMoodBooster2 [MMB2]), which is targeted toward perinatal depression, with an aim to assess the effectiveness of the smartphone version of this tool. Primary outcomes were targeted toward analyzing the extent to which MMB2 relieved the severity of anxiety and depression symptoms in general (using both perinatal and postpartum tools); secondary outcomes focused on usage trends along with ratings of usability and helpfulness. Participants were recruited from the Perinatal Depression Program (PDP) in the NorthShore University HealthSystem. Eligibility criteria included pregnant women and women less than a year postpartum, age older than 18 years, no active suicidal ideation, access to internet, and English language proficiency. REDCap (Vanderbilt University Nashville, Tenn) was used for onboarding and randomization. Final analyses included 191 patients randomized into 2 groups, one with MMB2 and the PDP protocol and one with only PDP. After program completion, 93% of patients completed an associated posttest. Primary screenings were not significantly different between groups, and baseline characteristics were likewise consistent. Controlling for perinatal status, posttests showed a significant decrease in depression severity, anxiety, stress, and automatic thoughts (P ≤ 0.001), as well as an increase in behavioral activation and self-efficacy. Further analysis showed that the MMB2 group showed greater decreases from baseline to posttest in both stress (P = 0.019) and depression severity (P = 0.003). No other significant effects were found when comparing the 2 groups. Usage of MMB2 varied, but generally showed that patients visited the program shortly after receiving the first invitation and then periodically on multiple distinct days between their first and last visit to their health care provider (mean [SD] visits, 49.4 [30.2] distinct days). Perinatal tools were used by 41% of participants, and 43% used postpartum tools, with 10% using both tools because of being pregnant at initial recruitment but delivering over the course of the study. The program included text messages for the first 12 weeks, and impact of these was not directly assessed. Of ratings provided, 96% rated the program as “somewhat” to “extremely” easy to use, and 83% of participants rated it as “somewhat” to “extremely” helpful. Many participants in both groups reported using other management strategies such as medication, therapy sessions, and physician advice, but use of these interventions did not differ between groups. These results indicate that MMB2 is effective at reducing anxiety and depression severity, as well as improving self-efficacy. Clinically, this eHealth tool may be an appropriate way to subsidize care for women where in-person options are limited or other options are unavailable. It could also be used to augment in-person options for management of depressive symptoms. Further research should focus on larger and more diverse populations, to understand if the findings are generalizable beyond this small population. In addition, the sustainability and adoption strategies should be optimized to allow this program to be as far reaching as possible. More research could also examine long-term follow-up and durability of the effects of this treatment.

A-170 Investigation of High Rate of Low Positive Quantiferon-TB Gold Plus Results

Abstract Background Tuberculosis (TB) is a communicable disease, transmitted almost exclusively by cough aerosols carrying pathogens of the M. tuberculosis complex. TB continues to be a major public health threat, causing an estimated 10.4 million new cases and 1.3 million deaths from TB globally in 2016. Many more people may have latent tuberculosis infection (LTBI), which may go undetected without further laboratory investigation. The Quantiferon-TB Gold Plus (QFT-Plus) is an Interferon Gamma Release Assay (IGRA) for the identification of LTBI. It detects the cellular immune response to antigens of M. tuberculosis and represents an indirect marker of M. tuberculosis exposure. In January of 2021, the NorthShore University HealthSystem Core Laboratory transitioned from a reference laboratory ELISA-based QFT-Plus test to an in-house DiaSorin LIAISON® QuantiFERON®-TB Gold Plus test. After implementation, we noticed a higher rate of low positive QFT-Plus results (1.3%–5.4%) in our patient population that we regard as a mixed risk population. The expected percent of low positive results in a mixed risk population is 2%–3%. Objective To determine the potential causes of a higher rate of low positive Quantiferon-TB Gold Plus Results. Methods Forty specimens with Antigen-Nil results between 0.35–1.00 IU/mL using LIAISON® QuantiFERON®-TB Gold Plus reagent from 8/2022–10/2022 were collected for this study. All forty specimens were re-tested using ELISA-based methodology. Patient demographics and medical history were reviewed for any factor that may be responsible for the low positive results. Results Results from the two different methodologies were compared: 28/40 (70%) specimens showed positive results on the DiaSorin LIAISON®-XL platform, but negative results on the ELISA platform. Review of medical history showed that 92% of the sample population had received more than 2 doses of COVID-19 vaccine and 12.5 % had previous COVID-19 infection. 30% had an underlying autoimmune disease, with psoriasis and rheumatoid arthritis being the most common. However, no correlation was found between medical or vaccination history and the QFT-Plus results. Conclusion LIAISON® QuantiFERON®-TB Gold Plus is a Chemiluminescence immunoassay which is more sensitive than ELISA, resulting in an increased number of low positive QFT-Plus results. Physicians need to correlate clinical findings and TB exposure history to the QFT-Plus results when making clinical decisions.

A Prospective Randomized Controlled Pilot Simulation Study to Investigate the Effect of Audiovisual Decision Support on Diagnosis and Therapeutic Interventions.

Combining audiovisual decision support during perioperative critical events might enhance provider diagnostic and therapeutic accuracy and efficiency. This study is a prospective, randomized controlled pilot trial studying the impact of audiovisual decision support on anesthesia professional performance at NorthShore University HealthSystem's high fidelity simulation center. Twenty anesthesia professionals (>2 years of clinical experience in the current role) were randomized to 2 groups (current care model vs. audiovisual assistance) and underwent 3 periprocedural simulation scenarios, where patient deterioration occurs: anaphylaxis, amniotic fluid embolism, and cardiac arrest during dental case. Overall, there was a statistically significant decrease in the mean and median pooled times to diagnosis in both the amniotic fluid embolism and pediatric dental scenarios. There was a statistically significant increase in the number of participants in the intervention group who made diagnosis 3 before the end of the scene (P = 0.03) in the amniotic fluid embolism case. In the pediatric dental case, there was a statistically significant reduction in the median time to diagnosis 1 and diagnosis 3 in the intervention group versus control (P = 0.01 and P = 0.0002). A significant increase in the number of participants in the intervention group versus control made the correct diagnosis 2 before vital sign change 3 (P = 0.03), and more participants in the intervention group made the correct diagnosis 3 before the end of the scene when compared with control (P = 0.001). The median time to start intervention 2 during the dental case was statistically significantly greater in the intervention group versus the control (P = 0.05). All other endpoints were not statistically significant among the 3 simulation scenarios. Six questions were answered by all participants upon immediate completion of the simulation scenarios and revealed that 19 of 20 participants had delivered anesthesia care to patients similar to the 3 simulation scenarios and 18 of 20 participants reported that they would prefer audiovisual assistance to detect abnormalities in vital signs that subsequently provides appropriate diagnostic and therapeutic options. This pilot study suggested some significant improvement in anesthesia professional time to correct diagnosis and completion of identification of the correct diagnosis before the next vital change in the audiovisual cue group versus control, particularly in the outpatient dental case. In addition, the mean and median pooled times to diagnosis were significantly reduced by approximately 1 minute in both evaluated simulation scenarios. The postsimulation survey responses also suggest the desirability of an audiovisual decision support tool among the current anesthesia professional participants. However, overall, there were no significant differences in the time to intervention between groups in all simulation scenarios.

A Quality Improvement Study Designed to Optimize Scheduling Geographic/Site Preferences Among Anesthesia Professionals Utilizing Decision Support Tool Assistance.

This is a quality improvement pilot study comparing percentages of anesthesia professionals receiving their first choice of workplace location both pre-, and post-implementation of an electronic decision support toolfor anesthesia-in-charge schedulers.The study evaluates anesthesia professionals who use theelectronic decision support tool and scheduling system at four hospitals and two surgical centers within NorthShore University HealthSystem. The subjects in the study are those anesthesia professionals that work at NorthShore University HealthSystem and are subject to being placed in their desired location by anesthesia schedulers who use the electronic decision support tool. The primary author developed the current software system enabling the electronic decision support tool implementation into clinical practice. All anesthesia-in-charge schedulers were educated during a three-week time period via administrative discussions and demonstrations on how to effectively operate the tool in real time. The total numbers and percentage of1st choice of location selection by anesthesia professionals were summarized each week using interrupted time series Poisson regression. Slope before intervention, slope after intervention, level change, and slope change were all measured over 14-week pre- and post- implementation periods. The level of change (difference in percentage of anesthesia professionals who receivedtheir first choice) was statistically (P<0.0001) and clinically significant when comparing the historical cohorts of 2020 and 2021 to the 2022 intervention group weeks. Therefore, the implementation of an electronic decision support scheduling tool resulted in a statistically significant increase in those anesthesia professionals receiving their first-choice workplace location. This study provides the basis for further investigating whether this specific tool may improve anesthesiaprofessional satisfaction within their work-life balance by enhancing workplace geographic/site choice.

Abstract P5-03-15: Application of 21-gene Breast Recurrence Score® assay to evaluate prognosis and benefit of adjuvant chemotherapy in BRCA1 and BRCA2 pathogenic variant carriers with early stage, estrogen receptor positive breast cancer

Abstract Background: Minimal data exists for the utilization of the Oncotype Dx® assay specifically in breast cancers associated with BRCA1/2 pathogenic variants (PVs). It is unknown whether estrogen receptor positive (ER+) breast cancer associated with an inherited BRCA1 or BRCA2 (BRCA1/2) PV is more aggressive than disease seen in patients who do not carry an inherited PV, and whether there are differences between BRCA1 and BRCA2. In prostate cancer patients with inherited cancer predisposition due to a BRCA2 PV, more aggressive cancers are observed, which influences first-line treatment. Limited data exists for the optimal management of early stage ER+ breast cancer in BRCA1/2 PV carriers. Comparing Recurrence Score® (RS) results in ER+ breast cancer patients with an inherited BRCA1/2 PV (cases) versus matched patients who test negative for a PV in BRCA1/2 (controls) may inform whether biologically more aggressive breast cancer is seen in BRCA1/2 carriers and optimal treatment approaches. Methods: A retrospective case control study was performed to compare RS results in women with breast cancer with an inherited BRCA1/2 PV versus patients who tested negative for an inherited BRCA1/2 PV. Female breast cancer patients seen between 2005-2020 at NorthShore University Health System with ER+Her2- early stage invasive breast cancer with 0-3 lymph nodes who completed genetic testing for BRCA1/2 were eligible for enrollment. BRCA1/2 cases were defined as individuals with an inherited PV in BRCA1/2 and controls were negative for BRCA1/2 or other known breast cancer risk gene PVs tested. Subjects were excluded if they had neoadjuvant therapy (hormonal or cytotoxic chemotherapy). Eligible cases were matched to control patients by age, grade, and stage. The Recurrence Score result was obtained by chart review; if not previously evaluated, Oncotype Dx assay was performed by Exact Sciences. Statistical analysis of the primary outcome used the paired t-test to determine mean difference in RS results between BRCA1/2 PV carriers and patients negative for a PV in BRCA1/2 using a 1:1 matched pairs design. Results: A total of 46 matched cases and controls were analyzed. Median age was 50 with a range of 28-74. Of the cases, 18 had a BRCA1 PV and 28 had a BRCA2 PV. Cases and controls were well matched for age (&amp;gt; 50 and ≤ 50); race, grade, stage, and progesterone receptor status. As expected, a higher number of BRCA1/2 carriers were treated with mastectomy while more of the controls received breast-conserving surgery. Chemotherapy was utilized more frequently in the cases (67.4%) versus the controls (54.4%). The average RS result was higher in the cases (27) than the controls (21.3) by a mean difference of 5.7 (p = 0.0195). Using Oncotype Dx cutoffs of low &amp;lt; 18, intermediate 18-30 and high ≥ 31, a statistically significant difference in RS result was noted in the cases versus controls. For cases in the highest risk group (Oncotype Dx ≥ 31), only 20% of their matches also had a score in the highest risk group while 35% had a score in the lowest risk group. Subgroup analysis showed that the cases had the largest difference in RS result from their controls in premenopausal women (age ≤ 50), BRCA1 carriers, and the node negative population. Conclusion We present one of the largest data sets available to date of a well-matched cohort of cases and controls which shows that BRCA1/2 PV carriers are more likely to have a higher Recurrence Score result than their matched controls when matched for age, grade, and stage. These findings suggest ER+ breast cancer in BRCA1/2 PV carriers is biologically more aggressive. Further investigation is warranted to evaluate how this important finding impacts adjuvant therapy recommendations for BRCA1/2 PV carriers. Citation Format: Poornima Saha, Ashley Aller, Amanda Deliere, Peter Hulick, Katharine Yao, Kristine Kuchta, Megan Sullivan, Allison DePersia. Application of 21-gene Breast Recurrence Score® assay to evaluate prognosis and benefit of adjuvant chemotherapy in BRCA1 and BRCA2 pathogenic variant carriers with early stage, estrogen receptor positive breast cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-03-15.

Abstract P6-02-03: Breast Health Assessment: A family health history tool using the electronic health record and clinical decision support to facilitate guidelines-driven hereditary breast cancer genetic testing at the time of screening mammogram

Abstract Background: Genetic testing (GT) is recommended for women who have a personal or family history of breast cancer and are at increased risk of carrying an inherited breast cancer risk gene pathogenic variant (PV) as defined by the National Comprehensive Cancer Network (NCCN) guidelines. Data shows that traditional GT workflows do not reach a large proportion of women eligible for GT. NorthShore University HealthSystem previously implemented the Genetic Wellness Assessment, a family health history (FHH) screening tool utilizing the electronic health record (EHR) and clinical decision support, to identify individual and familial risks to health conditions and personalize screening and prevention practices in primary care. To increase access to hereditary breast cancer GT, we implemented a similar FHH screening tool called the Breast Health Assessment (BHA) for patients completing routine screening mammogram. We describe uptake and results from implementation of the BHA in conjunction with routine screening mammogram. Methods: Patients scheduled for screening mammogram were assigned the BHA prior to their mammogram via the EHR portal. BHA questions addressed personal and family history of breast cancer and other cancer types associated with hereditary breast cancer syndromes. Upon completion of the BHA, patients who screened positive, i.e. identified as having a high-risk personal or family cancer history based on NCCN guidelines, were offered a comprehensive hereditary cancer panel (HCP). HCP included 38 genes associated with common cancer types, including all high and moderate risk breast cancer genes for which there are NCCN management guidelines. Individuals who were not identified as high-risk were offered a genetic health screen, which consisted of 148 genes associated with common cancer types, genetic forms of heart disease, medication response, and other health conditions. Saliva sample collection for GT occurred at the time of the patient’s screening mammogram appointment. Results: From August 2021 through May 2022, 32,438 patients were assigned the BHA prior to screening mammogram. Of these patients, 14,128/32,438 (44%) completed the BHA questionnaire. Based on BHA reponse, 3,490/14,128 (25%) screened positive and met NCCN criteria for GT for hereditary breast cancer risk genes and 529/3,490 (15%) completed GT. Additionally, 713/10,638 (7%) patients who screened negative on the BHA completed testing. In total, 1,242/14,128 patients (9%) completed GT and 78/1,242 (6%) were found to carry an inherited PV in a cancer risk gene, 35 of which were in an NCCN guidelines breast cancer risk gene. Of the 78 patients with a positive GT result, 57/78 (73%) had not been previously recommended for a genetics evaluation and/or received a genetics referral. Conclusion: The BHA is a novel FHH tool which increases access to hereditary breast cancer GT at the time of screening mammogram. Nearly half of women who completed screening mammogram completed the BHA and learned valuable information about their breast cancer risk and were invited to complete GT. Genetic testing completed through the BHA identified 78 patients with an actionable inherited PV in a cancer risk gene. This invaluable information will lead to potentially lifesaving personalized cancer screening and risk reduction and help identify additional at risk family members. Notably, 73% of patients who carried an inherited PV had not been previously recommended by their medical teams for genetic counseling and/or testing. The BHA has the potential to help close the care gap in GT for women at increased risk of breast cancer. Citation Format: Allison DePersia, Sarah Choi, Katharine Yao, Henry Dunnenberger, Peter Hulick. Breast Health Assessment: A family health history tool using the electronic health record and clinical decision support to facilitate guidelines-driven hereditary breast cancer genetic testing at the time of screening mammogram [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P6-02-03.

Abstract 12053: Worsening Tricuspid Regurgitation After Leadless Pacemaker Implantation Leads to Higher Hospitalization for Heart Failure

Introduction: One of the many purported benefits of a leadless pacemaker (LP) is avoidance of interaction with the tricuspid valve, decreasing tricuspid valve dysfunction from chronic injury resulting from contact with transvenous leads. Data suggests that 31-38% of patients develop worsening tricuspid regurgitation (TR) after transvenous pacemaker implantation. However, some recent data suggest that LP therapy is also associated with a higher incidence of worsening TR, possibly similar to transvenous pacemakers. We present data from a large community-based health system on the incidence of worsening TR after LP implantation and its clinical implications. Methods: A total of 256 patients (mean age 80±10 years, 61% male) who received Micra leadless single chamber pacemaker devices at the NorthShore University HealthSystem between April 2017 and November 2021 were retrospectively reviewed. A total of 103 patients (40%) received both a transthoracic echocardiogram within 6 months pre-implantation and 6 months post-implantation. Characterization of TR and heart failure hospitalization were gathered through chart review. Results: Of the 103 patients, 39 (38%) were found to have worsening of their TR after LP implantation when compared to before. Of the patients with worsening TR, 18 (46%) required hospitalization for heart failure within 12 months, compared to 15 (23%) without worsening TR ( X 2 = 5.7, p = 0.02). Conclusions: LP implantation is associated with comparable levels of worsening TR (38%) when compared to transvenous pacemakers. Worsening TR is associated with increased heart failure hospitalization within 12 months. More data is required to establish the reasoning behind the comparable levels of worsening TR in LP given the lack of mechanical interaction with the tricuspid valve apparatus.

The 17-gene Genomic Prostate Score assay as a predictor of biochemical recurrence in men with intermediate and high-risk prostate cancer.

The validated 17-gene Oncotype DX Genomic Prostate Score® (GPS™) assay risk-stratifies prostate-cancer patients with localized disease. The assay has primarily been utilized in lower risk patients deciding between active surveillance versus definitive therapy. In this retrospective cohort study, we analyze the association of the GPS result with time to biochemical recurrence post-prostatectomy in patients with National Comprehensive Cancer Network® (NCCN) intermediate and higher risk prostate cancer. The 141 patients included in the study were from the NorthShore University HealthSystem diagnosed 2014-2019 with NCCN intermediate (n = 109) or higher risk (n = 32) prostate cancer, treated with radical prostatectomy 2015-2019. The association of GPS result with time to biochemical recurrence was evaluated using univariable and multivariable Cox proportional hazards models in 120 patients with unfavorable intermediate or higher risk. Median (interquartile range) follow-up time was 28 (20 to 38) months. The GPS result was significantly associated with time to biochemical recurrence as both a continuous and dichotomous variable in univariable (hazard ratio [HR] per 20 GPS units 2.36, 95% CI 1.45-3.80, p < 0.001; HR for GPS result 41-100 vs 0-40 3.28, 95% CI 1.61-7.19, p < 0.001) and in multivariable models accounting for NCCN risk group (HR per 20 GPS units 2.14, 95% CI 1.31-3.46, p = 0.003; HR for GPS result 41-100 vs 0-40 3.00, 95% CI 1.43-6.72, p = 0.003) or biopsy Gleason Score and diagnostic PSA or PSA density. These results indicate that the GPS assay was a strong predictor of biochemical recurrence after radical prostatectomy in this unfavorable intermediate and higher risk prostate cancer patient population.

Successful Hepatitis C Birth Cohort Screening and Linkage to Care in a US Community Health System.

Context:Birth cohort (“baby boomer”) screening represents a well-validated strategy for the identification of asymptomatic hepatitis C–infected patients. However, successful linkage of newly diagnosed patients to antiviral therapy has been more difficult to accomplish.Objective:To analyze the results of a systemwide birth cohort screening program in a US community health care system.Design:We analyzed the data from an ongoing hepatitis C virus (HCV) screening and treatment program that was established at NorthShore University Health System in 2015. Hepatitis C virus screening by primary care providers was prompted through automated Best Practice and Health Maintenance alerts. Patient visits and screening orders were tracked using a customized HCV dashboard. Virologic, demographic, and treatment data were assessed and compared with those of a cohort of patients with previously established HCV infection.Results:Since program inception, 61 8161 (64.3%) of the entire NorthShore baby boomer population of 96 001 patients have completed HCV antibody testing, and 160 patients (0.26%) were antibody positive. Of 152 antibody-positive patients who underwent HCV RNA testing, 53 (34.2%) were viremic. A total of 39 of 53 patients (73.6%) underwent antiviral therapy and achieved a sustained virologic response. Compared with patients identified through screening, a comparison cohort of patients with previously established HCV had more advanced fibrosis and significantly lower dropout rates. The COVID-19 pandemic was associated with a decrease in the number of outpatient visits of screening-eligible patients and with a reduction in HCV screening rates.Conclusion:Our data demonstrate the electronic medical records–assisted systemwide implementation of HCV birth cohort screening and successful linkage to antiviral therapy in a community-based US multihospital system.

CORR Insights®: Phone Administration of the Western Ontario Shoulder Instability Index Is More Reliable Than Administration via Email.

1Clinical Professor, NorthShore University Health System, Northshore Evanston Hospital, Evanston, IL, USA J. L. Koh, Evanston Hospital, Northshore University Health System, 1000 Central Street, Suite 880, Evanston, IL 60201, USA, Email: [email protected] This CORR Insights® is a commentary on the article “Phone Administration of the Western Ontario Shoulder Instability Index Is More Reliable Than Administration via Email” by Goetti and colleagues available at: DOI: 10.1097/CORR.0000000000002320. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Continuous Remote Patient Monitoring in Patients With Heart Failure (Cascade Study): Protocol for a Mixed Methods Feasibility Study.

BackgroundHeart failure (HF) is a prevalent chronic disease and is associated with increases in mortality and morbidity. HF is a leading cause of hospitalizations and readmissions in the United States. A potentially promising area for preventing HF readmissions is continuous remote patient monitoring (CRPM).ObjectiveThe primary aim of this study is to determine the feasibility and preliminary efficacy of a CRPM solution in patients with HF at NorthShore University HealthSystem.MethodsThis study is a feasibility study and uses a wearable biosensor to continuously remotely monitor patients with HF for 30 days after discharge. Eligible patients admitted with an HF exacerbation at NorthShore University HealthSystem are being recruited, and the wearable biosensor is placed before discharge. The biosensor collects physiological ambulatory data, which are analyzed for signs of patient deterioration. Participants are also completing a daily survey through a dedicated study smartphone. If prespecified criteria from the physiological data and survey results are met, a notification is triggered, and a predetermined electronic health record–based pathway of telephonic management is completed. In phase 1, which has already been completed, 5 patients were enrolled and monitored for 30 days after discharge. The results of phase 1 were analyzed, and modifications to the program were made to optimize it. After analysis of the phase 1 results, 15 patients are being enrolled for phase 2, which is a calibration and testing period to enable further adjustments to be made. After phase 2, we will enroll 45 patients for phase 3. The combined results of phases 1, 2, and 3 will be analyzed to determine the feasibility of a CRPM program in patients with HF. Semistructured interviews are being conducted with key stakeholders, including patients, and these results will be analyzed using the affective adaptation of the technology acceptance model.ResultsDuring phase 1, of the 5 patients, 2 (40%) were readmitted during the study period. The study completion rate for phase 1 was 80% (4/5), and the study attrition rate was 20% (1/5). There were 57 protocol deviations out of 150 patient days in phase 1 of the study. The results of phase 1 were analyzed, and the study protocol was adjusted to optimize it for phases 2 and 3. Phase 2 and phase 3 results will be available by the end of 2022.ConclusionsA CRPM program may offer a low-risk solution to improve care of patients with HF after hospital discharge and may help to decrease readmission of patients with HF to the hospital. This protocol may also lay the groundwork for the use of CRPM solutions in other groups of patients considered to be at high risk.International Registered Report Identifier (IRRID)DERR1-10.2196/36741

Assessment of Awake Prone Positioning in Hospitalized Adults With COVID-19

Awake prone positioning may improve hypoxemia among patients with COVID-19, but whether it is associated with improved clinical outcomes remains unknown. To determine whether the recommendation of awake prone positioning is associated with improved outcomes among patients with COVID-19-related hypoxemia who have not received mechanical ventilation. This pragmatic nonrandomized controlled trial was conducted at 2 academic medical centers (Vanderbilt University Medical Center and NorthShore University HealthSystem) during the COVID-19 pandemic. A total of 501 adult patients with COVID-19-associated hypoxemia who had not received mechanical ventilation were enrolled from May 13 to December 11, 2020. Patients were assigned 1:1 to receive either the practitioner-recommended awake prone positioning intervention (intervention group) or usual care (usual care group). Primary outcome analyses were performed using a bayesian proportional odds model with covariate adjustment for clinical severity ranking based on the World Health Organization ordinal outcome scale, which was modified to highlight the worst level of hypoxemia on study day 5. A total of 501 patients (mean [SD] age, 61.0 [15.3] years; 284 [56.7%] were male; and most [417 (83.2%)] were self-reported non-Hispanic or non-Latinx) were included. Baseline severity was comparable between the intervention vs usual care groups, with 170 patients (65.9%) vs 162 patients (66.7%) receiving oxygen via standard low-flow nasal cannula, 71 patients (27.5%) vs 62 patients (25.5%) receiving oxygen via high-flow nasal cannula, and 16 patients (6.2%) vs 19 patients (7.8%) receiving noninvasive positive-pressure ventilation. Nursing observations estimated that patients in the intervention group spent a median of 4.2 hours (IQR, 1.8-6.7 hours) in the prone position per day compared with 0 hours (IQR, 0-0.7 hours) per day in the usual care group. On study day 5, the bayesian posterior probability of the intervention group having worse outcomes than the usual care group on the modified World Health Organization ordinal outcome scale was 0.998 (posterior median adjusted odds ratio [aOR], 1.63; 95% credibility interval [CrI], 1.16-2.31). However, on study days 14 and 28, the posterior probabilities of harm were 0.874 (aOR, 1.29; 95% CrI, 0.84-1.99) and 0.673 (aOR, 1.12; 95% CrI, 0.67-1.86), respectively. Exploratory outcomes (progression to mechanical ventilation, length of stay, and 28-day mortality) did not differ between groups. In this nonrandomized controlled trial, prone positioning offered no observed clinical benefit among patients with COVID-19-associated hypoxemia who had not received mechanical ventilation. Moreover, there was substantial evidence of worsened clinical outcomes at study day 5 among patients recommended to receive the awake prone positioning intervention, suggesting potential harm. ClinicalTrials.gov Identifier: NCT04359797.

Male Infertility.

Male Infertility.

An operationally implementable model for predicting the effects of an infectious disease on a comprehensive regional healthcare system.

An operationally implementable predictive model has been developed to forecast the number of COVID-19 infections in the patient population, hospital floor and ICU censuses, ventilator and related supply chain demand. The model is intended for clinical, operational, financial and supply chain leaders and executives of a comprehensive healthcare system responsible for making decisions that depend on epidemiological contingencies. This paper describes the model that was implemented at NorthShore University HealthSystem and is applicable to any communicable disease whose risk of reinfection for the duration of the pandemic is negligible.

Continuous Remote Patient Monitoring: Evaluation of the Heart Failure Cascade Soft Launch.

We report on our experience of deploying a continuous remote patient monitoring (CRPM) study soft launch with structured cascading and escalation pathways on heart failure (HF) patients post-discharge. The lessons learned from the soft launch are used to modify and fine-tune the workflow process and study protocol. This soft launch was conducted at NorthShore University HealthSystem's Evanston Hospital from December 2020 to March 2021. Patients were provided with non-invasive wearable biosensors that continuously collect ambulatory physiological data, and a study phone that collects patient-reported outcomes. The physiological data are analyzed by machine learning algorithms, potentially identifying physiological perturbation in HF patients. Alerts from this algorithm may be cascaded with other patient status data to inform home health nurses' (HHNs') management via a structured protocol. HHNs review the monitoring platform daily. If the patient's status meets specific criteria, HHNs perform assessments and escalate patient cases to the HF team for further guidance on early intervention. We enrolled five patients into the soft launch. Four participants adhered to study activities. Two out of five patients were readmitted, one due to HF, one due to infection. Observed miscommunication and protocol gaps were noted for protocol amendment. The study team adopted an organizational development method from change management theory to reconfigure the study protocol. We sought to automate the monitoring aspects of post-discharge care by aligning a new technology that generates streaming data from a wearable device with a complex, multi-provider workflow into a novel protocol using iterative design, implementation, and evaluation methods to monitor post-discharge HF patients. CRPM with structured escalation and telemonitoring protocol shows potential to maintain patients in their home environment and reduce HF-related readmissions. Our results suggest that further education to engage and empower frontline workers using advanced technology is essential to scale up the approach.

MP62-13 ASSOCIATION OF PROSTATE CANCER POLYGENIC RISK SCORE WITH NUMBER AND LATERALITY OF TUMOR CORES IN ACTIVE SURVEILLANCE PATIENTS

You have accessJournal of UrologyProstate Cancer: Localized: Active Surveillance II (MP62)1 Sep 2021MP62-13 ASSOCIATION OF PROSTATE CANCER POLYGENIC RISK SCORE WITH NUMBER AND LATERALITY OF TUMOR CORES IN ACTIVE SURVEILLANCE PATIENTS Jianfeng Xu, William Isaacs, Mufaddal Mamawala, Zhuqing Shi, Patricia Landis, Jacqueline Petkewicz, Jun Wei, W. Kyle Resurreccion, Rong Na, Yasin Bhanji, Kristian Novakovic, Patrick Walsh, S. Lilly Zheng, Brian Helfand, and Christian Pavlovich Jianfeng XuJianfeng Xu More articles by this author , William IsaacsWilliam Isaacs More articles by this author , Mufaddal MamawalaMufaddal Mamawala More articles by this author , Zhuqing ShiZhuqing Shi More articles by this author , Patricia LandisPatricia Landis More articles by this author , Jacqueline PetkewiczJacqueline Petkewicz More articles by this author , Jun WeiJun Wei More articles by this author , W. Kyle ResurreccionW. Kyle Resurreccion More articles by this author , Rong NaRong Na More articles by this author , Yasin BhanjiYasin Bhanji More articles by this author , Kristian NovakovicKristian Novakovic More articles by this author , Patrick WalshPatrick Walsh More articles by this author , S. Lilly ZhengS. Lilly Zheng More articles by this author , Brian HelfandBrian Helfand More articles by this author , and Christian PavlovichChristian Pavlovich More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002102.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Prostate cancer (PCa) is characterized by its tendency to be multifocal. However, few studies have investigated the endogenous factors that explain multifocal disease. The primary objective of the current study is to test whether inherited PCa risk is associated with multifocal tumors in PCa patients. METHODS: Subjects in this study were Caucasian PCa patients undergoing active surveillance (AS) at Johns Hopkins Hospital (JHH, N=805) and NorthShore University HealthSystem (NSUHS, N=432). Inherited risk was measured by genetic risk score (GRS), an odds ratio (OR)-weighted and population-standardized polygenic risk score based on known risk-associated SNPs. PCa multifocality was indirectly measured by the number and laterality of positive tumor cores from a 12-core systematic biopsy. RESULTS: In the combined cohort, 36% and 66% of patients had ≥2 tumor cores at the initial diagnostic biopsy and on at least one subsequent surveillance biopsy, respectively. For tumor laterality, 8.0% and 47% patients had bilateral tumor cores at diagnostic and surveillance biopsies, respectively. We found, for the first time, that patients with higher numbers of positive cores at diagnostic and surveillance biopsies, respectively, had significantly higher mean GRS values, p=0.02 and p<0.001 (Table). Additionally, patients with bilateral tumors at diagnostic and surveillance biopsies, respectively, had significantly higher mean GRS values than those with unilateral tumors, p=0.005 and p=0.03. In contrast, no association was found between GRS and maximum core length of tumor or tumor grade at diagnostic/surveillance biopsies (all p>0.05). Finally, we observed a modest trend that patients with higher GRS quartiles had higher risk for tumor upgrading on surveillance biopsies. The trend, however, was not statistically significant (p>0.05). CONCLUSIONS: The associations of GRS with two measurements of PCa multifocality (core numbers and laterality) provide novel and consistent evidence for the link between inherited PCa risk and multifocal tumors. Source of Funding: This study was partially supported by grants from Department of Defense (W81XWH-16-1-0764, W81XWH-16-1-0765, and W81XWH-16-1-0766) and the National Cancer Institute (P30CA006973) © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1097-e1097 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jianfeng Xu More articles by this author William Isaacs More articles by this author Mufaddal Mamawala More articles by this author Zhuqing Shi More articles by this author Patricia Landis More articles by this author Jacqueline Petkewicz More articles by this author Jun Wei More articles by this author W. Kyle Resurreccion More articles by this author Rong Na More articles by this author Yasin Bhanji More articles by this author Kristian Novakovic More articles by this author Patrick Walsh More articles by this author S. Lilly Zheng More articles by this author Brian Helfand More articles by this author Christian Pavlovich More articles by this author Expand All Advertisement Loading ...

Safe Transitions and Congregate Living in the Age of COVID-19: A Retrospective Cohort Study.

COVID-19 represents a grave risk to residents in skilled nursing facilities (SNFs). To determine whether establishment of an appropriate-use committee was associated with a reduction in SNF utilization. Retrospective cohort study at NorthShore University HealthSystem, a multihospital integrated health system in northern Illinois. Participants were patients hospitalized from March 19, 2019, to July 16, 2020. Creation of a multidisciplinary committee to assess appropriateness of discharge to SNF following hospitalization. Primary outcome was total discharges to SNFs. Secondary outcomes were new discharges to SNFs, readmissions, length of stay (LOS), and COVID-19 incidence following discharge. Matched populations pre and post intervention were each 4424 patients. Post intervention, there was a relative reduction in total SNF discharges of 49.7% (odds ratio [OR], 0.42; 95% CI, 0.38-0.47) and in new SNF discharges of 66.9% (OR, 0.29; 95% CI, 0.25-0.34). Differences in readmissions and LOS were not statistically significant. For patients discharged to a SNF, 2.99% (95% CI, 1.59%-4.39%) developed COVID-19 within 30 days, compared with 0.26% (95% CI, 0.29%-0.93%) of patients discharged to other settings (P < .001). Implementing a review committee to assess for appropriateness of SNF use after a hospitalization during the COVID-19 pandemic is highly effective. There was no negative impact on safety or efficiency of hospital care, and reduced SNF use likely prevented several cases of COVID-19. This model could serve as a template for other hospitals to reduce the risks of COVID-19 in SNFs and as part of a value-based care strategy.