Newsbrief - Center of Innovation for Complex Chronic Healthcare
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Newsbrief

The NEWSBRIEF is a publication written and produced by CINCCH staff. Its mission is to disseminate current directives from Headquarters, to update interested individuals on recent activities of CINCCH investigators, and to acknowledge professional accomplishments of our center staff.

The NEWSBRIEF editors encourage comments and suggestions; if you wish contact us, please call (708) 202-2414 or e-mail:Madeline.thornton@va.gov.

Contents of our current Newsbrief  Volume 26 Issue 1, April 2020

Dr. Gordon Develops Telehealth Infographic for MDs

Dr. Howard Gordon
Video visits are face-to-face medical appointments between a provider and a patient. Video visits use communication technology and a smartphone, tablet, computer, to allow a provider to make real-time video and audio assessment of a patient when the patient and provider are in separate locations. Video visits can occur at various locations. For example, video visits can be scheduled between a provider at a large urban medical center and a patient at an outlying community clinic or between a provider in a hospital or clinic and a patient at home. However, due to the technology, video visits may result in unintended consequences related to the patient-provider interaction. Communication between provider and patient in a video visit is different than communication in an inperson visit. Because there are technical and interpersonal aspects of video visits that could impact patient-provider communication, health care provider-patient communication during video visits may be less patient-centered than communication in face-to-face encounters.

In a VA HSRD funded study (SDR12-282 PI Gordon), we examined differences in communication in video visits. We identified the perspectives of patients and providers on video visits compared with in-person visits. Our results indicate that in general, patients and providers expressed satisfaction with video visits. Patients were generally satisfied with better access to appointments, shorter travel time, and less time in the waiting room. Patients also identified several challenges and concerns about video visits compared with in-person visits, including: perceptions that providers paid less attention to them; that patients found it more difficult to find opportunities to speak up to ask questions or express concerns, and that patients felt rushed by the provider.

Recognizing how using video influences provider-patient communication helps suggest remedies to the challenges. Awareness about the configuration of the technology such as those related to perceptions of lack of eye contact or lack of engagement in the visit due to camera positioning or use of multiple monitors and awareness to limitations of sensing from a 2-dimensional viewpoint allowed us to identify strategies to address the differences between video and in-person visits.

With the recent increase in use of video visits resulting from the COVID-19 coronavirus pandemic, Dr. Gordon adapted study materials to make them available as info-graphics. Material from the study was originally designed as pamphlets to be mailed out to study participants. These were not ideally suited for display on a website. The content was adapted and used to produce an infographic to help providers prepare for more patient-centered video visits. The infographic based on our brochure suggests 5 habits providers may use to navigate successive and successful steps in the medical interview. An infographic for patients will also be developed.

The infographic can be found on the CINCCH website at:

https://www.cmc3.research.va.gov/Banners/H-Gordon-Telehealth.asp 

If you’d like to stay abreast of the work of Department of Veterans Affairs researchers nationwide, sign up here for email updates from VA’s Office of Research and Development. You will receive emails two to three times per month with links to feature stories, news briefs, researcher interviews, and other content highlighting study findings and other news from VA Research. 

Dr. Fitzpatrick Promoted to an Associate Professor

Dr. Margaret Fitzpatrick

Margaret Fitzpatrick, MD was recently informed by Norberto M. Grzywacz, PhD, Provost Loyola University of Chicago of his approval to promote her to the rank of Associate Professor in the Department of Medicine, Stritch School of Medicine and in the Parkinson School of Health Sciences and Public Health. The recommendation came from the University Rank and Tenure Committee and is effective July 1, 2020.              

Dr. Fitzpatrick recently was awarded a Career Development Award from VA Rehabilitation Research & Development (RR&D) for her project titled “Optimizing Management of Urinary Tract Infections in Patients with Neurogenic Bladder Through Improved Knowledge of Provider Practice and Patient-reported Outcomes.”

Her mentoring team is quite impressive including: Charlesnika Evans, PhD, MPH (Primary Mentor), Stephen Burns, MD (Clinical Mentor), Eileen Collins, RN, PhD (Rehabilitation Research Mentor), Nasia Safdar, MD, PhD (Infectious Diseases Mentor), Frances Weaver, PhD (Patient-Reported Outcomes Mentor) and Katie J. Suda, PharmD, MS (Quantitative Methods Mentor). 

Opioid Paper chosen for Editor’s Choice

Dr. Charlesnika Evans
Dr. Charlesnika Evans of CINCCH was one of the authors of an Editors' Choice article from the April, 2020 issue of the American Journal of Preventive Medicine titled, “Overprescribing of Opioids to Adults by Dentists in the U.S., 2011−2015.” Using national private sector prescription data, the authors found that over half (53%) of opioid prescriptions by dentists exceeded the recommended days’ supply and nearly 30% exceeded the recommended morphine equivalents for appropriate management of acute pain. Inappropriate opioid prescribing by dentists was highest in patients aged 18−34 years, men, patients residing in the Southern U.S., and those receiving oxycodone. 

The findings suggest that opioid-prescribing interventions should be tailored to oral health conditions and dentists. This study was funded by Agency for Healthcare Research and Quality (AHRQ), R01 HS 25177 (PI: Katie Suda). Am J Prev Med 2020;58(4):473−486. Published by Elsevier Inc. on behalf of American Journal of Preventive Medicine.  

Dr. Saul Weiner’s New Book

Dr. Saul Weiner
Saul Weiner has a new book, On Becoming a Healer: The Journey from Patient Care to Caring about Your Patients, published by Johns Hopkins University Press (April 2020).  Described as an “invaluable guide to becoming a competent and compassionate physician” On Becoming a Healer is intended as a companion for those on the arduous journey of medical training or well into their medical careers seeking greater fulfillment.  While medical training is steeped in scientific learning and technical skill building, there is little guidance on the emotional side of becoming a healer. On Becoming a Healer is written for those seeking more nourishing relationships both with patients and in the personal sphere.

Novel MS Pilot Study Shows Very Promising Findings

Dr. Sherri LaVela
Dr. Sherri LaVela was the Principal Investigator on an innovative study funded by the National Multiple Sclerosis Society.  She and her colleagues, Drs. Rymer, Sandhu, and Motl recently completed the pilot and the findings were promising for positive outcomes in persons with MS.  In this randomized, cross-over and placebo-controlled pilot study,  we measured ankle strength following a single sequence of acute intermittent hypoxia (AIH) or sham AIH in 10 individuals with relapsing-remitting MS. Each subject participated in 2 sessions (AIH & sham AIH) at least 1 week apart. AIH sessions consisted of 1-minute of 9% O2 alternating with 1-minute of 21% O2 for a total of 15 iterations. Sham AIH consisted of 15, 60-second periods of normoxia (21% O2).  Ankle plantarflexion torque and electromyography measures were collected at several timepoints (baseline, 0, 30, 60 minutes post-intervention). We also used validated instruments, California Verbal Learning Test (CVLT)-2 and Single Digit Modalities Test (SDMT), to collect cognitive measures pre/post AIH & sham AIH for each subject at each session. Repeated-measures crossover statistical tests were used to analyze if a single sequence of mild AIH improved ankle strength and cognitive outcomes.  Our findings showed that maximal isometric plantar flexion torque increased in 7/10 participants at 60 mins post-AIH, compared to baseline (at least 10% change). Minimal increase was seen following sham AIH in the same subjects. Mean plantarflexion torque changed from 65.3 ± 11.4 N.m to 64.2 ± 11.1 N.m at 60 minutes after sham AIH and changed from 70.8 ± 11 N.m at baseline to 85.9 ± 17.2 N.m at 60 minutes post-AIH. Our study participants showed a mean percent change of 17.2% ± 5.3% from baseline following AIH intervention. This change was significantly (p < 0.05, 2-tailed t-test) higher compared to sham AIH intervention (-0.6% ± 2.8%).  There were no significant differences by group (AIH v. sham AIH) in the CVLT-2 results, but our SDMT findings showed a consistent improvement pre/post for the AIH condition. There was a statistically significant difference in change in SDMT score between treatment conditions (AIH vs. sham, p=0.00007); with an increase of 10.1 in SDMT score in the AIH condition.  Our findings demonstrated that a single AIH exposure (15 episodes) improves motor function and maximal voluntary plantar flexion torque generation in PwMS.  Our pilot findings suggest that AIH is an effective intervention for modulating voluntary strength in people with MS.  The statistically significant improvement in the SDMT cognitive measure after AIH (that was not present after the control condition) was unexpected and should be examined further.  Our ankle strength and cognitive findings are promising and inform the need for a larger study. 

Selected CINCCH Publications December 2019 to March 2020

Adeola J, Badejo OA, Ahonkhai A, Okonkwo P, Aboh Akande P, Evans CT, McHugh M, Pierce L, Ahmed I, Jolayemi T, Ladi Akinyemi B, Onwuatuelo I, Murphy R, Kyriacou D, Musa J, Agaba P. Effect of Baseline Symptom Manifestations on Retention in Care and Treatment among HIV-Infected Patients in Nigeria. J Int Assoc Provid AIDS Care. 2020 Jan-Dec;19:2325958220903575. doi: 10.1177/2325958220903575. PMID: 32027211

Ahmad FS, Rasmussen LV, Persell SD, Richardson JE, Liss DT, Kenly P, Chung I, French DD, Walunas TL, Schriever A, Kho AN. Challenges to electronic clinical quality measurement using third-party platforms in primary care practices: the healthy hearts in the heartland experience. JAMIA Open. 2019 Sep 20;2(4):423-428. doi: 10.1093/jamiaopen/ooz038. eCollection 2019 Dec. PMID: 30205638

Binns-Calvey AE, Sharma G, Ashley N, Kelly B, Weaver FM, Weiner SJ. Listening to the Patient: A Typology of Contextual Red Flags in Disease Management Encounters. J Patient Cent Res Rev. 2020 Jan 27;7(1):39-46. eCollection 2020 Winter. PMID: 32002446

Bui DP, Griffin SC, French DD, Hu C, Pollack Porter K, Jung AM, Crothers S, Burgess JL. The use of proactive risk management to reduce emergency service vehicle crashes among firefighters. J Safety Res. 2019 Dec;71:103-109. doi: 10.1016/j.jsr.2019.09.020. Epub 2019 Nov 13. PMID: 31862021

Etingen B, Grubbs KM, Harik JM4. Drivers of Preference for Evidence-Based PTSD Treatment: A Qualitative Assessment. Mil Med. 2020 Jan 7;185(Supplement_1):303-310. doi: 10.1093/milmed/usz220. PMID: 32074319

Heinemann AW, Deutsch A, Fatone S, Soltys N, McPherson V, Peterson M, Slater BCS, LaVela SL.  Patient and Clinician Perspectives on Quality-of-Care Topics for Users of Custom Ankle-Foot Orthoses.
Am J Phys Med Rehabil. 2019 Dec 19. doi: 10.1097/PHM.0000000000001373. [Epub ahead of print] 

Musuuza JS, McKinley L, Keating JA, Obasi C, Knobloch MJ, Crnich C, Evans CT, Evans ME, Livorsi D, Morgan DJ, Perencevich EN, Reisinger HS, Schweizer ML, Suda KJ, Simbartl LA, Safdar N. Correlation of prevention practices with rates of health care-associated Clostridioides difficile infection. Infect Control Hosp Epidemiol. 2020 Jan;41(1):52-58. doi: 10.1017/ice.2019.290. Epub 2019 Oct 29. PMID: 31658933

Ramanathan S, Fitzpatrick MA, Suda KJ, Burns SP, Jones MM, LaVela SL, Evans CT. Multidrug-resistant gram-negative organisms and association with 1-year mortality, readmission, and length of stay in Veterans with spinal cord injuries and disorders. Spinal Cord. 2019 Dec 11. doi: 10.1038/s41393-019-0393-y. [Epub ahead of print]. PMID: 31827257

Stroupe KT, Martinez R, Hogan TP, Evans CT, Scholten J, Bidelspach D, Osteen C, Taylor BC, Smith BM. Health Care Utilization and Costs of Veterans Evaluated for Traumatic Brain Injury Through Telehealth. Telemed J E Health. 2019 Dec;25(12):1144-1153. doi: 10.1089/tmj.2018.0182. Epub 2019 Mar 15. PMID: 30874499

Suda KJ, Zhou J, Rowan SA, McGregor JC, Perez RI, Evans CT, Gellad WF, Calip GS. Overprescribing of Opioids to Adults by Dentists in the U.S., 2011-2015. Am J Prev Med. 2020 J an 27. pii: S0749-397(19)30527-6. doi: 10.1016/j.amepre.2019.11.006. [Epub ahead of print]. PMID: 32033856

Wilson GM, Jackson VB, Boyken LD, Schweizer ML, Diekema DJ, Petersen CA, Breheny PJ, Nonnenmann MW, Perencevich EN, CDC Prevention Epicenter Program. Bioaerosols generated from toilet flushing in rooms of patients with infection. Infection control and hospital epidemiology. 2020 Jan 31; 1-5. PMID: 32000872 

 updated 5-15-20