Demo_C2

Ira Hofer, MD & Susana Vacas, MD, PhD

Posted on by Erin Luers

Icahn School of Medicine; Massachusetts General Hospital

Mitigation of Postoperative Delirium in High-Risk Patients

Health Care Systems

Mount Sinai Hospital System

Project Snapshot

Dr. Hofer is a practicing anesthesiologist and clinical informaticist at The Icahn School of Medicine at Mount Sinai. Dr. Hofer has been working in the field of big data analytics for over 15 years in a variety of leadership roles. His research interests involve leveraging the data from the electronic health records (EHR) to understand, quantify and ultimately mitigate risk in the perioperative period. His work includes some of the first papers to apply machine learning techniques for perioperative outcome prediction and has been featured on the covers of Anesthesiology and Anesthesia & Analgesia. Dr. Hofer has a K01 from the National Heart Lung and Blood Institute and serves as an associate editor for Anesthesia & Analgesia. His research focuses on creating featurization techniques to incorporate a wide range of EHR data into machine learning models to improve discrimination and calibration, and establishing multi-center perioperative collaboratives to better share raw and processed EHR data.

Dr. Vacas is a neuroanesthesiologist at the Massachusetts General Hospital, Harvard Medical School. She completed her postdoctoral work at the University of California, San Francisco, where her research focused on the underlying mechanisms and risk factors of perioperative neurocognitive disorders, including postoperative delirium. Incorporating her bench work with the advent of new and emerging technologies, Dr. Vacas seeks to improve patient outcomes after surgery by blocking and/or alleviating perioperative exacerbated inflammation and brain lesions. Her research focuses on vulnerable surgical populations, and her work is helping to understand the pathogenic mechanisms behind these devastating conditions. She seeks to develop strategies that can be applied to prospective surgical patients.

RATIONALE: Postoperative delirium is the most common complication after surgery and a major cause of morbidity in patients with cognitive impairment. Perioperative clinical decision support tools may decrease the incidence of this devastating and potentially preventable condition by increasing adherence to clinical best practices.

OBJECTIVE: To leverage our experience in informatics and postoperative delirium research to perform a prospective randomized controlled embedded pragmatic clinical trial to test the effectiveness of a clinical decision support system to promote adherence to best practices with the goal of decreasing postoperative delirium in patients with baseline cognitive impairment.

SETTING: Perioperative setting at Mount Sinai Health System, an integrated health system that encompasses 130 operating rooms.

POPULATION: Patients with cognitive impairment undergoing surgery.

INTERVENTION: The intervention consists of clinical decision support alerts in the electronic health record directed towards anesthesiologists caring for patients with preexisting cognitive impairment. This intervention will promote 12 evidence-based best practices during care for perioperative patients.

OUTCOMES: The primary clinical outcome is the incidence of postoperative delirium. We will also evaluate practice adherence and effectiveness to reduce postoperative delirium in key groups and study the influence of each practice on postoperative delirium prevention.

IMPACT: Our rigorous and innovative approach, based on established methods and executed by an experienced multidisciplinary team with access to unique resources and tested platforms, will lead to insights that are clinically relevant and change clinical practice for postoperative delirium prevention in patients with cognitive impairment.

Lisa Kern, MD, MPH

Posted on by Erin Luers

Weill Cornell Medicine

Improving How People Living with Dementia are Selected for Care Coordination: Pragmatic Clinical Trial Embedded in an Accountable Care Organization

Health Care Systems

NewYork Quality Care

Project Snapshot

Dr. Kern is an associate professor of medicine at Weill Cornell Medicine. Dr. Kern’s clinical background is in general internal medicine, and her MPH degree included a concentration in health policy and management. Dr. Kern is a health services researcher whose work focuses on improving the delivery of ambulatory care, especially for patients with chronic conditions. She is a national expert on healthcare fragmentation in the ambulatory setting, which occurs when a patient is cared for by many different outpatient providers, but no single provider accounts for a substantial proportion of visits. Dr. Kern recently completed an R01 grant from the National Heart, Lung, and Blood Institute on “Healthcare Fragmentation and Cardiovascular Outcomes” (R01 HL135199). The results of that work helped to shape this demonstration project. Dr. Kern received her undergraduate and medical degrees from Harvard University, and received her Master of Public Health degree from Johns Hopkins University.

RATIONALE: Many people living with dementia (PLWD) and their care partners may benefit from the assistance of a care coordinator, a member of the medical team who facilitates communication among all of the people involved. However, care coordinators’ time is limited, and there is uncertainty about which patients should be selected to receive their help. In a national survey, 31% of care partners for PLWD reported difficulty with coordinating care, but these observations have not been leveraged to improve care.

OBJECTIVE: This pragmatic clinical trial embedded (ePCT) in an accountable care organization (ACO) will determine the comparative effectiveness of two approaches for assigning care coordinators to PLWD.

SETTING: NewYork Quality Care, the ACO that brings together NewYork-Presbyterian Hospital, Weill Cornell Medicine, and ColumbiaDoctors.

POPULATION: Community-dwelling Medicare beneficiaries aged ≥65 years with dementia who have been attributed to the NewYork Quality Care ACO and who have ambulatory care spread out among many providers (which increases the risk of problems with communication among providers).

INTERVENTION: The intervention is a novel approach to assign care coordinators to PLWD whose care partners report problems with care coordination based on a survey of perceptions of care coordination. By contrast, usual care assigns PLWD to care coordinators after hospital discharge.

OUTCOMES: The primary clinical outcome is the combined endpoint of an emergency department or hospital admission over 12 months of follow-up. The implementation endpoints include four measures (acceptability, appropriateness, fidelity, and efficiency), to inform future dissemination.

IMPACT: This ePCT has the potential to show that an innovative, yet pragmatic change in the way care coordinators are deployed can reduce emergency department visits and hospital admissions compared to usual care.