Health Systems Research
This section includes Class of 2024 Embark Projects within the Health Systems research areas. This is a wide range of projects including Quality Improvement, Patient Safety and Health Systems studies.
Cancer Screening Guidelines in Midwest Adult Correctional Facilities
Stephen Greenwell, B.S.1,3, Jason Adam Wasserman, Ph.D.2,3
1Oakland University William Beaumont School of Medicine, Rochester, Michigan
2Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, Michigan
3Department of Pediatrics, Oakland University William Beaumont School of Medicine, Rochester, Michigan
INTRODUCTION
National cancer screening guidelines (CSGs) exist to promote early cancer detection, reducing mortality, morbidity, and cost. The incarcerated population is at increased risk for certain cancers, decreased cancer screening, and barriers to treatment. In this study we investigate how state and federal prison CSGs differ from the National Comprehensive Cancer Network’s (NCCN) CSGs.
METHODS
CSGs for lung, prostate, colorectal, cervical, and breast cancer were evaluated. Screening protocols were solicited from state and federal prisons in Midwestern states and compared to the NCCN CSGs.
RESULTS
28/60 CSGs from state and federal prisons were obtained from publicly available sources (e.g. Department of Corrections’ websites). These represent CSGs for 146 prisons in Ohio, Iowa, Illinois, Kansas, and Wisconsin. Five CSGs for cervical, two for colorectal, and one for prostate adhered to the NCCN’s. Sixteen CSGs adhered more closely to the United States Preventative Services Task Force (USPSTF) grade A CSGs than NCCN’s. Kansas’s breast CSGs followed more closely to USPSTF CSGs until age 50 then followed NCCN CSGs.
CONCLUSIONS
Most CSGs were not accessible through their public website. The CSGs for Kansas were the only guidelines which did not appear to adhere to either the NCCN or USPSTF CSGs and was instead a mixture of both. The majority of CSGs adhered to USPSTF’s grade A or B guidelines (78%). Limitations included website dysfunction and vague or absent guidelines. Further research should investigate non-accessible CSGs, and determine how the actual practices differ from the posted CSGs. Insofar as screening guidelines for the incarcerated population appear to follow reasonably closely with national best practices, efforts to improve cancer treatment among this population should focus on 1) compliance with these guidelines, 2) intervention for those with cancer in prison, or 3) continued treatment and screening after release.
Vesicants Not Associated with IV Failure
Mahmoud Hijazi, B.A.1, Amit Bahl, M.D.2, Nai-Wei Chen, Ph.D.3
1Oakland University William Beaumont School of Medicine, Rochester, Michigan
2Department of Emergency Medicine, Beaumont Hospital, Royal Oak, Michigan
3Department of Biostatistics, Beaumont Hospital, Royal Oak, Michigan
INTRODUCTION
Intravenous vesicants are commonly infused via peripheral intravenous catheters (PIVC) despite guidelines recommending administration via central route. The impact of these medications on PIVC failure is unclear. We aimed to assess dose-related impact of these caustic medications on ultrasound-guided (US) PIVC survivorship.
METHODS
We performed a secondary analysis of a randomized control trial that compared survival of two catheters: a standard long (SL) and an ultra-long (UL) US PIVC. This study involved reviewing and recording all vesicants infusions through the PIVCs. Type and number of vesicants doses were extracted and characterized as one, two or multiple. The most commonly used vesicants were individually categorized for further analysis. The primary outcome was PIVC failure accounting for use and timing of vesicant infusates.
RESULTS
Between October 2018 and March 2019, 257 subjects were randomized with 131 in the UL group and 126 in the SL group. Vesicants were infused in 96 (37.4%) out of 257 study participants. In multivariable time-dependent extended Cox regression analysis, there was no significant increased risk of failure due to vesicant use [adjusted hazard ratio, aHR 1.71 (95% CI 0.76–1.81) p = 0.477]. The number of vesicant doses was not significantly associated with the increased risk of PIVC failure [(1 vs 0) aHR 1.20 (95% CI 0.71–2.02) p = 0.500], [(2 vs 0) aHR 1.51 (95% CI 0.67–3.43) p = 0.320] and [(≥ 3 vs 0) aHR 0.98 (95% CI 0.50–1.92) p = 0.952].
CONCLUSIONS
Vesicant usage did not significantly increase the risk of PIVC failure even when multiple doses were needed in this investigation. Ultrasound-guided PIVCs represent a pragmatic option when vesicant therapy is anticipated. Nevertheless, it is notable that overall PIVC failure rates remain high and other safety events related to vesicant use should be considered when clinicians make vascular access decisions for patients.
Demographics of Patient Over-Utilizers of the Emergency Department
Donna Kayal, B.S.1, Jacob Keeley, M.S.2, Ramin Homayouni, Ph.D.3
1Oakland University William Beaumont School of Medicine, Rochester, Michigan
2Department of Research, Oakland University William Beaumont School of Medicine, Rochester, Michigan
3Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, Michigan
INTRODUCTION
Emergency departments (EDs) have been designed to provide rapid and accessible care for emergent and acute needs for a broad scope of illnesses and injuries. However, the ED has been facing an overwhelming increase in demand, leading to increasing wait times and overcrowding, which decreases the effectiveness of the ED. The goal of this study is to assess the demographics and determinants of health of over-utilizers of the ED and assess whether an involvement of primary care physicians (PCPs) impacts utilization of the ED.
METHODS
A retrospective study of 3917 patients between the ages of 18 and 65, from a large suburban Level 1 ED who lived within the adjacent zip codes of the hospital during 2017, 2018, and 2019. All patients had an assigned PCP. Patient demographics and social determinants of health were retrieved from the Epic Clarity data warehouse. Additionally, the number of ED and PCP visits for each patient in each year were assessed. Bivariate significance testing was performed using Chi-Square and multivariate analysis was performed using logistic regression.
RESULTS
In 2017, patients who visited their PCP more frequently had a lower odds of being high utilizers of the ED, however, the data was not significant (OR 0.85, p-value 0.4278). In contrast, there was a significant association between frequent ED utilization and Medicaid (OR 2.7, p-value 0.0073), Medicare ( 2.04, p-value 0.0073), and the number of chronic conditions (OR 1.96, p-value 0.0017). Similar results were observed in 2018 and 2019.
CONCLUSIONS
The results indicate that PCP utilization may not have a major impact on decreasing ED utilization. However, chronic disease burden and socioeconomic factors may contribute to over-utilization of the ED. Further studies and initiatives must take place to provide patients easier access to regular care to help decrease the burden on EDs.
Catholic Hospitals Should Permit Physicians to Provide Emergency Contraception to Rape Victims as an Act of Conscientious Provision
Marlee Mason-Maready, B.S.1, Abram Brummett, Ph.D.1, Victoria Whiting, B.S.1
1Oakland University William Beaumont School of Medicine, Rochester, Michigan
INTRODUCTION
Some Catholic hospitals provide emergency contraception (EC) to rape victims while others prohibit it based on institutional conscience. We argue that this reasonable internal disagreement offers grounds for Catholic hospitals to accommodate physicians compelled by conscience to provide EC. U.S. legal asymmetries protect conscientious objection in health care, but not conscientious provision.
METHODS
This cross-sectional study used a "mystery patient" approach to reflect a layperson’s experience. All 24 Catholic hospitals in Michigan were called on a single day to ask about their EC availability. The ramifications of EC access barriers are also reviewed.
RESULTS
Of the 24 Catholic hospitals in Michigan, one (4.2%) provides EC without restriction, three (12.5%) provide it with restrictions, 18 (75%) don’t provide EC and two (8.3%) refused to respond. EC restrictions among hospitals that provide it included variable physician willingness to prescribe (n=1), limited to sexual assault victims (n=1), and needing to pick up/order EC within hospital pharmacy business hours (n=2). Only 14 (58.3%) hospitals informed the caller of EC availability over the counter. Staff at eight (33.3%) hospitals specifically stated that their pharmacy doesn’t stock EC at all. The two times that staff refused to respond, the reason given was "I can't answer that over the phone". In three instances, staff inappropriately hung up on the caller.
CONCLUSIONS
Most Catholic hospitals in Michigan don’t provide EC at all. Of those that do, most have restrictions. These results highlight the disagreement in Catholic healthcare about the moral permissibility of EC, a compelling basis for accommodating physicians who want to conscientiously provide EC just as Catholics expect accommodation of conscientious objection to EC. Many barriers impede timely EC access, especially for low-income people. Rape-related pregnancies often lead to long-term trauma, adverse health outcomes and complex legal ties.
You’re Testing My Patients: Clinicians’ Preferences for Structured Reporting and Measurement Data. Current Problems in Diagnostic Radiology.
Davit Melik, B.S.1, A. Pouzar, M.D.1, A. Brazier, M.D.1, S. Al-Katib, M.D.1
1Oakland University William Beaumont School of Medicine, Rochester, Michigan
INTRODUCTION
The purpose of this study is to determine reporting preferences of referring providers for oncologic patients undergoing chest CT.
METHODS
Key clinicians involved in cancer patient care at our institution were surveyed anonymously regarding their preferences for various radiological report formatting. The survey consisted of 22 multiple choice questions.
RESULTS
The survey was completed by 46 clinicians representing a variety of clinical specialties. A significant majority of physicians surveyed preferred bullet point structured reporting (76%) over a traditional paragraph narrative style (15%). A slight majority favored the impression of the report at the end of the report (52%) compared to at the beginning of the report (34%). For measurements of non-spherical nodules, most prefered reporting in 3 dimensions (50%) compared with 2 dimensions (32%) and single largest dimension (13%). Most respondents (76%) thought it was at least moderately important for the image number to be provided for each lung nodule. Most prefered a total of between 2-4 nodules to be detailed in the report (48%) compared with 5-8 nodules (20%), greater than 8 nodules (17%) and only the single most significant nodule (7%). Most prefered nodules reported in order of significance (50%) compared with organized by lobe location (30%). For the impression of the report, most clinicians preferred changes in nodule size to be reported in absolute size difference (70%) compared with volume doubling time (9%), percentage change in diameter (7%), and semi-quantitative comparison (2%).
CONCLUSIONS
Based on our analysis, there are certain preferences for reporting of chest CT in oncologic patients. Surveyed clinicians prefer structured reports with nodules presented in order of significance with the 2-4 most significant nodules measured in 3 dimensions with image numbers provided.
With these findings in mind, radiologists can appropriately tailor their dictations to streamline reporting and optimize communication.
Gender, Race, and Ethnic Representation of Incoming Transplant Hepatology Fellows: A 14-Year Analysis of Fellowship Diversity
Thomas Meram, B.S.1, Meghan Mansour, B.S.1, Ali Rida, B.S.1, Eric Denha, M.D.2, Adrian Michel, M.D.1
1Oakland University William Beaumont School of Medicine, Rochester, Michigan
2Henry Ford Health, Detroit, Michigan
INTRODUCTION
Increasing diversity in the field of medicine is imperative to serving the increasingly diverse US population. A diverse physician workforce that reflects the ever-evolving US population is necessary to provide culturally competent, patient-centered care.
METHODS
Data regarding the self-identified gender and ethnic identities of incoming transplant hepatology fellows from the years 2007-2021 were collected from the Graduate Medical Education Census and analyzed to determine any trends over the 14-year-period.
RESULTS
Within this 14-year interval, male trainees comprised 54.2% and female trainees comprised 45.8% of incoming transplant hepatology fellows. Self-identified race and ethnic representation was as follows: White (n=176, 44.8%), Asian (n=166, 42.2%), Other/Unknown (n=37, 9.4%), Black (n=24, 6.1%), Multiracial (n=3, 0.8%), Native Hawaiian/Pacific Islander (n=1, 0.3%), and American Indian/Alaska Native (n=1, 0.3%). In addition, thirty trainees (7.6%) identified as Hispanic Ethnicity. The average yearly rate of change was -0.93% for males and +0.93% for females.
CONCLUSIONS
From 2007-2021, the proportion of incoming female transplant hepatology fellows fell among the proportion of female internal medicine residents and females of the general population. Of note, female representation has slightly increased with a rate of change of 0.93% over the 14-year period. Data analysis also revealed an increase in the proportion of incoming Black fellows within this time frame, peaking at 7.7% of matriculants in 2018-2019. This peak, however, is still almost half of the number of Black Americans in the general population. Those of Asian descent represent 6.1% of the general population but constituted 40.7% of matriculants within this timeframe. However, representation of Asian fellows slightly decreased over the years. Barriers may include lack of mentors and sponsors of similar backgrounds as well as limited exposure to resources.
Use of Machine Learning Algorithms to Predict Patient Length of Stay in Emergency Department
Hashem Mohilldean, B.S.1, Richard Olawoyin, Ph.D.2, Hassan Hijry, Ph.D.2
1Oakland University William Beaumont School of Medicine, Rochester, Michigan
2Oakland University, Department of Industrial and Systems Engineering, Rochester, Michigan
INTRODUCTION
Extended emergency department (ED) wait times correlate with elevated mortality rates, heightened patient anxiety, and physician limitations in delivering timely medical care. Having the ability to understand a patient’s length of stay (LOS) in the hospital can yield great benefits to a hospital’s workflow and mitigate problems from ED overcrowding. Deep learning (DL) algorithms have been used in previous studies to predict a patient’s queuing time. This project aimed to identify key factors influencing ED LOS and evaluate the accuracy of one type of DL algorithm for LOS prediction.
METHODS
The outline was proposed by Dr. Hassan Hijry and Dr. Olawoyin, who both have extensive research in queueing theories and artificial intelligence (AI) systems. An encoder was used to transform the categorical or text data into binary data which was then inputted into the machine learning process. The dataset is split into subsets that train the algorithm and a subset that predicts data and compares it to the expected results. The predicted output and model accuracy were then calculated using a combination of linear regression, logistic regression, and a neural network algorithm simulator. Artificial neural networks (ANN) was cited in multiple papers as a useful mathematical model to for creating computational algorithms.
RESULTS
Correlation analysis revealed age, comorbidities, mode of transportation to the ED, and ICU admission as the most impactful factors on LOS. Machine learning, including neural networks, linear, and classification regression, was used to train and predict the data. Dr. Hassan Hijry's analysis yielded a 78.29% accuracy using the ANN algorithm to predict patient LOS.
CONCLUSIONS
This study found factors that contribtued to patient LOS and used a mathematical model to predict LOS. Integrating DL algorithms can enhance hospital workflow, anticipating ED overcrowding and enabling resource allocation to prevent overwhelming the hospital from high patient flow.
Predictors of ICU Admission following Endoscopic Endonasal Skull Base Surgery
Brandon Prentice, M.S.1, Max Dehaan, M.D.2, Adam Folbe, M.D.3
1Oakland University William Beaumont School of Medicine, Rochester, Michigan
2Wayne State University, Detroit, Michigan
3Corewell Health, Department of Otolaryngology, Royal Oak, Michigan
INTRODUCTION
Following endoscopic endonasal skull base surgery (EESBS) patients are routinely admitted to the intensive care unit (ICU) due to the intrinsic risk of serious complications. At the same time, ICU stays are a major economic burden with some studies estimating a cost of $2902 per day. The purpose of this study is to identify predictors of postoperative complications requiring ICU admission or in order to identify patients who may not need to stay in the ICU.
METHODS
A retrospective analysis was performed of patients undergoing endoscopic endonasal resection of skull base tumors at a tertiary referral center from 2015 to 2022. Patient demographics, comorbidities, intraoperative details, and post-operative complications were collected from the electronic medical record and analyzed using binomial logistic regression and Poisson regression analysis.
RESULTS
A total of 210 patients were included in this study. Average length of ICU stay was 2.9 days and average total length of stay was 5.3 days. Of the observed comorbidities, obstructive sleep apnea was the only comorbidity significantly associated with developing a critical, postoperative complication with an odds ratio of 24.020. Patients with a history of hypertension and the occurrence of an intraoperative CSF leak increased ICU length of stay by 39.9% and 32.9% respectively.
CONCLUSIONS
While patients following EESBS are routinely admitted to the ICU, not all require intensive care and monitoring. This study identifies OSA as a risk factor for post-operative complication that would benefit from a post-operative stay in the ICU. While HTN and intra-operative CSF leak did not increase the risk of complications, they did increase the length of overall stay. These results can allow for stratification of patients who may benefit from ICU care following EESBS.
The HIV Care Continuum - A Quality Improvement Project to Reconnect with HIV-positive Patients Lost to Follow-up Care
Kate Romero, B.S.1, Janet Lombardi2, Carmen DeMarco, M.D.3, Paul Johnson, M.D.3
1Oakland University William Beaumont School of Medicine, Rochester, Michigan
2Oakland County, MI
3Division of Infectious Diseases, Corewell Health East - William Beaumont University Hospital, Royal Oak, MI
INTRODUCTION
This project aimed to identify barriers to care faced by patients with Human Immunodeficiency Virus (HIV) established in Beaumont Hospital, Royal Oak’s Outpatient Clinic in Infectious Diseases which prevented follow-up care. Without antiretroviral therapy, HIV can progress to Acquired Immunodeficiency Syndrome (AIDS) and subsequently, death. Therefore, consistent HIV management with routine follow-up care, antiretroviral therapy, and viral load testing is critical. Previously known barriers to care include insurance challenges, forgetfulness, lack of transportation, homelessness, and inadequate understanding of follow-up needs. This study, however, aims to look specifically at barriers faced by patients in Southeast Michigan.
METHODS
In this prospective cross-sectional study, patients who had not attended HIV follow-up appointments in the past year were identified and called to discuss barriers to care, using a script that ensured confidentiality. Barriers were recorded in a data collection tool. For patients with barriers to care such as confusion over medication regimens or transportation insecurity, education and resources were provided.
RESULTS
Of 61 patients contacted, 24 patients participated in the study. Barriers to care included lack of transportation (1), misconception surrounding antiretroviral treatment (1), phone issues (1), and forgetfulness (8). 3 patients attended a follow-up appointment. 1 patient was connected with resources to arrange transportation to the clinic for a follow-up appointment.
CONCLUSIONS
To summarize, the results show some common barriers to HIV care, including forgetfulness, unawareness of necessity, and lack of transportation. Three patients were retained to care after not having been seen in over a year, therefore, clinics may benefit from identifying and calling patients who have not attended their appointments in over 1 year to discuss barriers to care. Future goals include discussing barriers to care of populations outside of the limited population samples in Southeast Michigan.
HIV Diagnosis and Linkage to Care in the Emergency Department
Gabrielle Rowlison, B.S.1, Christopher Carpenter, M.D.1,2
1Oakland University William Beaumont School of Medicine, Rochester, Michigan
2Corewell Health East William Beaumont University Hospital, Department of Internal Medicine, Section of Infectious Diseases, Royal Oak, Michigan
INTRODUCTION
The Centers for Disease Control and Prevention (CDC) estimates that 1.2 million people in the United States have human immunodeficiency virus (HIV), and that 14% of this population is unaware of their status. HIV testing is estimated to be at 0.2% in Corewell Health (CH) Emergency Department’s. The primary aim of this study was to increase HIV testing rates in the ED by introducing an order panel that includes HIV into CH’s electronic health record (EHR).
METHODS
An order set that includes Hepatitis C, syphilis, and HIV was implemented into the EHR (Epic) and launched at CH Grosse Pointe’s ED. Providers were encouraged to use this panel via “Best Practice Advisories” (BPA), triggered for every patient age 18-65 who has a complete blood count (CBC) ordered for them. After the order set had been in use for seven months, HIV testing frequency and positivity rate were compared to the baseline rate.
RESULTS
Over the pilot period, there were 7822 BPA triggers, each representing an opportunity for HIV testing. Of this, 4772 (61.0%) of the BPA’s were cancelled by ED providers, 2013 (25.7%) patients declined testing, 1145 (14.7%) patients were tested for HIV, and 18 of these patients (1.6%) tested positive. Three of these patients were linked to HIV care within 30 days.
CONCLUSIONS
HIV testing rates improved from 0.2% to 14.7% (p < 0.001) after the introduction of the panel, further supporting the efficacy of EHR-based interventions for improving quality metrics in the ED. This could be due in part to decreasing emergency provider burden and simplifying clinical workflow by capturing patients who are already being testing for another STI with one comprehensive order panel. Routine HIV testing is crucial in getting patients linked to care faster and reducing transmissions, and this study supports the ED as an ideal opportunity for testing.
