Research Spotlight

Chhatriwalla, A. K., S. Vemulapalli, M. Szerlip, S. Kodali, R. T. Hahn, J. T. Saxon, M. J. Mack, G. Ailawadi, J. Rymer, P. Manandhar, A. S. Kosinski and P. Sorajja (2019). “Operator Experience and Procedural Results of Transcatheter Mitral Valve Repair in the United States.” Journal of the American College of Cardiology Sep 19. [Epub ahead of print].

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BACKGROUND: Transcatheter mitral valve repair (TMVr) for the treatment of mitral regurgitation (MR) is a complex procedure that requires development of a unique skillset. OBJECTIVE: To examine the relationship between operator experience and procedural results of TMVr with MitraClip (Abbott Structural, Santa Clara, CA). METHODS: TMVr device procedures from the STS/ACC TVT Registry were analyzed with operator case number as a continuous and categorical (1-25, 26-50, and >50) variable. Outcomes of procedural success, procedural time, and in-hospital procedural complications were examined. The learning curve for the procedure was evaluated using generalized linear mixed models adjusting for baseline clinical variables. RESULTS: All TMVr device procedures (n=14,923) performed by 562 operators at 290 sites between November 2013 and March 2018 were analyzed. Optimal procedural success (less-than-or-equal-to 1+ residual MR without death or cardiac surgery) increased across categories of operator experience (63.9%, 68.4%, and 75.1%; p<0.001), while procedural time and procedural complications decreased. Acceptable procedural success (less-than-or-equal-to 2+ residual MR without death or cardiac surgery) also increased with operator experience, but the differences were smaller (91.4%, 92.4%, and 93.8%, p<0.001). These associations remained significant in adjusted, continuous variable analyses. Visual inflection points in the learning curves for procedural time, procedural success, and procedural complications were evident after approximately 50 cases, with continued improvements observed up to 200 cases. CONCLUSIONS: For TMVr device proceedures, operator experience was associated with improvements in procedural success, procedure time, and procedural complications. The impact of operator experience was greater when considering the goal of achieving 1+ residual MR.

Hull, B. L. and M. C. Thut (2019). “Improving Operational Efficiency, Effectiveness, and Value in Acute Care Physical Therapy Using the Therapy Value Quotient.” Journal of Acute Care Physical Therapy 10(3): 107-116.

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Background and Purpose: The shift in health care is toward value. However, operational efficiency measurement remains volume driven. Using behavioral economic heuristic theories and the Therapy Value Quotient (TVQ) as a basis for decision-making, the authors hypothesized that clinicians would demonstrate more effective and efficient clinical outcomes compared with the control group outcomes using traditional productivity decision-making heuristics. Methods: A quasiexperimental study design with quantitative analysis using the TVQ calculator was used. Also, an anonymous questionnaire on perceived decision-making empowerment and a semistructured focus group discussion with qualitative thematic analysis was used to understand better the heuristic strategies employed while trying to improve the TVQ Value Quotient. Results: Overall, the Value Quotient increased 14.7% resulting from a multitude of subcomponent improvements including increasing Activity Measure for Post-Acute Care (AM-PAC) Inpatient Mobility Short Form (IMSF) average change 28% from 2.84 to 3.64 points and decreasing Cost per Visit 8.9%. In addition, TVQ use improved clinician value focus, engagement, and perceived empowerment as evidenced by the 5 identified themes: (1) improved efficiency and staffing, (2) improved teamwork, (3) improved focus on value and not units, (4) improved patient-centeredness, and (5) professional empowerment. Discussion: Pursuing the simplicity of basic value-focused goals using the TVQ along with fast and frugal System 1 heuristics was more efficient and provided higher aggregated value compared with baseline management practice of units (Visits, Current Procedural Terminology codes, Relative Value Units) generated per hour. Furthermore, using the TVQ facilitated a paradigm shift from typical acquisition of units per hour worked to promoting an emphasis on delivering the highest overall value. The authors recommend acute care hospitals adopt the TVQ as a primary operational measurement to promote the highest value utilization of acute care physical therapy resources.

Exum, E. and B. L. Hull (2019). “The Process of Implementing a Mobility Technician in the General Medicine and Surgical Population to Increase Patient Mobility and Improve Hospital Quality Measures: A Pilot Study.” Journal of Acute Care Physical Therapy 10(4): 129-138.

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Background: Hospital-associated disability (HAD) has been linked to prolonged and inappropriate immobility. HAD and increased postacute care (PAC) rehabilitation spending are also associated. Purpose: This pilot aims to describe the implementation processes of a designated mobility technician (MT), providing daily mobility on a medical and surgical acute care unit. During the MT implementation, we explore the resulting effects on patient length of stay (LOS), PAC utilization, patient satisfaction, falls, and hospital cost. Methods: A quality improvement pilot study was created comparing the percentage of PAC discharge locations before and during the mobility pilot (MP) on 1 general medical (GM) unit (37 beds) and 1 general surgical (GS) unit (27 beds). Following the nursing assessment of medical stability and mobility with a progressive mobility algorithm, patients were assigned a Johns Hopkins Highest Level of Mobility (JH-HLM) score and placed on the MT schedule. The MT mobilized each selected patient to the next appropriate level of mobility, with a goal of at least 1 JH-HLM level of increase and recorded the score. Patient discharge location was recorded at the end of the inpatient stay. Patient satisfaction scores, LOS, and incidence of falls were also monitored throughout the pilot. Outcomes: Eighty-nine percent of GM compared with 83% of the baseline data group patients and 83% of the GS compared with 90% for the baseline data group patients discharged to home with an average increase in JH-HLM score of 1.22 per mobility session. In addition, during the MP both units decreased the LOS by 5.84% to 9.03%, the GS unit experienced increased patient satisfaction scores by 9.19%, and both units improved Press Ganey ratings of Responsiveness of Staff by 16.47% to 37.00%. No falls were associated with the MT or MP and the GM unit decreased overall falls by 53.3%. Discussion: The MP is a promising tool for increasing patient mobility in the nonintensive care GM and GS setting, while potentially decreasing the need for PAC rehabilitation for many patients with minimal mobility deficits. Although not all of the results were statistically significant, positive effects on hospital ratings show promise toward helping to improve the overall patient experience during admission, decreasing LOS, decreasing overall fall rate, and an associated decrease in GM patient PAC spending in those most likely to be affected by HAD related to immobility. These positive effects can potentially improve hospital profit margins through the Centers for Medicare & Medicaid Services’ value-based purchasing reimbursement program.

Ding, L., Y. Su, A. Fassl, K. Hinohara [. . .] G. Ethington, L. Panos [. . .] and K. Polyak (2019). “Perturbed Myoepithelial Cell Differentiation in Brca Mutation Carriers and in Ductal Carcinoma in Situ.” Nat Commun 10(1): 4182.

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Myoepithelial cells play key roles in normal mammary gland development and in limiting pre-invasive to invasive breast tumor progression, yet their differentiation and perturbation in ductal carcinoma in situ (DCIS) are poorly understood. Here, we investigated myoepithelial cells in normal breast tissues of BRCA1 and BRCA2 germline mutation carriers and in non-carrier controls, and in sporadic DCIS. We found that in the normal breast of non-carriers, myoepithelial cells frequently co-express the p63 and TCF7 transcription factors and that p63 and TCF7 show overlapping chromatin peaks associated with differentiated myoepithelium-specific genes. In contrast, in normal breast tissues of BRCA1 mutation carriers the frequency of p63(+)TCF7(+) myoepithelial cells is significantly decreased and p63 and TCF7 chromatin peaks do not overlap. These myoepithelial perturbations in normal breast tissues of BRCA1 germline mutation carriers may play a role in their higher risk of breast cancer. The fraction of p63(+)TCF7(+) myoepithelial cells is also significantly decreased in DCIS, which may be associated with invasive progression.

Xu, Y., D. R. Surman, L. Diggs, S. Xi, S. Gao, D. Gurusamy, K. McLoughlin, J. Drake, P. Feingold, K. Brown, D. Wangsa, D. Wangsa, X. Zhang, T. Ried, J. L. Davis, J. Hernandez, C. Hoang, R. F. Souza, D. S. Schrump and R. Taylor Ripley (2019). “Bile Acid-Induced “Minority Momp” Promotes Esophageal Carcinogenesis While Maintaining Apoptotic Resistance Via Mcl-1.” Oncogene Sep 30. [Epub ahead of print].

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Barrett’s esophagus (BE) is associated with reflux and is implicated the development of esophageal adenocarcinoma (EAC). Apoptosis induces cell death through mitochondrial outer membrane permeabilization (MOMP), which is considered an irreversible step in apoptosis. Activation of MOMP to levels that fail to reach the apoptotic threshold may paradoxically promote cancer-a phenomenon called “Minority MOMP.” We asked whether reflux-induced esophageal carcinogenesis occurred via minority MOMP and whether compensatory resistance mechanisms prevented cell death during this process. We exposed preneoplastic, hTERT-immortalized Barrett’s cell, CP-C and CP-A, to the oncogenic bile acid, deoxycholic acid (DCA), for 1 year. Induction of minority MOMP was tested via comet assay, CyQuant, annexin V, JC-1, cytochrome C subcellular localization, caspase 3 activation, and immunoblots. We used bcl-2 homology domain-3 (BH3) profiling to test the mitochondrial apoptotic threshold. One-year exposure of Barrett’s cells to DCA induced a malignant phenotype noted by clone and tumor formation. DCA promoted minority MOMP noted by minimal release of cytochrome C and limited caspase 3 activation, which resulted in DNA damage without apoptosis. Upregulation of the antiapoptotic protein, Mcl-1, ROS generation, and NF-kappaB activation occurred in conjunction with minority MOMP. Inhibition of ROS blocked minority MOMP and Mcl-1 upregulation. Knockdown of Mcl-1 shifted minority MOMP to complete MOMP as noted by dynamic BH3 profiling and increased apoptosis. Minority MOMP contributes to DCA induced carcinogenesis in preneoplastic BE. Mcl-1 provided a balance within the mitochondria that induced resistance complete MOMP and cell death. Targeting Mcl-1 may be a therapeutic strategy in EAC.