Research Spotlight

Raj, S. D., M. M. Agrons, P. Woodtichartpreecha, M. J. Kalambo, B. E. Dogan, H. Le-Petross and G. J. Whitman (2019). “MRI-guided needle localization: Indications, tips, tricks, and review of the literature.” Breast J 25(3): 479-483.

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We describe the history of, indications for, and techniques involved in MRI-guided needle localization (MRI-NL). MRI-NL continues to be a safe, effective method of sampling lesions that are only detected with MRI, particularly for anatomically challenging lesions such as those near the chest wall, the nipple, the skin, and/or in close proximity to implants.

Packer, M. and P. A. Grayburn (2019). “Contrasting Effects of Pharmacological, Procedural and Surgical Interventions on Proportionate and Disproportionate Functional Mitral Regurgitation in Chronic Heart Failure.” Circulation May 1. [Epub ahead of print].

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Two distinct pathways can lead to functional mitral regurgitation (MR) in patients with chronic heart failure and a reduced ejection fraction. When remodeling and enlargement of the left ventricle (LV) causes annular dilatation and tethering of the mitral valve leaflets, there is a linear relationship between LV end-diastolic volume and the effective regurgitant orifice area (EROA) of the mitral valve. These patients – designated as having proportionate MR – respond favorably to treatments that lead to reversal of LV remodeling and a decrease in LV volumes (e.g., neurohormonal antagonists and LV assist devices), but they may not benefit from interventions that are directed only at the mitral valve leaflets (e.g., transcatheter mitral valve repair). In contrast, when ventricular dyssynchrony causes functional MR due to unequal contraction of the papillary muscles, the magnitude of regurgitation is greater than that predicted by LV volumes. These patients – designated as having severe but disproportionate MR – respond favorably to treatments that are directed to the mitral valve leaflets or its supporting structures (e.g., cardiac resynchronization or transcatheter mitral valve repair), but they may derive little benefit from interventions that act only to reduce LV cavity size (e.g., pharmacological treatments). This novel conceptual framework reflects the important interplay between LV geometry and mitral valve function in determining the clinical presentation of patients, and it allows characterization of the determinants of functional MR to guide the most appropriate therapy in the clinical setting.

Packer, M. (2019). “Is Any Patient With Chronic Heart Failure Receiving the Right Dose of the Right Beta-Blocker in Primary Care?” Am J Med Apr 12. [Epub ahead of print].

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Are physicians prescribing the right beta-blockers in the right way to patients with chronic heart failure and a reduced ejection fraction? Beta-blockers carry the strongest possible level of recommendations in guideline documents throughout the world. Yet, numerous surveys have shown that this class of drugs is greatly underutilized in clinical practice, particularly amongst primary care physicians in the US. In the most recently published survey, amongst primary care physicians, fewer than 10% of patients with heart failure who had no contraindication to beta-blockade and should have been treated with a beta-blocker actually were prescribed an evidence-based beta-blocker at the right dose. The news might even be worse, because the survey did not evaluate whether the use of these drugs in patients with atrial fibrillation was appropriate. Internists and family physicians are responsible for the care of most patients with chronic heart failure in the United States. If they are not prescribing life-saving drugs in the right manner, then millions of people with a highly treatable disease and highly preventable cause of death are receiving suboptimal therapy. The benefits of beta-blockers are remarkable and not controversial. The strongest possible evidence supporting their widespread use has been available to the clinical community for more than 15 years. Furthermore, the recommended formulations are generic and inexpensive and do not require preauthorization or complicated preapprovals. It is time for primary care organizations to sound the alarm. Heart failure is the most common, most serious and most responsive disorder that community-based practitioners can treat without the need for complex testing or referral for subspecialist care. What are we waiting for? (Excerpt from text of article-in-press, not paginated; no abstract available.)

Hull, B. L. and M. C. Thut (2018). “A Simple Tool Using AM-PAC “6-Clicks” to Measure Value Added in Acute Care Physical Therapy: The Therapy Value Quotient.” Journal of Acute Care Physical Therapy 9(4): 155-162.

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Background and Purpose: Acute physical therapy practitioners and leaders continue to search for a practical method to measure value. The purpose of this case report is to introduce the Therapy Value Quotient and its simple yet effective use of Activity Measure for Post-Acute Care Inpatient Mobility Short Form, also known as “6-Clicks,” and common payroll data to measure changes in value added to patient care. Case Description: Health care service value should be measured by outcomes produced divided by the cost of services to produce those outcomes. Although acute physical therapy practice continues to progress toward consistent outcome measurement, widespread application of outcomes to quantify value is rare. This lack of value measurement leaves acute care practitioners’ value measured primarily in terms of how many units or visits a therapist can code in a certain number of hours worked. Unfortunately, quantities of units or visits are not synonymous with value. Acute care managers and practitioners need a viable and easy-to-use tool that requires minimal data entry and uses existing, easily accessible payroll and electronic health record data. Outcomes: The goal of this project was to create a value calculation with commonly used systems (payroll, electronic health record) data and Activity Measure for Post-Acute Care Inpatient Mobility Short Form data to quantify value. Minimizing manual data entry decreases errors and improves real-time calculations. The purposely minimized design of the equation allows clinicians and managers freedom to create highest-value processes that achieve the maximal value added. Discussion: The Therapy Value Quotient can help managers and clinicians investigate and measure value-adding tactics while improving care delivery and efficiency instead of simply increasing the number of procedures per hour worked.

Packer, M. (2019). “Disproportionate functional mitral regurgitation: a new therapeutic target in patients with heart failure and a reduced ejection fraction.” Eur J Heart Fail Apr 24. Epub ahead of print].

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Patients with chronic heart failure and a reduced ejection fraction who have severe and disproportionate mitral regurgitation (MR) are likely to experience important clinical consequences resulting from the haemodynamic stresses imposed by the regurgitant lesion, and the severity of MR is not likely to be reduced by conventional therapy with neurohormonal antagonists, even when administered in maximally tolerated doses. Such patients should first be treated with cardiac resynchronization (if they qualify for the procedure), and non‐candidates and non‐responders should be seriously considered for transcatheter mitral valve repair. Therefore, when treating heart failure with a reduced ejection fraction, it is now time for physicians to identify patients who also have severe and disproportionate MR, because they require specialized procedures beyond optimal pharmacological therapy. (Excerpt from text, p. 2-3; no abstract available.)