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Gerard R. Martin - One of the best experts on this subject based on the ideXlab platform.

  • telemedicine in Pediatric Cardiology a scientific statement from the american heart association
    Circulation, 2017
    Co-Authors: Gary Satou, Gerard R. Martin, Karen S Rheuban, Dale C Alverson, Mark B Lewin, Christopher Mahnke, James P Marcin, Lisa Schmitz Mazur, David J Sahn, Sanket Shah
    Abstract:

    Advancements in technology and broadband have revolutionized the current practice of medicine. The field of Pediatric Cardiology is no exception given the need for prompt diagnosis and reliance on cardiac imaging to identify infants and children with potentially life-threatening cardiovascular disease. As the relationship between telemedicine and Pediatric Cardiology has advanced, it has created a need to develop a broad, comprehensive document reviewing all the various aspects of telemedicine in Pediatric Cardiology. For more than a decade, a significant body of literature has been published describing individual experiences and practices, yet there remains no comprehensive statement or document summarizing this rapidly advancing field. In an effort to describe the collective experience and to provide structure and guidance for Pediatric Cardiology practitioners and healthcare providers, we have developed a scientific statement on the use of telemedicine in Pediatric Cardiology. Specific areas explored in this document include both neonatal and fetal tele-echocardiography, implications for training community sonographers, pulse oximetry programs, qualitative improvement and appropriate use criteria initiatives, and remote electrophysiological monitoring. This document also includes teleconsultation and teleausculation, direct-to-consumer and home monitoring programs, and a look into the use of telemedicine and Pediatric Cardiology in the intensive care setting. Furthermore, a detailed review of the legislative, public policy, and legal aspects of telemedicine is provided, along with financial and reimbursement information. Several terms are used in the literature interchangeably; a brief explanation is provided to help readers of this document. The term telehealth is defined as the use of technology to bridge distances in any aspect of medicine; telemedicine is the specific application of technology to conduct clinical medicine at a distance. The term teleCardiology is defined as the broad application of telemedicine in the field of Cardiology specifically, and tele-echocardiography is the most common application used within this field. Echocardiography is …

  • task force 1 Pediatric Cardiology fellowship training in general Cardiology
    Journal of the American College of Cardiology, 2015
    Co-Authors: Alan B Lewis, Gerard R. Martin, Peter J Bartz, Peter S Fischbach, David Fulton, Paul G Matherne, Benjamin E Reinking, Robert L Spicer
    Abstract:

    ### 1.1. Document Development Process The Society of Pediatric Cardiology Training Program Directors (SPCTPD) board assembled a Steering Committee that nominated 2 chairs, 1 SPCTPD Steering Committee member, and 5 additional experts from a wide range of program sizes, geographic regions, and subspecialty focuses. Representatives from the American College of Cardiology (ACC), American Academy of Pediatrics (AAP), and American Heart Association (AHA) participated. The Steering Committee member was added to provide perspective to each Task Force as a “nonexpert” in that field. Relationships with industry and other entities were not deemed relevant to the creation of a general Cardiology training statement; however, employment and affiliation information for authors and peer reviewers are provided in Appendixes 1 and 2, respectively, along with disclosure reporting categories. Comprehensive disclosure information for all authors, including relationships with industry and other entities, is available as an online supplement to this document. The writing committee developed the document, approved it for review by individuals selected by the participating organizations (Appendix 2), and addressed the comments. The final document was approved by the SPCTPD, AAP, and AHA in February 2015 and approved by the ACC in March 2015. This document is considered current until the SPCTPD revises or withdraws it. ### 1.2. Background and Scope The goals of Pediatric Cardiology training include the acquisition of cognitive and procedural expertise needed to provide high-quality care to the fetus, infant, and child with congenital and acquired cardiovascular disease and the adult with congenital heart disease, along with the acquisition of the academic skills to make meaningful scholarly contributions to the specialty and to develop the capacity for career-long self-education beyond the years of formal training.1 The 2005 training guidelines emphasized the “time” (ie, the number of months or procedures) devoted to a particular “topic.” Since then, competency-based training has become the general framework for medical education and …

  • improvement in interstage survival in a national Pediatric Cardiology learning network
    Circulation-cardiovascular Quality and Outcomes, 2015
    Co-Authors: Jeffrey B Anderson, Gerard R. Martin, David W. Brown, Robert H Beekman, John D Kugler, Geoffrey L Rosenthal, Kathy J Jenkins, Thomas S Klitzner, Steven R Neish, Colleen Mangeot
    Abstract:

    Infants with univentricular congenital heart disease (CHD), including those with hypoplastic left heart syndrome (HLHS), regularly pose dilemmas in decision-making because their anatomy and physiology are often unique and variable. The typical staged surgical course for infants with complex univentricular anatomy with systemic outflow obstruction begins with the Norwood (stage 1) operation or variant shortly after birth, followed several months later by superior cavopulmonary anastomosis (stage 2 palliation) with an ultimate goal of a Fontan-type operation several years later.1–3 Improvement in surgical and postoperative management has led to considerable improvement in early post-Norwood survival in the recent era.4–7 However, after the Norwood procedure and before stage 2 palliation, a high-risk time period termed interstage, mortality has been previously been reported at 10% to 15%.8–10 The rare nature of this disorder has limited robust learning about successful strategies to improve survival undertaken by single-surgical centers, and a gap exists in our ability to further improve mortality in this population. The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC), the first multicenter learning network within Pediatric Cardiology,11 was established with the goal of improving care and outcomes for children with univentricular heart after the Norwood operation and specifically to (1) improve interstage mortality, (2) decrease interstage growth failure, and (3) reduce interstage hospital readmissions for major medical events. There were several perceived challenges to success in changing clinical outcomes before starting the NPC-QIC collaborative. A primary challenge in collaboration among multiple sites can be agreement on best practices that should be implemented. This is especially true for rare diseases, such as univentricular heart disease, where evidence-based clinical guidelines are not available to clinicians. As noted above, major variation persists in management practices among individuals and institutions caring for children with HLHS and other …

  • impact of prenatal diagnosis in survivors of initial palliation of single ventricle heart disease analysis of the national Pediatric Cardiology quality improvement collaborative database
    Pediatric Cardiology, 2015
    Co-Authors: David W. Brown, Gerard R. Martin, Robert H Beekman, John D Kugler, Thomas S Klitzner, Steven R Neish, Katie E Cohen, Patricia Obrien, Kimberlee Gauvreau, Geoffrey L Rosenthal
    Abstract:

    Among infants with single ventricle congenital heart disease (SVD) requiring Stage I palliation (S1P), the impact of prenatal diagnosis (PD) on outcomes has been variably characterized. We investigated the impact of PD in a large multi-center cohort of survivors of S1P in the National Pediatric Cardiology Quality Improvement Collaborative (NPCQIC) registry. Retrospective analysis of demographic and outcomes data among infants enrolled in the NPCQIC database; eligibility includes SVD requiring S1P and survival to discharge. From 43 contributing surgical centers, 591 infants had data available through time of BDG (519) or interstage death (55). Median gestational age was 39 weeks (31–46), and 66 % had variants of hypoplastic left heart syndrome. PD was made in 445 (75 %), with significant variation by center (p = 0.004). While infants with PD had slightly lower gestational age at birth (p < 0.001), there were no differences in birth weight, the presence of major syndromes or other organ system anomalies. Those without PD were more likely to have atrioventricular valve regurgitation (p = .002), ventricular dysfunction (p = 0.06), and pre-operative risk factors including acidosis (p < 0.001), renal insufficiency (p = 0.007), and shock (p = 0.05). Post-operative ventilation was shorter in the PD group (9 vs. 12 d, p = 0.002). Other early post-operative outcomes, interstage course, and outcomes at BDG were similar between groups. In a large cohort of infants with SVD surviving to hospital discharge after S1P, PD showed significant inter-site variation and was associated with improved pre-operative status and shorter duration of mechanical ventilation. The significance of such associations merits further study.

  • identified mortality risk factors associated with presentation initial hospitalisation and interstage period for the norwood operation in a multi centre registry a report from the national Pediatric Cardiology quality improvement collaborative
    Cardiology in The Young, 2014
    Co-Authors: Russell R Cross, Ashraf S Harahsheh, Robert Mccarter, Gerard R. Martin
    Abstract:

    Hypoplastic left heart syndrome remains A challenging diagnosis with substantial mortality risk. Families and healthcare mortality risk. Families and healthcare providers invest tremendous time and effort to ensure the likelihood of survival and well-being of children with such a diagnosis. Children with hypoplastic left heart syndrome typically undergo staged palliation; however, some centres favour the hybrid procedure or transplantation as the initial treatment for hypoplastic left heart syndrome.1-3 Despite improvements in pre-operative care, surgical technique, perfusion strategy, and post-operative cardiac intensive care, the mortality rate remains high. Reports of early Stage 1 mortality vary widely and are centre dependent, but recent reports suggest that nationally approximately one of every five patients undergoing the Norwood operation will not survive to hospital discharge.4-8 The time between the Stage 1 and Stage 2 operations, referred to as the interstage period, also continues to be a period of potential haemodynamic instability regardless of the surgical approach taken, with additional interstage mortality ranging from 4% to 15% for Stage 1 survivors.9-13 Some of the identified risk factors specific to interstage mortality have included hypoplastic left heart syndrome with intact or restrictive atrial septum, re-coarctation of the aortic arch, obstruction of the pulmonary arteries or shunt, age at operation >7 days, longer aortic cross-clamp time, and post-operative renal dysfunction.10,12,14,15 Other factors implicated in the overall mortality include lower pre-operative pH, smaller ascending aorta diameter, longer deep hypothermic circulatory arrest, severe right ventricular dysfunction, presence of significant tricuspid regurgitation, and higher incidence of airway or respiratory complications.10,16 Most of these reports have been either single centred, retrospective, or covered a long period of time during which multiple changes in the care of children with hypoplastic left heart syndrome could have been implemented. It has also been shown that there is wide variation in the management approach to patients in the interstage period, making generalisations about care and outcomes of this patient population difficult.17 The Joint Council on Congenital Heart Disease National Pediatric Cardiology-Quality Improvement Collaborative was created to promote wide-ranging improvements in congenital heart disease outcomes through the use of quality improvement science techniques and education, as well as development of national paediatric congenital heart disease data registries to monitor care delivery and outcomes. Details regarding the collaborative’s structure and composition are reported elsewhere.18,19 The first improvement effort chosen by the National Pediatric Cardiology-Quality Improvement Collaborative was to decrease interstage mortality following the Stage 1 operation. The key drivers of the improvement effort are focused on improving care transitions, achieving adequate growth, engaging parents, and improving care coordination among parents, cardiologists, and the primary care medical home.18,19 The associated multi-centre data registry focuses on many aspects of the initial hospitalisation and Stage 1 procedure, interstage hospitalisation and outpatient encounters, as well as the Stage 2 hospitalisation that are impacted by these key drivers. It is expected that the registry will enable practitioners to understand risk factors and outcomes associated with the management of these challenging patients. Owing to the paucity of multi-centre prospective data on the interstage period, we sought to identify risk factors of interstage mortality in the present era using the National Pediatric Cardiology-Quality Improvement Collaborative multi-centre data registry. The analysis was intended to be exploratory and hypothesis generating as opposed to hypothesis driven, with the goal of identifying potential risk factors documented in the registry that could lead to improvement in interstage management approaches. A secondary aim was to identify patient management issues that could call for immediate attention by the collaborative in the early phase of registry data collection.

David W. Brown - One of the best experts on this subject based on the ideXlab platform.

  • a revamped Cardiology curriculum for Pediatric residents
    Pediatrics, 2019
    Co-Authors: Christina Ronai, David W. Brown, Roger E Breitbart
    Abstract:

    Purpose: The American Board of Pediatrics (ABP) has issued guidelines for Pediatric residents on Pediatric Cardiology (PC) topics. At many academic institutions, the teaching on the inpatient subspecialty PC service is very dependent upon the patient volume and mix, and residents may not have exposure to the ABP topics over the course of their PC rotations. We sought to assess Pediatric residents'; comfort with ABP Cardiology topics, and subsequently developed and implemented a structured PC curriculum. Methods: A needs-based assessment was performed …

  • identifying best practices in interstage care using a positive deviance approach within the national Pediatric Cardiology quality improvement collaborative
    Cardiology in The Young, 2019
    Co-Authors: Katherine E Bates, David W. Brown, Colleen Mangeot, Judy A Shea, Karen Uzark
    Abstract:

    IntroductionTo identify interstage best practices associated with lower mortality, we studied National Pediatric Cardiology Quality Improvement Collaborative centres registry using a positive deviance approach. Methods Positive deviant and control centre team members were interviewed to identify potential interstage best practices. Subsequently, all collaborative centres were surveyed on the use of these practices to test their associations with centre mortality. Questionnaires were scored using Likert scales; the overall score was linearly transformed to a 0-100-point scale with higher scores indicating increased use of practices. Mortality was based on patients enrolled after a centre's first year in the collaborative. Centre mortality rates were divided into tertiles. Survey scores for the low mortality tertile were compared with the other tertiles. Results For this study, seven positive deviant and four control teams were interviewed. A total of 20 potential best practices were identified, including team composition, improvement practices, and parent involvement. Questionnaires were completed by 36/43 eligible centres, providing 1504 patients for analysis. Average survey score was 50.2 (SD 13.4). Average mortality was 6.1% (SD 4.1). There was no correlation between survey scores and mortality (r=0.14, p=0.41). The one practice associated with the low mortality tertile was frequency of discussion of interstage results: 58.3% of low mortality teams discussed results at least monthly versus 8.4% of the middle and high tertile centres (p=0.02). Conclusions Low-mortality centres more frequently discuss interstage results than high-mortality centres. Heightened awareness of outcomes may influence practice; however, further study is needed to understand the variation in outcomes across centres.

  • examining variation in interstage mortality rates across the national Pediatric Cardiology quality improvement collaborative do lower mortality centres have lower risk patients
    Cardiology in The Young, 2018
    Co-Authors: Katherine E Bates, David W. Brown, Ray Lowery, Sara K Pasquali, Peter B Manning, Karen Uzark
    Abstract:

    BACKGROUND Although interstage mortality for infants with hypoplastic left heart syndrome has declined within the National Pediatric Cardiology Quality Improvement Collaborative, variation across centres persists. It remains unclear whether centres with lower interstage mortality have lower-risk patients or whether differences in care may explain this variation. We examined previously established risk factors across National Pediatric Cardiology Quality Improvement Collaborative centres with lower and higher interstage mortality rates. METHODS Lower-mortality centres were defined as those with >25 consecutive interstage survivors. Higher-mortality centres were defined as those with cumulative interstage mortality rates >10%, which is a collaborative historic baseline rate. Baseline risk factors and perioperative characteristics were compared. RESULTS Seven lower-mortality centres were identified (n=331 patients) and had an interstage mortality rate of 2.7%, as compared with 13.3% in the four higher-mortality centres (n=173 patients, p<0.0001). Of all baseline risk factors examined, the only factor that differed between the lower- and higher-mortality centres was postnatal diagnosis (18.4 versus 31.8%, p=0.001). In multivariable analysis, there remained a significant mortality difference between the two groups of centres after adjusting for this variable: adjusted mortality rate was 2.8% in lower-mortality centres compared with 12.6% in higher-mortality centres, p=0.003. Secondary analyses identified multiple differences between groups in perioperative practices and other variables. CONCLUSIONS Variation in interstage mortality rates between these two groups of centres does not appear to be explained by differences in baseline risk factors. Further study is necessary to evaluate variation in care practices to identify targets for improvement efforts.

  • risk factors for unanticipated readmissions during the interstage a report from the national Pediatric Cardiology quality improvement collaborative
    Seminars in Thoracic and Cardiovascular Surgery, 2016
    Co-Authors: Samuel P Hanke, David W. Brown, Eileen King, Colleen Mangeot, Brian F Joy, Elise Riddle, Chitra Ravishankar, Laura E Peterson, Pamela J Schoettker, Jeffrey B Anderson
    Abstract:

    This study describes unanticipated interstage readmissions in patients with hypoplastic left heart syndrome, identifies independent risk factors for unanticipated interstage readmissions, and evaluates variation in unanticipated readmission rates among collaborative centers. Retrospective data of patients enrolled in the National Pediatric Cardiology Quality Improvement Collaborative registry from July 2008 to July 2013 were analyzed. Risk factors present at the beginning of the interstage were captured. Competing risks time to event analyses determined the association between these factors and unanticipated interstage readmission. Readmission center variation was examined using funnel plots. Unanticipated interstage readmissions occurred in 66% of 815 patients at 50 centers. The median readmission length of stay was 2 days (interquartile range: 0-6) and median time to first readmission was 29 days (interquartile range: 9-63). Most readmissions were prompted by minor changes in clinical status (64%), whereas only 6% were major adverse event readmissions. Independent readmission risk factors included genetic syndrome (HR = 1.40, 95% CI: 1.05-1.88), center volume (small vs large HR = 1.32, CI: 1.04-1.66, medium vs large HR = 1.35, CI: 1.09-1.68), preoperative ventricular dysfunction (HR = 2.02, CI: 1.31-3.10), tricuspid regurgitation (HR = 1.36, CI: 1.08-1.72), duration of circulatory arrest (HR = 0.99, CI: 0.989-0.998), and undergoing Hybrid procedure relative to Norwood/right ventricle to pulmonary artery conduit (HR = 1.40, CI: 1.02-1.93). There was significant center variation in the number of readmissions and duration of readmissions. Unanticipated readmissions are common during the interstage period with notable center variation. However, these readmissions are short and are rarely in response to major adverse events.

  • The United States Pediatric Cardiology 2015 Workforce Assessment: A Survey of Current Training and Employment Patterns: A Report of the American College of Cardiology, American Heart Association, American Academy of Pediatrics Section on Cardiology a
    Journal of the American College of Cardiology, 2016
    Co-Authors: Robert D. Ross, Shubhika Srivastava, Antonio G. Cabrera, Holly Ruch-ross, Carrie L. Radabaugh, L. Luann Minich, William T. Mahle, David W. Brown
    Abstract:

    The number of Pediatric Cardiology trainees in the United States doubled between 2004 and 2015, but there is a lack of information on the current Pediatric Cardiology workforce. Therefore, a survey was administered to members of the American Academy of Pediatrics Section on Cardiology and Cardiac

Robert H Beekman - One of the best experts on this subject based on the ideXlab platform.

  • association of interstage home monitoring with mortality readmissions and weight gain a multicenter study from the national Pediatric Cardiology quality improvement collaborative
    Circulation, 2015
    Co-Authors: Matthew E Oster, Jeffrey B Anderson, Eileen King, Alexandra Ehrlich, Christopher J Petit, Martha L Clabby, Sherry Smith, Michelle Glanville, Lynn Darbie, Robert H Beekman
    Abstract:

    Background—Daily home monitoring of oxygen saturation and weight has been reported to improve outcomes for patients with single-ventricle heart disease during the period between stage I palliation and stage II palliation. However, these studies have been limited to single institutions and used historical control subjects. Our objective was to determine the association of various interstage home monitoring strategies with outcomes using a multicenter cohort with contemporary control subjects. Methods and Results—We performed a retrospective cohort study using prospectively collected data from the National Pediatric Cardiology Quality Improvement Collaborative from 2008 to 2012. We compared interstage mortality, unscheduled readmissions, and change in weight-for-age Z score for various home monitoring strategies of oxygen saturation (n=494) or weight (n=472), adjusting for sex, syndrome, tricuspid regurgitation, arch obstruction, and shunt type. Overall interstage mortality was 8.1%, and 47% had ≥1 unschedu...

  • improvement in interstage survival in a national Pediatric Cardiology learning network
    Circulation-cardiovascular Quality and Outcomes, 2015
    Co-Authors: Jeffrey B Anderson, Gerard R. Martin, David W. Brown, Robert H Beekman, John D Kugler, Geoffrey L Rosenthal, Kathy J Jenkins, Thomas S Klitzner, Steven R Neish, Colleen Mangeot
    Abstract:

    Infants with univentricular congenital heart disease (CHD), including those with hypoplastic left heart syndrome (HLHS), regularly pose dilemmas in decision-making because their anatomy and physiology are often unique and variable. The typical staged surgical course for infants with complex univentricular anatomy with systemic outflow obstruction begins with the Norwood (stage 1) operation or variant shortly after birth, followed several months later by superior cavopulmonary anastomosis (stage 2 palliation) with an ultimate goal of a Fontan-type operation several years later.1–3 Improvement in surgical and postoperative management has led to considerable improvement in early post-Norwood survival in the recent era.4–7 However, after the Norwood procedure and before stage 2 palliation, a high-risk time period termed interstage, mortality has been previously been reported at 10% to 15%.8–10 The rare nature of this disorder has limited robust learning about successful strategies to improve survival undertaken by single-surgical centers, and a gap exists in our ability to further improve mortality in this population. The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC), the first multicenter learning network within Pediatric Cardiology,11 was established with the goal of improving care and outcomes for children with univentricular heart after the Norwood operation and specifically to (1) improve interstage mortality, (2) decrease interstage growth failure, and (3) reduce interstage hospital readmissions for major medical events. There were several perceived challenges to success in changing clinical outcomes before starting the NPC-QIC collaborative. A primary challenge in collaboration among multiple sites can be agreement on best practices that should be implemented. This is especially true for rare diseases, such as univentricular heart disease, where evidence-based clinical guidelines are not available to clinicians. As noted above, major variation persists in management practices among individuals and institutions caring for children with HLHS and other …

  • impact of prenatal diagnosis in survivors of initial palliation of single ventricle heart disease analysis of the national Pediatric Cardiology quality improvement collaborative database
    Pediatric Cardiology, 2015
    Co-Authors: David W. Brown, Gerard R. Martin, Robert H Beekman, John D Kugler, Thomas S Klitzner, Steven R Neish, Katie E Cohen, Patricia Obrien, Kimberlee Gauvreau, Geoffrey L Rosenthal
    Abstract:

    Among infants with single ventricle congenital heart disease (SVD) requiring Stage I palliation (S1P), the impact of prenatal diagnosis (PD) on outcomes has been variably characterized. We investigated the impact of PD in a large multi-center cohort of survivors of S1P in the National Pediatric Cardiology Quality Improvement Collaborative (NPCQIC) registry. Retrospective analysis of demographic and outcomes data among infants enrolled in the NPCQIC database; eligibility includes SVD requiring S1P and survival to discharge. From 43 contributing surgical centers, 591 infants had data available through time of BDG (519) or interstage death (55). Median gestational age was 39 weeks (31–46), and 66 % had variants of hypoplastic left heart syndrome. PD was made in 445 (75 %), with significant variation by center (p = 0.004). While infants with PD had slightly lower gestational age at birth (p < 0.001), there were no differences in birth weight, the presence of major syndromes or other organ system anomalies. Those without PD were more likely to have atrioventricular valve regurgitation (p = .002), ventricular dysfunction (p = 0.06), and pre-operative risk factors including acidosis (p < 0.001), renal insufficiency (p = 0.007), and shock (p = 0.05). Post-operative ventilation was shorter in the PD group (9 vs. 12 d, p = 0.002). Other early post-operative outcomes, interstage course, and outcomes at BDG were similar between groups. In a large cohort of infants with SVD surviving to hospital discharge after S1P, PD showed significant inter-site variation and was associated with improved pre-operative status and shorter duration of mechanical ventilation. The significance of such associations merits further study.

  • predictors of prolonged length of intensive care unit stay after stage i palliation a report from the national Pediatric Cardiology quality improvement collaborative
    Pediatric Cardiology, 2014
    Co-Authors: Carissa M Bakersmith, Gerard R. Martin, Robert H Beekman, John D Kugler, Kathy J Jenkins, Thomas S Klitzner, Steven R Neish, Carole Lannon, Carolyn M Wilhelm, Geoffrey L Rosenthal
    Abstract:

    The objective of this study is to identify predictors of prolonged intensive care unit (ICU) length of stay (LOS) for single ventricle patients following Stage I palliation. We hypothesize that peri-operative factors contribute to prolonged ICU stay among children with hypoplastic left heart syndrome (HLHS) and its variants. In 2008, as a part of the Joint Council on Congenital Heart Disease initiative, the National Pediatric Cardiology-Quality Improvement Collaborative established a data registry for patients with HLHS and its variants undergoing staged palliation. Between July 2008 and August 2011, 33 sites across the United States submitted discharge data essential to this analysis. Data describing the patients, their procedures, and their hospital experience were entered. LOS estimates were generated. Prolonged LOS in the ICU was defined as stay greater than or equal to 26 days (i.e., 75th percentile). Statistical analyses were carried out to identify pre-operative, operative, and post-operative predictors of prolonged LOS in the ICU. The number of patients with complete discharge data was 303, and these subjects were included in the analysis. Univariate and multivariate analyses were performed. Multivariate analysis revealed that lower number of enrolled participants (e.g., 1-10) per site, the presence of pre-operative acidosis, increased circulatory arrest time, the occurrence of a central line infection, and the development of respiratory insufficiency requiring re-intubation were associated with prolonged LOS in the ICU. Prolonged LOS in the ICU following Stage I palliation in patients with HLHS and HLHS variant anatomy is associated with site enrollment, circulatory arrest time, pre-operative acidosis, and some post-operative complications, including central line infection and re-intubation. Further study of these associations may reveal strategies for reducing LOS in the ICU following the Norwood and Norwood-variant surgeries.

  • the clinical utility of health related quality of life assessment in Pediatric Cardiology outpatient practice
    Congenital Heart Disease, 2013
    Co-Authors: Karen Uzark, Robert L Spicer, Eileen King, Robert H Beekman, Thomas R Kimball, James W Varni
    Abstract:

    Objectives Children with congenital heart disease may experience significant psychosocial morbidity related to impaired quality of life (QOL). The aim of this study was to evaluate the clinical utility of health-related QOL assessment in a Pediatric Cardiology outpatient clinic. Design The Pediatric Quality of Life Inventory (PedsQL) 4.0 Generic Core Scales were completed by a convenience sample of 176 patients, aged 8–18 years, being seen in a Pediatric Cardiology clinic. Three cardiologists enrolled in this study reviewed the completed PedsQL during the clinic visit and recorded their responses to items reported to be a problem “Often” or “Almost Always.” This utilization of the instrument was compared to standardized scoring and the practicality and perceived usefulness of the practice was evaluated by physician interview. Results PedsQL responses showed 38% of patients reporting significant (Often or Almost Always) problems on at least one domain (19% Physical Functioning, 18.2% Emotional Functioning, 11.4% Social Functioning, and 22.3% School Functioning problems). Using standardized scoring, the prevalence of scores below the cutoff score for clinically significant impaired QOL in each domain ranged from 10% to 20%, with agreement between scoring methods ranging from 89% to 93%, sensitivity 68% to 86%, and specificity 89% to 97%. Cardiologists reported interventions in 30.1% of patients. They found that the PedsQL was easy to use, did not interfere with clinic operations, required minimal time (1–5 minutes), and provided information that had an important impact on their practice in some patients. Conclusions This study demonstrates the clinical utility of health-related QOL assessment using the PedsQL in a Pediatric Cardiology outpatient setting. Identification of significant impairments in QOL can impact clinical decision making and may change psychosocial outcomes in children with congenital heart disease.

David M Axelrod - One of the best experts on this subject based on the ideXlab platform.

  • abstract 15181 the national Pediatric Cardiology boot camp training program five years evidence of consistent educational benefit
    Circulation, 2020
    Co-Authors: Loren D Sacks, Inger Olson, Kara S Motonaga, Alisa Arunamata, David M Axelrod, David M Kwiatkowski, Catherine D Krawczeski, Robert Bishop, Shiraz A Maskatia, Alaina K Kipps
    Abstract:

    Introduction: The transition from residency to subspecialty fellowship in Pediatric Cardiology is challenging, with the daunting requirement to rapidly acquire a broad scope of knowledge and skill....

  • 49 implementation and utility of a phone based application for teaching auscultation skills to incoming Pediatric Cardiology fellows
    Academic Pediatrics, 2020
    Co-Authors: Inger Olson, Kara S Motonaga, Loren D Sacks, Alisa Arunamata, David M Axelrod, Lillian Su, Alaina K Kipps, David M Kwiatkowski, Catherine D Krawczeski, Rajesh U Shenoy
    Abstract:

    Background Mastery of cardiac auscultation is a core component of Cardiology training. New computer-based auscultation teaching tools have been developed to help teach this skill to trainees. OBJECTIVE: To assess incoming Pediatric Cardiology fellows’ auscultation skills and evaluate a phone-based application (app) to teach auscultation. Methods At the annual national Pediatric Cardiology Fellows’ Boot Camp at Stanford, the eMurmur© app was utilized to teach core auscultation skills to incoming Pediatric Cardiology fellows. In groups of 5 trainees each, attendees were taught basic auscultation skills in 30-minute blocks. Auscultation teaching centered around distinguishing innocent (INN) vs pathological murmurs (PATH) and focused on key diagnoses and murmurs most frequently encountered by Pediatric cardiologists. Pre- and post-training assessments and surveys [Likert scoring 1-5] were administered to all attendees and were analyzed via paired t-test and sign rank test. Results A total of 40 incoming Cardiology fellows from 35 training programs attended the Boot Camp at Stanford University in Palo Alto, CA from June 1-3, 2019. All trainees completed the pre- and post-training assessments. Prior to the course, trainees were less likely to correctly distinguish innocent murmurs vs. pathologic murmurs (INN 77 ± 26 % vs. PATH 92 ± 11%; p = 0.001). 73% of trainees reported the auscultation session improved their auscultation skills. Though there was no difference in overall test scores (PRE 82 ± 16% vs. POST 85 ± 17%; p = 0.13), after the training the trainees’ self-reported comfort in identifying the auscultatory findings for the most common lesions seen in Pediatric Cardiology were higher (PRE 3.3 ± 0.9 vs. POST 3.8 ± 0.8; p = 0.03). Comfort scores improved most for distinguishing systolic vs. diastolic murmurs (PRE 3.7 ± 0.7 vs. POST 4.1 ± 0.6 POST; p = 0.05) and gallops (PRE 3.3 ± 0.09 POST 3.8 ± 0.7; p = 0.005). Conclusions The use of an app-based teaching tool is an effective method to teach auscultation skills to incoming Pediatric Cardiology fellows. The app can improve fellows’ comfort with identifying the most common lesions seen in Pediatric Cardiology.

  • development and validation of a multimedia Pediatric Cardiology assessment tool for Pediatric resident trainees
    Pediatrics, 2020
    Co-Authors: Hunter C Wilson, David M Axelrod, Sonal T Owens, Tiffany R Lim, David K Werho, Stephanie S Handler, Patricia B Mullan, James M Cooke
    Abstract:

    Purpose: Pediatric Cardiology requires a clear understanding of how cardiovascular structure and physiology guide therapeutic decisions. Pediatric residents have limited exposure to Pediatric Cardiology during training, and outside of standard clinical oversight, there is a paucity of methods available for assessing trainee knowledge despite the need for trainees to recognize and properly refer these patients in a general Pediatric setting after graduation. Here we describe a multicenter collaborative effort to develop and validate a multimedia assessment tool for assessing Pediatric residents’ knowledge of key concepts of …

  • virtual reality in Pediatric Cardiology hype or hope for the future
    Current Opinion in Cardiology, 2020
    Co-Authors: Loren D Sacks, David M Axelrod
    Abstract:

    Purpose of reviewIn the field of Pediatric Cardiology, a sub-specialty that relies on an understanding of complex three-dimensional structures, virtual reality technology may represent a new and exciting tool for both practitioners and patients. Here, the current medical and surgical applications of

  • advances in Pediatric Cardiology boot camp boot camp training promotes fellowship readiness and enables retention of knowledge
    Pediatric Cardiology, 2017
    Co-Authors: Scott R. Ceresnak, Kara S Motonaga, Loren D Sacks, David M Axelrod, Emily R. Johnson, Catherine D Krawczeski
    Abstract:

    We previously demonstrated that a Pediatric Cardiology boot camp can improve knowledge acquisition and decrease anxiety for trainees. We sought to determine if boot camp participants entered fellowship with a knowledge advantage over fellows who did not attend and if there was moderate-term retention of that knowledge. A 2-day training program was provided for incoming Pediatric Cardiology fellows from eight fellowship programs in April 2016. Hands-on, immersive experiences and simulations were provided in all major areas of Pediatric Cardiology. Knowledge-based examinations were completed by each participant prior to boot camp (PRE), immediately post-training (POST), and prior to the start of fellowship in June 2016 (F/U). A control group of fellows who did not attend boot camp also completed an examination prior to fellowship (CTRL). Comparisons of scores were made for individual participants and between participants and controls. A total of 16 participants and 16 control subjects were included. Baseline exam scores were similar between participants and controls (PRE 47 ± 11% vs. CTRL 52 ± 10%; p = 0.22). Participants’ knowledge improved with boot camp training (PRE 47 ± 11% vs. POST 70 ± 8%; p < 0.001) and there was excellent moderate-term retention of the information taught at boot camp (PRE 47 ± 11% vs. F/U 71 ± 8%; p < 0.001). Testing done at the beginning of fellowship demonstrated significantly better scores in participants versus controls (F/U 71 ± 8% vs. CTRL 52 ± 10%; p < 0.001). Boot camp participants demonstrated a significant improvement in basic Cardiology knowledge after the training program and had excellent moderate-term retention of that knowledge. Participants began fellowship with a larger fund of knowledge than those fellows who did not attend.

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  • development of quality metrics in ambulatory Pediatric Cardiology
    Journal of the American College of Cardiology, 2017
    Co-Authors: Devyani Chowdhury, Michelle Gurvitz, Ariane Marelli, Jeffrey B Anderson, Carissa M Bakersmith, Karim A Diab, Thomas C Edwards, Tom Hougen, Roy Jedeikin, Jonathan N Johnson
    Abstract:

    The American College of Cardiology Adult Congenital and Pediatric Cardiology (ACPC) Section had attempted to create quality metrics (QM) for ambulatory Pediatric practice, but limited evidence made the process difficult. The ACPC sought to develop QMs for ambulatory Pediatric Cardiology practice. Five areas of interest were identified, and QMs were developed in a 2-step review process. In the first step, an expert panel, using the modified RAND-UCLA methodology, rated each QM for feasibility and validity. The second step sought input from ACPC Section members; final approval was by a vote of the ACPC Council. Work groups proposed a total of 44 QMs. Thirty-one metrics passed the RAND process and, after the open comment period, the ACPC council approved 18 metrics. The project resulted in successful development of QMs in ambulatory Pediatric Cardiology for a range of ambulatory domains.

  • practice trends over time in the care of infants with hypoplastic left heart syndrome a report from the national Pediatric Cardiology quality improvement collaborative
    Congenital Heart Disease, 2017
    Co-Authors: Waldemar F Carlo, James F Cnota, Robert J Dabal, Jeffrey B Anderson
    Abstract:

    Objective The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) was established in 2008 to improve outcomes of hypoplastic left heart syndrome (HLHS) during the interstage period. They evaluated changes in patient variables and practice variation between early and late eras. Design Data including demographic, operative, discharge, and follow-up variables from the first 100 patients (6/2008–1/2010) representing 18 centers were compared with the most recent 100 patients (1/2014–11/2014) from these same centers. Results Prenatal diagnosis increased from 69% to 82% (P = .05). There were no differences in gestational age or weight at Norwood. A composite of any preoperative risk factor occurred more frequently in the early era (59% vs. 34%, P < .01). While mean age at Norwood was similar (8.3 vs. 6.6 days, P = .2), the standard deviation was significantly lower in the recent era (10.4–6.4 days, P = .04). Use of RV-PA conduit increased (67%–84%, P < .01). Rates of complete discharge communication with both the primary care physician (31%–97%, P < .01) and primary cardiologist (44%–97%, P < .01) increased substantially. There were limited changes in feeding strategies. Use of home monitoring program increased (76%–99%, P < .01) with all participants in the late era monitoring both oxygen saturation and weight. Conclusions Among NPC-QIC centers contributing patients to both eras, there were significant changes in preoperative risk factors, surgical strategy, discharge communication, and interstage care. Further study is required to determine an association between these changes and decreased mortality.

  • risk factors for unanticipated readmissions during the interstage a report from the national Pediatric Cardiology quality improvement collaborative
    Seminars in Thoracic and Cardiovascular Surgery, 2016
    Co-Authors: Samuel P Hanke, David W. Brown, Eileen King, Colleen Mangeot, Brian F Joy, Elise Riddle, Chitra Ravishankar, Laura E Peterson, Pamela J Schoettker, Jeffrey B Anderson
    Abstract:

    This study describes unanticipated interstage readmissions in patients with hypoplastic left heart syndrome, identifies independent risk factors for unanticipated interstage readmissions, and evaluates variation in unanticipated readmission rates among collaborative centers. Retrospective data of patients enrolled in the National Pediatric Cardiology Quality Improvement Collaborative registry from July 2008 to July 2013 were analyzed. Risk factors present at the beginning of the interstage were captured. Competing risks time to event analyses determined the association between these factors and unanticipated interstage readmission. Readmission center variation was examined using funnel plots. Unanticipated interstage readmissions occurred in 66% of 815 patients at 50 centers. The median readmission length of stay was 2 days (interquartile range: 0-6) and median time to first readmission was 29 days (interquartile range: 9-63). Most readmissions were prompted by minor changes in clinical status (64%), whereas only 6% were major adverse event readmissions. Independent readmission risk factors included genetic syndrome (HR = 1.40, 95% CI: 1.05-1.88), center volume (small vs large HR = 1.32, CI: 1.04-1.66, medium vs large HR = 1.35, CI: 1.09-1.68), preoperative ventricular dysfunction (HR = 2.02, CI: 1.31-3.10), tricuspid regurgitation (HR = 1.36, CI: 1.08-1.72), duration of circulatory arrest (HR = 0.99, CI: 0.989-0.998), and undergoing Hybrid procedure relative to Norwood/right ventricle to pulmonary artery conduit (HR = 1.40, CI: 1.02-1.93). There was significant center variation in the number of readmissions and duration of readmissions. Unanticipated readmissions are common during the interstage period with notable center variation. However, these readmissions are short and are rarely in response to major adverse events.

  • association of interstage home monitoring with mortality readmissions and weight gain a multicenter study from the national Pediatric Cardiology quality improvement collaborative
    Circulation, 2015
    Co-Authors: Matthew E Oster, Jeffrey B Anderson, Eileen King, Alexandra Ehrlich, Christopher J Petit, Martha L Clabby, Sherry Smith, Michelle Glanville, Lynn Darbie, Robert H Beekman
    Abstract:

    Background—Daily home monitoring of oxygen saturation and weight has been reported to improve outcomes for patients with single-ventricle heart disease during the period between stage I palliation and stage II palliation. However, these studies have been limited to single institutions and used historical control subjects. Our objective was to determine the association of various interstage home monitoring strategies with outcomes using a multicenter cohort with contemporary control subjects. Methods and Results—We performed a retrospective cohort study using prospectively collected data from the National Pediatric Cardiology Quality Improvement Collaborative from 2008 to 2012. We compared interstage mortality, unscheduled readmissions, and change in weight-for-age Z score for various home monitoring strategies of oxygen saturation (n=494) or weight (n=472), adjusting for sex, syndrome, tricuspid regurgitation, arch obstruction, and shunt type. Overall interstage mortality was 8.1%, and 47% had ≥1 unschedu...

  • improvement in interstage survival in a national Pediatric Cardiology learning network
    Circulation-cardiovascular Quality and Outcomes, 2015
    Co-Authors: Jeffrey B Anderson, Gerard R. Martin, David W. Brown, Robert H Beekman, John D Kugler, Geoffrey L Rosenthal, Kathy J Jenkins, Thomas S Klitzner, Steven R Neish, Colleen Mangeot
    Abstract:

    Infants with univentricular congenital heart disease (CHD), including those with hypoplastic left heart syndrome (HLHS), regularly pose dilemmas in decision-making because their anatomy and physiology are often unique and variable. The typical staged surgical course for infants with complex univentricular anatomy with systemic outflow obstruction begins with the Norwood (stage 1) operation or variant shortly after birth, followed several months later by superior cavopulmonary anastomosis (stage 2 palliation) with an ultimate goal of a Fontan-type operation several years later.1–3 Improvement in surgical and postoperative management has led to considerable improvement in early post-Norwood survival in the recent era.4–7 However, after the Norwood procedure and before stage 2 palliation, a high-risk time period termed interstage, mortality has been previously been reported at 10% to 15%.8–10 The rare nature of this disorder has limited robust learning about successful strategies to improve survival undertaken by single-surgical centers, and a gap exists in our ability to further improve mortality in this population. The National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC), the first multicenter learning network within Pediatric Cardiology,11 was established with the goal of improving care and outcomes for children with univentricular heart after the Norwood operation and specifically to (1) improve interstage mortality, (2) decrease interstage growth failure, and (3) reduce interstage hospital readmissions for major medical events. There were several perceived challenges to success in changing clinical outcomes before starting the NPC-QIC collaborative. A primary challenge in collaboration among multiple sites can be agreement on best practices that should be implemented. This is especially true for rare diseases, such as univentricular heart disease, where evidence-based clinical guidelines are not available to clinicians. As noted above, major variation persists in management practices among individuals and institutions caring for children with HLHS and other …