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Cardiopulmonary Implementation Science Scholars tackle common clinical challenges

Physician-scientists launch research projects to identify and bring what works into practice

By Sandra Gray

UMass Medical School Communications

October 04, 2018
  (from left) Co-investigator Thomas Houston; Science Scholars Mayuko Ito Fukuyama, Lauren Westafer and Westyn Branch-Elliman; and co-investigator Stephenie Lemon

(from left) Co-investigator Thomas Houston; Science Scholars Mayuko Ito Fukuyama, Lauren Westafer and Westyn Branch-Elliman; and co-investigator Stephenie Lemon

How can you prevent infection from an implanted cardiac device? Which emergency department patients need to be screened for blood clots? And, how can doctors encourage more patients at risk to be screened for lung cancer?

These are the very real and practical problems facing three doctors who are studying not only what solutions could help, but also how to put them into clinical practice. It’s known as implementation science.

Westyn Branch-Elliman, MD, MMSc; Mayuko Ito Fukunaga, MD; and Lauren Westafer, DO, MPH, are the inaugural fellows in the Massachusetts Consortium for Cardiopulmonary Implementation Science Scholars program at UMass Medical School. The grant will support four additional junior faculty over the next four years.

The projects are funded through a five-year, $2.7 million Cardiopulmonary Implementation Science Scholars Program K12 training grant from the National Heart, Lung and Blood Institute to UMMS. The grant is led by principal investigators Thomas Houston, MD, professor of quantitative health sciences, and Stephenie Lemon, PhD, professor of quantitative health sciences and chief of the Division of Preventive and Behavioral Medicine. The purpose is to support mentored research and career development for junior faculty to address the complex process of bridging research and practice in a variety of real-world settings, with a focus on heart, lung, blood, and sleep diseases.

“We’re incredibly pleased by the caliber of our three inaugural K12 scholars,” said Dr. Lemon. “Each will be conducting studies that address important research to practice translation gaps in the context of local care delivery while also advancing the field more broadly.”

Implementation scientists develop and test methods that bring evidence-based findings into routine clinical practice. The grant consortium brings together three institutions across Massachusetts to spread its impact. Dr. Branch-Elliman, assistant professor of medicine at Harvard Medical School, is an infectious disease attending physician at VA Boston Healthcare System and Beth Israel Deaconess Medical Center; Dr. Ito Fukunaga, assistant professor of medicine at UMass Medical School, practices pulmonology at UMass Memorial Medical Center in Worcester; and Dr. Westafer is clinical instructor of emergency medicine at UMMS-Baystate and emergency medicine physician at Baystate Medical Center in Springfield. The scholars will receive interdisciplinary mentorship from individuals at their own and other consortium member institutions.

They are conducting these investigations:

Dr. Branch-Elliman, Implementation of an Infection Prevention Program for Reducing Cardiac Device Infections Following Invasive Electrophysiology Procedures. Mentors: Kalpana Gupta, MD, MPH, chief of infectious diseases at VA Boston Healthcare System and professor of medicine at Boston University School of Medicine; Allen Gifford, MD, director of the Center for Healthcare Organization and Implementation Research at VA Boston Healthcare System.

Cardiac device infections are common, highly morbid, and difficult and costly to treat. Branch-Elliman’s goal is to improve cardiovascular health by reducing procedure-related infections in patients with implanted cardiac devices. Evidence-based interventions are available but rarely used; the reasons for this are unknown. The project will identify addressable barriers that are keeping effective infection prevention practices from being applied and develop a trial to test an intervention aimed at overcoming barriers and replacing the current practices with effective ones.

“The focus of my work is to take what we know about infection prevention in other areas and then adapt and apply it to prevent infections from pacemakers and cardiac defibrillators,” said Branch-Elliman. “Infections complicate 2 percent of cardiac implant procedures but have an 18 percent mortality rate, so there’s a huge premium on preventing these infections.”

Branch-Elliman is especially interested in expanding infection prevention services to currently uncovered areas, including the outpatient electrophysiology clinics where numerous patients receive cardiac implants.

“We know that infection prevention programs can be helpful and can reduce infections between 50 and 80 percent, so we can get a lot bang for our buck by being smart up front,” she said.

Dr. Ito Fukuyama, Implementation of Informed Proactive Patient and Provider-Communication Technology. Mentors: Dr. Houston; Kathleen M. Mazor, EdD, professor of medicine; Rajani S. Sadasivam, PhD, associate professor of quantitative health sciences.

While lung cancer screening with low-dose CT is recommended for patients at high risk based on age and smoking history, only 3.9 percent of eligible patients receive it. Ito Fukuyama aimsto help providers promote lung cancer screening discussion during office visits with eligible patients. Improving the accuracy and use of electronic health record data to identify appropriate patients will be key to the effort. Technology will likewise be the means to help patients access information through online patient portals.

“We didn’t have any good early detection protocol available before low-dose CT and it is relatively new, so a lot of primary care providers are not familiar with it, but patients have a right to know the screening, although not perfect, is available to them,” said Ito Fukuyama.

She is a 2017 graduate of the UMMS Junior Faculty Development Program, where her project likewise focused on overcoming barriers to increase lung cancer screening for appropriate patients. She anticipates the concepts and expertise she acquires through her project will be readily applicable to other diseases in pulmonary and critical care medicine.

“When we as pulmonologists find lung cancers, they are often already late stage and not curable,” she said. “It’s very important to catch early as treatment methods have improved and we can save lives.”

Dr. Westafer, Identifying Barriers and Facilitators to an Evidence-based Approach to Diagnosing Pulmonary Embolism in the Emergency Department. Mentors: Peter Lindenauer, MD, MSc, professor of quantitative health sciences; Timothy Mader, MD, professor of emergency medicine; Mihaela Stefan, MD, PhD, associate professor of medicine; Dr. Mazor.

As an emergency room physician, Westafer must quickly assess whether to order computed tomographic pulmonary angiography imaging for a patient who may be suffering from a pulmonary embolism, a dangerous blood clot in the lung. But high use of the technique despite potential false positives can lead to incorrect diagnosis and unnecessary and potentially harmful blood-thinning treatment for patients who don’t need it. The goal of her research project is to increase the use of risk stratification tools in patients with suspected PE in the emergency department.

“We want to encourage providers to use risk-stratification tools to decrease overall use of CT scans while increasing the value of those scans that are performed,” said Westafer. “We’ve got all these tools and guidelines, but providers aren’t following them.”

Westafer is a fellow of the Institute for Healthcare Delivery and Population Science at UMMS-Baystate and has recently assumed a faculty role at the Springfield campus.

“Implementation science is what brings research to patients. It should be a cornerstone of any research training,” she said. “I’m glad to see an increased focus on and funding for it.”

Houston agrees. “Interest in Implementation Science is growing at NIH, and we are excited that we have one of the first institutional K awards is this important area of scientific discovery,” he said.