Govindarajan cer saem 2011


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This is to be presented at Society of Academic Emergency Medicine 2011 Annual Meeting for clinical researchers.

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  • First of all, I would like to thank the organizers of this didactic session, Brendan and Rahul for giving me an opportunity to talk here. I am PG, asst professor of emergency medicine at UCSF, a clinical researcher with a interest in the field of prehospital care and neurovascular emergencies. I will be discussing a few examples of funded research in Comparative Effectiveness Research in clinical care in emergency medicine, systems based research in prehospital care and public health. By presenting these examples, my goal is to let the group know about successful grants in emergency medicine and CER and also encourage young researchers to learn from these successful grants to prepare future grant applications.
  • This is a grant awarded to an EM investigator and was funded by the Agency of Healthcare Research and Quality to study HIV screening in the ED. Following the CDC mandate to perform non-targeted opt out screening for HIV in healthcare settings, the investigators designed a study to compare conventional methods (high risk screening) versus a HIV screening using a clinical prediction rule to identify high risk patients in the ED. This is an example of a effectiveness study comparing clinical outcomes of HIV identification for diagnostic test in the ED.
  • R01 – CER funding (UCSF PI). The second example is a R01 grant funded by AHRQ to study the effectiveness of three strategies in the ED for diagnosis of urolithiasis. This is a RCT and falls under CER since this compares diagnostic accuracy and effectiveness of modalities as well as cost of the strategies.
  • Another example of a funded research is similar to the HIV diagnostic test we talked about earlier. This is funded by the NIH and compares standard of care screening tool with another research tool for early diagnostic testing in undifferentiated CP and SOB in the ED. This falls under CER since we are comparing the diagnostic accuracy of two tests and its impact on outcomes in the second stage of the study
  • The next example I will be talking about is a study comparing the diagnostic accuracy of two triage protocols for stroke which has been funded by the American Heart/Stroke Association, Western States Affiliate Clinical research program. Since I am the PI of the study, I can elaborate on this a bit more than the others. The aims of this study are to compare the diagnostic accuracy of the old stroke protocol – card 28 with the new stroke protocol which is a combination of Card 28 and Cincinnati Stroke Scale. This is a prospective study and although not funded through the CER mechanism, this falls under CER since two diagnostic tests are being compared for accuracy of stroke recognition.
  • I would like to now shift gears and move onto examples from systems based research ( research with partnerships with community based healthcare settings)
  • Funded by K08 AHRQ to study the comparative effectiveness of regionalized and non-regionalized stroke care. This was funded by the CER program and aims to compare the rates of IV t-PA before and after regionalization of stroke in two counties in the state of CA. We will also compare the diagnostic accuracy of prehospital triage before and after regionalization and study the impact on treatment rates. In other words, we will compare the diagnostic accuracies after a system-wide intervention and effectiveness of the intervention on clinical outcomes.
  • R01 –AHRQ ( UCSF –PI). The second example is a R01 funded application to reduce inappropriate use of antibiotics for acute respiratory tract infections. They compared community education versus community and physician directed education on outcomes of care. This was also funded by AHRQ as 2 R01 grants. The first step involved comparing strategies in the office based setting and the second stage involved comparing effects of a multi-faceted intervention in the EDs and its impact on outcomes
  • The last example is also a R01 funded by AHRQ. This is different from the other studies I have presented in that this aims to create a statewide database to promote research in the future. The ARRA definition of CER includes “Encourage the development and use of clinical registries, clinical data networks, and other forms of electronic health data that can be used to generate or obtain outcomes data” and this study is an example of creating a linked database to obtain outcome data for assessment of prehospital care.
  • Govindarajan cer saem 2011

    1. 1. Prasanthi Govindarajan MD, MAS Assistant Professor of Emergency Medicine University of California, San Francisco
    2. 2. Disclosure of Commercial Relationships <ul><li>Advisory Board: None </li></ul><ul><li>Consultant: None </li></ul><ul><li>Employee: University of California, San Francisco </li></ul><ul><li>Officer or Board Member: None </li></ul><ul><li>Shareholder: None </li></ul><ul><li>Grant Recipient: AHRQ K08 HS 017965-02, American Heart Association/ American Stroke Association Western States Affiliate Clinical Research Program, Clinical Translational Science Institute Pilot award for young investigators, UCSF. </li></ul><ul><li>Speaker’s Bureau: None </li></ul><ul><li>Intellectual Property/Patents: None </li></ul><ul><li>Other Relationships: None </li></ul><ul><li>Off Label Disclosure: None </li></ul>
    3. 3. Discussion points <ul><li>Present examples of studies in emergency medicine and its subspecialties funded under CER program </li></ul><ul><li>Name of the agencies that have funded CER </li></ul><ul><li>List name of authors and grants nos </li></ul><ul><li>What will not be discussed? </li></ul><ul><li>In depth discussion of the research studies </li></ul><ul><li>Research Methodologies used in CER studies </li></ul>
    4. 5. HIV Screening in the Emergency Department <ul><li>Strategies to diagnose unidentified HIV in the emergency department. </li></ul><ul><li>This study was initiated after CDC called for non-targeted opt out screening </li></ul><ul><li>The goals of this study was to compare diagnostic strategies for improved identification of HIV in the emergency department </li></ul><ul><ul><li>Clinically derived prediction rule </li></ul></ul><ul><ul><li>Conventional HIV screening instrument </li></ul></ul><ul><ul><li>No screening </li></ul></ul>
    5. 6. CHOICE <ul><li>This is a multicenter, randomized controlled trial of ultrasonography compared with computed tomography for the evaluation of patients with suspected kidney stones. Subjects will be randomized to one of three arms (US in the emergency department, US in radiology and CT in radiology) and outcomes related to accuracy, cost and safety will be measured in these groups. </li></ul>
    6. 7. Undifferentiated Chest Pain in the Emergency Department <ul><li>This compares a computerized quantitative pre-test tool with current standard of care for work up of patients presenting with chest pain or SOB to the emergency department. </li></ul><ul><li>After testing the reliability of the pre-test tool (PT), this will be applied in the second phase. Those with low PT probability will be discharged home and outcomes will be obtained using follow up interviews. </li></ul>
    7. 8. Diagnostic accuracy of dispatch protocols for stroke <ul><li>National Association of Emergency Medical Dispatchers recently implemented Scripted Cincinnati Stroke Scale (CSS) for use by emergency medical dispatchers to improve recognition of stroke </li></ul><ul><li>Our goal was to compare the diagnostic accuracy of old stroke protocol (Card 28) with the current protocol (Card 28 + CSS) </li></ul>
    8. 10. Regionalization of Stroke <ul><li>My research involves comparing systems of care in stroke </li></ul><ul><li>Funded by AHRQ K08 </li></ul><ul><li>The aims of this project is to compare </li></ul><ul><ul><li>Diagnostic accuracy of prehospital recognition of stroke before and after regionalization of care </li></ul></ul><ul><ul><li>Rates of treatment for acute ischemic stroke before and after regionalization of stroke care </li></ul></ul><ul><ul><li>Regionalization involves transport of subjects with symptoms suggestive of stroke to primary stroke centers only . In non-regionalized systems, patients are transported to the nearest emergency department </li></ul></ul>
    9. 11. Minimizing Antibiotic Resistance In Colorado (MARC) <ul><li>The goal of this project was to use large scale efforts to reduce antibiotic usage in the community for acute respiratory infections </li></ul><ul><li>The investigators compared independent and combined impact of two community educational interventions ( mass media versus office based education) on outcomes of care. </li></ul>
    10. 12. Prehospital and ED state wide database <ul><li>This project focuses on creating a registry that will provide opportunities for future CER research. </li></ul><ul><li>Since evidence for prehospital care is often lacking, this project was created to link prehospital and hospital records and create a statewide data infrastructure. Using this data infrastructure, they will study effects of prehospital hypothermia versus normothermia in post cardiac arrest care. </li></ul>
    11. 13. Summary <ul><li>More information about the studies/grants discussed in this talk can be obtained from </li></ul><ul><li>Grants Online Database </li></ul><ul><li> </li></ul><ul><li>List of authors and grant numbers </li></ul><ul><li>1. Jason Haukoos MD </li></ul><ul><li> Strategies to Identify Undiagnosed HIV Infection in the Emergency Department (K02 HS17526 – AHRQ) </li></ul><ul><li>2 . Rebecca Smith-Bindman MD </li></ul><ul><li>AHRQ Clinical and Health Outcomes Initiative in Comparative Effectiveness (CHOICE) (R01) - Randomized Controlled Trial of Ultrasound versus Computed Tomography for Patients in the Emergency Department with Suspected Renal Colic </li></ul><ul><li>(R01 HS19312-AHRQ) </li></ul>
    12. 14. <ul><li>3.Jeffrey Kline MD </li></ul><ul><li>Quantitative Pretest Probability to Reduce Cardiopulmonary Imaging in the Emergency Department (R18 HS18519-AHRQ) </li></ul><ul><li>4. Prasanthi Govindarajan MD, MAS </li></ul><ul><li>American Heart/Stroke Association </li></ul><ul><li>Western States Affiliate Clinical Research Program Spring 2011 cycle </li></ul><ul><li>AHA Application #11CRP7190008 </li></ul><ul><li>5. Prasanthi Govindarajan MD, MAS </li></ul><ul><li>Impact of Regionalization of Care in Acute Stroke Patients </li></ul><ul><li>(K08 HS17965 –AHRQ) </li></ul>
    13. 15. <ul><li>Ralph Gonzales MD </li></ul><ul><li>Minimizing Antibiotic Resistance in Colorado (MARC) </li></ul><ul><li>(R01 HS13001 –AHRQ) </li></ul><ul><li>Improving Antibiotic Use in Acute Care Settings </li></ul><ul><li>(R01 HS13915-AHRQ) </li></ul><ul><li>Derek Delia </li></ul><ul><li>Comparative Effectiveness of Prehospital and Hospital Emergency Care </li></ul><ul><li>(R01 HS20097-AHRQ) </li></ul>
    14. 16. Questions