Cedars-Sinai

Medical Staff Pulse Newsletter

Spreading High-Value Care

When new clinical guidelines for preoperative testing rolled out across the health system this year, it was part of a larger effort by a team of clinician leaders at Cedars-Sinai focused on reducing unnecessary care that wastes patients' time and money, and exposes them to needless risk. Led by the Ambulatory High-Value Care Committee, a diverse group of physicians and executive leaders, these efforts have proved so successful that some goals for the current fiscal year are based on the committee's prior work in specialties such as oncology and preoperative testing.

» Read more

New Way to Counter Spinal Disc Degeneration

Cedars-Sinai investigators have been able to prevent degeneration of spinal discs in laboratory animals with a new approach that uses stem cell technology. The study was recently published in the journal Theranostics. If confirmed in people, the study's findings could point to a potential way to treat back pain that is related to degenerative disc disease, which occurs when the discs between the vertebrae of the spinal column deteriorate or break down. Lower back pain in particular affects many adults and is a frequent cause of disability

» Read more

Streisand and Bairey Merz on JAMA Podcast

Actress, singer and activist Barbra Streisand has teamed up again with C. Noel Bairey Merz, MD, director of the Barbra Streisand Women's Heart Center at the Smidt Heart Institute, to warn women and their physicians about how women experience ischemic heart disease differently than men. The duo shared their perspectives with the Journal of the American Medical Association (JAMA) podcast, JAMA Author Interviews. Click here to listen to the complete JAMA Podcast. 

» Read more

Torrance Memorial to Open Cancer Center in December

Torrance Memorial, a Cedars-Sinai affiliate, will open its 38,000-square-foot Donald and Priscilla Hunt Cancer Center in December, 18 months after breaking ground. In the new facility, specialists from Torrance Memorial and Cedars-Sinai will treat more than 60 types of cancer and offer new and innovative clinical trials.

» Read more

Kimberly Gregory, MD, Named Helping Hand of Los Angeles Miriam Jacobs Chair in Maternal Fetal Medicine

Kimberly Gregory, MD, MPH, vice chair of Women's Healthcare Quality and Performance Improvement in the Department of Obstetrics and Gynecology and director and fellowship director of the division of Maternal Fetal Medicine, has been named the second Helping Hand of Los Angeles Miriam Jacobs Chair in Maternal Fetal Medicine.

» Read more

Helping Seniors Avoid Social Isolation Over the Holidays

The holidays are supposed to be a time for celebration and togetherness, but they can be tough on older adults who run a high risk of being socially isolated. Social isolation can be easily overlooked as a health concern even though it can have the same negative impact on an older adult's health as smoking 15 cigarettes a day, according to Sonja Rosen, MD, chief of Geriatric Medicine at Cedars-Sinai.

» Read more

New Social Media Policies Encourage Engagement

Employees are often Cedars-Sinai's best advocates, and their voice helps shape how the community, and world, views the medical center. To ensure employees feel empowered and encouraged to talk about Cedars-Sinai online, the digital strategy team updated their existing employee social media policy and created a new social media policy for departments or institutions interested in establishing branded social media accounts.  

» Read more

Core Labs Updating Anion Gap Calculation

Beginning Dec. 16, the Core Laboratories within the Department of Pathology and Laboratory Medicine will update the anion gap calculation to include potassium. This calculation normally includes the difference between the major measured cations and anions in blood serum/plasma.

» Read more

Pharmacy and Therapeutics Product Updates

See production information updates for October.

» Read more

CS-Link Tip: View a Lifetime of Care at a Glance

Lifetime, a new feature in CS-Link™, rolled out on Nov. 3. The updated feature allows you to see a visual timeline of a patient's entire medical history at Cedars-Sinai. This useful tool can be used in numerous ways, such as quickly familiarizing yourself with a new patient or seeing a detailed review of a patient's medication history. It is accessible through the Encounters tab in Chart Review and in Synopsis. Look for the Lifetime icon (a green infinity symbol) in the toolbar.

» Read more

Spreading High-Value Care

When new clinical guidelines for preoperative testing rolled out across the health system this year, it was part of a larger effort by a team of clinician leaders at Cedars-Sinai focused on reducing unnecessary care that wastes patients' time and money, and exposes them to needless risk.

Led by the Ambulatory High-Value Care Committee, a diverse group of physicians and executive leaders, these efforts have proved so successful that some goals for the current fiscal year are based on the committee's prior work in specialties such as oncology and preoperative testing.

"Our entire focus is on promoting resource stewardship and creating a culture at Cedars-Sinai that practices evidence-based medicine," said Bradley Rosen, MD, vice president of Physician Alignment and Care Transitions, and co-chair of the Ambulatory High-Value Care Committee with Karyn Eilber, MD. "The key word is 'value.' We always want patients to receive the best possible care, which sometimes means undergoing a more extensive work-up, but in many cases the situation warrants less testing and fewer interventions. The best clinicians in the country know the difference."

The Ambulatory High-Value Care Committee works with key clinicians in particular specialty areas to translate guidelines from professional medical societies and Choosing Wisely into everyday practice.

During the past fiscal year, they focused on four areas: cardiology, gynecology, oncology and preoperative evaluations. Their success with several pilot projects in FY18 suggests the potential for greater returns going forward.

A new focus area this past year was a collaboration between gynecology and primary care. This team identified an opportunity to use more cost-effective intrauterine devices (IUDs). They found that most IUDs implanted in Medical Network patients in 2018 were a brand that's almost twice as expensive as a nearly identical and equally effective alternative. The less expensive IUD could reduce $200,000 in costs annually with no effect on patient care. This group ran a pilot and was able to increase the number of cost-effective IUDs used from 4% in the first quarter of FY19 to 37% in the first quarter of FY20.

"The challenge is that physicians are creatures of habit," Eilber said. "But if we make the case to our doctors and make it easy for them to do the right thing, we have seen that they will embrace the new approach and run with it."

The gynecology and primary care group also worked to reduce unnecessary screening for cervical cancer. Evidence has shown that patients who have normal Pap smear results need less frequent screening, and over-screening could result in harm. Cedars-Sinai was over-screening 11.46% of these patients in CY17, and a pilot program resulted in a reduction to 9.36% in CY18. The group also created patient education brochures and digital monitor signage for OB-GYN waiting rooms.

The other three specialty groups, cardiology, oncology and preoperative testing, built upon their successes from FY18.

The cardiology group had developed computer alerts embedded in electronic health records to flag when cardiac imaging or lab orders might not be necessary. This year, they rolled out these best practice alerts to faculty physicians while working to maintain low rates of inappropriate ordering in the Medical Network. Alerts for cardiac imaging orders by both physician groups decreased by 8% in FY19 compared to FY18, while alerts for lab orders decreased by 100% during the same time period.

The oncology group aimed to improve early intervention by Supportive Care Medicine for oncology patients with metastatic cancers and solid tumors. Studies have shown that getting this care earlier can lead to improvements in a patient's quality of life, treatment decision-making, healthcare utilization, advance care planning, patient satisfaction and end-of-life care. This work led to an increase in advance care planning for these patients from 46% to 52% in FY19 compared to FY18.

The preoperative group rolled out the best-practice guidelines across the health system, including to Cedars-Sinai Marina del Rey Hospital, and monitored adherence. They maintained the FY18 quarterly average of 89 preoperative chest X-rays for patients with no history of cardiac or pulmonary disease. They also reduced "type and screen" orders by 15% compared to FY18 to a quarterly average of 302. This work saved an estimated $380,012 in avoided unnecessary testing before 993 low-risk procedures in the Medical Network in FY19 that were tracked to demonstrate impact.

In FY20, the Ambulatory High-Value Care Committee will build on previous successes while examining new opportunities in different specialty areas.

New Way to Counter Spinal Disc Degeneration

spine480px.jpg

A new study by Cedars-Sinai investigators could ultimately lead to better treatments for lower back pain.

Cedars-Sinai investigators have been able to prevent degeneration of spinal discs in laboratory animals with a new approach that uses stem cell technology.

The study was recently published in the journal Theranostics. If confirmed in people, the study's findings could point to a potential way to treat back pain that is related to degenerative disc disease, which occurs when the discs between the vertebrae of the spinal column deteriorate or break down. Lower back pain in particular affects many adults and is a frequent cause of disability. It is one of the major clinical and socioeconomic global health burdens.

Despite decades of research, most existing therapies for degenerative disc disease treat the symptoms rather than the causes, said Dmitriy Sheyn, PhD, who heads a laboratory focusing on orthopedic stem cell research at the Cedars-Sinai Board of Governors Regenerative Medicine Institute.

"There is an urgent need for an alternative treatment such as stem cell therapy, which is focused on correcting the underlying pathogenesis of disc disease," said Sheyn, an assistant professor of Orthopaedics, Surgery and Biomedical Sciences. He was co-corresponding author of the study.

The study team's approach focuses on notochordal cells, which are responsible for the formation and maintenance of spinal discs. These cells eventually may be lost in adolescence. Previous studies have associated dwindling numbers of notochordal cells with degenerative disc disease.

Replacing notochordal cells is a challenge, explained Zulma Gazit, PhD, associate professor of Surgery and co-director of the Skeletal Regeneration and Stem Cell Therapy Program at the institute. "We lack an appropriate cell source — one that can be compatible with the harsh environment in which these cells live, yet is safe and sufficiently available," said Gazit, senior author of the study.

To solve this problem, the study team first took small samples of dermal fibroblasts — the cells that form the skin's connective tissue and perform repairs — from human subjects. Using stem cell technology, they transformed these cells into induced pluripotent stem cells (iPSCs), which can multiply rapidly and morph into different, specialized types of cells.

By exposing these iPSCs to a protein modifier and encapsulating them in a hydrogel that simulated the spinal disc environment, the cells began to mimic notochordal cells. The team used these manufactured cells to treat laboratory pigs that had induced spinal disc degeneration.

After eight weeks, examination of the spinal discs of the treated subjects showed that they appeared to have been protected from further degeneration. The pH level of the discs, an indicator of healthy tissues, also was close to a normal level. In an additional experiment, the engineered cells were injected into immune-compromised laboratory mice to demonstrate that the cells did not induce tumors as a side effect.

"Restoration of disc function and prevention of degeneration remain the ultimate goals of current research," Sheyn said. "In this study, we showed a way to generate functioning notochordal cells from pluripotent cells that have a functional protective and regenerative effect without causing side effects or introducing safety concerns. This outcome has real potential for being the next cell therapy for intervertebral disc degeneration."

Funding: Research reported in this publication was supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases of the National Institutes of Health under award numbers R01AR066517 and K01AR071512 and by the California Institute for Regenerative Medicine (DISC1-10643).

 

Streisand and Bairey Merz on JAMA Podcast

barbrastreisand480px.jpg

Barbra Streisand advocates for women's heart health research. Photo courtesy of Barbra Streisand.

Bairey-Merz-140px.jpg

C. Noel Bairey Merz, MD

Actress, singer and activist Barbra Streisand has teamed up again with C. Noel Bairey Merz, MD, director of the Barbra Streisand Women’s Heart Center at the Smidt Heart Institute, to warn women and their physicians about how women experience ischemic heart disease differently than men. The duo shared their perspectives with the Journal of the American Medical Association (JAMA) podcast, JAMA Author Interviews.

The podcast comes on the heels of a review article published today in JAMA authored by Bairey Merz and colleagues in the Smidt Heart Institute, including cardiologist Janet Wei, MD, assistant professor of Medicine and director of the Barbra Streisand Women’s Heart Center, and Susan Cheng, MD, MPH, MMSc, director of Public Health Research and director of Cardiovascular Population Sciences at the Barbra Streisand Women's Heart Center.

In the review article, Bairey Merz, a professor of Medicine, and authors explain how physicians should evaluate female patients who complain about chest pain.

Frequently, standard tests show that women with ischemia—chest pain and abnormal stress testing—do not have clogged arteries, as men with heart disease often do. Too frequently, these female patients are told their hearts are fine and their symptoms are imagined.

Therefore, the review paper recommends physicians use a new diagnostic protocols to see if those female patients have coronary microvascular dysfunction, which is abnormal blood flow in the tiny vessels in the heart. Coronary microvascular dysfunction can occur in males but is relatively more prevalent among women.

Both the disparity in how women are diagnosed and treated with heart conditions like ischemic heart disease is why Streisand partnered with Bairey Merz more than a decade ago.

“It was 2007 when I discovered the staggering number of women who die from cardiovascular disease and that so few resources were put toward women’s heart health,” Streisand told Edward Livingston, MD, Deputy Editor for Clinical Content of JAMA and host of the podcast. “One in three women die of heart disease and stroke, whereas one in 31 women die of breast cancer. But the United States spends almost 10 times more research funding on women's cancer than heart disease.”

As Streisand explains, cancer research funding shouldn’t go down, but “heart disease funding needs to go way up, to help the number of women that are affected.”

Cardiovascular disease is the No. 1 cause of death for women in the United States and two out of three American women have at least one risk factor for heart disease. Equally as alarming, 12 times as many women die of heart disease every year as die from breast cancer.

In addition to increasing funding for cardiovascular disease in women, Streisand also suggests more women are needed in clinical trials.

“How can we optimize diagnostics and therapeutics for women if we're not including more of them in our research,” Streisand shared. “Women have different plumbing, smaller hearts, and narrower arteries. And because of the lack of research, they are often misdiagnosed or under-treated.”

When asked by Livingston how Streisand stays motivated to spread awareness about women’s heart health, her response was simple.

“Improving heart health is everybody’s responsibility,” said Streisand. “Because cardiovascular disease is everybody’s problem.”

Click here to listen to the complete JAMA Podcast. 

Torrance Memorial to Open Cancer Center in December

Torrance Memorial, a Cedars-Sinai affiliate, will open its 38,000-square-foot Donald and Priscilla Hunt Cancer Center in December, 18 months after breaking ground. In the new facility, specialists from Torrance Memorial and Cedars-Sinai will treat more than 60 types of cancer and offer new and innovative clinical trials.

The center, named after the late Donald Hunt and his wife, Priscilla, consolidates cancer treatment services to one location, including its nurse navigators, cancer education, genetic counseling services, clinical research trials, infusion and chemotherapy therapies. It also offers a 32-station infusion center equipped with a multimedia info-tainment system and room for a supportive guest during treatment.

The affiliation between the two medical centers was first announced in May 2017 and became official Feb. 1, 2018. The affiliation provides new opportunities for coordination of care and resources between the two organizations, and joint programs to provide access to more people for needed medical services—as well as access to clinical trials and the latest developments in medical research.

Torrance Memorial includes the 470-bed Torrance Memorial Medical Center in addition to a multispecialty physician group (Torrance Memorial Physician Network), an independent physician association (Torrance Health IPA) and an Accountable Care Organization (Torrance Memorial Integrated Physicians), which collectively include more than 500 physicians. Torrance Memorial also has several outpatient centers located throughout the South Bay region.

For more information regarding the affiliation between Cedars-Sinai and Torrance Memorial, view the Frequently Asked Questions.

 

Kimberly Gregory, MD, Named Helping Hand of Los Angeles Miriam Jacobs Chair in Maternal Fetal Medicine

gregory-kimberly.gregory140px.jpg

Kimberly Gregory, MD

Kimberly Gregory, MD, MPH, vice chair of Women's Healthcare Quality and Performance Improvement in the Department of Obstetrics and Gynecology and director and fellowship director of the division of Maternal Fetal Medicine, has been named the second Helping Hand of Los Angeles Miriam Jacobs Chair in Maternal Fetal Medicine.

The Miriam Jacobs Chair in Maternal Fetal Medicine was first established in 1984 by The Helping Hand of Los Angeles and awarded to Calvin Hobel, MD, a world-renowned expert in infant prematurity.

At a ceremony in Harvey Morse Auditorium, Gregory thanked Hobel for his mentorship and spoke of her goal to pay it forward.

"This endowed chair will be used to supplement the already rich teaching and learning opportunities for residents, fellows and maternal-fetal medicine members," said Gregory. "I envision that as we embrace technology and optimize clinical efficiency via virtual visits and telemedicine consults, there will be new research opportunities to study how this impacts maternal and newborn clinical outcomes and patient satisfaction."

Gregory has been at Cedars-Sinai since 1992, when she was first recruited as a staff physician after completing her residency at Beth Israel Deaconess Medical Center and medical school at Charles Drew/UCLA Medical Center. She earned her Master's in Pubic Health from Harvard and her fellowship in maternal-fetal medicine at LAC-USC Medical Center.

 

 

Helping Seniors Avoid Social Isolation Over the Holidays

socialisolation480px.jpg

Exercise classes and other group activities can help seniors avoid being isolated during the holidays. 

The holidays are supposed to be a time for celebration and togetherness, but they can be tough on older adults who run a high risk of being socially isolated.

Social isolation can be easily overlooked as a health concern, even though it can have the same negative impact on an older adult's health as smoking 15 cigarettes a day, according to Sonja Rosen, MD, chief of Geriatric Medicine at Cedars-Sinai.

"The medical community and government leaders are increasingly recognizing loneliness as a significant public health issue for older adults," Rosen said. "There are many ways to combat social isolation, especially over the holidays when it's easy to feel alone."

Isolation can be a health risk for older adults even if they prefer to live alone, like Gypsy Hartman, 67, who prizes her privacy and freedom. Like many baby boomers, she prefers to keep living at home on her own.

After suffering a broken leg last year, Hartman joined free exercise classes offered by the Cedars-Sinai Geriatrics Program and nonprofit partners at local community centers. Supported by a grant from the AARP Foundation, the Leveraging Exercise to Age in Place classes bring older adults together for group workouts that aim to help prevent falls and combat social isolation.

Hartman enjoys lifting light weights, stretching and doing calisthenics in the class held at a senior center near her home. In addition to strengthening her muscles, it's provided an opportunity to connect with others."It's nice to get out and be around other people. It gives me something to look forward to and a sense of wellbeing," Hartman said. "I really wanted to get stronger, and it feels good to stretch and build up my strength."

The classes—light or enhanced strength training and tai chi—have been shown in clinical research to decrease the risk of falling. Cedars-Sinai has been studying the fitness program to determine if the classes also decrease social isolation. Early data suggests they do.

"We hope that these classes improve social connectedness among participants and increase their ability to lead independent,vibrant lives," said geriatrician Allison Mays, MD, MAS, who is leading the study.

In addition to group fitness, Cedars-Sinai geriatricians suggest the following to fight loneliness over the holidays:

Volunteer. Nonprofit organizations need help serving meals, caring for animals or reading with kids.

Tap community resources. Recreation centers, libraries, museums, places of worship and colleges host free and low-cost community events.

Reconnect with friends and family. The holidays are a good excuse to call loved ones and catch up.

Seek medical advice. A geriatrician can connect older adults with other resources and potential treatments.

For information about the exercise program, contact Katrina Rosales at 310-248-6242 or katrina.rosales@csmns.org.

New Social Media Policies Encourage Engagement

sharesandlikes480px.jpg

Employees are often Cedars-Sinai's best advocates, and their voice helps shape how the community, and world, views the medical center. To ensure employees feel empowered and encouraged to talk about Cedars-Sinai online, the digital strategy team updated their existing employee social media policy and created a new social media policy for departments or institutions interested in establishing branded social media accounts.

The policies are intended to serve as both a resource and a guide.

"We want to encourage social media use for individuals and departments," said Carrie Yutzy, associate director of social media in digital strategy. "Our hope is for employees to feel motivated to share more about the important work they do here at Cedars-Sinai, without feeling unclear on our policies."

Employees are encouraged to read both policies in full, including the Cedars-Sinai Social Media Accounts and Contributor Guidelines and the Cedars-Sinai Employee Policy for Personal Social Media Use. Both can be found in the links above and in the Policy and Procedure Manager. Key takeaways from each policy are shared below.

Key Takeaways From the Policy on Personal Social Media Use

  • It's OK to have social media profiles and identify Cedars-Sinai as your employer.
  • Talking about the work you do at Cedars-Sinai is encouraged, as long as it doesn't include protected health information, patient photos or any internal, confidential information.
  • If you're endorsing the medical center for anything, such as its impressive care, it's important to disclose that you're an employee.
  • It's OK to talk about your specialty or the conditions you treat in general, but don't provide one-on-one or personalized medical advice on social media.
  • Included in this policy are tips to help employees, especially those interested in using social media accounts for professional purposes.

Key Takeaways From the Policy on Requests for Cedars-Sinai Social Media Accounts and Contributor Guidelines

  • Prior to this new policy, accounts using Cedars-Sinai's name were prohibited. Now, departments and institutions can have their own social media accounts if approved through a formalized process.
  • The formalized process includes an application, vice president approval, a training session and pre-populated accounts with brand-approved logos, cover photos and names.
  • Before a department can have an account, they should begin the application process by emailing the social media team.

If you have questions about these policies or any other social media inquiries, contact the social media team at socialmedia@cshs.org.

 

Core Labs Updating Anion Gap Calculation

Beginning Dec. 16, the Core Laboratories within the Department of Pathology and Laboratory Medicine will update the anion gap calculation to include potassium. This calculation normally includes the difference between the major measured cations and anions in blood serum/plasma.

We have historically used the following calculation:

Na - (Cl + HCO3)

Which will now go to:

(Na + K) - (Cl + HCO3)

The update should provide a slightly more accurate estimate of the anion gap. With this update to the calculation, we will also be updating the reference interval from 8-20 mmol/L to 10-20 mmol/L. This change to the reference interval doesn't coincide with the calculation change directly, but rather to current cited sources that include potassium.

If you have questions, contact Kimia Sobhani at kimiasobhani@cshs.org, or Anders Berg, PhD, at anders.berg@cshs.org.

Pharmacy and Therapeutics Product Updates

Product information updates for October from Pharmacy and Therapeutics are summarized in the PDF link below.

P and T Approvals - October 2019 (PDF)  

CS-Link Tip: View a Lifetime of Care at a Glance

Lifetime, a new feature in CS-Link™, rolled out on Nov. 3. The updated feature allows you to see a visual timeline of a patient's entire medical history at Cedars-Sinai.

This useful tool can be used in numerous ways, such as quickly familiarizing yourself with a new patient or seeing a detailed review of a patient's medication history. It is accessible through the Encounters tab in Chart Review and in Synopsis. Look for the Lifetime icon (a green infinity symbol) in the toolbar.

The Lifetime activity displays a calendar timeline, below which are individual timelines grouped into categories—Problems, History and Medications. The bottom Timespan Selection Bar allows you to zoom in and out of the timeline to expand or narrow the amount of time shown on the screen and to move along different intervals in the patient's record.

Hover over and click on the various timelines and icons to obtain more detailed information. You can expand the categories on the right to drill down to specific problems or medications. Hovering over the dashed circle to the left of the History category will display a pop-up box where you can switch between Past Medical History or Past Surgical History.

You can include or remove outside records pulled in from CareEverywhere by toggling the On/Off switch with the CareEverywhere logo located on the upper right. Next to the switch is a Legends button, which can help you better understand the icons that are displayed in Lifetime.

For more information, please see this CS-Link™ Job-Aid.

If you have further questions, feel free to contact us at groupeisphysicians@cshs.org.