October 24, 2022

HOMERuN Collaborative: Announcing HOMERuN Studies and HOMERuN's Statement on Racial Bias in Pulse Oximetry

The Hospital Medicine Reengineering Network (HOMERuN) is a rapidly growing collaborative made up of more than 50 Hospital Medicine groups from academic and non-academic hospitals across the United States.

Presenters: Stephanie Mueller, Andrew Auerbach, David Sterken

Recently Funded HOMERuN Studies

Identification and Prevention of Potentially Inappropriate Interhospital Transfers Study

Principal Investigator: Stephanie Mueller, Brigham and Women's Hospital Funding Agency: Agency for Healthcare Research and Quality Overview: Interhospital transfer (IHT, the transfer of patients from one acute care hospital to another) is common among hospitalized medical patient. Our study seeks to accurately define and estimate the incidence and patient safety impact of potentially inappropriate IHT among medical patients who have undergone transfer to a large network of US hospitals, characterize and identify at-risk patients, and develop a toolkit of best practices to reduce potentially inappropriate IHT for future dissemination (e.g., by replacing it with safer alternatives).

Aim 1: Utilize stakeholder input (including patients and families, clinicians from transferring and receiving hospitals, and hospital leadership) to define potentially inappropriate inter-hospital transfers. Aim 2: Identify and determine the incidence of potentially inappropriate inter-hospital transfers and estimate their patient safety impact among hospitalized medical patients using a standardized adjudication process of patients transferred to hospitals affiliated with HOMERuN. Aim 3: (A) Combine adjudication data from HOMERuN sites with data from Vizient to retrospectively characterize a population of potentially inappropriate inter-hospital transfers; and (B) Derive and validate a model to prospectively identify potentially inappropriate inter-hospital transfers. Aim 4: To use data from Aims 2 and 3 and key stakeholder input to iteratively develop and refine a generalizable intervention toolkit intended to reduce inappropriate interhospital transfers across multiple settings.

Site Participation: Brigham and Women’s Hospital (BWH) will serve as the coordinating site. We are looking for 18 participating sites with Hospital Medicine groups that have at least 100 transfer patients over 2 years and have experience with (or feel they could carry out) the tasks of case reviews/adjudications, including: case identification, review, and data checking. Expected Deliverables from Sites: Identify/recruit stakeholder to participate in focus groups (anticipated beginning January 2023) Chart review of 100 cases at each site (anticipated beginning September 2023 through December 2024) Participation in twice monthly conference calls and webinars Additional attendance at SHM meetings during these years (for those attending SHM)

The Study Team Will Provide: Teaching and mentoring for the chart review process Supporting documentation and guides for how to expand this review process at your site Collaborative tools Opportunity to present preliminary information/data from your site (e.g., poster and/or oral presentations at the annual SHM conference) Networking with other centers $1000 (per site lead) paid in annual installments for the duration of the study; $40 per completed adjudication per person Other anticipated recognition: Non-named authorship and/or acknowledgement on all resultant publications; Potential for named authorship (e.g., contributions to adjudication improvements, identification of additional sites, spin-off evaluation); Ability to add “site lead” for this federally funded study on your CV Academic connections and mentoring through the study team-HOMERuN Possibly CME or MOC credit

If you are interested in participating, complete our following brief intake form.

Achieving Diagnostic Excellence through Prevention and Teamwork (ADEPT) Study

Principal Investigator: Andrew Auerbach, University of California, San Francisco Funder: Agency for Healthcare Research and Quality Overview: The purpose of ADEPT is to understand factors which produce problems in making accurate and timely diagnoses, as well as factors which are part of making a great diagnosis, or ‘good catches.’ ADEPT will use research results to help hospitals improve diagnostic processes and improve patient outcomes.

Aim 1: To implement an enhanced case review infrastructure which can accurately identify diagnostic errors and characterize diagnostic processes among patients suffering inpatient deaths, ICU transfers, or rapid-response team calls taking place at hospitals associated with UPSIDE. Aim 2: To develop site-level and group-wide benchmarking reports of error rates, diagnostic processes, and diagnostic performance and incorporate them into sites’ safety and quality programs.  Aim 3: To use Aim 2 infrastructure to identify and pilot Safety I and Safety II interventions.

Expected Deliverables from Sites Readiness assessment survey Chart reviews Data checks and corrections as needed Review of draft benchmarking reports Participation in intervention (e.g. diagnostic time out program) development Participation in twice-monthly conference calls and webinars Additional meetups at SHM meetings during those years (for those attending SHM) Epic Clarity data

The Study Team Will Provide Teaching and mentoring on the review process Supporting documentation and guides for how to expand this review process at your site Collaborative tools CME/MOC for case reviews, based on minimum number of cases In context of annual conference Opportunity to present preliminary information from sites Networking with other centers At least $15,000 paid in 4 installments, based on successful achievement of study milestones

HOMERuN-Affiliated Study Seeking Partners

Roflumilast or Azithromycin to Prevent COPD Exacerbations (RELIANCE) Study

Purpose of RELIANCE: Both roflumilast and azithromycin have been shown to reduce the risk of COPD exacerbations compared to placebo. However, there has not been a head-to-head comparison of these two FDA-approved medications. RELIANCE is intended to support hospital efforts to reduce the risk of all-cause hospitalization and premature deaths in individuals with COPD.  RELIANCE is Seeking Community-Based Hospitalists: Hospitalists are critical in the development of post-discharge care plans and medications used by people with COPD. We found from preliminary work that identification of people with COPD while they are hospitalized is an efficient recruitment method for RELIANCE. Benefits and Compensation: $500/year honorarium for being a community partner (paid after registration) plus $200 per patient enrolled. Option to participate in clinical roundtables with COPD thought leaders. Contribute topic ideas for future grant proposals or publications related to hospitalist care. Community Partners will not be investigators / authors, but will be acknowledged in the RELIANCE publication.  Please reach out to Tiffany.Lee@ucsf.edu if you are interested in participating and would like more information about RELIANCE.

Racial Bias in Pulse Oximetry

As hospitalists we rely on pulse oximetry measurements every day to make crucial clinical decisions. Unfortunately, multiple recent studies have now demonstrated that pulse oximetry can falsely overestimate the oxygen saturations of Black, Asian, and Hispanic patients, which has created a racial bias in these measurements and may be contributing to many of the devastating racial and ethnic disparities in health that we see today. There is no sufficient clinical solution to this problem aside from improving the way our medical devices measure oxygen saturation for all patients; anything short of this would be a mere stopgap solution.

The FDA has convened a public meeting on November 1 of the Medical Devices Advisory Committee to discuss whether requirements of pulse oximeter manufacturers should change. Public comments that were submitted to the FDA on or before October 18 will be provided to the committee. The HOMERuN Antiracism, Social Justice, and Equity Work Group drafted, collected 157 signatures from over 30 health care institutions, and submitted a statement on racial bias in pulse oximetry on behalf of HOMERuN.

In the letter, we made these 8 recommendations for the FDA and related agencies to address racial bias in pulse oximeters: Require that subgroup analyses by skin pigmentation, race and ethnicity, and gender be conducted as part of the approval process for pulse oximetry devices to demonstrate equitable accuracy across a range of skin pigmentation, racial and ethnic groups, and genders. Prohibit the use of “race correction factors” by manufacturers and instead require that calibration be based on objective measures of skin pigmentation, not the social construct of race. Require that data include measurements from both healthy and hospitalized participants to reflect the real-life use of these devices. Intensify the approval requirements for medical-grade pulse oximeters and consider requirements for “over-the-counter” devices. Have these new approval requirements apply retroactively to previously approved devices. Investigate other similar devices (e.g., optical devices) for the presence of racial bias. Deploy safeguards to detect and prevent biases in our other diagnostic tools, similar to #6, above. The FDA could also consider creating a dedicated committee to review all future devices for potential biases prior to their approval. Invest in research in conjunction with the NIH to better study the racial biases seen in these devices and to develop innovative new technologies that are not impacted by skin pigmentation.

Our next meeting will be on December 9, 2022.

Image Attributions: Cartoon Vectors by Vecteezy @ Vecteezy.com; Pulse Oximeter via Unsplash

Check out the HOMERuN website for more information. If you would like to join the HOMERuN Collaborative calls, please reach out to Tiffany.Lee@ucsf.edu.