»» Hello everyone and welcome. Today's session is the Research Spotlight, Practice Management, Leadership and Quality Session 1914. My name is Heather Vincent. I'm an Associate Professor at the University of Florida and Director of Research of the Program of Physical Medicine and Rehabilitation. I'm also a member of the Evidence Committee. And before we begin our presentations, I just want to alert a few items for housekeeping. First we are recording this webcast and that if you could kindly all remember if you are joining us today to mute your microphone and should you wish to ask questions of our panelists today, kindly use the chat feature and then I will get to those questions at the end of the session when all the speakers can come back and speak to you. We are here also to support you. If you are running into any technical support issues, again, please feel free to use the chat function and we will try and get with you with the AAPM and our production team to see how we can assist you. If we can advance the slide, please. As we begin, the first thing I would like to do is just indicate that the presentations that you are about to see are considered the best of in this particular category. All of these abstracts have undergone rigorous review by the Evidence Committee, as well as peer volunteers from the Academy. We thank all of you for your selection. And the very first presentation is by Dr. Larissa Richards, who is from Johns Hopkins University and the PM in our program. She will be speaking to us about cognitive impairment in people with dysvascular lower limb loss. Dr. Richards. Can you advance the slide? Thank you. So to start out, this was a QI project that we began and part of it was because we had a lot of amputee patients coming into our acute patient rehab and started to notice cognitive impairment was common among them. However, we didn't have actual data as to how many and how many were getting speech involvement in addition to occupational therapy. And so that's how this QI study began. Dysvascular limb loss and dysvascular etiology of limb loss is a major cause in the U.S. Patients have increased risk factors for dysvascular limb loss, including peripheral arterial disease and diabetes that also put them at risk for cognitive impairment. Persons with limb loss have an increased risk, therefore, of cognitive impairment and more importantly, reduced performance with their prosthesis. Our goal in this study was to do MOCA or Montreal Cognitive Assessment exams on all the patients that were admitted to Bayview Acute Rehab and then consult speech as appropriate. Once speech was involved, the R-BANs was done to classify their cognitive impairment. So the first 20 that were admitted with acute and chronic dysvascular amputations without a neurodiagnosis were enrolled. And so for a neurodiagnosis, for example, a stroke would make someone ineligible. The MOCA was done by OT and then SLP was consulted if the MOCA score was low. And this happened in actually all of our patients. Speech language pathologists would then do the R-BANs and help tailor the treatment plan for these patients. Now, going over to the right, looking at the results, all of the MOCA scores were low. In fact, the average of the MOCA score was around 20. If you look where the red bar is, that's the normal. And so all of those scores were well below that. The R-BANs was then done when speech was involved and these scores were also low. The average of here was 70 and you can see the red line noted there is the normal. Again, looking below that graph, you can see the R-BANs indexes to see which scores were low. And this was used in order to help further tailor the treatment plan to see which domains were lower and how we could potentially help our patients. So the ones that were lowest were attention, immediate memory, and delayed memory. And you can see why that would be important for whether it be an acute or chronic limb loss in order to see how to use the prosthesis, how to help with healing and how to, in the future, make sure that they can use their prosthesis appropriately. So in conclusion, as seen by the data above, cognitive impairment was very common in patients with limb loss. Early MOCA and R-BANs testing gave a better understanding of the deficits to help with discharge planning and future prosthesis use. Risk factors that led to amputation were the same established risk factors for cognitive impairment with significant functional implications. An incorporation of cognitive compensatory strategies developed by the treatment team helped optimize this population for successful post-amputation rehab, improve safety at discharge, allow for greatest level of independence, and to decrease caregiver burden. Excellent. Thank you very much. This was a great example of clinical observation driving changes in how patients are treated. Thank you very much. Our next speaker we're excited to announce is Dr. Clifford Kisling, who is from the University of Missouri-Columbia in their PM&R program. He will be speaking to us about enhancing comprehension of relative value units among resident physicians. Dr. Kisling, the floor is yours. Thanks, Dr. Vincent. So again, I'm Cliff Kisling. I'm a PGY-4 with the University of Missouri. Thanks for taking the time to review this QI project that myself, Dr. Benjamin Gill, and Dr. Greg Worsowitz worked on. So the main objective of this project was to assess residents' knowledge of relative value units, or RVUs. We assessed their ability to calculate their own RVU production while they were working at a freestanding inpatient rehab unit. And this is a skill that all physicians should have regardless of their specialty. So it was a cohort of four PGY-2 physicians. Each participant tallied their individual patient encounters over four consecutive days. So then they attempted to total their work RVU production for each of those given days. The initial set of data, the residents for this initial set, they were given no formal instruction on billing and coding. They only had their previous knowledge to go on. So participants, they were allowed to use resources at their disposal to help with this, but no resources were specifically given. So any resource that was used during this pre-intervention data collection wasn't reviewed at the conclusion of the study either. So then after these initial four days of data collecting, a formal education session with a billing and coding specialist took place. So this education session lasted about 30 minutes and covered the basics on billing and coding with an emphasis on that flow chart in the middle of the poster. So basically we outlined the process of seeing a patient, writing a note, how that note's converted to a CPT code, and then that CPT code converted to an RVU. And then that RVU is translated into reimbursement from insurance. All right, so they were also provided a table that showed specific RVU values for inpatient CPT codes. So the initial visit, the subsequent visits, they were given kind of that conversion for CPT code to RVU. But the components of what's required for like a level one CPT code versus a level three CPT code, that was briefly discussed, but not really discussed at length. They were given a handout that discussed other details on how to code which level, but that was not the focus of the education session. So then after education, the residents, again, tracked their patient encounters for four consecutive days and estimated their RVU production for those days. So then getting to our results. So our outcome measure, the actual RVU total, that was determined by the billing and coding specialist. So the note was written, the coding specialist, they determined what that actual RVU, that actual CPT code and RVU conversion was. The estimated total was each resident's estimation of their work for that day. So then that average difference between the two values is in that table on the right. And as you can see, the initial estimation of RVUs was pretty off. Each resident averaged a difference of 76 RVUs. So combined all four days, all four residents, their average RVU estimation was 76 RVUs different than what was actually billed, actually coded. Let me get back on track here. And then the standard deviation pre-intervention, 82.3. So that shows a really wide range of knowledge or maybe even guessing that each of those four residents were doing before they had the education. So then post-intervention, RVU totals came very close to the actual bill, remarkably close with a much tighter range and a tighter standard deviation. So it shows that knowledge is, they're all coming kind of closer together, greater understanding of what their actual work is translating to in RVUs. And so then that average difference between actual and estimated post-intervention, it was eightfold better. So a large improvement there. So main conclusion from this study, a brief education can increase resident accuracy and comprehension of RVUs. Knowledge and understanding of billing and coding as well as RVU production. It empowers residents as we're entering the workforce to be able to analyze contracts more critically. RVU targets are very commonly used in physician contracts. So having an idea of what that actually means translates into actual work so that you can analyze that contract better. It's also critically important from a medical legal perspective so that we can avoid fraudulent billing. There's a lot of other areas that we can take this type of study to, inpatient consult services, procedural clinics, outpatient clinics. So lots of other directions. And then there's obviously some critiques from the study, the ways that I would do it different in the future, specifically noting that the total encounters are quite different pre and post. There was actually a COVID outbreak on the unit between pre and post that really limited our total encounters and changed that. And then it didn't really encounter, it didn't account for their ability to code notes. It really just accounted for their ability to estimate their RVUs. So that would be another step to take in this. Can they accurately code their note? So that's the work I've got now and happy to answer questions here at the end. Excellent. Thank you so much. This is such an important issue for people who are training, going into their independent careers. This is a great project. Thank you so much. The next on the docket, we have Dr. Ebony Reed from the University of Michigan. We're very excited to introduce her and her topic, Examining Institutional Integrity, Race and Rehabilitation Service Utilization in a Global Pandemic. Dr. Reed, we're excited to hear your project. Thank you, Dr. Vincent. Hello and welcome. As Dr. Vincent noted, I will be presenting on race and rehabilitation service utilization in a global pandemic, in which our aim was to identify any differences based on race and acute rehabilitation care for patients hospitalized with COVID-19. Looking at the why behind our study, there are several contributing aspects. Starting with timing, we were in the height of a global pandemic in which chaos is expected and systems were pushed to the max, leaving policies at risk of being broken. Simultaneously, black communities were experiencing unjust losses and they were impacted heavily by COVID-19. And in fact, even pre-pandemic, black patients have been at increased risk of medical comorbidities as a result of healthcare inequalities stemming from systemic racism and residential segregation. Our study focuses to investigate the gap of knowledge. We know about the historical discrimination amongst blacks in healthcare and the resultant health disparities, but what we don't know is how does a global pandemic affect our institution's integrity and specifically for our field? Did rehabilitation care during this time contribute to any of the pre-existing inequalities? This study was completed as a prospective chart review of patients 18 and older admitted to the University of Michigan during the first wave of the pandemic with a positive COVID test. Individual charts were reviewed to assess patient demographics and several main outcome measures. This data was used in multiple studies, but for our study in particular, we focused on patient demographics, functional decline, number of therapy sessions, discharge location, length of stay, and time on the ventilator. When looking at our final study population, we had 239 participants with nearly equal portions of black compared to white patients. And of those participants, we noted the following characteristics, a larger percentage being men, approximately 57%, an average of 62 years of age with the survivors being younger at 61 compared to the age of 69 for those deceased. And lastly, we saw that the average length of stay was around 13 for all study participants and survivors, but approximately 15 for deceased patients. Now, moving away from characteristics of our patient population and diving into examining the true differences, again, the aim of our study was to identify any differences in rehabilitation care. With that being said, let's look at functional decline. Our method of measuring functional decline was to review each individual patient's chart and look through individual therapy notes to assess for documentation of decline from their known baseline. And these patients were identified with a yes or no in our chart review of whether they had functional decline. So I direct your attention to the first graph on the left. You'll see that a higher percentage of black patients had functional decline at approximately 45%. Now, we sought to also look at the amount of therapy sessions. While not highlighted on our poster, we did find that black patients received more physical therapy sessions, approximately four, when compared to the 2.6 of white patients. The reason behind us not highlighting this today is that we wanted to assess therapy allocation in a way that compared patients of similar severities. Our method of completing this analysis was to select covariates that would provide reflection of disease severity, such as length of stay, age, and time on mechanical ventilation. Thereby, when comparing therapy utilization based on race with the covariates of age and length of stay, or similarly, age and days on mechanical ventilation, we see clinically that black patients receive slightly more therapy sessions. However, statistically, there was no significant difference in the amount of therapy sessions based on race. And the last analysis that I would like to address is discharge location. As rehabilitation specialists, we know that in rehab, in the acute setting, rehabilitation is only one small aspect of their care, and a very large portion of rehabilitation care is what happens after discharge. When looking at discharge location based on race, we saw that 82% of black patients were discharged home with 12% being discharged to subacute facilities, where 66% of white patients were discharged home and 22% were discharged to subacute facilities. So I've given you a lot of numbers and data, but what I want to summarize is what that means as a whole. Our study found that black patients were more likely to experience functional decline, and when comparing the amount of therapy sessions of black patients to patients of other races with similar lengths of stay, age, and time on mechanical ventilation, we saw that they were provided an equitable amount of therapy sessions. Yet when looking into discharge location, white patients were nearly twice as likely to be discharged to subacute rehabilitation when compared to black patients. Now, with all transparency, with our study's current data, we cannot yet say why this difference in discharge location exists, and there are so many things to consider in future studies, such as insurance status, patient preference, financial security, and multiple different socioeconomic factors that can contribute to discharge location. However, this leads me to the continued aim and the crux of our project, which is expanding our understanding on the differences that exist within healthcare based on race. Our study was a systematic study looking into systemic issues of healthcare related to racial inequalities, and this study can be done at any institution. This study can be done amongst multiple subspecialties. Without us understanding the potential biases that we have at our own institutions, we cannot make change. Therefore, the largest aim of my project is to challenge you all to consider reflections and investigations into your own institution's integrity. And with that, I thank you all for your time, and I welcome any questions you may have. Excellent. Thank you so much, Dr. Reed. We really appreciate that. This is a very timely and important topic for all of us to consider going forward. The next up is Dr. Elizabeth Chan, who is from the Shirley Ryan Ability Lab at Northwestern. We're excited to have her here today speaking about filling in the gaps to early detection of cerebral palsy and treatment within a neonatal follow-up program. Dr. Chan. Good afternoon, everyone. This is presented on behalf of Lurie Children's Hospital's neonatal intensive care unit follow-up clinic in collaboration with the Shirley Ryan Ability Lab. We are a recent early detection site through the Cerebral Palsy Foundation as of November, 2020. And I'd like to thank the authors, Nicole Popert, Rayanne O'Donoghue, Mary-Kane Centella, and Deborah Gabler-Sfera. So recent recommendations call for earlier detection and intervention for cerebral palsy. More and more studies have been coming out that show that this is possible using a combination of imaging, clinical assessment, as well as standardized clinical objective measures. The Pre-Native Infant Neurologic Examination, or the HINE, is one such tool that assists in predicting risk. To align our practice within these recommendations, we evaluate the feasibility of implementing an early detection management algorithm using the HINE in our neonatal follow-up program. This poster describes data which was obtained between January 1st, 2019 and December 31st, 2019. It represents the pre-network status feasibility study portion of incorporating the Hammersmith Infant Neurologic Examination into the NICU follow-up clinic at the three-month screening visit by the PT and the physician. We developed a HINE management algorithm that you see in the figure one, sorry about that, that uses the HINE score to stratify infants into three groups, at-risk, suboptimal, and optimal. Team members received HINE training sessions prior to the initiation in the clinic. Referrals for PT and physiatry team embedded within our clinic are also included in the algorithm. So the data was procured from a quality improvement process looking at a total of 342 high-risk initial visits. Demographically, we aim to have patients scheduled to be seen at around three months of corrected age for this initial visit. In table one, the majority of our patients were seen between three to four months, or about 92%. Out of those visits, our compliance rate for performing the HINE was 91.2%. Of note, 5% or 17 out of the 342 visits of the HINEs initiated were incomplete for various reasons. 12 infants were eventually given a diagnosis of cerebral palsy. Of these infants, one did not complete the HINE testing, seven had HINE scores less than 56, one had a HINE score between 56 and 67, and three had HINE scores greater than 67. Our mean age at diagnosis was eight months, which is significantly improved upon the standard two years from several years prior. Additional outcome measures examined related to our algorithm using the HINE score include HINE scores that fell in the at-risk group, 100% were referred to therapies, and 85.7 were referred to the physiatry team. The HINE has proven to be an extremely useful tool for improving early detection of cerebral palsy. We hope this presentation helps provide a framework for how the HINE can be successfully incorporated into the flow of a clinic and inspires increased confidence in the utility of the HINE as a standardized clinical tool to help predict risk for CP and the need for services. Update as to where we are right now, we have successfully been able to incorporate the HINE as well as the GMA, which is a separate clinical standardized tool to be used for the detection of cerebral palsy. Thank you so much. Thank you very much, Dr. Chan. Much appreciated. I look forward to asking some questions. Next slide, please. Thank you. I am excited to welcome Dr. Cecilia Cordova-Variejos, and she is going to be talking to us about support and follow-up of an underserved amputee population, a quality improvement project. And she's from the Montefiore Medical Center, Albert Einstein College of Medicine. Thank you so much for joining us today. Thank you, Dr. Vincent. Hello, it is my pleasure to present our QI project, support and follow-up of an underserved amputee population, a quality improvement project. Doctors Atalaya, Dinesh Devik, Patel, Fung and I decided to embark on this project as we had observed that most of our amputee patients seen here in the Bronx had preventable causes of amputation. Unfortunately, some had more than one amputation and many had multiple hospital visits. And we wonder if there was anything we could do about it. Our primary objective was to be able to contact and follow up patients that have been seen within our department, either inpatient, outpatient or consult services, and give them information and resources regarding community reinsertion and health behaviors. The secondary objective was to evaluate and establish a protocol on how to communicate and follow up with our patients, looking for sustainability, growth, and hopefully impact health outcomes in the future. We used a plan-do-study-act model as our working methodology so that we could make changes, resolve problems and come out with upgrades as we continue to advance in the project. We started by creating an EpicShare folder for the whole department of rehab in the institution to refer the patients into, and an Excel sheet for the data collection. With the support of our attending Dr. Rahn, we created a new institutional email called MPT Support for communication purposes with the patients. We work by one volunteer resident per month that would log and check on the Epic Share folder and contact those new patients that had been added and let them know of the information and registering the data. Next slide, please. We measure as primary outcomes the number of people that were added to the Epic folder and the number of people contacted and interested in the services provided, information and resources. Secondary outcomes were to determine the impact of follow-up, the number of patients contacted that were later seen in our prosthetics and orthotics clinics, the use of resources given, and if there were any health complications, such as emergency room visits or hospitalizations or any needs that the patient had, such as therapy or prosthesis visits during that period of time. The results we obtained were as follows. 56 patients were added to our list between the month of September 2020 and February 2021, of which 43% showed interest in either being followed or in their resources or both. 16 showed no interest when we contacted them or just not interest at all. And other 16% had no information registered despite having a date of successful contact. So that was our fault, we didn't know. And the remaining 25% had communication problems with either incorrect phone numbers or email addresses, so we couldn't really contact them. Unfortunately, we were unable to analyze our secondary outcomes, given the lack of best standardization in our data collection. This prevented secure evaluation of the follow-up of our patients, their complications or needs. Of the demographic data, we had more men than women. We found that 66% had a below-knee amputation as a level of amputation. We had no patients referred to us that had suffered from upper limb loss, and 25% had more than one amputation, with the principal cause of amputation being peripheral artery disease. Next slide, please. We concluded that communication determinants and data collection were an important barrier to our analysis and follow-up, but it was clear that of the successfully contacted patients, most showed interest in our service. 24 out of the 33 successfully contacted patients, making us believe that a protocol is not only feasible but needed for a successful impact in health outcomes in the amputee population. We're currently undergoing our second stage of the project with over 90 patients. We're continuously working on organization and improvement in the data collection to develop a successful and reproducible protocol for communication and follow-up of an amputee population. This has helped us to raise awareness within our own department, and we hope that our intervention spreads further in our hospital and beyond to be able to improve the quality of life and reduce the morbidity and mortality that this population is at increased risk of. Thank you for your attention and time, and I'm welcome to have any questions if you need. Very nice. Thank you very much. A very important question that you're working on there, keeping people involved in care. As our final presentation today, I welcome Dr. David Schultz from the University of California, Los Angeles, from the greater Los Angeles area. We are delighted to have you. He is going to be sharing his work on telemedicine practice and its influence on neurosurgery referrals among patients with low back pain. Dr. Schultz, the stage is yours. Thank you very much. Thank you, Jim. It's lovely to be here today. Very excited to be presenting on this. It's a really interesting... Why don't you click to the next slide there? So it's really interesting. So COVID has changed a lot of things about how we do practice. And one of the big things that changed is telemedicine has... Telephone video was at 70% last week in March. And so it's like boomed. And it's gone down a little bit, but telemedicine is really here to stay. And so it's really important that we kind of look at it and see, being PNR doctors, when we bring someone in for a physical exam or to see them in clinic, how important is that physical exam? How important is that in person? Are there changes and differences in how we practice given this new landscape? And so we looked at something very interesting. What we looked at was we took a lot of veterans that we had, and we looked at in-person visits versus telemedicine visits. And for patients who are new patients coming to the clinic presenting with low back pain. And so one of the things that we looked at was we looked at how often we were... And how often do we refer patients to neurosurgery from that initial visit? And one of the things that was very interesting about this, and it opens up a lot more questions which you're looking into now, is we ordered about the same amount of imaging. So if you look up here in the results, those who received imaging in person was about 28.81%. And on the telephones, about 25%. And so not really statistically significantly different. Yet, the amount of people who were referred to neurosurgery was very significantly different. On the telephone, we had almost a four to one increase in how many people we referred directly to neurosurgery. And so this opens a lot of questions. Are those referrals good referrals? Are they referrals that need to be done? Are people necessarily, or is that physical exam really needed so we don't make those unnecessary referrals if they are necessary? And so it's a really great kind of, this is the beginning of a lot of research in this topic on telemedicine and how it impacts us, especially being in our field where physical exam is so important. So kind of our conclusions were, it does make a big effect. So telemedicine can have a large effect on referral patterns, especially to neurosurgery. Now, are those referrals necessary? That's the next part that we're kind of looking into. And so I'm really excited to see where we go with that. But everything else was about the same, same amount of imaging, same amount of referrals to physical therapy, occupational therapies, but referrals to surgery, significantly different. So definitely more questions that we need to have answered here. But great, interesting preliminary thing to look at. And I look forward to answering any of y'all's questions later. Thank you very much. Thank you very much, Dr. Soltz, really appreciate that. Also a very timely issue as we are all searching for new ways to accommodate the changing landscape of clinical practice. What I'd like to do is open up the floor to the audience. If anyone has questions, please feel free to put them in the chat. It looks like we have a couple coming in. So I'll start with one from Dr. Blankenship for Dr. Chan. We are currently working on developing our early diagnosis program and now have therapists trained in HINE, but not yet in GMA. What has been your experience with the change in your practice or program for infants under five months of age with adding GMA versus HINE? Is the GMA done by the physician or a therapist in clinic or reviewing videos outside of clinic? Thank you. Hi, so that's a great question. Definitely the GMA, one of the biggest barriers has been getting people trained and getting them involved in the course with the time and cost. As far as how we're doing it right now, we have our nurse do the GMA video in clinic and it is reviewed by two advanced providers afterwards on a day we usually do once a week where we go through some of the GMA videos that have been taken. Sometimes we have the parents do it at home as well. They are given information on how to do the video and they send it back to us via, and the protocol is the Australian protocol that is done. I hope that answers the question. Excellent. Thank you very much for that answer. We have another question from Dr. Smith for Dr. Reed. Really enjoyed your presentation. Do you have suggestions for ways we can be proactive to ensure equitable post-COVID care, even for those discharged home and dealing with long-term issues? Yes, excellent question, Dr. Smith. I think this really branches open something very larger that we should be considering at our institutions and that's understanding the differences that exist amongst our patients. Some of those can be socioeconomic differences such as transportation status, financial status, knowing when we discharge these patients home, what level of support they truly have. And if we are examining that for every single patient, then when discharging them, we can have more control in dealing with these long-term issues. And I think in fact, in the case of my study, what could have contributed further is having more PM&R physicians consulted on all of these patients so that we can be the ones spearheading and knowing that these differences exist and are important when they're discharged home, thereby we can make further recommendations for those patients. Excellent, thank you very much. We have another quick question, it looks like from Dr. Clohan. Dr. Schultz, very interesting. Please say again the sample size or N of your study. Absolutely. Hi, can you see me there? Let's see. Don't quite see you yet. Can you see me on the thing? Can you hear me? We can hear you. Okay, yeah, great question. Oh, there we are. Great question. So what we looked at was we did a retrospective cohort and we looked at 1,322 cases and then we narrowed that down to 542 patients. Of that, 427 were in-person and 115 were telemedicine phone visits. So still in that, definitely less of the telemedicine, but then again, we have a large, large population of in-person that we can go off of. Telemedicine is a little bit new to us, especially at the VA at West L.A. And so this is one of the things that we were definitely looking at. And actually now we have a lot more of that data. So it'd be even more interesting to add more into this. But yeah, our overall N was 542 with in-person, outweighing the amount of phone people, 427 in-person and 115 on the phone. Great question, thank you. Excellent. Actually, if I could piggyback a question onto your presentation, Dr. Scholz as well, out of curiosity, were you able to tell if there were differences in patient satisfaction, whether or not they went the regular visit route versus telemedicine? That may not have been an outcome, but I was curious if you, yeah. Absolutely. No, so it's really interesting. So this isn't something necessarily looked at as one of the things, but I can just talk from my personal experience is that a lot of patients, especially for that initial visit, they like to be seen in person. There's something about the hands-on, the physical care approach. And oftentimes if something's a little bit complicated, we're just like, well, we'll have to see you in person anyways. And so I really think perhaps in a, again, just my personal experience, we didn't look at this clinically for our data here, but I think sometimes for that follow-up, if it's something quick to check on or something, telemedicine might be a little bit more reasonable. But kind of that initial visit, I definitely think a lot of people kind of prefer to come in and it's different by generation too, I will say. Younger people are a lot more okay just being like, yeah, hey, give me a call, let's do a video chat. Whereas an older person, especially our veteran population has hearing issues. And so that's a big thing too. Yeah, excellent. Ooh, you have two more follow-ups. Another follow-up. It said, what do we know, oh, this is from Dr. Hearn. What do we know about how phone versus in-person visits were offered? Is it possible that the phone visits were more frequently offered to patients triaged to have potentially urgent symptoms who could not wait for an in-person appointment? Fantastic question. I love this question. And there's a lot of wonderful things that we have to look at. So during one period of time, we switched to pretty much not, I wanna say exclusively, but very high telemedicine. So everyone was pretty much put in the same kind of group. When COVID hit really, really heavily back in the 2020 area. And then again, we had a little bit of a surge in Los Angeles. So telemedicine was really our way to go. So they weren't necessarily triaged towards like, if they're really urgent, we'll put them in and we'll give them a call. There wasn't a lot of that. It was more just everyone kind of funneled into this kind of group. But as for, and again, this is one of these interesting things about telemedicine happening, is it wasn't a very clear guideline on like, oh, this patient has this going on, this symptom, and they need to be directly sent to in-person versus telephone. But yeah, that's a very, very good question. Okay, perfect. Thank you. And then, oh, there's another one too. Yep, there's another one too here from Dr. Blankenship. By chance, have you looked at what percentage of those referrals for each group went on to need surgery? Fantastic question. That's literally what we're looking into now. So this initial data really made us question, are those referrals necessary for us? And I think that's one of the biggest things. Or, and the previous point is that a lot of, I think we might've noticed this in our practice too, but a lot of patients are like, well, it's COVID. We have a lot of older population at the VA. They're like, well, it's COVID. I don't want to go into a hospital. Maybe if it's not that bad, I won't go in or I won't seek care. And then we get this backlog of people who haven't sought care. And then they have those red flag symptoms, you know, loss of bladder or bowel. You know, maybe they're weaker than they would've thought. And they're like, well, I'm not gonna worry about it. But yeah, it's very interesting as to what's the issue. Are we getting sicker people? And then they're coming in the telemedicine? Or are we referring unnecessarily because of that lack of hands-on physical exam? So that is absolutely something that after we got this initial data and we saw that there was something there, absolutely what we want to look into. So I'm literally doing that. I was working on that yesterday, but great question and great future direction. These are great questions that are coming in. Thank you. I actually have a question for Dr. Richards on her work. I'd love to bring her back. So Dr. Richards had done some work on the cognitive impairment with limb loss. And so my question is, this sounds very exciting. Where do you see this going with these types of assessment? Would you recommend that this be a measurement done for all suspected amputees who might be at risk? Yes. So one of the changes we have made is now anytime an amputee, whether it be acute or chronic, comes to our inpatient rehab unit, we automatically get speech involved. We don't even, we don't, so initially the process was to get an occupational therapist to do the MOCA and then if low, get speech involved, but we get them involved sooner, figure out which domains in the index scores are lower and work on, start developing strategies immediately. Excellent. And do the patients appreciate that? Does this resonate with them? It does. And you know what? It also resonates with the families of those caregivers or who's helping them when they go home. So getting them, one of the things I've noticed we do more is more handouts with these patients. So giving them written instructions, not only for the patient, but also for families to have for future reference. Excellent. And I guess my next question moving forward would be, how does this affect things in the longterm? But we do not have that data. Oh, this is excellent. All of these projects are really moving medicine forward. Thank you so much, Dr. Richards. Appreciate that. You're welcome. If Dr. Kisling is here, I would love to ask him a question as well. His work was very practical and I think could really be implemented in quite a widespread scenario, if you will. So this apparently was done in PGY-2 residents. Correct. Is that correct? Okay, good. So going forward, it seemed like they learned a lot from even just this one experience with coding. Do you think you might get continued enhancement if they were given additional training with feedback on either mock-up patients or whatnot? But what would be your advice going forward? Yeah, so I think the easiest piece of advice is just talk with your billing and coding specialists in your department. That's been a tremendous resource for myself as I was negotiating contracts, but they have so much knowledge that it's just things we don't deal with on a day-to-day basis. So that would be the place to start. And then just continuing to kind of go back and ask those questions, you know, why was this note this? There's so many nitpicky things you can get into, but just starting to understand that knowledge a little bit more, because it's not what we learn in medical school, but it's very practical to what we do as clinicians. Right, excellent. And from your advice too, would there be value to even an elective course for medical students, even if it were a brief week of exposure of these types of things? Do you think there would be value in that even starting earlier? Absolutely, just starting to understand some of that lingo, CPT code, RBU, just having that so that when you're actually getting into those clinical settings and doing those notes, putting things together, you can ask those questions. You know the language, you know how to ask instead of starting from this point of just learning the vocab. So yeah, bringing it more into medical school, absolutely. Yeah, well, thank you so much for that work. I look forward to reading about it in print. Thank you. And I had one more question. I want to make sure I involve all of our speakers. And so I would love to get Dr. Cordova-Variejos back if we possibly could. And I would love to hear your thoughts on, it looks like when you were canvassing your amputee population about potential interest in some of these follow-up programs, it looks like about a third of them weren't really interested at all. Could you speculate on maybe why this group was so disinterested? Was it socially determinant related? Was it other comorbidities? Could you maybe give us a little insight what you experienced with this group? So I think, thank you for the question. It's not that a third was not interested. I think it was a little less than that. We had about 75 to 80% that were interested. The main problem was communication. So a lot of them we couldn't contact. And then the ones that we contacted, we didn't have, for some reason, the registration if they were or were not interested. So we don't know. The ones that were not interested, it was nine out of 56. So it was not that many. And some of them, it was mainly because they didn't have time or they were not first-time amputees. So they've had a long time already and they were not interested in the resources anymore. Most of the new amputees, and that's what we're collecting now, they are super happy of having those resources, of talking about support groups, of knowing who to contact. And they are very, very welcoming on that. So I think the most of them that are not interested, it's just that they've been amputees for a long time. Understood. And that makes perfect sense. So it sounds like maybe your program would be that excellent fit for that transition, early recovery into those first couple, few years. Would that make sense? Okay. Yes, exactly. We didn't discriminate this time. Any patient that had an amputation, we contacted them. And now we're trying to get those to those first-time amputees early on. Excellent. Excellent. That's a huge help. Thank you for clarifying. No problem. Well, this session has been terrific. Are there any other last questions from the audience that we can address today? I'm so delighted to have met each of you as speakers. We had a terrific panel. I'd also thank very much the AAP MNR, as well as the BDANCE group who is producing this for us. They have been lifesavers, making sure this all runs very smoothly. I appreciate all of your time and look forward to seeing you in person next year. Thank you. Thank you very much.

cognitive impairment in amputees

comprehension of relative value units

race and rehabilitation service utilization

early detection of cerebral palsy

support and follow-up for amputees

influence of telemedicine on neurosurgery referrals

low back pain

physical medicine and rehabilitation