Richard J. Caplan, Ph.D

Senior Biostatistician

Publications

COVID-19 in hospitalized adult patients with sickle cell disease: A 2020 US cohort using Cerner Real-World Data (CRWD)
COVID-19 in hospitalized adult patients with sickle cell disease: A 2020 US cohort using Cerner Real-World Data (CRWD)
Guarino SH, Williams KD, Caplan RJ, Fawcett M, Lanzkron S

J Clin Transl Sci 2023 ;7(1):e152

PMID: 37528938

Abstract

We used Cerner Real-World Data™, representing hospital admission records from 2020, to examine patients with co-occurring sickle cell disease and COVID-19 by discharge disposition grouped as death/hospice versus transfers to other facilities, returned home, or left against medical advice. Among the death/hospice group, we found older age and higher rates of congestive heart failure and diabetes. There were also significant differences in tachypnea, mechanical ventilation, minimum O saturation, and length of stay with higher rates in the death/hospice group. Awareness of such factors and associated mortality risks for this population may aid in patient care.
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Predictors and Outcomes of Patient Knowledge of Plan of Care in Hospital Medicine: A Quality Improvement Study
Predictors and Outcomes of Patient Knowledge of Plan of Care in Hospital Medicine: A Quality Improvement Study
Bhamidipati VS, Hicks LS, Caplan R, Ingraham B, Rn PM, Robinson EJ

Jt Comm J Qual Patient Saf 2021 03;47(3):176-184

PMID: 33454235

Abstract

BACKGROUND">Patient understanding of plan of care is associated with positive outcomes in ambulatory settings. In hospital medicine settings, patient-physician agreement on plan of care (concordance) has been limited and difficult to improve. This study examined the impact of adding a hospitalist to interdisciplinary rounds (IDR) on physician-patient-nurse concordance and the relationship between concordance and outcomes.</Abstr: Patient understanding of plan of care is associated with positive outcomes in ambulatory settings. In hospital medicine settings, patient-physician agreement on plan of care (concordance) has been limited and difficult to improve. This study examined the impact of adding a hospitalist to interdisciplinary rounds (IDR) on physician-patient-nurse concordance and the relationship between concordance and outcomes.

METHODS">IDR were conducted by core teams made up of unit-based nurses, a case manager, and a pharmacist. Over time, with cohorting, hospitalists were included in IDR (hospitalist IDR) for some patients assigned to unit-based hospitalists. In developing hospitalist IDR, the researchers emphasized using an IDR checklist, including a patient communication plan. Patient-nurse-physician interviews were used to assess concordance in the domains of diagnosis, tests and procedures, and expected discharge date. Using two-hospitalist review, agreement was rated as none, partial, or complete, and a total concordance score was calculated for each patient in both IDR groups. Multivariate analysis was used to examine the relationship between concordance, IDR type, patient factors, and utilization outcomes.</Abstr: IDR were conducted by core teams made up of unit-based nurses, a case manager, and a pharmacist. Over time, with cohorting, hospitalists were included in IDR (hospitalist IDR) for some patients assigned to unit-based hospitalists. In developing hospitalist IDR, the researchers emphasized using an IDR checklist, including a patient communication plan. Patient-nurse-physician interviews were used to assess concordance in the domains of diagnosis, tests and procedures, and expected discharge date. Using two-hospitalist review, agreement was rated as none, partial, or complete, and a total concordance score was calculated for each patient in both IDR groups. Multivariate analysis was used to examine the relationship between concordance, IDR type, patient factors, and utilization outcomes.

RESULTS">For 658 patients, the mean concordance score was 11.71 out of a possible 18. There was no difference in concordance between hospitalist and core IDR groups (11.68 vs. 11.84, p = 0.7). Higher total concordance score was associated with lower lengths of stay (p < 0.001) and readmission rates (p = 0.001). Total concordance had a negative association with patient age (p = 0.04).</Abstr: For 658 patients, the mean concordance score was 11.71 out of a possible 18. There was no difference in concordance between hospitalist and core IDR groups (11.68 vs. 11.84, p = 0.7). Higher total concordance score was associated with lower lengths of stay (p < 0.001) and readmission rates (p = 0.001). Total concordance had a negative association with patient age (p = 0.04).

CONCLUSION">Concordance did not change with IDR type. Higher concordance appears to be related to positive utilization outcomes. Future studies are needed to evaluate potential interventions to improve concordance.Copyright © 2020 The Joint Commission. Published by Elsevier Inc. All rights reserved.</CopyrightInfo: Concordance did not change with IDR type. Higher concordance appears to be related to positive utilization outcomes. Future studies are needed to evaluate potential interventions to improve concordance.

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Evaluation of N95 respirator ultraviolet decontamination and clinical reuse with quantitative fit testing
Evaluation of N95 respirator ultraviolet decontamination and clinical reuse with quantitative fit testing
Wanner GK, Ader D, Caplan R, Padaki AS, Ravert D, Drees M

Infect Control Hosp Epidemiol 2021 May;():1-3

PMID: 33934738

Abstract

The supply of N95 respirators has been severely strained by the coronavirus disease 2019 (COVID-19) pandemic. We used quantitative fit-testing to evaluate 16 participants and 45 respirators through up to 4 rounds of ultraviolet decontamination and clinical reuse. The mean fit-test failure rate was 29.7%, and the probability of failure increased through N95 reuse.
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The Effects of Virtual Reality on Anxiety and Self-Efficacy Among Patients With Cancer: A Pilot Study
The Effects of Virtual Reality on Anxiety and Self-Efficacy Among Patients With Cancer: A Pilot Study
Birkhoff SD, Waddington C, Williams J, Verucci L, Dominelli M, Caplan R

Oncol Nurs Forum 2021 07;48(4):431-439

PMID: 34142994

Abstract

OBJECTIVES">To examine the impact of a nurse-led intervention on anxiety levels and perceived self-efficacy to cope in patients receiving first-time chemotherapy using a customized prechemotherapy educational virtual reality (VR) video.</Abstr: To examine the impact of a nurse-led intervention on anxiety levels and perceived self-efficacy to cope in patients receiving first-time chemotherapy using a customized prechemotherapy educational virtual reality (VR) video.

SAMPLE &AMP; SETTING">35 patients with cancer receiving first-time chemotherapy participated in this study at a large suburban cancer center in Newark, Delaware.</Abstr: 35 patients with cancer receiving first-time chemotherapy participated in this study at a large suburban cancer center in Newark, Delaware.

METHODS &AMP; VARIABLES">A single-group, quasi-experimental pilot study was conducted to examine the feasibility of a customized prechemotherapy educational VR video in patients receiving first-time chemotherapy. The State-Trait Anxiety Inventory, heart rate, and blood pressure were used to measure anxiety, and the Cancer Behavior Inventory-Brief Version measured perceived self-efficacy to cope with cancer. Measures were taken pre- and postintervention, and patient satisfaction was examined postintervention.</Abstr: A single-group, quasi-experimental pilot study was conducted to examine the feasibility of a customized prechemotherapy educational VR video in patients receiving first-time chemotherapy. The State-Trait Anxiety Inventory, heart rate, and blood pressure were used to measure anxiety, and the Cancer Behavior Inventory-Brief Version measured perceived self-efficacy to cope with cancer. Measures were taken pre- and postintervention, and patient satisfaction was examined postintervention.

RESULTS">Anxiety level, heart rate, and blood pressure significantly decreased from baseline to postintervention, and perceived self-efficacy to cope significantly increased from baseline to postintervention.</Abstr: Anxiety level, heart rate, and blood pressure significantly decreased from baseline to postintervention, and perceived self-efficacy to cope significantly increased from baseline to postintervention.

IMPLICATIONS FOR NURSING">Personalized prechemotherapy educational VR videos could be further examined as an innovative nursing intervention to meet the health, emotional, and educational needs of diverse patient populations.</Abstr: Personalized prechemotherapy educational VR videos could be further examined as an innovative nursing intervention to meet the health, emotional, and educational needs of diverse patient populations.

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Outcomes with advanced versus basic life support in blunt trauma
Outcomes with advanced versus basic life support in blunt trauma
Farrell MS, Emery B, Caplan R, Getchell J, Cipolle M, Bradley KM

Am. J. Surg. 2020 Jan;

PMID: 32000980

Abstract

INTRODUCTION: The role of advanced life support (ALS) versus basic life support (BLS) in blunt trauma is controversial. Previous studies have shown no mortality benefit with ALS for penetrating trauma but the blunt population has mostly remained unaddressed.
METHODS: A retrospective cohort study was conducted at a Level 1 trauma center comparing outcomes in blunt trauma patients managed by ALS versus BLS from July 1, 2014 to December 31, 2014. Both Injury Severity Score (ISS) and select Abbreviated Injury Score (AIS) were used to determine differences in mortality, length of stay (LOS) and complications based on mode of transportation, prehospital time, and number of prehospital interventions.
RESULTS: 698 total patients were identified. Mortality and complications were grossly higher in ALS patients (p = 0.01 and < 0.001, respectively). When accounting for ISS and AIS there was no difference in mortality (p=<0.001-0.003). Prehospital interventions did not increase prehospital time (p = 0.7) but did correlate with increased mortality (p < 0.001).
CONCLUSION: There is no mortality advantage for blunt trauma patients managed by ALS versus BLS.
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Impact of an external ventricular drain bundle and limited duration antibiotic prophylaxis on drain-related infections and antibiotic resistance
Impact of an external ventricular drain bundle and limited duration antibiotic prophylaxis on drain-related infections and antibiotic resistance
Whyte C, Alhasani H, Caplan R, Tully AP

Clin Neurol Neurosurg 2019 Dec;190:105641

PMID: 31869626

Abstract

BACKGROUND/OBJECTIVE: Systemic prophylactic antibiotics have been used to reduce the rate of neurosurgical drain-related infections (DRIs) but the optimal duration is unknown. The Neurocritical Care Society Consensus Statement for External Ventricular Drain (EVD) management recommends a single antibiotic dose preoperatively. Data regarding antibiotic management for other neurosurgical drains (e.g. subgaleal and subdural drains) are lacking. Previously at our institution antibiotics were continued for the duration of drain placement. In 2016 an EVD bundle was implemented to standardize nursing care, and antibiotic duration was changed to one preoperative dose for all neurosurgical drains. The objective of this study was to compare the incidence of DRI, non-DRI, and antibiotic resistance before and after the implementation of an EVD bundle and limited duration antibiotics.
PATIENTS AND METHODS: This was a single center, quasi-experimental study that included patients status post EVD or craniotomy/craniectomy with subgaleal or subdural drain placement. The pre-intervention period was June 2014 through May 2015 and the post-intervention period was January 2017 through December 2017.
RESULTS: Ninety-one patients were included in the pre-intervention group and 54 in the post-intervention group. The use of limited duration antibiotics (< 48 h) was 14.3 % in the pre-intervention group and 96.3 % in the post-intervention group (p < 0.001). Five DRIs were identified in the pre-intervention group and 3 in the post-intervention group (5.5 % vs 5.6 %, p = 1.00). Of patients who developed a non-DRI, 77.5 % had a resistant non-DRI in the pre-intervention group compared to 48 % in the post-intervention group (p = 0.01). The rates of resistant DRI (80 % vs 66.7 %, p = 1.00) andClostridium difficile infection (1.1 % vs 3.7 %, p = 0.56) were similar between groups.
CONCLUSIONS: Implementation of an EVD bundle and limited duration antibiotics reduced antibiotic exposure with no associated increase in risk of DRI. Rates of resistant non-DRI were significantly lower in the post-intervention group.
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Even Faster Door-to-Alteplase Times and Associated Outcomes in Acute Ischemic Stroke
Even Faster Door-to-Alteplase Times and Associated Outcomes in Acute Ischemic Stroke
Jung S, Rosini JM, Nomura JT, Caplan RJ, Raser-Schramm J J Stroke Cerebrovasc Dis 2019 Dec;28(12):104329 PMID: 31607439
Abstract
BACKGROUND AND PURPOSE: The timely administration of thrombolytic therapy for acute ischemic stroke has been associated with good functional outcomes. Current guidelines recommend alteplase administration within 60 minutes in 75% of eligible patients and within 45 minutes in 50% of patients. There is limited evidence guiding these measures and their effect on outcomes. We report a single-center, retrospective assessment of the safety and efficacy of alteplase treatment within 45 minutes. METHODS: Five hundred and eighty-six patients were treated with alteplase in our emergency departments (EDs) between January 2014 and October 2016; 368 patients were included for analysis. Multivariate regression analysis was used to assess the association between door-to-alteplase (DTA) times and 90-day modified Rankin scale (mRS) scores. Incidence of intracerebral hemorrhage (ICH) was also documented. RESULTS: The median DTA time was 29 minutes versus 64 minutes in the DTA less than or equal to 45 minutes arm and more than 45 minutes arm, respectively. The primary outcome of 90-day mRS 0-1 was achieved in 56% of patients in the less than or equal to 45 minutes group versus 58% in more than 45 minutes group (P = .67). Odds of achieving mRS 0-1 were not significantly impacted by DTA times. In the multivariate regression analysis, patient characteristics associated with achieving mRS 0-1 were: younger age, male sex, not requiring intubation in the ED, and without prior history of hypertension, atrial fibrillation, or stroke. There was no significant difference in rates of ICH for patients less than or equal to 45 minutes versus more than 45 minutes. CONCLUSIONS: Rapid administration of alteplase was not associated with significantly better outcomes nor increased risk of ICH. Conclusions about efficacy are limited due to the retrospective nature of the study, small sample size, and incomplete data points.
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Investigation of age-adjusted D-dimer using an uncommon assay
Investigation of age-adjusted D-dimer using an uncommon assay
Parks C, Bounds R, Davis B, Caplan R, Laughery T, Zeserson E

Am J Emerg Med 2018 Sep;

PMID: 30291035

Abstract

BACKGROUND: Use of an age-adjusted D-dimer for the evaluation of acute pulmonary embolus (PE) has been prospectively validated in the literature and has become a practice recommendation from major medical societies. Most research on this subject involves the most common D-dimer assays reporting in Fibrinogen Equivalent Units (FEU) with a non-age-adjusted manufacturer-recommended cutoff of 500 ng/ml FEU. Limited research to date has evaluated age-adjustment in assays that report in D-Dimer Units (D-DU), which use a manufacturer-recommended cutoff of 230 ng/ml D-DU. Despite scant evidence, an age-adjusted formula using D-DU has been recently endorsed by the American College of Emergency Physicians (ACEP). This formula seems arbitrary in its derivation and unnecessarily deviates from existing thresholds, thus prompting the creation of our novel-age adjustment formula. The goal of this study was to retrospectively evaluate the test characteristics of our novel age-adjusted D-dimer formula using the D-DU assay in comparison to existing traditional and age-adjusted D-dimer thresholds for the evaluation of acute PE in the ED.
METHODS: This was a retrospective chart review at an academic quaternary health system with three EDs and 195,000 combined annual ED visits. Only patients with D-dimer testing and CT PE protocol (CTPE) imaging were included. Admission and discharge diagnosis codes were used to identify acute PE. Outcome measures were sensitivity, specificity, negative predictive value (NPV) and positive predictive value (PPV) of an unadjusted traditional threshold (230) compared with both novel and ACEP-endorsed age adjusted thresholds, (Age × 5) - 20 and Age × 5 if >50, respectively. Estimates with their exact 95% threshold were performed.
RESULTS: 4846 adult patients were evaluated from January 2012 to July 2017. Group characteristics include a mean age of 52 and a frequency of acute PE diagnosis by CTPE of 8.25%. Traditional D-dimer cutoff demonstrated a sensitivity of 99.8% (95% CI 98.6-100), specificity of 16.7% (95% CI 15.6-17.8) and NPV of 99.9% (95% CI 99.3-100). Our novel age-adjusted D-dimer thresholds had a sensitivity of 97.0% (95% CI 94.8-98.4), specificity of 27.9% (95% CI 26.6-29.2) and NPV of 99.0% (95% CI 98.3-99.5) with the ACEP-endorsed formula demonstrating similar test characteristics.
CONCLUSION: Use of an age-adjusted D-dimer on appropriately selected patients being evaluated for acute PE in the ED with a D-DU assay increases specificity while maintaining a high sensitivity and NPV. Both our novel formula and the ACEP-endorsed age-adjusted formula performed well, with our novel formula showing a trend towards improved testing characteristics.
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