Andre Kumar MD, MEd

All Publications

• Evaluation of Trainee Competency with Point-of-Care Ultrasonography (POCUS): a Conceptual Framework and Review of Existing Assessments. Journal of general internal medicine Kumar, A., Kugler, J., Jensen, T. 2019

  Abstract

  Point-of-care ultrasonography (POCUS) has the potential to transform healthcare delivery through its diagnostic expediency. Trainee competency with POCUS is now mandated for emergency medicine through the Accreditation Council for Graduate Medical Education (ACGME), and its use is expanding into other medical specialties, including internal medicine. However, a key question remains: how does one define "competency" with this emerging technology? As our trainees become more acquainted with POCUS, it is vital to develop validated methodology for defining and measuring competency amongst inexperienced users. As a framework, the assessment of competency should include evaluations that assess the acquisition and application of POCUS-related knowledge, demonstration of technical skill (e.g., proper probe selection, positioning, and image optimization), and effective integration into routine clinical practice. These assessments can be performed across a variety of settings, including web-based applications, simulators, standardized patients, and real clinical encounters. Several validated assessments regarding POCUS competency have recently been developed, including the Rapid Assessment of Competency in Echocardiography (RACE) or the Assessment of Competency in Thoracic Sonography (ACTS). However, these assessments focus mainly on technical skill and do not expand upon other areas of this framework, which represents a growing need. In this review, we explore the different methodologies for evaluating competency with POCUS as well as discuss current progress in the field of measuring trainee knowledge and technical skill.

  View details for PubMedID 30924088

• Duty-Hour Flexibility Trial in Internal Medicine NEW ENGLAND JOURNAL OF MEDICINE Kumar, A., Chi, J. 2018; 379 (3): 300

  View details for Web of Science ID 000439063900020

• The Role of Technology in the Bedside Encounter. The Medical clinics of North America Kumar, A., Liu, G., Chi, J., Kugler, J. 2018; 102 (3): 443–51

  Abstract

  Technology has the potential to both distract and reconnect providers with their patients. The widespread adoption of electronic medical records in recent years pulls physicians away from time at the bedside. However, when used in conjunction with patients, technology has the potential to bring patients and physicians together. The increasing use of point-of-care ultrasound by physicians is changing the bedside encounter by allowing for real-time diagnosis with the treating physician. It is a powerful example of the way technology can be a force for refocusing on the bedside encounter.

  View details for PubMedID 29650066

• To Cure Sometimes, to Relieve Often, to Comfort Always. JAMA internal medicine Kumar, A., Allaudeen, N. 2016; 176 (6): 731–32

  View details for PubMedID 27110667

• Preparing to take the USMLE Step 1: a survey on medical students' self-reported study habits POSTGRADUATE MEDICAL JOURNAL Kumar, A. D., Shah, M. K., Maley, J. H., Evron, J., Gyftopoulos, A., Miller, C. 2015; 91 (1075): 257-261

  Abstract

  The USA Medical Licensing Examination Step 1 is a computerised multiple-choice examination that tests the basic biomedical sciences. It is administered after the second year in a traditional four-year MD programme. Most Step 1 scores fall between 140 and 260, with a mean (SD) of 227 (22). Step 1 scores are an important selection criterion for residency choice. Little is known about which study habits are associated with a higher score.To identify which self-reported study habits correlate with a higher Step 1 score.A survey regarding Step 1 study habits was sent to third year medical students at Tulane University School of Medicine every year between 2009 and 2011. The survey was sent approximately 3 months after the examination.256 out of 475 students (54%) responded. The mean (SD) Step 1 score was 229.5 (22.1). Students who estimated studying more than 8-11 h per day had higher scores (p<0.05), but there was no added benefit with additional study time. Those who reported studying <40 days achieved higher scores (p<0.05). Those who estimated completing >2000 practice questions also obtained higher scores (p<0.01). Students who reported studying in a group, spending the majority of study time on practice questions or taking >40 preparation days did not achieve higher scores.Certain self-reported study habits may correlate with a higher Step 1 score compared with others. Given the importance of achieving a high Step 1 score on residency choice, it is important to further identify which characteristics may lead to a higher score.

  View details for DOI 10.1136/postgradmedj-2014-133081

  View details for Web of Science ID 000355010900004

  View details for PubMedID 25910497

• Evaluation of Trainee Competency with Point-of-Care Ultrasonography (POCUS): a Conceptual Framework and Review of Existing Assessments JOURNAL OF GENERAL INTERNAL MEDICINE Kumar, A., Kugler, J., Jensen, T. 2019; 34 (6): 1025–31

  View details for DOI 10.1007/s11606-019-04945-4

  View details for Web of Science ID 000469884700053

• CMS Billing Guidelines and Student Documentation: a New Era or New Burden? JOURNAL OF GENERAL INTERNAL MEDICINE Kumar, A., Chi, J. 2019; 34 (4): 634–35

  View details for DOI 10.1007/s11606-019-04853-7

  View details for Web of Science ID 000463219100035

• Thrombophilia testing in the inpatient setting: impact of an educational intervention. BMC medical informatics and decision making Kwang, H., Mou, E., Richman, I., Kumar, A., Berube, C., Kaimal, R., Ahuja, N., Harman, S., Johnson, T., Shah, N., Witteles, R., Harrington, R., Shieh, L., Hom, J. 2019; 19 (1): 167

  Abstract

  Thrombophilia testing is frequently ordered in the inpatient setting despite its limited impact on clinical decision-making and unreliable results in the setting of acute thrombosis or ongoing anticoagulation. We sought to determine the effect of an educational intervention in reducing inappropriate thrombophilia testing for hospitalized patients.During the 2014 academic year, we implemented an educational intervention with a phase implementation design for Internal Medicine interns at Stanford University Hospital. The educational session covering epidemiology, appropriate thrombophilia evaluation and clinical rationale behind these recommendations. Their ordering behavior was compared with a contemporaneous control (non-medicine and private services) and a historical control (interns from prior academic year). From the analyzed data, we determined the proportion of inappropriate thrombophilia testing of each group. Logistic generalized estimating equations were used to estimate odds ratios for inappropriate thrombophilia testing associated with the intervention.Of 2151 orders included, 934 were deemed inappropriate (43.4%). The two intervention groups placed 147 orders. A pooled analysis of ordering practices by intervention groups revealed a trend toward reduction of inappropriate ordering (p = 0.053). By the end of the study, the intervention groups had significantly lower rates of inappropriate testing compared to historical or contemporaneous controls.A brief educational intervention was associated with a trend toward reduction in inappropriate thrombophilia testing. These findings suggest that focused education on thrombophilia testing can positively impact inpatient ordering practices.

  View details for DOI 10.1186/s12911-019-0889-6

  View details for PubMedID 31429747

• A high value care curriculum for interns: a description of curricular design, implementation and housestaff feedback. Postgraduate medical journal Hom, J., Kumar, A., Evans, K. H., Svec, D., Richman, I., Fang, D., Smeraglio, A., Holubar, M., Johnson, T., Shah, N., Renault, C., Ahuja, N., Witteles, R., Harman, S., Shieh, L. 2017

  Abstract

  Most residency programmes do not have a formal high value care curriculum. Our goal was to design and implement a multidisciplinary high value care curriculum specifically targeted at interns.Our curriculum was designed with multidisciplinary input from attendings, fellows and residents at Stanford. Curricular topics were inspired by the American Board of Internal Medicine's Choosing Wisely campaign, Alliance for Academic Internal Medicine, American College of Physicians and Society of Hospital Medicine. Our topics were as follows: introduction to value-based care; telemetry utilisation; lab ordering; optimal approach to thrombophilia work-ups and fresh frozen plasma use; optimal approach to palliative care referrals; antibiotic stewardship; and optimal approach to imaging for low back pain. Our curriculum was implemented at the Stanford Internal Medicine residency programme over the course of two academic years (2014 and 2015), during which 100 interns participated in our high value care curriculum. After each high value care session, interns were offered the opportunity to complete surveys regarding feedback on the curriculum, self-reported improvements in knowledge, skills and attitudinal module objectives, and quiz-based knowledge assessments.The overall survey response rate was 67.1%. Overall, the material was rated as highly useful on a 5-point Likert scale (mean 4.4, SD 0.6). On average, interns reported a significant improvement in their self-rated knowledge, skills and attitudes after the six seminars (mean improvement 1.6 points, SD 0.4 (95% CI 1.5 to 1.7), p<0.001).We successfully implemented a novel high value care curriculum that specifically targets intern physicians.

  View details for PubMedID 28663352

• Magnitude of Potentially Inappropriate Thrombophilia Testing in the Inpatient Hospital Setting. Journal of hospital medicine Mou, E., Kwang, H., Hom, J., Shieh, L., Kumar, A., Richman, I., Berube, C. 2017; 12 (9): 735–38

  Abstract

  Laboratory costs of thrombophilia testing exceed an estimated $650 million (in US dollars) annually. Quantifying the prevalence and financial impact of potentially inappropriate testing in the inpatient hospital setting represents an integral component of the effort to reduce healthcare expenditures. We conducted a retrospective analysis of our electronic medical record to evaluate 2 years' worth of inpatient thrombophilia testing measured against preformulated appropriateness criteria. Cost data were obtained from the Centers for Medicare and Medicaid Services 2016 Clinical Laboratory Fee Schedule. Of the 1817 orders analyzed, 777 (42.7%) were potentially inappropriate, with an associated cost of $40,422. The tests most frequently inappropriately ordered were Factor V Leiden, prothrombin gene mutation, protein C and S activity levels, antithrombin activity levels, and the lupus anticoagulant. Potentially inappropriate thrombophilia testing is common and costly. These data demonstrate a need for institution-wide changes in order to reduce unnecessary expenditures and improve patient care.

  View details for PubMedID 28914278

• The Illness of Present Histories. Academic medicine : journal of the Association of American Medical Colleges Kumar, A. D., Chi, J. 2017; 92 (4): 434–35

  View details for PubMedID 28350609

• A resident-created hospitalist curriculum for internal medicine housestaff. Journal of hospital medicine Kumar, A., Smeraglio, A., Witteles, R., Harman, S., Nallamshetty, S., Rogers, A., Harrington, R., Ahuja, N. 2016; 11 (9): 646-649

  Abstract

  The growth of hospital medicine has led to new challenges, and recent graduates may feel unprepared to meet the expanding clinical duties expected of hospitalists. At our institution, we created a resident-inspired hospitalist curriculum to address the training needs for the next generation of hospitalists. Our program provided 3 tiers of training: (1) clinical excellence through improved training in underemphasized areas of hospital medicine, (2) academic development through required research, quality improvement, and medical student teaching, and (3) career mentorship. In this article, we describe the genesis of our program, our final product, and the challenges of creating a curriculum while being internal medicine residents. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine.

  View details for DOI 10.1002/jhm.2590

  View details for PubMedID 27079160

• Incidence and financial impact of inappropriate thrombophilia testing in the inpatient hospital setting: a retrospective analysis. Blood Mou, E., Kwang, H., Hom, J., Shieh, L., Ahuja, N., Harman, S., Johnson, T., Kumar, A., Shah, N., Witteles, R., Berube, C. 2016; 128: 2330
• Troubleshooting the NIHSS: question-and-answer session with one of the designers INTERNATIONAL JOURNAL OF STROKE Martin-Schild, S., Siegler, J. E., Kumar, A. D., Lyden, P. 2015; 10 (8): 1284-1286

  View details for DOI 10.1111/ijs.12196

  View details for Web of Science ID 000367673700022

  View details for PubMedID 26745704

• Persistent Leukocytosis-Is this a Persistent Problem for Patients with Acute Ischemic Stroke? JOURNAL OF STROKE & CEREBROVASCULAR DISEASES Boehme, A. K., Kumar, A. D., Lyerly, M. J., Gillette, M. A., Siegler, J. E., Albright, K. C., Beasley, T. M., Martin-Schild, S. 2014; 23 (7): 1939-1943

  Abstract

  In the setting of acute ischemic stroke (AIS), leukocytosis has been shown to be an indicator of inflammatory response. Although leukocytosis on admission has been shown to correlate with initial stroke severity in AIS patients, no work has been done to assess if there are differences in transient or persistent leukocytosis in patients without infection. The objective of this study is to determine the clinical significance of persistent versus transient leukocytosis during the early phase of AIS.Patients who presented with AIS to our center within 48 hours of symptom onset between July 2008 and June 2010 were retrospectively identified by chart review. Patients were included if they had leukocytosis on admission (defined as white blood cell count >11,000/μL based on laboratory reference range values). A logistic regression model was used to evaluate persistent leukocytosis (leukocytosis 48 hours after admission) as a predictor of several outcome measures, including good functional outcome (discharge modified Rankin Scale score of 0-2). Marginal effects were used to estimate the probability of poor functional outcome.Of the 438 patients screened, 49 had leukocytosis on admission and of those 24 (49%) had persistent leukocytosis. NIHSS score correlated significantly with persistence of leukocytosis (r = .306; P = .0044). More people with transient leukocytosis (leukocytosis lasting <48 hours) had a good functional outcome (44% versus 16%; P = .006). After adjusting for baseline NIHSS score, persistent leukocytosis was not a significant independent predictor of good functional outcome, but showed an association (OR, 2.5; 95% CI, .562-10.7; P = .2322). Persistent leukocytosis after adjusting for age and NIHSS score at admission is associated with a poor functional outcome, but it is not statistically significant (OR, 2.43; 95% CI, .59-9.87; P = .2151). After controlling for age and NIHSS score on admission, for patients with persistent leukocytosis, the probability of having poor functional outcome at discharge was increased by 16 percentage points.Persistent leukocytosis is associated with higher baseline NIHSS scores. Persistent leukocytosis is tightly linked with baseline stroke severity and is associated with poor patient outcomes. Our study found that patients with persistent leukocytosis are more likely to present with severe strokes and maintain a high NIHSS score at 24 hours after admission, unlike patients without leukocytosis or patients with transient leukocytosis. Furthermore, it appears that persistent leukocytosis outside the setting of an infection negatively impacts the short-term functional outcome of AIS patients. Identifying patients with persistent leukocytosis could help to prognosticate and target patients that may benefit from future anti-inflammatory interventions.

  View details for DOI 10.1016/j.jstrokecerebrovasdis.2014.02.004

  View details for Web of Science ID 000341484400028

  View details for PubMedID 24784010

• Infections Present on Admission Compared with Hospital-Acquired Infections in Acute Ischemic Stroke Patients JOURNAL OF STROKE & CEREBROVASCULAR DISEASES Boehme, A. K., Kumar, A. D., Dorsey, A. M., Siegler, J. E., Aswani, M. S., Lyerly, M. J., Monlezun, D. J., George, A. J., Albright, K. C., Beasley, T. M., Martin-Schild, S. 2013; 22 (8): E582-E589

  Abstract

  To date, few studies have assessed the influence of infections present on admission (POA) compared with hospital-acquired infections (HAIs) on neurologic deterioration (ND) and other outcome measures in acute ischemic stroke (AIS).Patients admitted with AIS to our stroke center (July 2010 to December 2010) were retrospectively assessed. The following infections were assessed: urinary tract infection, pneumonia, and bacteremia. Additional chart review was performed to determine whether the infection was POA or HAI. We assessed the relationship between infections in ischemic stroke patients and several outcome measures including ND and poor functional outcome. A mediation analysis was performed to assess the indirect effects of HAI, ND, and poor functional outcome.Of the 334 patients included in this study, 77 had any type of infection (23 POA). After adjusting for age, National Institutes of Health Stroke Scale at baseline, glucose on admission, and intravenous tissue plasminogen activator, HAI remained a significant predictor of ND (odds ratio [OR]=8.8, 95% confidence interval [CI]: 4.2-18.7, P<.0001) and poor functional outcome (OR=41.7, 95% CI: 5.2-337.9, P=.005), whereas infections POA were no longer associated with ND or poor functional outcome. In an adjusted analysis, we found that 57% of the effect from HAI infections on poor functional outcome is because of mediation through ND (P<.0001).Our data suggests that HAI in AIS patients increases the odds of experiencing ND and subsequently increases the odds of being discharged with significant disability. This mediated effect suggests a preventable cause of ND that can thereby decrease the odds of poor functional outcomes after an AIS.

  View details for DOI 10.1016/j.jstrokecerebrovasdis.2013.07.020

  View details for Web of Science ID 000327719000048

  View details for PubMedID 23954599

• Leukocytosis in Patients with Neurologic Deterioration after Acute Ischemic Stroke is Associated with Poor Outcomes JOURNAL OF STROKE & CEREBROVASCULAR DISEASES Kumar, A. D., Boehme, A. K., Siegler, J. E., Gillette, M., Albright, K. C., Martin-Schild, S. 2013; 22 (7): E111-E117

  Abstract

  Neurologic deterioration (ND) after acute ischemic stroke (AIS) has been shown to result in poor outcomes. ND is thought to arise from penumbral excitotoxic cell death caused in part by leukocytic infiltration. Elevated admission peripheral leukocyte levels are associated with poor outcomes in stroke patients who suffer ND, but little is known about the dynamic changes that occur in leukocyte counts around the time of ND. We sought to determine if peripheral leukocyte levels in the days surrounding ND are correlated with poor outcomes.Patients with AIS who presented to our center within 48 hours of symptom onset between July 2008 and June 2010 were retrospectively identified by chart review and screened for ND (defined as an increase in National Institutes of Health Stroke Scale score ≥ 2 within a 24-hour period). Patients were excluded for steroid use during hospitalization or in the month before admission and infection within the 48 hours before or after ND. Demographics, daily leukocyte counts, and poor functional outcome (modified Rankin Scale score 3-6) were investigated.Ninety-six of the 292 (33%) patients screened had ND. The mean age was 69.5 years; 62.5% were male and 65.6% were black. Patients with a poor functional outcome had significantly higher leukocyte and neutrophil levels 1 day before ND (P = .048 and P = .026, respectively), and on the day of ND (P = .013 and P = .007, respectively), compared to patients with good functional outcome.Leukocytosis at the time of ND correlates with poor functional outcomes and may represent a marker of greater cerebral damage through increased parenchymal inflammation.

  View details for DOI 10.1016/j.jstrokecerebrovasdis.2012.08.008

  View details for Web of Science ID 000325874200018

  View details for PubMedID 23031742

• Identification of Modifiable and Nonmodifiable Risk Factors for Neurologic Deterioration after Acute Ischemic Stroke JOURNAL OF STROKE & CEREBROVASCULAR DISEASES Siegler, J. E., Boehme, A. K., Kumar, A. D., Gillette, M. A., Albright, K. C., Beasley, T. M., Martin-Schild, S. 2013; 22 (7): E207-E213

  Abstract

  Neurologic deterioration (ND) after ischemic stroke has been shown to impact short-term functional outcome and is associated with in-hospital mortality.Patients with acute ischemic stroke who presented between July 2008 and December 2010 were identified and excluded for in-hospital stroke, presentation >48 hours since last seen normal, or unknown time of last seen normal. Clinical and laboratory data, National Institutes of Health Stroke Scale (NIHSS) scores, and episodes of ND (increase in NIHSS score ≥ 2 within a 24-hour period) were investigated.Of the 596 patients screened, 366 were included (median age 65 years; 42.1% female; 65.3% black). Of these, 35.0% experienced ND. Patients with ND were older (69 v 62 years; P < .0001), had more severe strokes (median admission NIHSS score 12 v 5; P < .0001), carotid artery stenosis (27.0% v 16.8%; P = .0275), and coronary artery disease (26.0% v 16.4%; P = .0282) compared to patients without ND. Patients with ND had higher serum glucose on admission than patients without ND (125.5 v 114 mg/dL; P = .0036). After adjusting for crude variables associated with ND, age >65 years, and baseline NIHSS score >14 remained significant independent predictors of ND. In a logistic regression analysis adjusting for age and serum glucose, each 1-point increase in admission NIHSS score was associated with a 7% increase in the odds of ND (odds ratio 1.07; 95% confidence interval 1.04-1.10; P < .0001).Older patients and patients with more severe strokes are more likely to experience ND. Initial stroke severity was the only significant, independent, and modifiable risk factor for ND, amenable to recanalization and reperfusion.

  View details for DOI 10.1016/j.jstrokecerebrovasdis.2012.11.006

  View details for Web of Science ID 000325874200031

  View details for PubMedID 23246190

• What Change in the National Institutes of Health Stroke Scale Should Define Neurologic Deterioration in Acute Ischemic Stroke? JOURNAL OF STROKE & CEREBROVASCULAR DISEASES Siegler, J. E., Boehme, A. K., Kumar, A. D., Gillette, M. A., Albright, K. C., Martin-Schild, S. 2013; 22 (5): 675-682

  Abstract

  Neurologic deterioration (ND) occurs in one-third of patients with stroke. However, the true incidence of ND and risk for adverse outcomes remains unknown because no standardized definition of ND exists. Our study compared the prognostic value of a range of definitions for ND in patients with acute ischemic stroke (AIS).All patients who presented to our center with AIS within 48 hours of symptom onset between July 2008 and June 2010 were retrospectively identified. Patient demographics, National Institutes of Health Stroke Scale (NIHSS) scores, etiologies of ND, and outcome measures were compared between patients according to a range of ND definitions using receiver operating characteristic analyses.Three hundred forty-seven patients were included. The 2 definitions of ND with the highest sensitivity and specificity for several outcome measures were tested against each other: an increase in the NIHSS score by ≥2 or ≥4 points in a 24-hour period. More than one third (36.9%) of patients experienced ≥2-point ND versus 17.3% with ≥4-point ND. Patients who experienced ND by either definition had prolonged hospitalization (P < .001), poorer functional outcome (discharge modified Rankin Scale score >2; P < .001), and higher discharge NIHSS score (P < .001) compared to patients without ND. Compared to patients without ND, a ≥2-point ND was associated with a 3-fold risk of death (odds ratio 3.120; 95% confidence interval 1.231-7.905; P < .0165) after adjusting for admission NIHSS score, serum glucose, and age.A ≥2-point ND is a sensitive indicator of poor outcome and in-hospital mortality. An accepted definition of ND is needed to systematically study and compare results across trials for ND in patients with stroke.

  View details for DOI 10.1016/j.jstrokecerebrovasdis.2012.04.012

  View details for Web of Science ID 000321550000014

  View details for PubMedID 22727922