1
|
Sharpe M, Toynbee M, van Niekerk M, Solomons L, Owens C, Price A, Yousif M, Palmer A, Clay F, Berk G, Burns J, Hill L, Harris J, Bajorek T, Sirois-Giguere G, Magill N, Aitken P, Dickens C, Walker J. Proactive and integrated consultation-liaison psychiatry for older medical inpatients: A mixed methods description of training, care provided and clinician experience in the HOME study. Gen Hosp Psychiatry 2024; 86:108-117. [PMID: 38185070 DOI: 10.1016/j.genhosppsych.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/09/2024]
Abstract
OBJECTIVES To describe the practical experience of delivering a proactive and integrated consultation-liaison (C-L) psychiatry service model (PICLP). PICLP is designed for older medical inpatients and is explicitly biopsychosocial and discharge-focused. In this paper we report: (a) observations on the training of 15 clinicians (seven senior C-L psychiatrists and eight assisting clinicians) to deliver PICLP; (b) the care they provided to 1359 patients; (c) their experiences of working in this new way. METHOD A mixed methods observational study using quantitative and qualitative data, collected prospectively over two years as part of The HOME Study (a randomized trial comparing PICLP with usual care). RESULTS The clinicians were successfully trained to deliver PICLP according to the service manual. They proactively assessed all patients and found that most had multiple biopsychosocial problems impeding their timely discharge from hospital. They integrated with ward teams to provide a range of interventions aimed at addressing these problems. Delivering PICLP took a modest amount of clinical time, and the clinicians experienced it as both clinically valuable and professionally rewarding. CONCLUSION The experience of delivering PICLP highlights the special role that C-L psychiatry clinicians, working in a proactive and integrated way, can play in medical care.
Collapse
Affiliation(s)
- Michael Sharpe
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK.
| | - Mark Toynbee
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Maike van Niekerk
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Luke Solomons
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Colm Owens
- NHS Devon Mental Health, Learning Disability and Neurodiversity Provider Collaborative, Devon, UK
| | - Annabel Price
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | | | - Aelfrida Palmer
- NHS Devon Mental Health, Learning Disability and Neurodiversity Provider Collaborative, Devon, UK
| | - Felix Clay
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Gunes Berk
- Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK
| | - Jonathan Burns
- NHS Devon Mental Health, Learning Disability and Neurodiversity Provider Collaborative, Devon, UK
| | - Laura Hill
- NHS Devon Mental Health, Learning Disability and Neurodiversity Provider Collaborative, Devon, UK
| | - Jessica Harris
- Gloucestershire Health and Care NHS Foundation Trust, Gloucester, UK
| | - Tomasz Bajorek
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Nicholas Magill
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Peter Aitken
- Sussex Partnership Foundation Trust, Worthing, UK
| | | | - Jane Walker
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| |
Collapse
|
2
|
Patient Satisfaction with a Psychology Consultation-Liaison Service at an Academic Medical Center. J Clin Psychol Med Settings 2021; 29:717-726. [PMID: 34618282 DOI: 10.1007/s10880-021-09829-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2021] [Indexed: 10/20/2022]
Abstract
One to two-thirds of all medically admitted patients have comorbid psychiatric concerns. To address the cognitive, behavioral, and emotional factors that affect medical hospitalization, psychological or psychiatric consultation-liaison (CL) services are consulted. The current study was designed to understand patient satisfaction with a CL psychology service and how it was associated with satisfaction with overall hospitalization, taking into consideration relevant factors. Adults medically admitted to an academic teaching hospital (N = 220), who were seen at least once by the CL psychology service, completed satisfaction and demographic questionnaires. Most patients reported being satisfied with the CL psychology service, with women reporting higher satisfaction than men. Satisfaction with the CL psychology service was associated with satisfaction with overall hospitalization, but did not differ based on age, race/ethnicity, education, income, length of stay, number of visits, or presence of psychiatric diagnosis. The results suggest that CL psychology services may contribute to improving overall patient experience.
Collapse
|
3
|
Oldham MA, Desan PH, Lee HB, Bourgeois JA, Shah SB, Hurley PJ, Sockalingam S. Proactive Consultation-Liaison Psychiatry: American Psychiatric Association Resource Document. J Acad Consult Liaison Psychiatry 2021; 62:169-185. [PMID: 33970855 DOI: 10.1016/j.jaclp.2021.01.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 01/20/2021] [Indexed: 11/27/2022]
Abstract
In 2019, the American Psychiatric Association Council on Consultation-Liaison (C-L) Psychiatry convened a work group to develop a resource document on proactive C-L psychiatry. A draft of this document was reviewed by the Council in July 2020, and a revised version was approved by this Council in September 2020. The accepted version was subsequently reviewed by the American Psychiatric Association Council on Health Care Systems and Financing in November 2020. The final version was approved by the Joint Reference Committee on November 24, 2020, and received approval for publication by the Board of Trustees on December 12, 2020. This resource document describes the historical context and modern trends that have given rise to the model of proactive C-L psychiatry. Styled as an inpatient corollary to outpatient collaborative care models, proactive C-L provides a framework of mental health care delivery in the general hospital designed to enhance mental health services to a broad range of patients. Its 4 elements include systematic screening for active mental health concerns, proactive interventions tailored to individual patients, team-based care delivery, and care integration with primary teams and services. Studies have found that proactive C-L psychiatry is associated with reduced hospital length of stay, enhanced psychiatric service utilization, reduced time to psychiatric consultation, and improved provider and nurse satisfaction. These favorable results encourage further studies that replicate and build upon these findings. Additional outcomes such as patient experience, health outcomes, and readmission rates deserve investigation. Further studies are also needed to examine a broader array of team compositions and the potential value of proactive C-L psychiatry to different hospital settings such as community hospitals, surgery, and critical care.
Collapse
Affiliation(s)
- Mark A Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, NY.
| | - Paul H Desan
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - Hochang B Lee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT
| | - James A Bourgeois
- Department of Psychiatry, Baylor Scott & White Health, Temple, TX; Department of Psychiatry, Texas A&M University College of Medicine, Temple, TX
| | - Sejal B Shah
- Department of Psychiatry, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Patrick J Hurley
- Department of Psychiatry, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY
| | - Sanjeev Sockalingam
- Department of Psychiatry, Centre for Addiction and Mental Health, University of Toronto, Toronto, ON
| | | |
Collapse
|
4
|
Proactive C-L Psychiatry Beyond Academic Hospital Settings: A Pilot Study of Effectiveness in a Suburban Community Hospital. PSYCHOSOMATICS 2020; 61:688-697. [DOI: 10.1016/j.psym.2020.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/14/2020] [Accepted: 05/14/2020] [Indexed: 11/24/2022]
|
5
|
Sharpe M, Toynbee M, Walker J. Proactive Integrated Consultation-Liaison Psychiatry: A new service model for the psychiatric care of general hospital inpatients. Gen Hosp Psychiatry 2020; 66:9-15. [PMID: 32592995 DOI: 10.1016/j.genhosppsych.2020.06.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To describe a new service model for the psychiatric care of general hospital inpatients, called Proactive Integrated Consultation-Liaison Psychiatry ('Proactive Integrated Psychological Medicine' in the UK). METHOD The new service model was developed especially for general hospital inpatient populations with multimorbidity, such as older medical inpatients. Its design was informed by the published literature and the clinical experience of C-L psychiatrists. It was operationalized by a process of iterative piloting. RESULTS The rationale for the new model and the principles underpinning it are outlined. Details of how to implement it, including a service manual and associated workbook, are provided. The training of clinicians to deliver it is described. The effectiveness and cost-effectiveness of this new service model is being evaluated. Whilst we have found it feasible to deliver and well-accepted by ward teams, potential challenges to its wider implementation are discussed. CONCLUSION Proactive Integrated Consultation-Liaison Psychiatry (PICLP) is a fusion of proactive consultation and integrated care, operationalized in a field-tested service manual. Initial experience indicates that it is feasible to deliver. Its effectiveness and cost effectiveness for older patients on acute medical wards is currently being evaluated in a large multicentre randomized controlled trial (The HOME Study).
Collapse
Affiliation(s)
- Michael Sharpe
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK.
| | - Mark Toynbee
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| | - Jane Walker
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| | -
- Psychological Medicine Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford, UK
| |
Collapse
|
6
|
Caravella RA, Deutch AB, Noulas P, Ying P, Liaw KRL, Greenblatt J, Collins K, Eastburn HK, Fries E, Khan S, Kozikowski A, Sidelnik SA, Yee M, Ginsberg D. Development of a Virtual Consultation-Liaison Psychiatry Service: A Multifaceted Transformation. Psychiatr Ann 2020. [DOI: 10.3928/00485713-20200610-02] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
7
|
The Impact of Integrated Psychiatric Care on Hospital Medicine Length of Stay: A Pre-Post Intervention Design With a Simultaneous Usual Care Comparison. PSYCHOSOMATICS 2019; 60:582-590. [DOI: 10.1016/j.psym.2019.05.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/18/2019] [Accepted: 05/20/2019] [Indexed: 11/17/2022]
|
8
|
Oldham MA, Chahal K, Lee HB. A systematic review of proactive psychiatric consultation on hospital length of stay. Gen Hosp Psychiatry 2019; 60:120-126. [PMID: 31404826 DOI: 10.1016/j.genhosppsych.2019.08.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 07/25/2019] [Accepted: 08/01/2019] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Roughly half of general hospital patients may have a psychiatric issue that impacts care, yet most of these are not recognized during hospital admission. Proactive mental health screening offers an opportunity for timely identification and clinical attention to improve outcomes. METHOD We conducted a PRISMA systematic review of Pubmed, Embase, PsycINFO, and Cochrane Library for proactive models of psychiatric consultation to reduce hospital length of stay (LOS) in adult inpatients. For each study, we evaluated the level of evidence and defined the study sample, means of group allocation, screening process, interventions, and outcomes. RESULTS Of the 12 included studies, the 8 whose screening was informed by clinicians with mental health care expertise or whose providers were integrated with primary services reported a reduction in LOS. Two of these also reported favorable cost-benefit analyses. All positive studies represent versions of either psychiatrists embedded within medical or surgical settings or a multidisciplinary team-based model. CONCLUSIONS Proactive CL psychiatry with clinically-informed screening and integrated care delivery appear to reduce LOS. Further studies are needed to explore a broader range of outcomes, hospital populations beyond hospital medicine, and additional benefits of proactive integrated mental health care in the general hospital.
Collapse
Affiliation(s)
- Mark A Oldham
- University of Rochester Medical Center, 300 Crittenden Blvd, Box PSYCH, Rochester, NY 14642, United States of America.
| | - Khushminder Chahal
- University of Rochester Medical Center, 300 Crittenden Blvd, Box PSYCH, Rochester, NY 14642, United States of America
| | - Hochang B Lee
- University of Rochester Medical Center, 300 Crittenden Blvd, Box PSYCH, Rochester, NY 14642, United States of America
| |
Collapse
|
9
|
Benjenk I, Chen J. Effective mental health interventions to reduce hospital readmission rates: a systematic review. JOURNAL OF HOSPITAL MANAGEMENT AND HEALTH POLICY 2018; 2:45. [PMID: 30283917 PMCID: PMC6167018 DOI: 10.21037/jhmhp.2018.08.05] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Hospitals in the United States are financially penalized for having a higher than expected thirty-day readmission ratio among patients initially hospitalized for heart failure, acute myocardial infarction (AMI), pneumonia, chronic obstructive pulmonary disease (COPD), coronary artery bypass graft (CABG) surgery, or hip and knee replacement. Patients hospitalized for these conditions that have comorbid mental health diagnoses or symptoms are at high risk for readmission. METHODS We conducted a systematic review to determine if interventions, that are specifically designed to assess or treat mental health symptoms, can effectively reduce risk of readmission following hospitalization for physical health conditions. We searched on PubMed and Google Scholar for peer-reviewed articles published between January 2010 and June 2018 that examined the impact of mental-health interventions on readmissions for physical conditions. RESULTS After screening 81 full text articles, we found eleven intervention studies, one meta-analysis, and one cross-sectional study that met our inclusion criteria. Only three of the intervention studies found significant differences in readmission rates between intervention and comparison groups. Each of these interventions targeted patients after discharge from the hospital. One of the interventions was a physical health telemonitoring and individual psychotherapy intervention for patients that were initially admitted for heart failure. The second intervention was individual and group psychotherapy sessions for patients who were initially admitted for AMI. The third intervention was a nurse-driven depression care management protocol for home care patients with depressive symptoms who were initially admitted for any physical health condition. The cross-sectional study showed that communities with a stronger, social-based public mental health infrastructure had significantly lower physical health readmission rates. CONCLUSIONS The literature identified in this review, appears to provide support for the use of mental health interventions after discharge as a mechanism for reducing physical health condition readmissions. Future research is needed to determine if these interventions can specifically reduce thirty-day readmissions for the six conditions linked to financial penalties.
Collapse
Affiliation(s)
- Ivy Benjenk
- Department of Health Services Administration, University of Maryland School of Public Health, College Park, MD, USA
| | - Jie Chen
- Department of Health Services Administration, University of Maryland School of Public Health, College Park, MD, USA
| |
Collapse
|
10
|
Pezzia C, Pugh JA, Lanham HJ, Leykum LK. Psychiatric consultation requests by inpatient medical teams: an observational study. BMC Health Serv Res 2018; 18:336. [PMID: 29739414 PMCID: PMC5941586 DOI: 10.1186/s12913-018-3171-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 05/01/2018] [Indexed: 11/10/2022] Open
Abstract
Background We describe the way psychiatric issues are addressed by inpatient medical teams through analysis of discussions of patients with behavioral health concerns and examination of teams’ subsequent consultation practices. Methods We observed morning rounds for nine inpatient medical teams for approximately month-long periods, for a total of 1941 observations. We compared discussions of patients admitted for behavioral health related medical conditions between those who did and did not receive a psychiatric consultation, developing categories to describe factors influencing consultation or other management. Results Out of 536 patients, 40 (7.5%) received a psychiatry consult. Evaluation of a known concern (i.e., substance use, affective disorder, or suicidal ideation) was the most common reason for referral (41.7%). Requests for medication review were second (30.6%). Thirty patients with concomitant behavioral and medical health issues did not receive a psychiatry consult. Cirrhosis with active substance use was the most common medical diagnosis (15), followed by alcohol withdrawal (9). Conclusions Four primary themes emerged from our data: positive identification of behavioral health issues by physicians, medication management as a primary reason for referral, patient preference in physician decision-making, and poor management of substance abuse. Our results identify two potential areas where skills-building for inpatient physicians could have a positive impact: management of medication and of substance abuse management.
Collapse
Affiliation(s)
- Carla Pezzia
- Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA. .,Department of Human Sciences in the Contemporary World, University of Dallas, 1845 East Northgate Drive, Irving, TX, 75062, USA.
| | - Jacqueline A Pugh
- Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.,South Texas Veterans Health Care System, 7400 Merton Minter, San Antonio, TX, 78229, USA
| | - Holly J Lanham
- Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.,South Texas Veterans Health Care System, 7400 Merton Minter, San Antonio, TX, 78229, USA.,McCombs School of Business, University of Texas At Austin, 2110 Speedway, Austin, TX, 78705, USA
| | - Luci K Leykum
- Department of Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX, 78229, USA.,South Texas Veterans Health Care System, 7400 Merton Minter, San Antonio, TX, 78229, USA
| |
Collapse
|
11
|
Desan PH, Lee HB, Zimbrean P, Sledge W. New Models of Psychiatric Consultation in the General Medical Hospital: Liaison Psychiatry Is Back. Psychiatr Ann 2017. [DOI: 10.3928/00485713-20170524-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
12
|
Taylor JB, Stern TA. Meeting Its Mission: Does Psychosomatics Align With the Mission of Its Parent Organization, the Academy of Psychosomatic Medicine? PSYCHOSOMATICS 2017; 58:375-385. [PMID: 28449827 DOI: 10.1016/j.psym.2017.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/05/2017] [Accepted: 03/06/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND The vision and mission statements of the Academy of Psychosomatic Medicine (APM) indicate that the APM should promote excellence in clinical care for patients with comorbid psychiatric and general medical conditions by seeking to influence research, public policy, and interdisciplinary education. OBJECTIVE As the APM owns the journal, Psychosomatics, we sought to assess whether the APM's journal was fulfilling the vision and mission of its parent organization by reviewing the content of articles published in the journal to determine whether it sufficiently addresses the various clinical care knowledge areas it seeks to influence. METHODS We categorized content in all review articles, case reports, and original research articles published in Psychosomatics in 2015 and 2016. Each article was assigned to as many categories that it covered. RESULTS In the 163 articles reviewed, the most frequently covered fund of knowledge area was psychiatric morbidity in medical populations (44.2%); among psychiatric disorders, mood disorders (22.1%), psychiatric disorders due to a general medical condition or toxic substance (21.5%), anxiety disorders (14.7%), and delirium (13.5) were the most frequently covered. Of the medical and surgical topics, neurology (19.6%), coping with chronic illness/psychological response to illness (17.8%), toxicology (11.7%), outpatient medicine (10.4%), and cardiology (9.8%) appeared most often. CONCLUSIONS Psychosomatics appears to be successfully providing content relevant to the APM's vision and mission statements and to practitioners of psychosomatic medicine.
Collapse
Affiliation(s)
- John B Taylor
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA.
| | - Theodore A Stern
- Department of Psychiatry, Massachusetts General Hospital, Boston, MA
| |
Collapse
|
13
|
Ketterer MW, Chawa M, Paone G. Prospective correlates of early (30 day) readmissions on a Cardiothoracic Surgery Service. PSYCHOL HEALTH MED 2017; 22:947-954. [PMID: 28161983 DOI: 10.1080/13548506.2017.1287408] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Known to vary widely among hospitals for unclear reasons, early readmissions are associated with higher mortality and are suspected to frequently be due to inadequate discharge preparation/planning. It has been previously documented that the strongest and most consistent predictor of early readmissions in CHF patients is chronic cognitive impairment, and compensatory assistance with adherence on discharge improves early readmission rates. Prospective observational study. The present investigation examined multiple putative perioperative predictors of early readmission in a hospitalized Cardiothoracic Surgery Service. A subtest of the Mini-Cog, Short Term Memory, was the strongestunivariate predictor of early readmissions (p < .001), but the overall Mini-Cog (p = .024), Age (p = .045), Number of Admissions over the Preceding Year (p = .036), an Anxiety Scale (p = .035), Years of Education (p = .055) and a Depression Scale (p = .056) also demonstrated covariation. In a Logistic Regression, only Short Term Memory survived as a predictor variable (p = .007), correctly classifying 76% of patients. Chronic cognitive impairment is a predictor of early readmissions in Cardiothoracic patients. A brief bedside exam interpreted in medical context may permit identification of patients requiring familial assistance for adherence on discharge.
Collapse
Affiliation(s)
- Mark W Ketterer
- a Department of Behavioral Health , Henry Ford Hospital/WSU , Detroit , MI , USA
| | - Mansi Chawa
- b Behavioral Health , Henry Ford Health System , Detroit , MI , USA
| | - Gaetano Paone
- c Division of Cardiothoracic Surgery , Henry Ford Hospital , Detroit , MI , USA
| |
Collapse
|