Kathryn Kvam

All Publications

• Education Research: Educational Outcomes Associated With the Introduction of a Neurohospitalist Program. Neurology. Education Dujari, S., Scott, B. J., Gold, C. A., Weng, Y., Kvam, K. A. 2024; 3 (2): e200131

  Abstract

  Background and Objectives: As the prevalence of the neurohospitalist (NH) practice model grows, understanding its effect on trainee education is imperative. We sought to determine the impact of an academic NH program on neurology resident evaluations of faculty teaching.Methods: We performed a retrospective study of faculty teaching evaluations before and after the implementation of a full-time NH service. Primary outcomes were neurology resident evaluations of faculty teaching, which were compared in the pre-NH period (August 2010-July 2014) vs the post-NH period (August 2016-July 2018). In a secondary analysis, we used the difference-in-difference approach to analyze the effect of introducing the NH service on resident evaluation of faculty teaching compared with stroke and neurocritical care faculty controls. We performed an additional descriptive analysis of medical student evaluation of faculty teaching and described Residency In-service Training Exam scores and Accreditation Council for Graduate Medical Education (ACGME) resident survey data before and after the intervention.Results: There were 368 resident and 360 medical student evaluations of faculty teaching during the study period. Compared to the pre-NH period, the post-NH period had significantly higher resident evaluations of faculty teaching in 19 of 27 questions of faculty teaching, across 5 of the 6 ACGME core competencies. Within the competencies of patient care, practice-based learning and improvement, and systems-based practice, the NH teaching faculty were rated significantly higher across all questions. In the difference-in-difference model, resident evaluations of faculty teaching following the implementation of the NH service remained significantly improved compared with controls in teaching evidence-based medicine, teaching diagnostic algorithms, and explaining rationale for clinical decisions. Medical student ratings of faculty teaching were unchanged in the pre-NH and the post-NH period.Discussion: Neurology residents may benefit from the clinical expertise of NHs and their ability to teach evidence-based practice and role model systems-based practice. Given the central role NHs may play in trainee education, additional focus on both the local and national levels should be dedicated to further developing the teaching skills of NHs.

  View details for DOI 10.1212/NE9.0000000000200131

  View details for PubMedID 39359890

• Education Research: Sustained Implementation of Quality Improvement Practices Is Observed in Early Career Physicians Following a Neurology Resident QI Curriculum. Neurology. Education Xiong, K., Miller-Kuhlmann, R. K., Scott, B. J., He, Z., Dujari, S., Gold, C., Kvam, K. 2024; 3 (2): e200137

  Abstract

  Background and Objectives: The Accreditation Council for Graduate Medical Education and American Board of Psychiatry and Neurology expect engagement in quality improvement (QI) activities for all residents and practicing neurologists. Our neurology residency program instituted an experiential Neurology Residency QI Curriculum in 2015 for all residents. In this study, we aimed to characterize the role of QI engagement in the early-career paths of program graduates.Methods: We distributed an online survey evaluating QI training, scholarship, and leadership (before, during, and after residency training) to all individuals who graduated from our residency program (graduation years 2017-2021). Primary outcomes were QI project leadership or mentorship and QI scholarship (projects, posters, and publications) after residency. Predictors of these outcomes were also evaluated using Fisher exact test.Results: Twenty-nine of 50 graduates (58%) completed the survey. Median time from residency graduation was 3 years. Of the respondents, 14% actively participated in a QI project before residency, 83% during residency, and 48% after graduating. In addition, 41% had led or mentored a QI project and 34% had performed QI scholarship since residency. Fourteen percent of participants held formal roles in QI or patient safety, while 24% received formal full-time equivalents for QI work. Significant predictors (p < 0.05) of QI leadership included older age, time since graduation, rank, and participation in Clinical Effectiveness Leadership Training (CELT-an institutional QI faculty development course). Significant predictors (p < 0.05) of QI scholarship included older age, time since graduation, participation in CELT, and participation in QI scholarship during residency. QI training, participation, and/or project leadership before residency did not predict either QI leadership or scholarship after residency.Discussion: Many neurology residency graduates continued to lead QI projects and produce QI scholarship in the early years after graduation. However, receiving protected time for leadership and academic work in this area is uncommon. Our findings suggest that more infrastructure, including training, career development, and mentorship, can foster neurologists interested in leading in quality and patient safety. In academic models, promotion pathways that support academic advancement for faculty leading in QI are needed.

  View details for DOI 10.1212/NE9.0000000000200137

  View details for PubMedID 39359889

• 2022-2023: A Message From the Editors to Our Reviewers. Neurology. Clinical practice Bartolini, L., Kvam, K., Jagolino-Cole, A., Ney, J., Savage-Edwards, B. A., Tsao, J. W. 2024; 14 (1): e200255

  View details for DOI 10.1212/CPJ.0000000000200255

  View details for PubMedID 38721412

  View details for PubMedCentralID PMC11073860

• Outcome and Sequelae of Infectious Encephalitis. Journal of clinical neurology (Seoul, Korea) Kvam, K. A., Stahl, J. P., Chow, F. C., Soldatos, A., Tattevin, P., Sejvar, J., Mailles, A. 2024; 20 (1): 23-36

  Abstract

  Acute infectious encephalitis is a widely studied clinical syndrome. Although identified almost 100 years ago, its immediate and delayed consequences are still neglected despite their high frequency and possible severity. We reviewed the available data on sequelae and persisting symptoms following infectious encephalitis with the aim of characterizing the clinical picture of these patients at months to years after hospitalization. We searched PubMed for case series involving sequelae after infectious encephalitis. We carried out a narrative review of the literature on encephalitis caused by members of the Herpesviridae family (herpes simplex virus, varicella zoster virus, and human herpesvirus-6), members of the Flaviviridae family (West Nile virus, tick-borne encephalitis virus, and Japanese encephalitis virus), alphaviruses, and Nipah virus. We retrieved 41 studies that yielded original data involving 3,072 adult patients evaluated after infectious encephalitis. At least one of the five domains of cognitive outcome, psychiatric disorders, neurological deficits, global functioning, and quality of life was investigated in the reviewed studies. Various tests were used in the 41 studies and the investigation took place at different times after hospital discharge. The results showed that most patients are discharged with impairments, with frequent deficits in cognitive function such as memory loss or attention disorders. Sequelae tend to improve within several years following flavivirus or Nipah virus infection, but long-term data are scarce for other pathogens. Further research is needed to better understand the extent of sequelae after infectious encephalitis, and to propose a standardized assessment method and assess the rehabilitation efficacy in these patients.

  View details for DOI 10.3988/jcn.2023.0240

  View details for PubMedID 38179629

• Outcome and Sequelae of Autoimmune Encephalitis. Journal of clinical neurology (Seoul, Korea) Kvam, K. A., Stahl, J. P., Chow, F. C., Soldatos, A., Tattevin, P., Sejvar, J., Mailles, A. 2024; 20 (1): 3-22

  Abstract

  Autoimmune etiologies are a common cause for encephalitis. The clinical syndromes consistent with autoimmune encephalitis are both distinct and increasingly recognized, but less is known about persisting sequelae or outcomes. We searched PubMed for reports on outcomes after autoimmune encephalitis. Studies assessing validated, quantitative outcomes were included. We performed a narrative review of the published literature of outcomes after autoimmune encephalitis. We found 146 studies that produced outcomes data. The mortality rates were 6%-19% and the relapse risks were 10%-62%. Most patients achieved a good outcome based on a score on the modified Rankin Scale (mRS) of ≤2. Forty-nine studies evaluated outcomes beyond mRS; these studies investigated cognitive outcome, psychiatric sequelae, neurological deficits, global function, and quality-of-life/patient-reported outcomes using various tools at varying time points after the index hospital discharge. These more-detailed assessments revealed that most patients had persistent impairments, with frequent deficits in cognitive function, especially memory and attention. Depression and anxiety were also common. Many of these sequelae continued to improve over months or even years after the acute illness. While we found that lasting impairments were common among survivors of autoimmune encephalitis, additional research is needed to better understand the nature and impact of these sequelae. Standardized evaluation protocols are needed to improve the ability to compare outcomes across studies, guide rehabilitation strategies, and inform outcomes of interest in treatment trials as the field advances.

  View details for DOI 10.3988/jcn.2023.0242

  View details for PubMedID 38179628

• Amyotrophic Lateral Sclerosis Quality Measurement Set 2022 Update: Quality Improvement in Neurology. Neurology Kvam, K. A., Benatar, M., Brownlee, A., Caller, T., Das, R. R., Green, P., Kolodziejczak, S., Russo, J., Sanders, D., Sethi, N., Stavros, K., Stierwalt, J., Giles Walters, N., Bennett, A., Wessels, S. R., Brooks, B. R. 2023; 101 (5): 223-232

  View details for DOI 10.1212/WNL.0000000000207166

  View details for PubMedID 37524529

• Outcomes of a Neurohospitalist Program at an Academic Medical Center. The Neurohospitalist Gold, C. A., Scott, B. J., Weng, Y., Bernier, E., Kvam, K. A. 2022; 12 (3): 453-462

  Abstract

  The purpose is to determine the impact of an academic neurohospitalist service on clinical outcomes.We performed a retrospective, quasi-experimental study of patients discharged from the general neurology service before (August 2010-July 2014) and after implementation of a full-time neurohospitalist service (August 2016-July 2018) compared to a control group of stroke patients. Primary outcomes were length of stay and 30-day readmission. Using the difference-in-difference approach, the impact of introducing a neurohospitalist service compared to controls was assessed with adjustment of patients' characteristics. Secondary outcomes included mortality, in-hospital complications, and cost.There were 2706 neurology admissions (1648 general; 1058 stroke) over the study period. The neurohospitalist service was associated with a trend in reduced 30-day readmissions (ratio of ORs: .52 [.27, .98], P = .088), while length of stay was not incrementally changed in the difference-in-difference model (-.3 [-.7, .1], P = .18). However, descriptive results demonstrated a significant reduction in mean adjusted LOS of .7 days (4.5 to 3.8 days, P < .001) and a trend toward reduced readmissions (8.9% to 7.6%, P = .42) in the post-neurohospitalist cohort despite a significant increase in patient complexity, shift to higher acuity diagnoses, more emergent admissions, and near quadrupling of observation status patients. Mortality and in-hospital complications remained low, patient satisfaction was stable, and cost was not incrementally changed in the post-neurohospitalist cohort.Implementation of a neurohospitalist service at an academic medical center is feasible and associated with a significant increase in patient complexity and acuity and a trend toward reduced readmissions.

  View details for DOI 10.1177/19418744221083182

  View details for PubMedID 35755235

  View details for PubMedCentralID PMC9214938

• Quality Improvement Metrics and Methods for Neurohospitalists. Neurologic clinics Kvam, K. A., Bernier, E., Gold, C. A. 2022; 40 (1): 211-230

  Abstract

  Measurement of clinical performance is largely driven by the requirements of the Centers for Medicare and Medicaid Services and accrediting bodies like The Joint Commission. Performance measures include length of stay, readmission rate, mortality rate, hospital-acquired complications, and stroke core measures. Hospital rankings also depend heavily on quality and patient safety indicators. Becoming facile with these measures can aid neurohospitalists in understanding their value and garnering resources to support improvement projects. Neurohospitalists can apply a structured A3-based method to define a clinical problem, perform systematic analysis, then design and test solutions to drive improved outcomes for patients with neurologic disease.

  View details for DOI 10.1016/j.ncl.2021.08.011

  View details for PubMedID 34798971

• Education Research: A novel resident-driven neurology quality improvement curriculum. Neurology Miller-Kuhlmann, R., Kraler, L., Bozinov, N., Frolov, A., Mlynash, M., Gold, C. A., Kvam, K. A. 2020; 94 (3): 137–42

  Abstract

  OBJECTIVE: To describe and assess the effectiveness of a neurology resident quality improvement curriculum focused on development of practical skills and project experience.METHODS: We designed and implemented a quality improvement curriculum composed of (1) a workshop series and (2) monthly resident-led Morbidity, Mortality, & Improvement conferences focused on case analysis and project development. Surveys were administered precurriculum and 18 months postcurriculum to assess the effect on self-assessed confidence with quality improvement skills, attitudes, and project participation. Scholarship in the form of posters, presentations, and manuscripts was tracked during the course of the study.RESULTS: Precurriculum, 83% of neurology residents felt that instruction in quality improvement was important, but most rated their confidence level with various skills as low. Following implementation of the curriculum, residents were significantly more confident in analyzing a patient case (odds ratio, 95% confidence interval) (2.4, 1.9-3.1), proposing system changes (3.1, 2.3-3.9), writing a problem statement (9.9, 6.2-13.5), studying a process (3.1, 2.3-3.8), identifying resources (3.1, 2.3-3.8), identifying appropriate measures (2.5, 1.9-3.0), collaborating with other providers to make improvements (4.9, 3.5-6.4), and making changes in a system (3.1, 2.3-3.8). Project participation increased from the precurriculum baseline (7/18, 39%) to the postcurriculum period (17/22, 77%; p = 0.023). One hundred percent of residents surveyed rated the curriculum positively.CONCLUSIONS: Our multifaceted curriculum was associated with increased resident confidence with quality improvement skills and increased participation in improvement projects. With adequate faculty mentorship, this curriculum represents a novel template for preparing neurology residents for meeting the expectations of improvement in practice and offers scholarship opportunities.

  View details for DOI 10.1212/WNL.0000000000008752

  View details for PubMedID 31959682

• Evaluation of the impact of a neurohospitalist program at an academic medical center Neurohospitalist Society Kvam, K. 2020
• Emergent neuroimaging for seizures in epilepsy: A population study. Epilepsy & behavior : E&B Lamsam, L. n., Bhambhvani, H. P., Ratliff, J. K., Kvam, K. A. 2020; 112: 107339

  Abstract

  We determined how often patients with epilepsy presented to the emergency department (ED) for seizure and the frequency and predictors for undergoing emergent neuroimaging during those visits. We conducted a retrospective population-based cohort study using administrative claims' data from 2007 to 2015. Adults with epilepsy were identified based on a diagnosis of epilepsy and an outpatient prescription for an antiepileptic medication. The Bonferroni corrected significance level was 0.0018. We identified 381,362 patients with a mean follow-up period of 1.99 years, of whom 35,015 (9.2%) patients presented to the ED for seizure at least once. Patients with at least one ED visit were younger, more likely to be male, had fewer comorbidities, and had longer follow-up as compared with those with no ED visit (all p < 0.001). Among the 35,015 patients presenting to the ED, 13.6% had neuroimaging, mostly commonly head computed tomography (CT; 95.5%). Patients undergoing neuroimaging were younger (46 versus 48 years) and with higher rates of psychosis (17.4% versus 13.8%) and depression (16.1% versus 12.2%; p < 0.001). This helps to quantify the burden of ED and emergent neuroimaging utilization for patients with epilepsy and can help inform efforts to curtail unnecessary neuroimaging.

  View details for DOI 10.1016/j.yebeh.2020.107339

  View details for PubMedID 32911297

• A Case of Progressive Myelopathy in a Middle-aged Woman. JAMA neurology Muccilli, A., Cayrol, R., Kvam, K. A. 2019

  View details for DOI 10.1001/jamaneurol.2019.2806

  View details for PubMedID 31479102

• Yield of Emergent CT in Patients With Epilepsy Presenting With a Seizure NEUROHOSPITALIST Kvam, K. A., Douglas, V. C., Whetstone, W. D., Josephson, S., Betjemann, J. P. 2019; 9 (2): 71–78

  Abstract

  Studies of emergent neuroimaging in the management of patients presenting with a breakthrough seizure are lacking. We sought to determine how often emergent computed tomography (CT) scans are obtained in patients with known epilepsy presenting with a seizure and how often acute abnormalities are found.This multicenter retrospective cohort study was performed in the emergency department at 2 academic medical centers. The primary outcomes were percentage of visits where a CT scan was obtained, whether CT findings represented acute abnormalities, and whether these findings changed acute management.Of the 396 visits included, CT scans were obtained in 39%, and 8% of these scans demonstrated acute abnormalities. Patients who were older, had status epilepticus, a brain tumor, head trauma, or an abnormal examination were all significantly more likely to undergo acute neuroimaging (P < .05). In the multivariable model, only history of brain tumor (odds ratio [OR] 5.88, 95% confidence interval [CI], 1.33-26.1) and head trauma as a result of seizure (OR 3.92, 95% CI, 1.01-15.2) reached statistical significance in predicting an acutely abnormal scan. The likelihood of an acute imaging abnormality in visits for patients without a history of brain tumor or head trauma as a result of the seizure was 2.7% (2 visits). Both of these patients had abnormal neurological examinations.Obtaining an emergent CT scan for patients with epilepsy presenting with a seizure may be avoidable in most cases, but might be indicated for patients with a history of brain tumor or head trauma as a result of seizure.

  View details for PubMedID 30915184

  View details for PubMedCentralID PMC6429671

• A Quality Improvement Curriculum for Neurology Residents Miller-Kuhlmann, R., Kraler, L., Bozinov, N., Frolov, A., Mlynash, M., Gold, C., Kvam, K. LIPPINCOTT WILLIAMS & WILKINS. 2018

  View details for Web of Science ID 000453090805218

• A case of progressive multifocal leukoencephalopathy in a lupus patient treated with belimumab LUPUS Fredericks, C. A., Kvam, K. A., Bear, J., CRABTREE, G. S., Josephson, S. A. 2014; 23 (7): 711-713

  Abstract

  Belimumab is a monoclonal antibody against soluble B-lymphocyte stimulator, an essential growth factor for B-cell maturation and activation, which was approved by the US FDA in 2011 for patients with active autoantibody-positive systemic lupus erythematosus (SLE) who have failed standard treatment. Here we present the case of a 40-year-old woman with SLE diagnosed with progressive multifocal leukoencephalopathy (PML) on belimumab. After a total of 10 infusions of belimumab, from August 2012 through April 2013, in April 2013 she developed progressive neurologic decline with episodic dystonia and autonomic symptoms. Her imaging showed multifocal, confluent regions of T2 hyperintensity in the white matter bilaterally, and CSF JCV PCR returned positive. Based on the patient's clinically mild SLE and the timing of symptom onset, belimumab likely played a key role in the development of PML. Trials of belimumab for other autoimmune diseases are ongoing; as applications for this novel drug broaden, careful monitoring for this potentially fatal adverse effect is warranted.

  View details for DOI 10.1177/0961203314524292

  View details for Web of Science ID 000339103900015

  View details for PubMedID 24531080

• Sedation with nitrous oxide compared with no sedation during catheterization for urologic imaging in children. Pediatric radiology Zier, J. L., Kvam, K. A., Kurachek, S. C., Finkelstein, M. 2007; 37 (7): 678-84

  Abstract

  Various strategies to mitigate children's distress during voiding cystourethrography (VCUG) have been described. Sedation with nitrous oxide is comparable to that with oral midazolam for VCUG, but a side-by-side comparison of nitrous oxide sedation and routine care is lacking.The effects of sedation/analgesia using 70% nitrous oxide and routine care for VCUG and radionuclide cystography (RNC) were compared.A sample of 204 children 4-18 years of age scheduled for VCUG or RNC with sedation or routine care were enrolled in this prospective study. Nitrous oxide/oxygen (70%/30%) was administered during urethral catheterization to children in the sedated group. The outcomes recorded included observed distress using the Brief Behavioral Distress Score, self-reported pain, and time in department.The study included 204 patients (99 nonsedated, 105 sedated) with a median age of 6.3 years (range 4.0-15.2 years). Distress and pain scores were greater in nonsedated than in sedated patients (P < 0.001). Time in department was longer in the sedated group (90 min vs. 30 min); however, time from entry to catheterization in a non-imaging area accounted for most of the difference. There was no difference in radiologic imaging time.Sedation with nitrous oxide is effective in reducing distress and pain during catheterization for VCUG or RNC in children.

  View details for DOI 10.1007/s00247-007-0508-z

  View details for PubMedID 17564739