The National Academies of Sciences, Engineering, and Medicine has published a detailed report on implementing efforts to address the social needs of patients.
Healthcare providers can address social determinants of health through five approaches—awareness, adjustment, assistance, alignment, and advocacy, according to a report from the National Academies of Sciences, Engineering, and Medicine.
Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address SDOHs and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.
"The consistent and compelling evidence concerning how social determinants shape health has led to a growing recognition throughout the healthcare sector that improvements in overall health metrics are likely to depend—at least in part—on attention being paid to these social determinants," the National Academies report says.
The report outlines the "5As" strategies that healthcare organizations can implement to address SDOHs in the communities they serve. The strategies were developed by the National Academies' Committee on Integrating Social Needs Care into the Delivery of Healthcare to Improve the Nation's Health, Board on Health Care Services, Health and Medicine Division.
1. Awareness
The committee says awareness should focus on identifying the social risks and assets of specific patients and populations of patients.
"On the clinical side, patients visiting healthcare organizations are increasingly being asked to answer social risk screening questions in the context of their care and care planning. In some places, screening is incentivized by payers. As part of the MassHealth Medicaid program, for instance, Massachusetts accountable care organizations now include social screening as a measure of care quality," the report says.
2. Adjustment
Instead of addressing social needs directly, healthcare organizations can pursue a strategy that focuses on adjusting clinical care to address social determinants of health.
"Many examples of adjustment strategies were identified in the literature, including the delivery of language- and literacy-concordant services; smaller doctor-patient panel sizes for cases with socially complex needs (e.g., teams caring for homeless patients in the U.S. Department of Veterans Affairs health system have panel sizes smaller than the size of other VA care teams); offering open-access scheduling or evening and weekend clinic access; and providing telehealth services, especially in rural areas," the report says.
3. Assistance
Healthcare organizations can pursue strategies to connect patients with social needs to government and community resources.
"The literature contains descriptions of a variety of assistance activities that have been undertaken by health systems and communities. These assistance activities vary in intensity, from lighter touch (one-time provision of resources, information, or referrals) to longer and more intensive interventions that attempt to assess and address patient-prioritized social needs more comprehensively," the report says.
Intensive interventions include relationship building, comprehensive biopsychosocial needs assessments, care planning, motivational interviewing, and long-term community-based supports.
4. Alignment
Healthcare providers can pursue an alignment strategy that assesses the social care assets in the community, organizes those assets to promote teamwork across organizations, and invests in assets to impact health outcomes.
"The committee defined alignment activities to include those undertaken by healthcare systems to understand existing social care assets in the community, organize them in such a way as to encourage synergy among the various activities, and invest in and deploy them to prevent emerging social needs and improve health outcomes," the report says.
5. Advocacy
Healthcare providers can form alliances with social care organizations to advocate for policies that promote the creation and distribution of assets or resources to address social determinants of health. For example, healthcare organizations can call for policy changes to overhaul transportation services in a community.
"In both the alignment and advocacy categories, healthcare organizations leverage their political, social, and economic capital within a community or local environment to encourage and enable healthcare and social care organizations to partner and pool resources, such as services and information, to achieve greater net benefit from the healthcare and social care services available in the community," the report says.
Implementing the five strategies
Assessing the level of existing social needs activities should be a starting point for healthcare organizations that want to address social determinants of health, the chairperson of the National Academies committee told HealthLeaders.
One of the first steps healthcare organizations can take is identifying activities they may already have underway that fit the 5As, then expand or enhance those activities through greater commitment from leadership, investment of resources into supporting infrastructure, and strengthening of engagement with patients and community stakeholders, said Kirsten Bibbins-Domingo, PhD, MD, MAS, professor and chair, Department of Epidemiology and Biostatistics, UCSF School of Medicine, University of California, San Francisco.
"Healthcare organizations may not have activities in all of the 5As and should use this framework to develop strategies that will work within their local context. In all cases, it is critical to be aware that addressing health-related social needs of their patients is essential to achieving goals of high quality and high-value care," she said.
"Partnerships are crucial," Bibbins-Domingo said.
"Activities in the clinical setting should be designed and implemented in a way that engages patients, community partners, frontline staff, social care workers, and clinicians in planning and evaluation, as well as in incorporating the preferences of patients and communities. Establishing linkages and communication pathways between healthcare and social service providers is critical, including personal care aides, home care aides, and others who provide care and support for seriously ill and disabled patients."
The number of physician assistants who received certification reached its highest annual mark in 2018.
Growth in the number of physician assistants is robust, according to the latest statistical profile published by the National Commission on Certification of Physician Assistants (NCCPA).
Physician assistant participation in clinical care teams is widely viewed as part of the solution to the country's physician shortage. By 2032, the physician shortage is expected to grow to about 122,000 doctors, according to the Association of American Medical Colleges. The U.S. Bureau of Labor Statistics projects 31% growth in the PA profession from 2018 to 2028, which the federal agency characterizes as "much faster than average" compared to other occupations.
The 9,287 physician assistants who received NCCPA certification in 2018 is the largest number of PAs ever certified in a single year, the NCCPA statistical profile published this month says. More than 160,000 PAs have received NCCPA certification since 1975.
The statistical profile, which features data from 2018, includes many key data points:
24% of PAs certified in 2018 are working in primary care
The median annual salary for PAs certified in 2018 is $95,000
Mirroring gender wage gaps among other clinicians, the mean salary for male PAs was $99,450 compared to $94,986 for female PAs
Nearly two-thirds of PAs certified in 2018 have a total educational debt of more than $100,000
The 2018 cohort of certified PAs is the youngest since NCCPA began issuing certifications in 1975: 72.5% were under 30, and 23.4% were 30 to 39 years old
59.0% of PAs certified in 2018 have accepted a clinical position as a physician assistant, and 74.4% of these clinicians received at least two PA job offers
85.6% of PAs certified in 2018 identified their ethnicity as white
Interpreting the data
Dawn Morton-Rias, EdD, PA-C, president and CEO of the NCCPA, told HealthLeaders that the relatively high number of recently certified PAs who have chosen to work in primary care is beneficial for U.S. healthcare.
"The number (24%) of recently certified PAs who have accepted a job working in primary care—family medicine, general internal medicine, and general pediatrics—is encouraging. This represents an increase in year over year comparison. We know from an American Association of Medical Colleges study that America is projected to have a shortage of primary care physicians as high as 55,200 by 2032," she said.
Morton-Rias said it was rewarding to learn that 71.9% of recently certified PAs who have accepted a position indicated that they did not face any challenges when searching for a job.
"When I entered this profession, it was still relatively new, and there wasn't always a certainty that those who studied to become a physician assistant would be able to find employment, nor did we know what the future was for the profession. To see that a majority of recently certified PAs are having no trouble finding employment—and also that 67% of them were offered employment incentive—is a positive indicator that employers not only see the value of certified PAs, but that they are willing to do what is necessary to bring them onboard," she said.
Recently certified PAs have shown a significant propensity to work in areas of the country that desperately need clinical professionals, Morton-Rias said. "We also see from the report that 43.6% of recently certified PAs who have accepted a position in a health professional shortage area—or a medically underserved area—are doing so because they prefer to work in this setting."
Room for improvement
Despite 2018 generating the most diverse cohort of PAs since NCCPA began publishing the statistical profile in 2013, more diversity is needed in the physician assistant ranks, Morton-Rias said.
"America is becoming more diverse, and so are patients. As the physician shortage worsens, PAs are increasingly finding themselves working in socioeconomically depressed and isolated communities that would benefit most from a more diverse selection of providers. Studies have shown that minority patients report higher rates of satisfaction when they receive care from minority providers, and that when providers share the same racial and cultural background as their patients, it can even lead to improved patient outcomes," she said.
The gender wage gap among PAs has worsened slightly in recent years, Morton-Rias says. "While the median salary for recently certified male and female PAs who have accepted a position has [been about $95,000] from 2016 to 2018, the disparities between the average salaries of recently certified male and female PAs who have accepted a position continues to grow."
The statistical profiles for 2016, 2017, and 2018 detail the wage gender gap:
In 2016, the average salary for recently certified male PAs who accepted a position was $95,244, while the average salary for recently certified females PAs who accepted a position was $91,132, for a difference of $4,112.
In 2017, the average salary for recently certified male PAs who accepted a position was $97,592, while the average salary for recently certified female PAs who accepted a position was $93,386, for a difference of $4,206.
In 2018, the average salary for recently certified male PAs who accepted a position was $99,450, while the average salary for recently certified female PAs who accepted a position was $94,486, for a difference of $4,464.
"When we think about delivery of healthcare, patients aren't going to receive more services or better care because of the gender of their provider. Providers must receive equal pay for equal work, and healthcare employers have a real opportunity to lead on this issue by making wage parity between male and female providers a reality," Morton-Rias said.
Gaining support for antibiotic stewardship in the urgent care setting involves commitment from top leadership down to the clinic staff level.
The Urgent Care Association (UCA) is stepping up efforts to improve antibiotic stewardship at the country's urgent care centers.
Appropriate prescribing of antibiotics is essential to help avoid the development of antibiotic-resistant infections, which the Centers for Disease Control and Prevention calls one of the most severe public health problems in the country. Last year, CDC researchers published a study in JAMA Internal Medicine that found inappropriate prescribing of antibiotics for respiratory conditions was highest in the urgent care setting, at 45.7% of patient visits.
This year, Warrenville, Illinois–based UCA and the UCA-affiliated College of Urgent Care Medicine launched their Antibiotic Stewardship Commendation program, which recognizes urgent care organizations that follow best practices for antibiotics prescribing.
A key requirement for earning the commendation is adhering to at least four core elements of the CDC's guidance for antibiotics stewardship in hospitals and long-term care: commitment, action for policy and practice, tracking and reporting, and education and expertise.
The CDC guidance has set the best practices for antibiotic stewardship, says Joseph Toscano, MD, a member of the board of directors at the College of Urgent Care Medicine.
"The CDC is regarded as an expert in this regard because of the resources and experience the organization possesses in the treatment of infectious diseases and public health, both of which are at play here. Currently, their core elements are proving successful and are being used by many organizations. They incorporate principles of change management and physician and patient behavior, which all have a bearing on changing antibiotic prescribing," says Toscano, who is chief of emergency medicine and an emergency physician at Northern California Emergency Medical Group, San Ramon Regional Medical Center in San Ramon, California.
Earning urgent care antibiotics stewardship commendation
Premier Health is one of the first urgent care organizations in the country to earn the UCA/College of Urgent Care Medicine antibiotic stewardship commendation.
Premier Health has followed all four of the UCA's recommended core elements for antibiotic stewardship in the urgent care setting, says Kevin DiBenedetto, MD, medical director of the Baton Rouge, Louisiana–based company.
1. Commitment: "This is the sort of thing you have to be all-in for. We're dedicated to optimizing antibiotic prescribing and patient safety. We want the people in our organization to be accountable for it. If you don't have the commitment, then nothing else falls into place," DiBenedetto says.
Premier Health has cultivated support for antibiotic stewardship from the company's top leadership to the clinic staff level, he says. "Having everyone onboard from the administration down to the clinical level and regional administrators is what is really pushing this effort out."
2. Action for policy and practice: "We have implemented antibiotics prescribing practices in our clinics and promoted antibiotics stewardship in our provider meetings as well as when we do reviews of charts. Part of that review is going over providers' records on how they are doing with antibiotics stewardship. We provide feedback to providers relative to the other providers as well as relative to the overall statistics for our company," DiBenedetto says.
3. Tracking and reporting: Monitoring clinician adherence to antibiotic prescribing best practices is crucial, he says. "For tracking and reporting, we worked with our electronic medical record vendor to be able to track and record compliance. If you can't track performance, then none of this works."
Premier Health is focusing on three diagnoses that are almost always viral conditions rather than bacterial conditions that respond to antibiotics: upper respiratory infections, pharyngitis that is not strep throat, and bronchitis and bronchiolitis. The company has set a goal to decrease antibiotic prescribing for the three conditions by 50%, DiBenedetto says. For all conditions treated at Premier Health clinics, antibiotics have been prescribed inappropriately in 30% of cases, and the company has set an initial goal of reducing that overall inappropriate prescribing rate to 25%, he says.
"There is a need to educate the providers to get the antibiotic prescribing down for the three targeted diagnoses. We have a goal to cut back to 25% of inappropriate prescribing within the first year of receiving our commendation. And we want to get even better after that," DiBenedetto says. "We thought this was a good starting point, so it is realistic as we push it out to the providers. We didn't want to give them an unrealistic goal of 8% or 10%, although that is ideally where you would like to be."
4. Education and expertise: In the urgent care setting, he says the educational challenge is two-fold: training clinicians in best practices for prescribing antibiotics and educating patients about appropriate utilization of antibiotics.
"We provide educational material and literature to our providers, some of which is mandatory as part of their educational process. It's not just important to know when to give an antibiotic—it's important to know that the right drug, the right dose, and the right duration is selected. A lot of people get caught up in whether to give an antibiotic or not, but there is more to it than that," DiBenedetto says.
To educate patients, Premier Health has posters about appropriate antibiotics prescribing in waiting rooms and exam rooms, along with literature that is provided to patients when they are discharged from a clinic. For patients who insist on receiving an antibiotic, face-to-face conversations with clinicians are very effective, he says.
"Those patients will say they always got an antibiotic in the past and they want one now because it has always worked for them. Providers must carve out extra time to talk with those patients to educate them on why antibiotics are not indicated and why antibiotics cannot be a good choice because of adverse effects, antibiotic resistance, and cost. There have been studies showing that doctors who take the extra time to explain proper use of antibiotics get better patient satisfaction scores than doctors who just write a prescription," DiBenedetto says.
Promoting clinician compliance
To monitor clinician compliance with antibiotic prescribing best practices, Premier Health is generating monthly reports by market and individual providers for upper respiratory infections, pharyngitis that is not strep throat, and bronchitis and bronchiolitis. "We've identified three basic diagnoses that we feel should always be diagnosed as viral—that's where you are going to get the most bang for your buck," DiBenedetto says.
For individual clinicians who prescribe antibiotics inappropriately at higher rates than their peers, presenting the data in a nonconfrontational manner is highly effective at gaining better compliance rates, he says.
"Most providers are people who excelled in school whether they are a doctor, a nurse practitioner, or other kind of clinician. They don't like to think that they are behind the crowd. So, when you present statistics and show clinicians that they are writing more antibiotic prescriptions than their peers and they are not meeting the standards you set in your organization, they respond to that. They don't like being at the bottom—they are used to being competitive and making good grades."
The "ADEPT" tool for delirium and agitation provides care guidelines for emergency department clinicians.
A recently developed tool for managing delirium and agitation in emergency room patients over age 65 features five steps: assess, diagnose, evaluate, prevent, and treat (ADEPT).
A recent journal article published in Annals of Emergency Medicine details how to use the ADEPT tool. "It is rare for patients in this age group to present with a new-onset primary psychotic disorder or new-onset schizophrenia, so a medical cause should almost always be assumed until proven otherwise. Furthermore, the signs and symptoms of these patients' presentation may be subtle or atypical, so the evaluation should be thorough," the co-authors of the article wrote.
The co-authors define delirium as an "acute change in mental status, with waxing and waning symptoms, that can present with hyperactive, hypoactive, or mixed symptoms. Its presentation can be subtle or can be confounded by other symptoms or disorders, such as strokes, sepsis, adverse drug reactions, or intoxication."
The following highlights the ADEPT tool's five approaches.
1. Assess
A. Perform a thorough evaluation to seek possible underlying causes: The first step is to determine whether there are life-threatening conditions such as hypoxia and hypoglycemia, then to ensure patient and staff safety. The next step is to find out whether the patient has deviated from baseline functioning and the time course of that deviation, which usually requires consulting with a family member or caregiver.
B. Patient history, medication review, and collateral information: In addition to considering whether an adverse medication effect is at play, three of the most common causes of a sudden change in mental status are infections, metabolic or electrolyte disorder, and neurologic disorders.
C. Thorough physical exam: Patients should be examined for trauma or infection such as sacral ulcers. Bruising or abrasions could be evidence of an accidental trauma from falls, but the possibility of intentional trauma or neglect should also be considered. A physical exam should include assessing signs of stroke, intracranial hemorrhage, or subclinical seizures, which are possible life-threatening causes of agitation or altered mental status.
2. Diagnose
A. Screen for delirium: Clear signs of delirium include sudden onset of changed mental status, waxing and waning symptoms, inattention such as an inability to recite the days of the week backward, altered cognition such as disorientation or a new memory deficit, or altered awareness of the environment such as drowsiness.
B. Screen for underlying major neurocognitive disorder: Clinicians should work with family members or caregivers to determine the presence of delirium, dementia, or psychiatric conditions such as psychosis. Questions for family members or caregivers include whether there is a previous diagnosis of dementia or a psychiatric condition, sudden changes in cognition or behavior that often indicate delirium, and sleep disturbances. Disrupted sleep is an indication for delirium, dementia patients can have normal or fragmented sleep, psychosis patients have variable sleep patterns.
3. Evaluate
The primary focus of the "diagnose" step is to determine whether delirium is present. The focus of the "evaluate" step is to look for underlying causes of delirium.
A. Medical workup for agitation or confusion: Infections are the most common cause of delirium in the emergency room setting, followed by acute neurologic disorders such as ischemic stroke and intracranial hemorrhage. Adverse medication reactions also are a common cause of delirium, so medical workups should include a review of medication changes and use of medications linked to a high risk of causing delirium.
B. General tests: General tests for delirium patients should include a complete blood count, electrocardiogram, metabolic panel, glucose level test, and urinalysis with culture.
C. Specific, targeted testing and evaluation: More specific tests for delirium patients should be guided by medical history, physical examination, and symptoms. A routine computed tomography of the brain should be performed on patients with decreased consciousness level, fall, focal neurologic deficits, or head trauma.
4. Prevent
A. Individual patient measures to prevent delirium: ER staff can take actions to prevent progression of delirium and ease symptoms, including treating underlying conditions, managing pain, and addressing unrelated symptoms such as nausea and constipation. If a patient has home medications, they should be administered as long as they are not contraindicated.
B. Hospital-based measures to prevent delirium: ER length of stay longer than 10 hours has been associated with increased delirium risk in older patients, so protocols should be in place to decrease length of stay for patients at risk of delirium such as transferring patients to the inpatient setting.
5. Treat
A. Multi-modal approach to treatment: Alternatives to medication such as distraction and reassurance are low-risk approaches to delirium treatment. A video message of family members can help calm patients.
B. Use verbal de-escalation principles: De-escalation through verbal interactions with patients can help them gain control without having to provide additional treatments.
C. Start with oral medications: If nonpharmacologic approaches are ineffective and a patient has an antipsychotic prescribed for home use, that medication should be administered in the ER. Other oral medication options include the following: risperidone, olanzapine, quetiapine, haloperidol.
D. Consider the use of intramuscular or intravenous medications: Although IM and IV medications should be used sparingly, they may be necessary if oral medications are ineffective or patients are at risk of harming themselves or others. IM and IV medications for delirium include ziprasidone, olanzapine, and haloperidol.
E. Avoid benzodiazepines: Clinicians should avoid administering benzodiazepines because they can cause prolonged sedation or increased delirium. If a patient has a home prescription for long-term use of benzodiazepines, the medication should be continued to avoid withdrawal symptoms.
F. Prevent harm and minimize side effects: Administering medications can place patients at risk, so they should be used mainly when patient and staff safety are in doubt. If medications are used, doses should be low.
Revenue opportunities for health systems and hospitals include manufacturing gene therapies on their own or in partnership with biotechnology companies.
After biotechnology companies or healthcare organizations receive approval for gene therapies, there are three key capabilities to bring the therapies to market, a new PwC Health Research Institute report says.
Gene therapies modify patient genes or cells to treat or cure disease. Over the next decade, the number of patients who will have received gene therapies is expected to reach 500,000.
Health systems and hospitals are playing a crucial role in the development of gene therapies, including autologous therapies that take cells from patients that are manipulated then reintroduced to the body, the PwC Health Research Institute report says.
"In contrast to traditional manufacturing, clinicians and health systems are often an essential part of gene therapy production. For, autologous therapies they participate in the first step of the production process—collecting the cells—and the last one—administering the altered gene therapy product. They are, in essence, extensions of the biopharmaceutical company."
Treatment facilities are pivotal in ensuring patient safety and maintaining quality, the report says. "Companies may need to expand their views of the 'production facility' to include treatment centers, since improper collection, handling or administration during the process could put patient safety at risk and undermine quality. Already, some organizations like the Foundation for the Accreditation of Cellular Therapy are working to set standards for these organizations to ensure consistency of quality standards."
After a gene therapy has received regulatory approval, the three crucial capabilities for biotechnology companies and their healthcare organization partners are advanced manufacturing, responsive supply chains, and tailored commercialization and reimbursement models.
1. Advanced manufacturing
Unlike traditional medications, most gene therapies are personalized treatments designed for an individual patient or manufactured in small batches, the PwC report says.
"Traditional medical products are made for many patients to take, with differences in doses, release mechanisms, or coatings allowing a regimen to be more personalized to the patients' needs. Manufacturers of these products have long relied on post-approval scale-up activities to quickly meet market demand by producing millions, and even billions, of doses of product per year."
For gene therapies, the inability to manufacture at large scale has three implications for biotechnology companies and their healthcare organization partners:
Competition for manufacturing capacity is expected to make acquisitions and partnerships attractive options.
Training staff will be essential to avoid production bottlenecks. "Due to the novel techniques and technologies used in manufacturing gene therapy products—and the small number of approved gene therapy products—few prospective employees have ready-to-hire experience in gene therapy," the PwC report says.
Manufacturers will have to focus on time-to-patient (TTP), which is the amount of time between when a treatment is prescribed and when it is received by a patient. Unlike traditional treatments, which often have TTP measured in hours, TTP timelines for gene therapies can be lengthy, the report says. "TTP can be weeks after accounting for doctor's visits, insurance approvals, manufacturing, and the treatment's time in transit. Decreasing this time will help increase patient and provider satisfaction, and potentially lead to better outcomes." Solutions include having multiple manufacturing sites across the country or manufacturing at the site of care.
2. Responsive supply chain
"Gene therapy companies often must rely on a robust supply chain with advanced capabilities, from collection of the cells from a patient to administration of the treatment. Key among these capabilities is a 'cold chain' ensuring products are stored at the right temperature and handled properly from manufacturer to patient or vein-to-vein. A single temperature failure in the supply chain could render the product useless, even dangerous," the PwC report says.
There are two implications from the need for a responsive supply chain:
Gene therapy manufacturers should consider personalized engagement of patients similar to apps offered by companies such as Domino's Pizza. "Gene therapy companies could borrow this approach, showing patients where their cells are, how far along they are in the production process, the status of delivery, when they need to prepare for treatment, and more. Companies also could include educational, payment information and other support tools in these applications," the report says.
Contracting with distributors and payers should account for the possibility of returned products. "Companies should consider what the 'return' process would look like in practice and how they might structure contracts with payers to account for this possibility. Companies could, for example, require the payer to cover the manufacturing costs of the product under certain circumstances beyond the biopharmaceutical companies' control," the report says.
3: Tailored commercialization and reimbursement models
Gene therapies can have high costs because they are not produced at large scale, so reimbursement models should be crafted to assure payers and patients that the therapies have value.
There are already examples of innovative pricing models, the PwC report says. "AveXis Inc., a subsidiary of Novartis Pharmaceuticals Corp., is offering payers a pay-over-time option for its new gene therapy treatment for spinal muscular atrophy in pediatric patients, a genetic disorder that causes muscles to atrophy. Under the plan, insurers would have up to five years to pay for the one-time therapy."
Opportunity for health systems and hospitals
Health systems and hospitals can generate revenue opportunities from gene therapy manufacturing, Karen Young, pharmaceutical and life sciences leader at PwC, told HealthLeaders.
"As gene therapy develops into the commercial space, health systems and hospitals may start to see gene therapy as a greater revenue opportunity. Some hospitals already discover, test, and administer gene therapies, which are key aspects to the overall process. Already, some academic medical centers have started investing in gene therapy manufacturing facilities and regulatory capacities, which could help them to control all aspects of the process. Even providers who aren't interested in making or developing gene therapies may wish to partner with companies that do, which could allow them to share in the costs—and rewards—of this space."
Healthcare providers are urged to vaccinate patients and report all suspected cases of the highly contagious illness to public health authorities.
The United States is experiencing the highest number of reported measles cases since the contagious and potentially fatal viral illness was declared eliminated in in the country in 2000, federal statistics show.
Measles is a highly contagious condition that causes fever and rash, with complications including diarrhea, ear infections, pneumonia, encephalitis, premature birth, and rarely death, according to the New York City Department of Health and Mental Hygiene.
According to the latest statistics from the U.S. Centers for Disease Control and Prevention, there have been 1,250 measles cases this year through Oct. 3. The number of cases has already exceeded the highest number of annual cases reported in the past 25 years. The next highest number of cases in that span of time was reported in 1994, when there were 963 cases reported. The last time there was more than 1,250 cases was 1992.
A journal article published this month in Annals of Emergency Medicine provides a snapshot of U.S. measles cases from Jan. 1 to April 26. The article features several key data points:
There were 704 reported measles cases
71% of the cases affected people who had not received the measles, mumps, and rubella (MMR) vaccine
Thirteen outbreaks were reported in the country, accounting for 94% of reported cases. Six of the 13 outbreaks occurred in under-immunized, close-knit communities, accounting for 88% of all cases.
Children and young people were the most affected population, with individuals age 4 and under accounting for nearly half of all cases. Individuals age 5 to 19 accounted for 29% of the cases. Only 4% of the cases were reported in people 50 or older.
New York was a hotspot for measles cases, accounting for 67% of reported cases.
Infection acquired in foreign countries was a significant factor in the measles cases, with 44 cases directly imported from abroad. Thirty-four of those cases were U.S. residents who had traveled overseas. The Philippines led source countries, with 14 cases. The other source countries linked to more than one U.S. case were Germany, Israel, Thailand, Ukraine, and Vietnam.
"High two-dose measles vaccination coverage in the United States has been critical to limiting transmission. However, increased global measles activity poses a risk to U.S. elimination, particularly when unvaccinated travelers acquire measles abroad and return to communities with low vaccination rates," the Annals of Emergency Medicine article says.
Healthcare provider guidance
The journal article offers the following guidance for clinicians to help address new measles cases and outbreaks:
Unless there are contraindications to administering the MMR vaccine or evidence of immunity to measles, Americans traveling overseas should be vaccinated. Evidence of immunity includes written documentation of age-appropriate vaccination and laboratory confirmation of immunity.
Infants from 6 to 11 months old should get one dose of MMR vaccine.
Infants given MMR vaccine before their first birthday should get two more doses—one dose at 12 to 15 months old, and an additional dose at least a month after the first dose.
All suspected cases of measles should be reported to public health authorities.
Vaccination is essential to stop measles infections, the journal article says. "Recent outbreaks have been driven by misinformation about measles and MMR vaccine, which has led to under-vaccination in vulnerable communities."
Medication management is the primary focus of a new care protocol for Parkinson's disease patients in the hospital setting.
Caring for hospital patients who have Parkinson's disease poses challenges for hospitals and health systems, but a new protocol drives significant clinical and financial benefits.
Research has shown that hospitalized Parkinson's patients have higher costs of care compared to patients without the disease, including longer lengths of stay and higher medication costs. A New Jersey-based healthcare organization has worked to improve these metrics.
In 2017, Hackensack University Medical Center in Hackensack, New Jersey, formally launched a strict medication adherence protocol for Parkinson's. In June 2018, the protocol was recognized by The Joint Commission as the Disease-Specific Certification in Parkinson's Disease.
Medication adherence is crucial in the care and daily functioning of people with Parkinson's, says Hooman Azmi, MD, director of the Division of Functional and Restorative Neurosurgery at Hackensack University Medical Center.
"Patients with Parkinson's have a significant reliance on their medication. Most patients with Parkinson's develop motor symptoms such as rigidity, stiffness, difficulty moving, and tremors. Rigidity and difficulty moving are particularly debilitating. The patients require their medicine for these symptoms to go away," he says.
In the outpatient setting, patients with Parkinson's work closely with neurologists to develop finely crafted medication regimens, Azmi says.
"When someone has Parkinson's for a long time, the management of symptoms becomes challenging because the effect of medicine is not long-lasting, and it becomes shorter and shorter. They end up requiring more and more doses of medicine. Sometimes, patients take medicine every three hours—or every two hours—around the clock. If patients don't take their medicine or the medicine is delayed, their symptoms can come out. Basically, they can go from being mobile to almost not being able to move," he says.
The strict medication adherence protocol for Parkinson's developed at Hackensack University Medical Center has generated statistically significant reductions in length of stay and hospital readmissions:
Length of stay for all Parkinson's patients at the hospital decreased from 7.125 days in 2017 to 6.750 days in 2018.
The readmissions rate for Parkinson's patients decreased from 13.9% in 2017 to 12.8% in 2018.
Hackensack University Medical Center's four primary components of the medication adherence protocol are as follows:
1. Patient identification
Most patients with Parkinson's do not go to a hospital for treatment of the disease, so identifying them and their underlying condition can be a challenge, Azmi says.
"They come into the hospital for everything that everybody else comes into the hospital for—they come in for back pain, kidney stones, heart attacks, and all kinds of conditions. The Parkinson's can be missed in the shuffle because caregivers will focus on the main reason why the patient came to the hospital. So, strict adherence to the Parkinson's medication can be completely misplaced and patients don't get their medication on time, which compounds their problems in the hospital," he says.
HMHUMC is using the hospital's electronic medical record to identify Parkinson's patients, Azmi says. "Whenever a doctor or nurse opens a chart of a patient who has Parkinson's, a flag comes up identifying the patient with the disease. Then care plans are included in the electronic record including the timing of medication and contraindicated medicine."
Delays in administering Parkinson's medications as short as 15 minutes can "wreak havoc," he says.
2. Metrics to assess medication management
To help ensure strict adherence to medication regimens, the hospital monitors several metrics for Parkinson's patients, Azmi says. "The metrics include patient identification, making sure all of the medicines are in the formulary, and making sure that patients get medication in the customized fashion that they get at home—we don't put in default medication regimens. We also have a metric to make sure patients are not getting contraindicated medication."
Close monitoring of the metrics impacts patient care, he says.
"Every time an order is placed for a Parkinson's medication, we make sure the order is placed in a customized fashion. We track the number of customized orders versus non-customized orders, and we try to correct inappropriate orders in real time. With contraindicated medications, we follow up when these medications are ordered. We work very hard to prohibit the ordering of these medications for Parkinson's patients."
3. Metrics evaluation and implementation of action plans
When care teams find that metrics performance needs to be improved for patients, the hospital's Disease-Specific Committee for Parkinson's Disease develops improvements through implementation of action plans, Azmi says.
"Sometimes, there is an issue in a part of the hospital, so we educate the staff in that area. There may be an instance when the pharmacy needs to develop options when certain medications are ordered. Through the disease-specific committee, we have been able to look at the data, assess it, then come up with plans to improve the compliance," he says.
4. Education
Staff throughout the hospital has received education and training for the strict medication adherence protocol, including physicians, advanced practice practitioners, nurses, physical therapists, radiation technologists, and pharmacists.
"Everyone needs to be aware about the importance of medication and avoiding contraindicated medication," Azmi says.
The education and training have been provided in several formats such as webinars, surveys, and a variety of grand rounds for nurses and physicians. "It's an ongoing educational process—it must be continuous because managing these patients poses problems on a continuous basis," he says.
The key to success of the strict medication adherence protocol has been the hospital-wide approach, Azmi says.
"It's a cliché to say it takes a village to raise a child, but it takes an entire hospital to care for one patient. Everything we do for this patient population translates to the entire hospital. This protocol makes us better, and it takes many people from different parts of the hospital—from physicians, to nursing, to physical therapy, to the pharmacy, to regulatory staff, to quality officers. It is truly an interdisciplinary effort to launch an initiative like this throughout the hospital. But it translates into better patient care and financial savings for the hospital."
Azmi is the co-author of a 2018 book about Parkinson's care in the hospital setting, Parkinson's Disease for the Hospitalist: Managing the Complex Care of a Vulnerable Population.
Factors that the ECRI Institute considers in developing the medical technology hazard list include severity of risk, frequency of harm, difficulty of recognizing problems, and preventability.
Surgical staplers are the top medical technology hazard for 2020, according to the ECRI Institute.
Twenty years after publication of the Institute of Medicine's landmark reportTo Err is Human: Building a Safer Health System, patient safety remains a significant concern for the healthcare sector. The Institute of Medicine report estimated 98,000 Americans were dying annually due to medical errors. Estimates of annual patient deaths due to medical errors have since risen steadily to 440,000 lives, which make medical errors the country's third-leading cause of death.
Earlier this year, the U.S. Food and Drug Administration published an analysis of more than 109,000 adverse stapler incidents from 2011 to 2018, including 412 deaths and 11,181 serious injuries.
"Injuries and deaths from the misuse of surgical staplers are substantial and preventable. We want hospitals and other medical institutions to be in a better position to take necessary actions to protect patients from harm," Marcus Schabacker, MD, PhD, president and CEO of the Plymouth Meeting, Pennsylvania-based ECRI Institute said this week in a prepared statement.
The following is the ECRI Institute's Top 10 list of medical technology hazards for 2020.
1. Surgical staplers:
"Consequences of a staple line failing or staples being misapplied can be fatal. Patients have experienced intraoperative hemorrhaging, tissue damage, unexpected postoperative bleeding, failed anastomoses, and other forms of harm," an ECRI Institute executive report released this week says.
Most surgical stapler adverse incidents are linked to human error such as picking an incorrect staple size and clamping on tissue that is too thick or too thin, the executive report says. ECRI Institute's recommendations for safe use of surgical staplers include hands-on practice with specific staplers that are used in healthcare settings.
2. Point-of-care ultrasound:
"A lack of oversight regarding the use of point-of-care ultrasound (POCUS)—including when to use it and how to use it—may place patients at risk and facilities in jeopardy," the executive report says.
Although POCUS has been established as a valuable technology for diagnosis and guiding interventional procedures, safeguards are insufficient at many healthcare facilities, the executive report says. "Safeguards for ensuring that POCUS users have the requisite training, experience, and skill have not kept pace with the speed of adoption."
Recommendations for POCUS safety include user training and credentialing, exam documentation, and data archiving.
3. Infection risks from sterile processing:
"Insufficient attention to sterilization processes in medical offices, dental offices, and some other ambulatory care settings can expose patients to contaminated instruments, implants, or other critical items," the executive report says.
Physician practice offices and dental offices are high-risk locations because they often do not have the sterilization resources found in hospitals, the executive report says. Recommendations to improve sterile processing in these settings include designating a qualified staff member to support infection prevention and control practices.
4. Hemodialysis risks with central venous catheters in the home health setting:
"Many hemodialysis patients receive treatment through a central venous catheter (CVC) well beyond the period when transition to another form of vascular access is recommended. And the U.S. federal government recently announced a push to increase the use of home treatment for kidney disease patients," the executive report says.
CVCs are often placed through the jugular vein and can result in severe adverse events such as infection, clotting, and disastrous blood loss if there is a disconnection. "Family members or other caregivers may be ill-equipped to manage the risks or to respond when a CVC problem occurs. The possibility that an increasing number of patients with CVCs might receive hemodialysis in the home raises concerns," the executive report says.
5. Surgical robotic procedures:
"While the use of surgical robots in innovative ways or for new procedures can help advance clinical practice, such uses can also lead to injury or unexpected complications and the potential for poorer long-term outcomes," the executive report says.
Although robots have benefits during surgical procedures such as improved dexterity and tremor reduction, they have drawbacks, including limited tactile feedback for forces exerted on tissue, the executive report says. Recommendations for safe use of surgical robots in new procedures include training, credentialing, and privileging operating room staff in the new applications.
6. Alarm, alert, and notification overload:
"More than ever before, clinicians have to divide their attention between direct patient care tasks and responding to prompts from medical devices and health IT systems. As the number of devices that generate alarms, alerts, and other notifications increases, so too does the risk that the clinician will become overwhelmed, creating the potential for a clinically significant event to go unaddressed," the executive report says.
Recommendations to address alert overload include decreasing overall notification burden and helping clinical staff to develop critical thinking skills to ease cognitive overload.
7. Cybersecurity risks in the home health setting:
"Remote patient monitoring technologies are increasingly being used for at-home monitoring to help clinicians identify deteriorating patients before they require hospitalization. As network-connected medical technologies such as these move into the home, cybersecurity policies and practices that address the unique challenges involved must be instituted," the executive report says.
8. Missing implant data for MRI scan patients:
"Patients presenting for magnetic resonance imaging (MRI) studies must be screened for implanted devices to avoid harm. Some implants can heat, move, or malfunction when exposed to an MRI system’s magnetic field. Thus, MRI staff must identify and follow any contraindications or conditions for safe scanning prescribed by the implant manufacturer," the executive report says.
Recommendations include creating implant lists in patients' electronic medical records.
9. Medication errors from dose timing discrepancies in electronic medical records:
"Missed or delayed medication doses can result from discrepancies between the dose administration time intended by the prescriber and the time specified within the automatically generated worklist viewed by the nurse," the executive report says.
10. Loose nuts and bolts in medical devices:
"The nuts, bolts, and screws that hold together medical device components can loosen over time with routine use. Failure to repair or replace loose or missing mechanical fasteners can lead to severe consequences: Devices can tip, fall, collapse, or shift during use—any of which could lead to patient, staff, or bystander injury or death," the executive report says.
Researchers focus on six categories of waste: failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity.
Waste accounts for about 25% of U.S. healthcare spending, new research indicates.
No other country spends more on healthcare than the United States, with the gross domestic product share of healthcare spending estimated at nearly 18% and rising. Earlier research on U.S. healthcare spending has estimated that waste accounts for about 30% of the spending total.
Reducing wasteful spending is a promising avenue to curb annual increases in the country's healthcare spending, according to the co-authors of the new research, which was published today in the Journal of the American Medical Association. "Implementation of effective measures to eliminate waste represents an opportunity reduce the continued increases in U.S. healthcare expenditures," the researchers wrote.
The researchers examined data from 54 published reports. They tallied waste in six categories identified in 2010 by the Institute of medicine (IOM): failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse, and administrative complexity. Pricing failure includes medication pricing, payer-based health services pricing, and laboratory-based and ambulatory pricing.
In 2019, total U.S. healthcare spending is projected at $3.82 trillion.
The JAMA researchers generated several key data points:
Annual wasteful spending on healthcare is estimated from $760 billion to $935 billion.
Interventions to reduce waste in the six IOM categories would result in annual savings from $191 billion to $282 billion.
The annual cost of wasteful spending from administrative complexity accounts for the highest category of waste, estimated at $265.6 billion.
The annual cost of waste from pricing failure is estimated from $230.7 billion to $240.5 billion.
The annual cost of waste from failure of care delivery is estimated from $102.4 billion to $165.7 billion.
The annual cost of waste from overtreatment or low-value care is estimated from $75.7 billion to $101.2 billion.
The annual cost of waste from fraud and abuse is estimated from $58.5 billion to $83.9 billion.
The annual cost of waste from failure of care coordination is estimated from $27.2 billion to $78.2 billion.
The impact of likely interventions to reduce wasteful spending are significant but limited, the researchers wrote.
"The best available evidence about the cost savings of interventions targeting waste, when scaled nationally, account for only approximately 25% of total wasteful spending. These findings highlight the challenges inherent in rapidly changing the course of a health system that accounts for more than $3.8 trillion in annual spending, 17.8% of the nation's GDP."
Assessing the data
The highest amount of wasteful spending was associated with the administrative complexity category. The development and adoption of value-based payment models has the most potential to impact this category of wasteful spending, the researchers wrote.
"In value-based models, in particular those in which clinicians take on financial risk for the total cost of care of the populations they serve, many of the administrative tools used by payers to reduce waste (such as prior authorization) can be discontinued or delegated to the clinicians, reducing complexity for clinicians and aligning incentives for them to reduce waste and improve value in their clinical decision-making."
Reducing spending the second-highest wasteful category—pricing failure—poses daunting challenges because of the rising prices of pharmaceuticals, the researchers wrote. "New high-cost specialty drugs, which will soon exceed 50% of pharmaceutical spending, are raising new questions about how to maintain affordability. This topic has thus received considerable attention from policy makers, and numerous proposals are currently under consideration."
The researchers say strategies to ease cost pressure in pharmaceuticals include increasing market competition, importing drugs from countries with lower medication prices, and reforming price transparency.
The big picture view
An editorial accompanying the new research says the findings are a significant contribution to the ongoing effort to rein in the country's healthcare spending.
"At a time when the United States is once again mired in a great debate about the future of its healthcare system, the data reported in the article … should become part of the national discussion. It would be nearly impossible for all waste to be eliminated in any healthcare system, just as it is impossible to know the true cost of any change in the delivery and financing of healthcare without understanding possible savings, and recognizing that there is complexity in knowing the savings," the editorial says.
Concentrating on wasteful spending is crucial, the editorial says. "While no single solution will solve the continuous increases in U.S. healthcare spending, identifying, reducing, and eliminating waste are important and appropriate places to start."
Researchers have found that the percentage of women in internal medicine specialties has decreased over the past two decades, which is likely contributing to the physician wage gender gap.
From 1991 to 2016, the percentage of women in internal medicine increased, but the percentage of women in subspecialty fellowships fell, recent research shows. The percentage of women enrolled in cardiovascular disease fellowships was particularly low.
An increasing number of women have been enrolling in medical schools, with women accounting for 50.7% of enrollees in 2017. However, female physicians have lagged behind their male counterparts in compensation.
The lead author of the recent research, which was published in the Journal of the American Medical Association, told HealthLeaders that the growing underrepresentation of women in internal medicine subspecialties is contributing to the compensation gap.
"The fewer women we have in the more highly reimbursed specialties of medicine, the wider the gender wage gap in medicine will be," said Mary Norine Walsh, MD, MACC, medical director of Heart Failure and Cardiac Transplantation at St. Vincent Heart Center in Indianapolis.
Walsh and her co-authors generated several key data points:
From 1991 to 2016, the percentage of female internal medicine residents increased from 30.2% to 43.2%.
In 1991, 33.3% of internal medicine subspecialty residents were women and 66.7% were men.
In 2016, 23.6% of internal medicine subspecialty residents were women and 76.4% were men.
The researchers examined data for nine subspecialties. Women represented 21.3% of cardiovascular disease fellows—the lowest representation of women in the nine subspecialties.
Women were most highly represented in geriatric medicine, at 76.9%.
"Between 1991 and 2016, although the percentage of women in internal medicine residencies increased, the percentage of women in subspecialty fellowships decreased," Walsh and her co-authors wrote.
Interpreting the data
Female and male physicians have significantly different views of careers in cardiology, the co-authors wrote.
"A survey of internal medicine residents about their professional preferences, their perceptions of cardiology, and how these attitudes combine to inform career choices showed substantial sex differences. More women than men reported never considering cardiology, and women had different perceptions of cardiology than men. Women cardiologists are more likely than men to experience sex and parenting discrimination, be single, not have children, and report less satisfaction in family life, though overall career satisfaction remains high for both men and women," they wrote.
Differing career goals between women and men could be influencing the choice of specialty between the genders, Walsh told HealthLeaders. "When asked, women internal medicine residents have assigned a greater importance to long-term patient relationships and family time than to financial considerations."
A lack of female role models in cardiology could be contributing to underrepresentation of women in the field, she said. "Because of the fewer numbers of female cardiologists, female trainees aren't always exposed to female cardiologist role models during their training."