Revised federal recommendations for blood glucose screenings do not address costs and are prompting questions about how the service can practically be implemented.
The pool of candidates for blood glucose screenings has widened.
The U.S. Preventive Services Task Force (USPSTF) last month issued new guidelines recommending that adults aged 40 to 70 years who are overweight or obese be screened for abnormal blood glucose as part of their cardiovascular risk assessment.
Michael Pignone, MD
According to the task force, patients should be screened even if they're asymptomatic. If patients are found to have high blood sugar, they "should be referred to intensive behavioral counseling interventions to promote a healthy diet and regular exercise."
The new guidelines are an update of a 2008 USPSTF recommendation which called for screening for diabetes in asymptomatic adults with hypertension. But since then, USPSTF says that six new studies have shown "consistent benefit of lifestyle modifications to prevent or delay progression to diabetes and longer-term follow-up has increased confidence that such interventions can improve clinical outcomes."
In light of these new studies, USPSTF says it has now concludes that there is "moderate net benefit to measuring blood glucose in adults who are at increased risk for diabetes."
In publishing the recommendations in Annals of Internal Medicine, USPSTF says it "does not consider the costs of providing a service in this assessment" and "recognizes that clinical decisions involve more considerations than evidence alone." Even so, such recommendations raise practical questions about how screenings might be implemented in clinical practice, and of course, how it would be paid for.
When asked about how such services might be covered, an HHS spokesperson told HealthLeaders Media via email that:
The final recommendation by the U.S. Preventive Services Task Force (USPSTF), an independent group of experts, confirm that because of the Affordable Care Act, issuers must cover, without cost sharing, screening for abnormal blood glucose as part of cardiovascular risk assessment in adults aged 40 to 70 years who are overweight or obese. After screening, patients with abnormal glucose will also be referred to intensive behavioral counseling, which insurers will also cover without cost sharing.
HealthLeaders also reached out to Michael Pignone, MD, a member of the task force and a professor at the University of North Carolina-Chapel Hill, to discuss. The transcript below has been lightly edited.
HLM: How would mass screenings work practically? Only by clinicians' referral? Or can an overweight/obese person request testing on their own?
Pignone: The Task Force's recommendations are developed for use in primary care settings by clinicians and to educate patients on the benefits and harms of screening. Through our final recommendations, we hope to provide medical professionals and patients with the science behind the benefits and harms of this preventive service, so that patients can make informed choices about the care they receive. Patients who are concerned about diabetes should talk to their doctor.
HLM: The recommendations say that "patients found to have high blood sugar should be referred to intensive behavioral counseling interventions." What happens next?
Michael Pignone: Task Force recommendations address only services offered in the primary care setting or services referred by a primary care clinician. Because intensive interventions may not be practical in many primary care settings, patients can be referred from primary care to community-based programs for these interventions. The Task Force defines such interventions as a combination of counseling, healthful diet, and physical activity, and are intensive, with multiple contacts over extended periods.
We are committed to providing recommendations based on the best available evidence to primary care professionals and to patients so that together they can make informed decisions about the benefits and risks of this preventive service. Patients should consult with their clinician on follow-up care and additional monitoring.
HLM: What does USPSTF mean when it says it concluded that there is "moderate net benefit to measuring blood glucose in adults who are at increased risk for diabetes?" Is that in dollars? In lives? Another metric?
Pignone: The Task Force's recommendations are based on an assessment of the strength of the evidence and on the balance of benefits and harms of the preventive service. For this topic, the Task Force found inadequate evidence that measuring blood glucose will help improve poor outcomes or prevent death from cardiovascular disease mortality or cardiovascular morbidity.
However, there is evidence that measuring blood sugar in adults at increased risk of diabetes, and treating those who have abnormal blood sugar with intensive lifestyle interventions, may decrease their risk of progression to diabetes. Benefits of behavioral interventions include reductions in blood pressure, glucose and lipid levels, and obesity and an increase in physical activity.
Physicians experience cognitive declines just like anybody else in the workforce. It's time for hospitals to establish policies that will protect patient safety and prepare the next generation of clinicians.
The healthcare industry is filled with people who view what they do for a living not as a job, but as their reason for being.
"Many people feel they are defined by the medical profession," says Karen Speirs, DO, MPH, president of the medical staff at Munson Medical Center in Traverse City, MI.
But the American workforce is aging, and that includes healthcare professionals. Unlike other industries, where retirement and slowing down professionally is often eagerly anticipated, many healthcare professionals are reluctant to retire. And as the years tick on, there will be more older workers than ever before.
According to the Bureau of Labor Statistics, from 1992 to 2002, the share of the labor force for those aged 55 and over increased from 11.8% to 14.3%. In 2012, their share of the labor force rose to 20.9%. That number is projected to grow to 25.6% by 2022.
Along with aging, of course, comes age-related health deterioration and cognitive decline that includes everything from fatigue and eye strain, to loss the loss of fine motor skills, to dementia. This presents hospitals and health systems with special considerations.
"Physicians get dementia just like anybody else. We're not immune to it," says Scott A. Syverud, MD, chair of the University of Virginia Health System's credentials committee.
Karen Speirs, DO, MPH
When healthcare providers face age-related health declines, though, it's not just their own health and wellness that's a factor; the health of their patients is at stake, too. Yet the years of experience that older clinicians bring to their institutions is incalculable; these aren't people who should just be kicked to the curb.
"To write them off would be a waste," says Peter McMenamin, PhD, Senior Policy Advisor and health economist for the American Nurses Association.
Syverud, agrees, saying, "These are the most-respected members of our clinical staff," and often they are department chairs.
Finding a Balance for Scaling Back Finding a balance between retaining older clinicians' decades of knowledge and experience and making sure that those clinicians can still safely provide the best patient care is central to how hospitals and health systems should respectfully manage a growing number of aging clinicians.
In nursing, McMenamin believes there should be enough new nurses to fill the vacancies as a bulge of older nurses retires over the next 10 to 15 years or so. But what worries him is that older nurses with invaluable experience are "going to be walking out the door."
"You can't replace 30 or 45 years' worth of experience with a new nurse," he says. "That doesn't compute."
Yet it's impossible to ignore that "there's a lot of physical demand to nursing care, in terms of the actual physical care of the patients," says John R. Combes, MD, AHA Senior Vice President and President and COO of the Center for Healthcare Governance.
Therefore, healthcare organizations should look for ways to reduce older nurses' physical workloads while leveraging their knowledge. Both Combes and McMenamin recommends mentorship programs as a way to do this. As an economist, he views them as a tactic for eliminating waste, as well as a way to allow older nurses to extend their careers and transfer some of their knowledge.
Peter McMenamin, PhD
"[Hospitals] should also be contemplating creating a human capital reserve," he says. "That would allow hospitals to grow their own experienced workforce over the next 15 years."
The same can be done for physicians, says Combes, who suggests tasking older physicians with teaching services, allowing them to advise younger physicians who might be the ones to actually render the patient care.
Transitioning to mentorship and teaching roles is just one way that hospitals can scale back their valuable older clinicians' workloads.
"I think it would make sense…if [hospitals] experimented with going back to eight-hour shifts for some of their more senior nurses," McMenamin says.
Combes also suggests ending mandatory on-call coverage for physicians at a certain age, such as 65, which many hospitals have done.
Cognitive Screening A growing, but anecdotally small, number of hospitals are being proactive by requiring older clinicians to undergo physical and cognitive screenings when they reach a certain age.
Since 2011, the University of Virginia Health System has required physicians to undergo neurocognitive and physical exams when they reach the age of 70, adding an extra step to renewing their hospital privileges. They have to repeat the exam at age 75 and every time they renew their privileges thereafter; the director of the physician wellness program has to sign off on it. Syverud says the exam takes about four hours, and costs about $2,000 apiece. The physicians' clinical departments cover the cost. "It only takes one bad outcome with a patient to make the entire program worthwhile."
That's because a bad outcome is sometimes the first indication of a clinicians' impairment.
"If we didn't have this policy, the traditional way that this happens with physicians is that something happens in their practice," Syverud says. "It's career-ending, and it's a public end to the career. It's not good for the physician, and more importantly, it's not good for the patient." Neither is it good for the hospital or health system.
About 50 clinicians have gone through the evaluation since the policy was established. The results are confidential and they determine what action is taken. For some clinicians, a clean bill of a health is a source of pride, and maybe also validation. If a weakness is detected, the "policy offers them a confidential way to discuss that," Syverud says. "I suspect that would be a relief for many people."
It also gives clinicians the power and privacy to decide how to wind down their own careers, on their own terms, depending on the findings. For instance, a physician might be having trouble with fine motor skills, but be neurocognitively fine and might be able to shift his or her responsibilities accordingly.
Munson Medical Center adopted a similar policy in 2014, requiring physicians at age 70 and every two years thereafter to undergo a physical exam, a hearing screen, and the Montreal Cognitive Assessment. The program is voluntary at age 65. If a physician hasn't taken the exam within 30 days of being notified to do so, he or she will be considered as having voluntarily relinquished their privileges.
Speirs says there was some resistance to the policy when it was first adopted.
"Some of the pushback was that they didn't feel that it was right to take a test, that they would know when they weren't able to practice medicine," she says. But, "the argument does not stand up. Even with signs of mild dementia, you cannot tell in yourself, many times. You may be the last to know."
And although accusations of ageism are a real possibility, age-related restrictions and screenings in other industries are standard. The Federal Aviation Admiration for instance, has a mandatory retirement age of 65 for pilots.
The University of Virginia received "a lot of resistance and negative feedback" to the policy when it was first adopted, Syverud says. Physicians wondered if it was just one more bit of red tape and questioned whether it really added value to patient care. But Syverud says he spoke individually with each of the clinicians to whom the policy applied, and now, there's widespread acceptance of it. In addition, most clinicians perform extremely well on the exams.
"To their credit, our senior clinicians who have gone through this process recognize the value," he says. The possible alternative—a bad patient outcome, having their privileges taken away, and being disciplined—"is a terrible way to end a career."
Being Proactive Syverud says he gets a lot of calls from other organizations looking for advice or information about implementing a similar program, usually after something has happened involving an older clinician.
"A lot of hospitals are struggling with whether to do this at all," he says.
McMenamin says adopting policies that address an aging workforce—whether it's establishing a nurse mentorship program or an assessment program of older clinicians—might not seem like an obvious priority now. "This is not a crisis that's going to show up in 2016," he says. But hospitals need to think about the long-term projections.
"We're going to be using this policy more and more. We feel we needed to have it in place for" the years ahead, says Speirs. "Instead of reacting, we're being proactive."
Three studies on sepsis reinforce the benefits of early clinical action: lower mortality rates, shorter lengths of stay, and reduced costs.
Three sepsis studies presented at October's American College of Chest Physicians'(CHEST) 2015 Annual Meeting in Montreal focused on different interventions and approaches to care, but shared a single theme: the need for early detection and treatment.
"There is a[n] increased focus on sepsis recently. Sepsis is one of the most common causes of critical illness and death," Christopher Carroll, MD, MS, professor of pediatrics in the Division of Pediatric Critical Care at Connecticut Children's Medical Center and Chair of Scientific Presentations and Awards Committee for CHEST 2015, said via email from the meeting. "Early identification and treatment is crucial toward improving outcomes in hospitalized patients."
ICU Admissions Criteria In one study, researchers from Northwest Hospital and Lifebridge Critical Care in Randallstown, MD, found that less stringent ICU admissions criteria improves sepsis mortality and reduces costs.
Researchers conducted a retrospective study of 886 medical records of sepsis patients and compared mortality and length of stay before and after easing ICU admission criteria. They found that after implementing the less-stringent criteria, overall mortality decreased by 45.4%, from 14.38% to 7.85%.
And although the severity of the illness was the same, ICU length of stay was 25.9% lower in the post-implementation cohort. According to the authors, these findings point to the need for a collaborative culture and standardized ICU admission criteria.
Rapid Response Training In the second study, researchers from Brooke Army Medical Center in San Antonio, TX, evaluated the rapid response system (RRS) training program on call rates and code blue events. They found that the training led to significant improvements in staff awareness and patient outcomes. After training, the average number of calls per month rose from 39 calls to 123 calls. The mean number for code blue events decreased from 1.5 codes per month to zero per month.
"Early identification of physiological deterioration with implementation of appropriate care can improve sepsis outcomes," CPT Nathan Boyer, MD, Brooke Army Medical Center and lead researcher, said in a statement.
Rapid ED Intervention Finally, the third study showed the success of using a sepsis and shock response team (SSRT) in the emergency department. Researchers from Mayo Clinic in Jacksonville, FL, formed a multidisciplinary SSRT in September 2013 to help alert ED providers when these disorders are suspected. First, an automated electronic sepsis alarm notified ED providers to possible cases of severe sepsis and septic shock, then systematic assessment and early intervention by the SSRT was activated.
Christopher Carroll, MD, MS
Researchers found that the observed/expected sepsis mortality index improved from 1.38 pre-SSRT to 0.68 post-SSRT implementation, but that there is still "room for improvement in rates of SSRT activations." The common theme in all three of these studies is early action.
"Early identification of impending deterioration and critical illness is one of the most important elements of critical care," Carroll says. "In each of these studies, the authors look to improve outcomes through earlier identification of sepsis and earlier initiation of therapies."
Taken as a group, Carroll believes that these three studies should reinforce for clinical and hospital leaders that "early identification and treatment of sepsis and septic shock improves outcomes."
"Hospital leaders should be looking at methods that can help them better identify who is at risk for developing sepsis and septic shock," he says. "These methods could include development of a rapid response team or increased involvement of critical care trained physicians in patients with 'borderline [or moderately severe] illness."
The dashboard developed at Vanderbilt University Hospital improved ventilator bundle compliance by serving as a "hard-wired reminder at the bedside"
Ventilator bundles—best practices that are grouped together to reduce and prevent ventilator-associated complications, such as pneumonia—are been shown to be effective, but compliance is difficult. Now a team at Vanderbilt University Hospitalhas developed a method of improving compliance that has lowered ventilator-associated pneumonia substantially.
In 2007, the hospital's ICUs not only developed and implemented a comprehensive ventilator bundle program, but linked it to a real-time computerized dashboard that was developed in-house. The dashboard alerts caregivers to which elements of the bundle need to be addressed for which patient at which time, and also tracks compliance.
Thomas R. Talbot, MD, MPH
Now, research in the journal Infection Control & Hospital Epidemiology shows that full and uninterrupted bundle compliance at the hospital increased from 23% in August 2007 (the first month of implementation) to 83% in June 2011. Additionally, use of the bundle was associated with significant and sustained decreases in ventilator-associated pneumonias (VAPs), with the combined rate in all six of the hospital's ICUs dropping from 19.5 to 9.2 VAPs per 1,000 ventilator-days.
The bundle and dashboard are still in use at the hospital, and researchers are now looking at data to see whether bundle compliance helps with the broader ventilator-associated events measure, too, says Thomas R. Talbot, MD, MPH, chief hospital epidemiologist and lead author of the study.
The dashboard is the screen saver on the bedside computer for every ICU patient, and includes data from the electronic nursing record, the physician order entry system, and respiratory therapy documentation. All vented patients on the unit are shown (de-identified) on the same dashboard.
"We saw a very dramatic uptick in compliance" with the bundle, Talbot says, along with the sustained drop in VAP rates. "It was a hard-wired reminder at the bedside."
The dashboard is divided into columns, each representing a different metric, such head-of-bed elevation. In addition to noting compliance, the dashboard sometimes requires users to input additional information for certain metrics, such as the angle of the bed or the patient's sedation score.
Each of the metrics is color-coded to show whether the metric is in compliance (green), will be out of compliance soon (yellow), or is out of compliance and overdue (red). The color-coded indicator is updated every five minutes.
"It really kind of facilitates that awareness for the need for a task," Talbot says, noting that the awareness extends to a clinician's managers and colleagues as well. If one nurse is too busy with one patient to perform an element of the bundle for another patient, for instance, a manager can easily see that on the dashboard and ask someone else to pick up the slack.
The dashboard "facilitates communication and makes sure the processes were sustained," Talbot says. "We were able to basically, in five-minute increments, to know: Is the patient compliant right now?"
Talbot says the dashboard works well in other respects, too. When it comes to reducing VAP rates, the dashboard shows true compliance with the bundle because it's measured in real-time with constant updates. When using a paper checklist, audits might occur just once a day, and while a patient might technically be in compliance at the moment the caregiver checks off the metric, 10 minutes later the patient might be out of compliance.
"It's more continual," Talbot says of the electronic dashboard.
The dashboard was built in-house with the caregivers' workflow in mind. The system was designed to fit into that workflow, not the other way around. Talbot says the organization's "strong bioinformatics group" worked in partnership with the faculty to develop the tool, kicking off the planning with an all-day, off-campus brainstorming event and implementing clinical input from the start.
"Everybody was onboard from the very beginning and had a shared vision," he says. "It had that input and partnership from the onset."
Applying a one-size-fits all approach to patient satisfaction is a sure-fire way to fail, experts say.
Where a patient receives care in a hospital has a lot to do with what types of care the patient values most.
In inpatient settings, for instance, patients value nursing care the most. In the emergency department, overall personal safety and continuity of care are most important. For pediatric care, factors affecting patient satisfaction vary a lot depending on which department patients are in, according to a study published this month in the American Journal of Medical Quality.
"Depending on where you are, one size does not fit all," says Stephen Lawless, MD, MBA, enterprise vice president of quality and safety at Nemours Children Health System and one of the authors of the study.
Delaware-based Lawless and his fellow researchers also found that for each one-hour increase in total time spent in the ED, satisfaction decreased by nearly three percentage points. On the flip side, patients who received a follow-up call after discharge from the ED rated their satisfaction significantly higher. Providing a patient's bill of rights during inpatient also boosted satisfaction scores.
"If you think about it, that makes sense," Lawless says of the findings.
But it's not always easy to think about these things when there are so many other important tasks for clinicians to accomplish. After all, the healthcare system is largely designed to be supportive of healthcare providers' work, rather than the needs of the patient, points out Sandra Myerson, MBA, MS, BSN, RN, Senior Vice President and Chief Patient Experience Officer at New York's Mount Sinai Health System.
But by doing things such as applying a one-size-fits all approach to patient satisfaction, something else does get easier: Sinking your satisfaction scores.
Healthcare professionals have an "ethical obligation" to provide the right kind of care—not too much, and not too little, says Vikas Saini, MD, president of the Lown Institute.
Not everything done in medicine is based on good, sound evidence, nor is it faithful to what patients and their families truly want. An initiative by the Lown Institute, a nonprofit healthcare think tank based in Brookline, MA, aims to change that.
Lown's RightCare Action Week, October 18 to 24, is viewed as "the start of a marathon," says Vikas Saini, MD, president of the Lown Institute. "We think that the time is right in American healthcare for a social movement that's really an alliance between healthcare professionals and the general public, to talk about the actual quality and experience of care that we all receive."
Vikas Saini, MD
HealthLeaders Media caught up with Saini by phone ahead of RightCare Action Week to learn more. The transcript below has been lightly edited.
HLM: What is RightCare?
Vikas Saini: The concept of RightCare emerged out of the growing awareness that a lot of what we do in medicine is either not based on good, sound evidence, or is not really truly faithful to what patients and their families really want. It is part of the growing awareness that there is such a thing as too much medicine in certain settings, and is wedded to the notion that more people are aware that it's also possible to not have enough access to medical care.
And so the concept [of] RightCare is really the view that healthcare professionals have an ethical obligation—a really important moral obligation, as well as part of our social mission—to really narrow that variance, narrow the range of the kind of care we provide so that it's…not too much, not too little. Just the right care.
There's a range of examples that we can talk about, but one of the commonest ones where I think most people understand the idea of too much medicine is end-of-life care, where quite often, patients end up in much more intensive settings of care than they would have wanted.
It's not always easy to predict the future, but anybody who looks at this knows that, systematically, more people die in hospitals and die in acute care settings than they would have wanted. So that's one clear example, I think.
HLM: What's one not-so-clear example?
VS: Well, there are areas in medicine where we don't really know the answer. We don't have the right answer. There are incredible gray zones, and some of it's because the studies that have been done are not as clear cut—[the way that] reality is not as clear cut. And sometimes it's because the situation of a given patient is really hard to plug into the studies that have been published.
So in those settings… there's no slam dunk.It's not easy to say, that was obviously wrong or that was obviously right; you really have to have been there. And that's where we emphasize a really important dimension: It's truly about knowing, for the healthcare professional, to know the patient—their preferences, their values—and to share with them an understanding of both what we know and what we don't know, let's say, what the results of a particular surgery will be, or what the side effects might be, etc.
When we give this message… a lot of healthcare professionals realize is that it's very true. The reason it's so moving to so many people we talk to, is that it feels like it's something we have always said we should do, it's something we have always wanted to do. But for all sorts of reasons it feels like it's harder and harder to have that kind of decision making.
There's too much rush, there's too much pressure around volume and getting patients through door, [there are] so many factors that are at play there.
HLM: How does this movement dovetail with something like the ABIM Foundation's Choosing Wisely campaign?
VS: We started our work at the Lown Institute pretty much the same month that Choosing Wisely came out, and so I'd say we're operating in very parallel tracks. There are two aspects to our approach that are a bit different. One is we're unofficial; were sort of grassroots and in that we're really developing interdisciplinary and inter-professional kinds of conversations that we plan to turn into new ways of looking at these problems.
The other way is that we really think that part of what has to happen to change culture is more about motivation and about gathering large enough groups to influence each other, and to begin to influence the system. [The aim is to] sort of create enough visibility and power for certain point-of-views to be able to help our patients and our communities shape the healthcare system in a way that serves them better.
HLM: If this is what patients and families want, and primarily what physicians want, then what's the pushback?
VS: I'm not aware of a whole lot of pushback on the core ideas. I think the real issue is more that there are a lot of perverse incentives in the system. There's a lot of inertia, there's a paradigm or frame of thinking about things that shapes the culture we've had. And if you add those items all up you get to a place that is what we have today, and…it's not working as well as it should.
And for too many people, it's really not working well at all.
There are individual areas where there's controversy, and so there's no question that when you get down to specific items or specific procedures (like the Choosing Wisely lists of things) when you get to that level of granularity, you always get great debate and you'll always get lots of differing of opinion.
From my point of view that's natural, but it misses the forest for the trees. While any individual issue can be debated, increasingly what isn't debated is that we as a system tend to do a lot of stuff that we really shouldn't be doing.
So it could save a lot of money. It could allow us to do a lot of other things, cover a lot more people, and invest in the other things that really drive health. And managing that transition is really an important goal for all society and should be an important goal for everyone in healthcare, though it does pose challenges for managing the transition smoothly.
HLM: What is RightCare Action Week, what does it aim to accomplish, and how can people take action?
VS: Our idea of RightCare Action Week was that those of us involved in this work and those of us getting involved and interested wanted to raise both the awareness of some of the issues, but also to take an act, take a stand, do it visibly, and do it in a way that would allow us to begin to show other ways of doing things.
And to show both elements of what goes on that could be better—when there's too much medicine, things that could be done differently—but also to show things that represent RightCare that would represent the right care and to show there are better ways for doing things.
We conceived of it as an opportunity to mobilize people around these ideas and to do it in a concrete way. What we found is that there is a lot of interest in the idea. To our surprise, a lot of organizations endorsed us, and endorsed the idea… that includes AMSA, IHI Open School, one of the nursing unions, National Physicians Alliance, National Patient Safety Foundation—a range or organizations.
Here are some of the things that are happening: A group of medical students [and] nursing students in several parts of the country are doing what they call "story slams." They're gathering—kind of like TheMoth Radio Hour—they're gathering and [are] going to be telling stories of what they've seen on the ward as a way of sharing, inspiring each other, to begin to offer insight into the process of care.
There is a whole group of chief residents around the country who are going to be doing kind of an "Audubon Bird Count" of the RightCare: going through the week and keeping track or taking notes of what it looks like. It could be an occasion that an opportunity is missed, either to deliver care that was really needed and missed, or not deliver care that probably wasn't necessary.
And again, using the count is a way of learning how to spot these things and begin a process. In the case of those chief residents, they're actually launching with us a program we call RightCare Rounds where they're going to be doing grand rounds and investigating in a case-based way clinical decision making… to tease out how these decisions get made and what drives them.
There's a couple of people who are promoting home visits for people who don't usually do it. [For instance,] there's a neurologist here in Boston who's active at McLean and Mass General who has set aside that day to actually go to the home to somebody who can't get out and to spend a whole lot of time—like an hour, hour-and-a-half—and highlight exactly some of the really important elements of care. [It's] a way of showing that what we need is a system that allows more of that. Not necessarily that everyone makes home visits, but the way in which we relate and interact with patient can really be at a much more deep level than we're able to do these days.
A doctor named Aaron Stupple and I are going to try something experimental: We're going to be going out into the neighborhoods of Boston and setting up a listening booth. It's a little bit whimsical, but it comes out of the idea that too often as docs, we're in the exam room, we're on the ward, and we're really busy with what we're doing, but we never really get an opportunity to share and hear the experiences of healthcare and the system as a whole from our patients or even the general public.
This is an attempt to kind of show that we need more of that. We need more listening from our patients and from our community about how we can change healthcare to improve it. And we're not sure how it'll go, but we think it'll be interesting, and we certainly think we're going to learn a lot. And we're hoping that by doing that we'll hear interesting and important stories. [Maybe] we'll inspire some of our colleagues, and maybe we'll actually create a program that allows us to do that in a more systematic way.
We're going to basically be asking them: What does really good healthcare mean to you? What have you experienced that leads you to that? What would you like to see that you haven't had that you think would make… care that much better?
We're not going to prompt, we're not going to put words in their mouths. But we're hoping that we will get enough insight—obviously we're not going to figure it all out in this—but get enough insight and enough information that there will be some stories that will allow us to think about our own work as we move forward, and design it in a way that we can get much more input on a much larger scale from people.
So as we think about health and healthcare, we're really getting informed by the people who really matter, which is the patients and communities we serve.
Hospitals are curbing the most common strain of MRSA, but the incidence hasn't decreased in the broader community.
The incidence of the most common strain of MRSA infections has decreased in hospital-onset cases, but has failed to do so in the broader community, finds a study published in September in the journal Infection Control & Hospital Epidemiology.
Kyle Popovich, MD
Researchers used electronic surveillance data to identify cases of Staphylococcus aureus bloodstream infections, and used medical charts and logistic regression to analyze risk factors. Of the 1,015 identified cases of Staphylococcus aureus bacterial bloodstream infections studied over a six-year period at a Chicago safety net hospital, researchers found that more than half of hospital-acquired cases were of the USA 300 strain, a community-acquired strain.
"Illicit drug use was a predictor for both community onset infections and hospital onset infections" of the USA 300 strain of MRSA, says Kyle Popovich, MD, MS, lead author of the study and assistant professor in the Section of Infectious Diseases, Rush University Medical Center.
Keith Armitage, MD, of the Division of Infectious Diseases at University Hospitals Case Medical Center says the study data reinforces what he has seen over past decade: That this strain, which was strongly associated with community onset, "has spilled over into the hospital." The Centers for Disease Control and Prevention describe USA 300 as the cause of "most community-associated MRSA infections [and] an increasingly common cause of health care-associated MRSA infections."
The rise of this strain reflects the way MRSA infections have evolved. Armitage says that up until about 10 or 15 years ago, MRSA was primarily seen in certain high-risk groups.
"Then the paradigm shifted," he says. Patients who are completely healthy, and have no risk factors, now come in already colonized with MRSA. Such an evolution isn't unusual, he says. "Things change. The prevalence and incidents... is constantly evolving and the model changes."
A study published in March by the American Society for Microbiology identified found that "households can serve as a reservoir for transmitting [MRSA]... Once the bacteria enters a home, it can linger for years, spreading from person to person and evolving genetically to become unique to that household."
The Rush researchers say that national surveillance has suggested a decrease in the incidence of invasive hospital-acquired MRSA infections during the past decade, and that is reiterated by this new study.
"A big take-home point of this is in hospitals there has been a lot of effort to reduce all healthcare-acquired infections, but particularly MRSA," Popovich says. "I think our study shows that hospitals have done a good job with infection control."
Keith Armitage, MD
Armitage echoes that.
"There's always been a strong emphasis in hospitals in trying to decrease complications. I think the patient safety and quality movements have really escalated in the last decade, especially since hospitals are faced with financial penalties," he says. "Hospitals always wanted to do the right thing, but these additional financial penalties" gave them even greater incentive.
Despite hospitals' diligence with curbing MRSA infections, the wider community clearly has additional work to do.
"I think still we probably need to do more research to see how we can optimize our infection prevention and infection control in the community," Popovich says.
A 2011 study published in the Annals of Emergency Medicine found that five percent of patients in a Boston emergency department tested positive for MRSA.
Popovich acknowledges that curbing infections within the community is much harder than it is in the hospital, where infection control measures are the standard operating procedure. In addition, the community is a much bigger population.
The key is figuring out where to target measures aimed at community infection control, she says. For instance, efforts to enhance awareness among people seeking care at health clinics, dialysis centers, and other healthcare associated or affiliated places, as well as general education about infection control, could be worthwhile.
"It's probably worth it to investigate this more because they're probably going to come into the hospital with a bloodstream infection," Popovich says. "So prevention of this is important."
A study of low-income women with pregnancy-related complications suggests that long-term health risks could be reduced through better monitoring and combined mother and baby visits.
Low-income women with recent, complicated pregnancies are using the ED at high rates after delivery, and could benefit from better monitoring, according to research published in the September issue of the Journal of Women's Health. This patient population may not be getting the postpartum care and follow-up needed to prevent further health problems, the study data suggests.
Ashley Harris, MD, MHS
Study lead author Ashley Harris, MD, MHS, a former senior clinical fellow in the Johns Hopkins University School of Medicine'sDivision of General Internal Medicine, and now a primary care doctor at Mary's Center in Washington, DC, says the research was prompted by the rising prevalence of hypertensive disorders and gestational diabetes among pregnant women, along with questions about the effects of these complications on overall health.
"[Pregnancy] is sort of an opportune time to get them into treatment," Harris says.
Such complications also put these women at long-term risk, not only for subsequent pregnancies, but also for the rest of their lives. The researchers wanted to know how the women were using healthcare postpartum, especially among the Medicaid population.
Nearly 70% of women in the study were eligible for Medicaid because they were pregnant. According to the study, "67% of [the] sample had a temporary form of Medicaid granted to pregnant women, which is discontinued at eight weeks postpartum."
Researchers analyzed more than 26,000 Maryland Medicaid claims made between 2003 and 2010, and linked that data with U.S. Census data to adjust by socioeconomic factors. Of the 26,074 pregnancies studied, 20% were complicated by
Gestational diabetes
Gestational hypertension, or
Preeclampsia
"The key results were that 25% of women had at least one ER visit, which is a big number," Harris says. Women with pregnancy complications had higher rates of ER utilization in the 6 months postpartum compared with women in the comparison pregnancy group (27.7% vs. 23.6%).
In the complicated pregnancy group (six months postpartum):
16.8% had 1 ER visit
8.5% had 2–3 visits
2.3% had 4–10 visits
0.13% had more than 10 visits
Women under 25 with complications had an even greater chance of going to the ER. In addition, most ER visits happened before the women's six-week postpartum appointment. All of this suggests that the health system has work to do in order to proactively address women's health needs postpartum, Harris says.
Postpartum Coordinated Care
Proactive, coordinated care isn't just good for new moms; it can dramatically improve outcomes for preterm babies, too, according to the results of a retrospective study, published online in the October 2015 issue of Obstetrics & Gynecology.
Stacy Beck
It looked at 101 infants born at 23 weeks gestation between 2004 and 2013 who received comprehensive perinatal and neonatal care. Clinician-researchers at Nationwide Children's Hospital and The Ohio State University Wexner Medical Center examined factors such as prenatal care, preterm labor, preterm premature rupture of membranes, surfactants in the delivery room, and prolonged intubation sequences.
"The goal of our care team for births at 23 week, whether anticipated or imminent, is to support families by supporting shared decision-making between families and health care providers," said Stacy Beck, MD, maternal fetal medicine physician at The Ohio State University Wexner Medical Center, in a statement.
"From an obstetrician perspective, when prenatal counseling is possible, we can improve the efficiency of care in the delivery room for these babies born extremely premature."
Researchers found that 60 infants survived to hospital discharge and more than half of the survivors had little to no neurological complications after being evaluated at 18 to 22 months. In past literature, a majority of babies born at 23 weeks had not survived, or had exhibited moderate impairment.
Another researcher, Leif Nelin, MD, Dean W. Jeffers Chair of Neonatology at Nationwide Children's and a Professor of Pediatrics at The Ohio State University College of Medicine, noted in a statement that the "study only describes outcomes in a best-case scenario, as all the neonates were all singleton pregnancies with time for prenatal counseling, which is not always the case."
Clearly, "best-case scenario," coordinated care, isn't always the case. Even with full-term pregnancies, women often aren't ready to go home at discharge, or have specific needs that they should be addressed at discharge, JHUMC's Harris says.
"The hospital visit and hospital stay for birth has gotten shorter and shorter and shorter," she noted. When it comes to maternal health, better and more specific discharge planning measures could help target the women who may need more care, as well as determine the kind of care they need.
Harris also says the study results point to the benefits of post-partum home visits.
"These can really help with the transition," she says. Other studies, including many that are cited in her research, show that home visits can be beneficial for high-risk populations. She notes that there are home visits aimed at infants under Patient Protection and Affordable Care Act, and says it would interesting to see how those might be paired with visits that also address the health of mothers.
That leads to a third possible recommendation based on the findings of the Hopkins study: Combining mother and baby visits, a topic that another Johns Hopkins researcher, Wendy Bennett, MD, MPHis investigating now, Harris says.
"They tend to put aside their own healthcare," Harris says of new mothers. In fact, Bennett's research from last year showed that slightly fewer than half of women make or keep their postpartum appointments. Other factors, such as lack of access, time, social support, and understanding of risks or medical comorbidities, may also cause women to neglect their own health, and ultimately wind up in the emergency department. Combining well-child checks and routine infant immunizations with check-ups for new moms, too, could help alleviate this issue.
"It would be more like one-stop shopping," Harris says.
Three more states—Nevada, Iowa, and Illinois—have enacted the compact since May, bringing the tally to eleven.
Eleven states have now passed legislation to enact the Interstate Medical Licensure Compact, which makes it easier for physicians to obtain licensure in multiple states.
"This has been a very rapidly accepted project," says Lisa Robin, chief advocacy officer at the Federation of State Medical Boards. "We exceeded…expectations by having 11 to date and possibly a couple others by the end of the calendar year."
In fact, the compact was completed and distributed in September 2014, and since late May, three more states—Nevada, Iowa, and Illinois—have also enacted the compact.
"It's very exciting," Robin says. "I've worked at the federation for 20 years, and there's been a lot of work towards license portability through the years."
But even as the compact is being readily adopted by many states, Robin says there are many still misconceptions about it.
"It does not create a national license," she says. "The compact is really just an administrative clearinghouse."
The compact simply provides an expedited process for obtaining multiple licenses. Robin compares the compact to the TSA pre-check at the airport; it speeds and streamlines the process, but doesn't remove safeguards. In airport terms, it's the equivalent of being able to move to the head of the line.
According to the compact's website, licenseportability.org, an estimated "80% of the physician population licensed in the United States would be eligible for expedited licensure." The physicians who wish to qualify for the compact must:
Possess a full and unrestricted license to practice medicine in a Compact state
Possess specialty certification or be in possession of a time unlimited specialty certificate
Have no discipline on any state medical license
Have no discipline related to controlled substances
Not be under investigation by any licensing or law enforcement agency
Have passed the USMLE or COMLEX within 3 attempts
Have successfully completed a graduate medical education (GME) program
Physicians who are ineligible for the expedited licensure process facilitated by the Compact would still be able to seek additional licenses in those states where they desire to practice, using traditional licensure processes.
While the process of getting the licenses might be different, physicians will still be bound by individual state laws in which they're licensed. States differ on some big issues, such as the use of medical marijuana or physician-assisted suicide, Robin points out, and that won't change.
Lisa Robin
"That was one of the issues that was a misunderstanding," Robin says. "We are trying to educate and make sure that people understand what the compact is and what it is not."
A Boon for Telemedicine Robin says an expedited interstate licensure process is helpful for the expansion of telemedicine, as well as for states with specific populations and needs.
"It benefits both very rural states and also those that may be more urban with these large centers," she says. "Some jurisdictions are going to be more an exporter of services and some states that are very rural are going to be more of an importer, so it works both ways."
Robin also says it would also help with any discipline issues that may arise; according to the website, the compact "would strengthen public protection because it would help states share investigative and disciplinary information that they cannot share now."
Robin says there are many ways that the compact will be beneficial, and it"s apparent in how quickly it's moving through the states.
"We believe this is a process that will achieve a mutual benefit for physicians, for those that recruit and employ physicians, and for patients," she says.
Three organizations discuss their experiences with CMS's bundled payment initiative.
For 120 years, Lawrence, MA-based Home Health Foundation has considered itself to be an innovative organization, so when it got the chance to participate in Model III of CMS's Bundled Payments for Care Improvement (BPCI) initiative, Peg Doherty, senior vice president of operations and strategic planning, says the decision was a "no-brainer."
"We definitely wanted to do it," she says. "We took the risk not so much to make money, [but]… to put our money where our mouth is and really deliver on what the system expects us to deliver on right now."
What the system expects them to deliver on is care that's both high-quality and cost-efficient. And that's what the BPCI initiative is ultimately trying to achieve.
"The best care is usually the lowest cost care. That's just a fact," Doherty says. "Bad care costs money. Frequent re-hospitalizations, frequent emergency room visits, lots of infections; all that costs money. So the best care delivers the best clinical outcome most efficiently."
As of mid-August, 360 organizations have entered into bundled payment agreements with CMS. An additional 1,755 organizations are partners in the program. Within the initiative are four models that vary by episodes of care; which services are included in the bundle; and whether the payments are retrospective or prospective.
"Over the course of the initiative, CMS will work with participating organizations to assess whether the models being tested result in improved patient care and lower costs to Medicare," according to the BPCI initiative's website.
Home Health Foundation is participating in Model III, which is for retrospective post-acute care only, in the congestive heart failure bundle for 60-day episodes of care.
"We're responsible for the 60 days of care starting on the first day that we provide care," Doherty says. "Once [patients are] under our care, we're responsible for all of their emergent, and pretty much all of their elective readmissions, and all of their post-acute care."
She says the only way a post-acute provider can "beat the bet finically, is by preventing re-hospitalization."
"The largest chunk of money that's spent post-acute is in re-hospitalization," she says. "Almost 50% of the cost that's associated with the bundle is for re-hospitalization. And we're on the hook for re-hospitalization; and if after the re-hospitalization they go to an SNF [skilled nursing facility], we're on the hook for that; and if they're in SNF then go to another home health agency, we're on the hook for that."
It's a pretty big risk, Doherty acknowledges, but she also believes it's an "important" one for her organization.
BCPI Model IV Jeffery D. Hurst, senior vice president and senior finance officer at Florida Hospital agrees, and would advise other healthcare leaders to take advantage of pilots like the bundled payment program now.
Jeffery D. Hurst
"Healthcare, and the future of healthcare, is about change and transformation, so take advantage of innovation pilots like BPCI to prepare your organization," he says via email. "Start small, learn as much as you can, and then transition rapidly and effectively to our new future."
Florida Hospital is participating in Model IV, where the time period for the clinical episode is three days prior to admission, the admission itself, and 30 days post-discharge. Payment is prospective, rather than retrospective. Hurst says that Florida Hospital selected model IV because it believed that the model provided more financial stability and predictability than the others.
"We believe we will have to accept more risk as we progress with our transition, but our preference is to do so in a manner that allows for as much financial stability and predictability as possible," Hurst says.
Florida Hospital included 12 clinical episodes (valve DRGs 216 – 221 and coronary artery bypass graft DRGs 231–236) in its pilot, which formally launched on January 1, 2014. Currently, its participating providers include 125 physicians in 10 different groups across multiple specialties.
"Going forward, we intend to maintain our focus on clinical performance, including readmissions and LOS, but also supply utilization and cost. Additionally, we still have improvements to achieve in our various revenue cycle processes, specifically as it relates to payment timeliness and payment accuracy," Hurst says.
"Lastly, we want to improve the granularity, sophistication and timeliness of our metrics and analytics, as we believe our ability effectively understand our data in as timely a manner as possible will be key to our success on all outcomes, clinical and financial."
BCPI Model II Geisinger Health System has already seen improvements since it started Model II on Jan 1, 2014 at three hospital campuses: Geisinger Wyoming Valley, Geisinger Medical Center, and Geisinger-Shamokin Area Community Hospital.
John Bulger, DO, MBA, chief medical officer for the Geisinger Health Plan, says the data shows that "it's improved with every quarter," both financially and for decreasing variation in patient care across providers.
John Bulger, DO, MBA
But bundled payments aren't new for Geisinger, which has "been doing bundled payment for some time in a partnership between our clinical enterprises and our health plan," Bulger says. Bundling "engenders collaboration between providers," he adds.
Now, in working with CMS, post-acute partners are involved, too. That's certainly changed the game, since Bulger says most of the cost is in the post-acute space.
"The way to impact that is preparation upfront," Bulger says. That involves things like risk stratification for the patient before surgery: Which patient has uncontrolled diabetes? Who might benefit from a smoking cessation program? It involves asking, who will the patient see throughout their care experience?
"You're really taking it apart soup to nuts," Bulger says. In that way, bundled payments not only align providers and incentives, but "in the long run it's much better for the patient as well."
For her part, Doherty says it's too soon to tell whether the risk for Home Health Foundation will pay off, but she is optimistic.
"If we can prevent unnecessary emergency room visits and unnecessary hospitalizations, patients will have better clinical outcomes, and we will also have good financial outcomes," she says. "Organizations that embrace this…should be applauded for their willingness to take a risk and have a vision as to how it might be better for patients."