With high costs, risks of adverse events, and scant evidence of effectiveness, surgery for chronic pain is a prime example of overutilization of healthcare services.
There is inadequate evidence to justify surgical procedures to treat chronic pain, recent research shows.
"Given their high cost and safety concerns, more rigorous studies are required before invasive procedures are routinely used for patients with chronic pain," researchers reported this month in the journal Pain Medicine.
Chronic pain is a widespread and costly condition in the United States, affecting more than 100 million people and costing as much as $635 billion annually.
The Pain Medicine research features a review of 25 clinical trials involving 2,000 patients with conditions including lower back pain, arthritis, angina, abdominal pain, and endometriosis.
The researchers compared outcomes for invasive procedures and sham procedures. In a sham procedure, the patient goes through the rituals of a surgical procedure such as preparations and set up, anesthesia if needed, and tissue penetration. However, the tissue is not manipulated in a way that is thought to correct the underlying problem, and the patient is closed up or the instrument withdrawn.
For adverse events, there was a significantly higher risk for invasive procedures (12%) than sham procedures (4%).
The risks associated with surgery for chronic pain are too high and more clinical trials should be conducted, the researchers wrote.
"The risks of surgical and invasive procedures are not minor and appear to be higher with real compared with sham procedures. Risks in both groups include anesthesia, permanent injury to the body, psychologic stress, and time, cost, and productivity losses. Without more rigorous examination, large numbers of patients are exposed to risky and possibly unnecessary procedures."
The lead author of the research, Wayne Jonas, MD, executive director of Samueli Integrative Health Programs at H&S Ventures in Alexandria, Virginia, says physicians and chronic pain patients should consider surgery carefully.
"Right now, the scientific evidence does not justify doing these procedures for chronic pain. However, patients and circumstances vary, and physicians and patients need to decide individually what's appropriate for any particular patient. Taking this evidence and discussing it with the patient in shared decision-making is the best approach," Jonas told HealthLeaders last week.
"It takes a multidisciplinary team of healthcare professionals at its center to help manage chronic pain. Yet one of the things the U.S. healthcare system as a whole systematically fails at is fostering coordinated care. Most care is piecemeal with little communication among providers. So, people with chronic pain are left to jump from provider to provider, often undergoing unnecessary, costly, duplicative procedures, and taking ineffective drugs—with ultimately little relief."
There are several options for treating chronic pain that do not involve invasive procedures or addictive medications such as opioids, he says.
"The American College of Physicians, the Centers for Disease Control and Prevention, the National Institutes of Health, and many other national bodies have recommended nonpharmacological approaches for the treatment of chronic pain. These include acupuncture, yoga, massage, and other such approaches. In addition, behavioral medicine has been demonstrated for many decades to be effective for chronic pain."
There are opportunities for value-based healthcare to benefit from cost-effectiveness analysis.
The healthcare economics toolbox is maturing and playing an increasingly valuable role for physicians and administrative leaders.
In particular, cost-effectiveness analysis and value-based healthcare, which are the primary tools of healthcare economics, are intersecting and drawing valuable insights from each other, recent research shows.
The lead author of the research, Joel Tsevat, MD, MPH, professor of medicine at UT Health San Antonio, is a cost-effectiveness analyst who is calling for a convergence of his discipline and value-based healthcare.
"We have been trying to quantify bang for your buck for thousands of clinical treatment or prevention paradigms. What I realized is we have been living in parallel worlds: the cost-effectiveness analysts and the value-based healthcare people," Tsevat told HealthLeaders this week.
Timeframe is one of the key differences between value-based healthcare and cost-effectiveness analysis, he says.
"Value-based healthcare tends to look at shorter-term outcomes. Bundled payments are 90-, 60-, or 30-day episodes. Accountable care organizations are year-to-year analyses of how they are doing compared to how they did the previous year or relative to a benchmark. Cost-effectiveness analysis generally takes a long-term view or a patient's lifetime view."
At the very least, healthcare leaders need to understand the different approaches, says Tsevat, who is also affiliated with the University of Texas at Austin's Dell Medical School. "These concepts are affecting care. Value-based healthcare is affecting care more overtly now because it is affecting reimbursement."
Cost-effectiveness analysis is a crucial tool for healthcare leaders who gauge the tradeoffs between patient benefits and therapies with astronomical costs such as expensive medications. "The rubber is hitting the road. We can't afford million-dollar treatments," he says.
Physicians can no longer afford to turn a blind eye to costs, Tsevat says.
"Historically, we were taught to provide whatever care is best, regardless of cost. If the patient needs an expensive medication or an expensive treatment, the physician is trained to do that. But as providers we are also becoming stewards of the healthcare economy, like it or not."
Physicians should be trained to understand cost-effectiveness analysis and value-based healthcare, he says. "Physicians have to understand these concepts. We have to understand tradeoffs."
Converging disciplines
Cost-effectiveness analysis and value-based healthcare can draw valuable elements from each other, Tsevat says.
Cost-effectiveness analysis is generally performed from a societal perspective or healthcare sector view, and the discipline would benefit from drawing on value-based healthcare's patient-centered approach, he says.
"If you have HIV or hepatitis C, the community might place a lower rating or value on that health state than you as a patient would, because it's your life. So, cost-effectiveness analysis could learn more about individualizing outcomes at the patient level."
Tsevat says value-based healthcare could benefit from the capability of cost-effectiveness analysis to gauge tradeoffs—the costs for the benefit.
"It's all well and good to eliminate waste and low-hanging fruit such as imaging for routine back pain that has little or no benefit. But after you have eliminated waste, there is going to be point where you start making tradeoffs. There are a lot of things that we do that have a little bit of benefit, but there is a question of whether it is worth the cost," he says.
The research examined 47 studies involving more than 42,000 physicians. "This meta-analysis provides evidence that physician burnout may jeopardize patient care; reversal of this risk has to be viewed as a fundamental healthcare policy goal across the globe," the researchers wrote.
In the study, patient safety incidents were adverse events such as diagnostic errors. Low professionalism included weak communication with patients and lack of empathy. Patient satisfaction featured patient-reported data.
The researchers found physician burnout has a negative impact on patient safety, professionalism, and patient satisfaction:
Overall physician burnout doubled the odds of involvement in patient safety incidents. All three dimensions of physician burnout—emotional exhaustion, depersonalization, and reduced personal accomplishment—were linked to involvement in patient safety incidents.
Overall physician burnout doubled the odds of low professionalism. Depersonalization was associated with the highest propensity for unprofessionalism with a 3-fold increased risk.
Overall physician burnout doubled the odds for low patient satisfaction. Depersonalization was linked to a 4.5-fold increased risk.
The researchers also found that physicians early in their career have a higher propensity for unprofessionalism. "The … association of burnout with low professionalism was significantly larger across studies based on residents and early-career physicians, compared with studies based on middle- and late-career physicians," the researchers wrote.
Implications and recommendations
The findings of the research have implications for healthcare costs and clinical care improvement.
The researchers found that physician burnout compromises care safety, and earlier research has shown that adverse events cost several billions of dollars annually. "Physician burnout therefore is costly for healthcare organizations and undermines a fundamental societal need for the receipt of safe care," the researchers wrote.
Addressing physician burnout is an opportunity to improve patient safety and the quality of care. "Our findings support the view that existing care quality and patient safety standards are incomplete; a core but neglected contributor is physician wellness," the researchers wrote.
The JAMA Internal Medicine study offers three recommendations to ease physician burnout:
Healthcare organizations should score physician depersonalization with other quality measures to drive interventions for improving quality and patient safety
Reporting for quality of care and patient safety should be standardized across healthcare organizations to boost understanding of physician burnout and its association with patient care deficiencies
Healthcare organizations should do more to support physicians in the early stages of their careers.
Supporting physicians when they are residents is crucial, the researchers wrote.
"Residents will be responsible for healthcare delivery for over two decades in the future. Investments in their wellness and professional values, which are largely shaped during early-career years, are perhaps the most efficient strategy for building organizational immunity against workforce shortages and patient harm."
Adopting an early warning system and deploying care bundles for the infection are keys to treating sepsis patients.
A pair of health systems have made strides in improving their treatment of sepsis with new screening protocols and standardized bundles of care for the deadly infection.
More than 1.7 million people contract sepsis annually in the United States, with 270,000 fatalities, according to the Centers for Disease Control and Prevention. About 1 in 3 of patients who die in a hospital have sepsis, the CDC says.
In response to the sepsis threat to patients and the sepsis core measure established in 2015 by the Centers for Medicare & Medicaid Services, DeKalb Medical in Decatur, Georgia, and AHMC Healthcare in Alhambra, California, have adopted early warning intervention systems for the infection and sepsis care bundles.
The early warning invention systems feature electronic alerts and staff training to heighten awareness of sepsis signs and symptoms. The sepsis care bundles feature treatment protocols for three hours and six hours after diagnosis.
1. Early detection screening
DeKalb launched its sepsis initiative in early 2017, beginning the process by examining data to determine care gaps.
"It became apparent that the majority of our sepsis population was coming through our emergency room, with some sort of infectious process already starting. So, we focused on our emergency room locations, and took time to look at sepsis as an organization in terms of how it presented," says Christina English, RN, performance improvement coordinator at DeKalb.
DeKalb adopted an approach that leveraged both data and clinical care team capabilities, with the help of IBM Watson Health CareDiscovery.
"We looked at different chief complaints associated with sepsis and some of the clinical presentations, then developed electronic alerts, nursing processes, and physician order sets to address these patients when they come through the door," she says.
Electronic alerts are generated through DeKalb's electronic health record.
"We hardwired alerts that are based off a combination of chief complaint and presenting vital signs comprised of SIRS criteria. So, once a patient meets several SIRS criteria and they have a chief complaint associated with an infection process, the nurse and the physician get an alert," English says.
Staff training and coordination are critical components of DeKalb's early warning intervention system for sepsis.
"We made sure pharmacy and the labs department [were] looped in, we had a lot of collaborative effort with the physician staff, and there was a clinical education component," she says.
AHMC started its sepsis care initiative in 2015. Educating staff is an essential element of the health system's screening processes for sepsis, says Jonathan Aquino, MHA, corporate chief quality officer of AMHC and CEO of San Gabriel Valley Medical Center in California.
"We have done a lot of training in all areas of the hospital—our emergency department frontline staff, physicians, floor nurses, and our leadership team. We have a number of screening protocols that are now in place; we check for sepsis at almost every juncture," he says.
Sepsis screening occurs in several settings, Aquino says. "There is a sepsis screening protocol in triage, at the time of admission, [and] for shift changes."
The AMHC nursing staff plays a key role in screening and intervention, he says. "Once we get indications from the screening process, our nursing teams start a process to initiate the sepsis bundle of care."
AMHC physicians have empowered the nursing staff to initiate sepsis interventions, Aquino says.
"Our physicians have allowed us to use nurse-driven protocols to initiate the bundle. Our medical executive committees have said that if the nurses see signs of sepsis or catch it in triage, we should execute the bundle right away. We don't wait for the doctors," Aquino says.
2. Sepsis care bundles
The treatment of sepsis patients at AHMC and DeKalb mirrors the recommendations of the CMS sepsis core measure.
The sepsis core measure features intervention sets that clinicians should initiate in three-hour and six-hour timeframes for patients who have reached severe sepsis or septic shock.
For example, in the first three hours after a patient has presented with severe sepsis, interventions include administration of antibiotics and lactate testing.
The care clock starts ticking as soon as a patient is identified with severe sepsis or septic shock, Aquino says.
"We know that if we can manage these patients aggressively and improve the continuum of care for sepsis, these patients will go home sooner. We know if we delay lab draws, antibiotics, an X-ray, an EKG, or whatever it may be, a patient's medical condition can progress for the worse. What that means is affecting the length of stay in the hospital and affecting our ability to treat the patient," he says.
Sepsis care impact
For some months and annual quarters, AHMC has achieved 100% compliance with the CMS sepsis core measure, Aquino says. "We didn't get to a success rate of 100% sepsis core measure compliance in some months and quarters overnight. We showed our staff that the clock starts ticking."
From 2016 to 2017, DeKalb has achieved sepsis care gains in several metrics:
The compliance rate for the CMS sepsis core measure increased 27%
Average length of stay for sepsis patients fell 2.3 days
Cost avoidance savings totaled $2.7 million
Mortality rate for sepsis patients decreased 30%, with about 48 lives saved
Although effective sepsis care requires aggressive interventions, the cost of care is justifiable clinically and financially, English and Aquino say.
"Implementing the sepsis core measure has a cost to it—there are medications, labs, and other resources; but it is very easy to justify being proactive when you look at how much sepsis costs on the back end when it progresses to an inpatient stay, or the patient is in shock or ventilated," English says.
Aggressive screening efforts also are clinically and financially effective, she says. "When you catch sepsis early, the treatment is antibiotics and a couple bags of IV fluid. If you don't catch it early, you could have several days in the ICU and ventilation."
Lessons learned
In launching and implementing its sepsis care initiative, DeKalb has learned about the importance of raising awareness and promoting care coordination, English says.
"The most beneficial component to the early warning system is not necessarily that the EHR catches 100% of the cases, but we have seen a positive shift in our nursing practice and awareness of sepsis. We have seen examples where the alert did not go off, but a nurse was already suspicious about sepsis. They can catch sepsis that may have been borderline under the rigid criteria of the electronic screening," she says.
Care coordination is critical to executing effective sepsis care, English says.
"We have also learned that the care of sepsis patients requires a lot of communication and collaboration between the different disciplines. So, it has tested our care continuum model and how we are able to work together in nursing, physicians, and labs."
AMHC's sepsis care initiative has succeeded in part through physician leadership, Aquino says.
"You need physician champions. For sepsis, you need infectious disease physician champions. You need to be able to lean on the leadership for infectious diseases and help them spread the message to the medical staff," he says.
An analysis of New York State's first-in-the-nation mandated reporting and care protocols for sepsis shows improvements in care, even without financial incentives.
The country's first state-mandated reporting initiative for sepsis has increased compliance with sepsis care bundles and helped reduce mortality rates for the deadly infection, recent research shows.
In 2013, the state of New York launched a public reporting initiative for sepsis that required adherence to care bundles for patients with severe sepsis and septic shock. The research, which examined data from April 2014 to June 2016, was published in the Journal of Respiratory and Critical Care Medicine.
"This study demonstrates the association between state-wide mandated public reporting of compliance with sepsis performance measures and outcomes, improving care, and decreasing mortality," the researchers wrote.
The research features 91,357 hospitalizations from 183 hospitals. The sepsis care bundles specify interventions for sepsis patients three hours and six hours after diagnosis. For example, the three-hour bundle includes drawing blood cultures, administration of antibiotics, and measuring of blood lactate levels.
The research has several key findings:
Of the 91,357 sepsis patients, 81.3% were treated under a sepsis care bundle
Compliance with the three-hour care bundle increased from 53.4% to 64.7%
Compliance with the six-hour care bundle increased from 23.9% to 30.8%
Risk-adjusted mortality decreased from 28.8% to 24.4%
Increased care bundle compliance was associated with shorter length of stay
"This study … demonstrates improved care for patients with sepsis as evidenced by increased compliance with performance metrics and decreased risk-adjusted mortality over the first two years of the ongoing initiative. A state-wide initiative using regulations and non-financial incentives appears to have substantially changed care," the researchers wrote.
The study's lead author, Brown University Professor of Medicine Mitchell Levy, MD, told HealthLeaders this week that there were six primary operational burdens on hospitals to comply with the state mandate:
Administration of data abstraction and collection
Incorporation of mandated sepsis care with existing quality improvement efforts
Costs associated with data extraction and analysis
Establishing stakeholder cooperation such as overcoming physician resistance to some elements of the sepsis protocols and care bundles
Identifying patients early for appropriate treatment
Competing priorities from other regulatory initiatives
Crowdsourced ratings such as Facebook reviews reflect patient experience better than clinical quality, and hospitals can push back.
Crowdsourced ratings of the "best overall" hospitals produce scores similar to Hospital Compare's ratings, but crowdsourced ratings are less reliable as indicators of clinical quality and patient safety, recent research shows.
The research, which was published in the journal Health Services Research, examined hospital ratings on Facebook, Google Reviews, and Yelp. The findings show crowdsourced ratings reflect patient experience rather than other factors.
"For the most part, what we found is that the social media scores tell us about patient experience, but they don't tell us about the best and worst hospitals on the basis of clinical quality or patient safety," the lead author of the research, Victoria Perez, PhD, told HealthLeaders last week.
The study has significant implications for how patients should view crowdsource ratings, said Perez, who is an assistant professor at Indiana University in Bloomington. "We wish that people would understand that even if hospitals are not scoring well on Facebook in user reviews, they could have excellent clinical scores."
Addressing bad reviews
If a hospital has generated negative reviews on a crowdsourcing site, there are ways to counteract the negative publicity, Perez said. "Hospitals can advertise that they score well on Hospital Compare and establish marketing strategies to respond to social media scores."
Hospital leaders also need to be aware that crowdsourcing scores are based largely on patient experience, she said.
"If hospitals are worried that patients are just looking at social media scores, they need to realize the scores reflect patient experience rather than clinical quality and patient safety. Other than advertising they don't have a lot of control over this. The options are marketing and engaging on the social media platform."
There are ways to shift the online focus of patients toward clinical quality and patient safety, Perez said.
"Hospitals can share Hospital Compare clinical quality and patient safety scores on their homepage, on their Facebook page, and on Twitter. Many hospitals have a social media presence, so they can definitely share clinical quality and patient safety information, and they can encourage patients to look at Hospital Compare."
Research findings
The research, which examined data from nearly 3,000 acute care hospitals, has several key findings:
For best-ranked hospitals on the crowdsourcing sites, 50% to 60% were ranked best in Hospital Compare's overall rating.
For best-ranked hospitals on the crowdsourcing sites, 20% ranked worst in Hospital Compares overall rating.
For clinical quality and patient safety, hospitals ranked best on crowdsourced sites were only ranked best on Hospital Compare about 30% of the time.
Perez said Hospital Compare, which combines as many as 57 metrics for patient experience and clinical quality, was used to gauge the accuracy of the crowdsourcing sites for several reasons.
"The clinical quality and patient safety measures are based on Medicare claims data, which means there is a lot of information about patients and they can do risk adjustment," she said of Hospital Compare.
Risk adjustment is crucial when comparing hospitals, Perez said. "Rather than being concerned that some hospitals are treating a sicker pool of patients and have worse outcomes as a result, the Hospital Compare data can be adjusted for the health of the patient mix."
The crowdsourcing sites are more prone to bias, she said. "A concern when you look at social media is that people only write reviews when they have really good or really bad patient outcomes."
As opposed to the general-purpose house call of the past, contemporary house calls can generate targeted benefits such as hospital readmission reductions.
Opportunity is knocking for physicians willing to make house calls.
Carefully targeted house calls can reduce patient anxiety, decrease hospital readmissions, improve patient safety, and increase physician familiarity with patients, says William Frishman, MD, of New York Medical College and Westchester Medical Center in Valhalla, New York.
"People spend more time at home than they do in a hospital or a clinic. You really have to see what their living conditions are like. It helps with the long-term care of the patient," Frishman says.
"When heart attack patients go home from the hospital, they are scared stiff. The husband or the wife doesn't know how to handle it. Having a doctor come to the home is extremely reassuring," he says.
Beyond reducing patient and caregiver anxiety, research published by The Journal of Thoracic and Cardiovascular Surgery has shown that house calls can effectively reduce 30-day hospital readmissions for cardiac surgery patients.
The research found that a physician assistant home care program including house calls reduced the 30-day readmission rate by 25%. The most common house call intervention was medication adjustment.
Another study found that house calls are a crucial component of managing care and boosting care quality for geriatric patients who are homebound.
Assessing patient safety should be a primary house call objective for physicians and nurses, Frishman says.
"Older patients in the home should not have to bend down to get something. They should not have to get up on a stool to get a dish. Everything should be at a level where the patient does not have to go up or bend over."
Physicians can learn essential information about their patients during house calls, he says.
"Unless you have a sense of what is happening in the home, you are missing something in your relationships with patients. … When I see them in the office later, I know the patients better. House calls give you another look at how the patients are doing."
Patient selection
Physicians need to make judgment calls when deciding which patients are most appropriate for house calls, Frishman says.
"If someone is having chest pain, you wouldn't make a house call. You would tell them to get to an emergency room. The traditional house calls from 50 years ago are different from house calls today. Part of today's house call is finding ways to keep people from coming back to the hospital."
Selecting patients for house calls must be an individualized process, he says.
"There is not the universal, middle ground patient. Even in the middle ground, there are some patients you will send to the hospital and others you can wait to see until the next day. It relates to your experience with the patient and your judgment. For new patients, I generally would not go to the house. I would tell them to come to the office or to the hospital."
Post-heart attack visit: For patients who have had their first heart attack, Frishman makes a house call about a week after hospital discharge. In addition to addressing patient and caregiver anxiety, these visits focus on medication reviews, care-related questions, and a walk with the patient.
Post-heart failure visit: After hospitalization for heart failure with or without a heart attack, Frishman's house calls focus on medications, diet, and body weight. As is the case with heart attacks, he takes a walk with the patient.
Geriatric visit: For new geriatric patients, Frishman makes house calls for homebound people. The primary goals of these visits include assessing fall risks and getting to know the patients more completely through observations in the home setting.
Post-funeral visit: After a patient's death, Frishman makes a house call to the family a few days later to help avoid years of psychopathology among the survivors. The primary objective of these visits is to reassure family members that they are not to blame for the loss of their loved one.
Electronic health records contribute to physician burnout and writing shorter case notes can ease the EHR burden.
Electronic health records (EHRs) have become a primary driver of physician burnout, a recent research article says.
Earlier research found physician burnout rose from 45.5% of doctors in 2011 to 54.4% in 2014. The time period corresponds with the introduction of mandatory use of EHRs.
The recent research article, which was published in The American Journal of Medicine, says EHRs contribute to all three elements of physician burnout—lack of enthusiasm, lack of accomplishment, and cynicism.
"The hours spent cloning notes in a mandated doctor-computer relationship leaves the physician unable to experience the best part of being a doctor. No humanistic physician gets up with zeal in the morning, hopeful for a chance to have a meaningful relationship with Epic or MEDITECH. Rational people should feel cynical if the institutional accomplishment for the day is to produce 20 cloned medical records," the researchers wrote.
Less is more
Writing shorter case notes is one of the key strategies to address EHR-related physician burnout, the researchers say.
Earlier research found that primary care physicians spend more time interfacing with EHRs than working with their patients. "Primary care physicians spend more than one-half of their workday, nearly six hours, interacting with the EHR during and after clinic hours."
Case notes can be shorter without compromising the quality of the information, the lead author of The American Journal of Medicine article told HealthLeaders this week.
"Shorter notes do not imply incomplete or partial notes," said Andrew Alexander, MD, associate dean at the University of California's Riverside School of Medicine in Riverside, California.
He said there are several best practices for taking shorter case notes:
The physician should record the patient's presenting complaint and all pertinent data that helps the doctor formulate the differential diagnosis (DDx) and a plan for concluding the visit.
Pertinent data can include testing, consultation, procedures, or medications.
Further documentation can degrade the quality of care because the doctor must attend to the computer keyboard and occupy the record with templated data that confound and camouflage the key patient care issues the next time a doctor sees the chart or the patient.
Take notes as the questions are being asked and look at the patient while inputting information into the EHR.
Use a basic template that auto-populates medications, vital signs, and simple exams.
Have separate templates for children and gynecological exams.
When formulating assessments or diagnoses, omit templates and hand-enter problems or assessments with alternative diagnoses. Physicians should include why preferred and alternative diagnoses are possible, which will help explain diagnosis reasoning in future viewings of the record.
The main pitfall of shorter notes is omitting the creation and chart entry of a differential diagnosis when there is uncertainty about a patient's diagnosis, Alexander said.
"Failure to create a DDx would force the physician to review the lab results, which arrive days later, without context. An on-call partner or a consultant might see the patient and repeat all testing and X-rays as they attempt to replicate the same logical clinical inquiry that you failed to document," he said.
San Diego's healthcare collaborative cut acute myocardial infarction hospitalizations through clinical care improvement and increased engagement with patients and community organizations.
A healthcare collaborative in San Diego achieved a 22% reduction in heart attack hospitalization rates compared to an 8% reduction in the rest of California, research published this week says.
The collaborative—Be There San Diego—launched in 2011. The 22% reduction in heart attack hospitalization rates was attained from 2011 to 2014, avoiding about 3,800 hospitalizations and attaining an estimated $86 million in savings.
The collaborative was designed to decrease cardiovascular events through spreading best practices for better control of hypertension, lipid levels, and blood sugar. Be There San Diego (BTSD) also sought to increase engagement with patients and community organizations.
The researchers, who published their study in Health Affairs, say the BTSD model can be recreated across the country.
"Although this type of collaborative might be more challenging to execute in geographic areas that have larger populations or are more spread out—with a greater number of healthcare systems—than is the case in San Diego County, the basic organization and implementation of BTSD should be generally applicable elsewhere," they wrote.
Clinical care
BTSD features physician groups, health plans, federally qualified health centers, and health systems that provide care for two-thirds of San Diego County's 3.3 million residents.
The clinical care efforts of the collaborative are focused on identifying and modifying risk factors, improving quality of care, and implementing best practices:
Use of a simplified hypertension treatment to improve management of hypertension, lipid levels, and blood sugar
Adoption of a medication bundle to boost medication adherence and reduce cardiovascular events among patients at high risk of heart attack
Expansion of health-coach services
Holding monthly meetings to share best practices among clinicians and community organizations, including the review of key clinical metrics
Sharing information through the Data for Quality project, which gives healthcare organizations the ability to share aggregated quality metric data confidentially
Patient engagement
Health coaches are playing a key role in BTSD's patient engagement efforts, particularly in increasing the use of medications for hypertension and hypercholesteremia.
The health coaches, who are deployed by healthcare organizations and trained by BTSD, engage patients with monthly phone calls to lower barriers to medication adherence and increase goal achievement.
Community engagement
BTSD has established a faith-based partnership with African American churches in Southeastern San Diego, which is one of the county's most socioeconomically disadvantaged communities. The partnership is designed to serve as a "cardiovascular learning community," the Health Affairs researchers wrote.
"This learning community consists of faith leaders who meet to discuss efforts to improve their congregants' cardiovascular health through changes such as improved organizational nutrition policies, promoting healthy behaviors through walking clubs and other organized activities, and linking congregants who have high blood pressure to clinical care."
Breast cancer survivors with lymphedema face high long-term costs, and there are several strategies for healthcare providers to help.
Many breast cancer survivors carry a crushing economic burden long after their initial treatment, new research shows.
Costs associated with ongoing care are particularly heavy for breast cancer survivors with lymphedema, the researchers wrote this month in the journal Supportive Care in Cancer.
"Interviews suggested that the cascading nature of economic burden on long-term savings and work opportunities—and insufficiency of insurance to cover lymphedema-related needs—drove cost differences. Higher costs delayed retirement, reduced employment, and increased inability to access lymphedema care."
The research featured a mixed-methods study of 129 breast cancer survivors from New Jersey and Pennsylvania.
Excluding productivity losses, annual out-of-pocket costs for breast cancer survivors with lymphedema totaled $2,306 compared to $1,090 for patients without lymphedema. When productivity losses were included, annual out-of-pocket costs for patients with lymphedema totaled $3,325 compared to $2,792 for patients without lymphedema.
The ongoing cost of care resulted in many patients foregoing treatment such as compression garments, the researchers wrote. "When patients could not cover their costs, family members or social service organizations were sometimes able to help, but often patients simply went without the care they needed."
Easing the burden
Earlier research and policy statements give guidance on how healthcare providers can help breast cancer patients manage and reduce treatment costs.
A recentstudy published in the Journal of the National Cancer Institute suggests three ways that healthcare providers can help cancer patients with the cost of care:
Oncologists should make sure they recommend care that has maximal value as opposed to interventions with low benefits and high costs.
Oncologists should initiate conversations about cost. These discussions can help direct patients to financial resources and give physicians opportunities to advocate for patients with insurance companies.
Oncologists should be prepared to help patients deal with financial costs. This preparation includes gaining familiarity with cost issues such as using the American Society of Clinical Oncology Value Framework. Physicians should also enlist other members of their care team such as pharmacists who can help patients address cost challenges.
There are several other recommendations for healthcare providers to help cancer patients who struggle with the cost of care:
A recent study in the Journal of Cancer Research and Clinical Oncology says that physicians can improve health outcomes and reduce financial burdens by encouraging patients to modify health-related factors such as sedentary lifestyles.
A policy statementfrom the American Society of Clinical Oncology makes multiple suggestions to ease the financial burden on patients such as tackling obesity, providing evidence-based care, optimizing cancer prevention techniques, and including patients in all decision making.
