To gauge readmission risk for patients with acute myocardial infarction, clinicians can easily assess seven variables during the first day of a hospital admission.
A new risk model provides a simple and inexpensive way to determine whether acute myocardial infarction patients are at high risk for hospital readmission.
Research published by the Healthcare Cost and Utilization Project shows that about 1 in 6 AMI patients are readmitted to a hospital within 30 days of discharge, with annual healthcare costs estimated at $1 billion.
Targeting AMI patients who are at high-risk of readmission also helps hospitals avoid financial penalties under the federal Hospital Readmissions Reduction Program and promotes cost-effective interventions, the JAHA researchers wrote.
"Although federal readmission penalties have incentivized readmissions reduction intervention strategies (known as transitional care interventions), these interventions are resource intensive, are most effective when implemented well before discharge, and have been only modestly successful when applied indiscriminately to all inpatients."
The risk model, which is detailed in a recent study published in the Journal of the American Heart Association (JAHA), features seven variables that can be scored in as little as five minutes during a patient's first day of hospital admission.
With a simple calculation at the bedside or in an electronic health record, physicians can determine whether a heart attack patient is at high risk for readmission and order interventions that can help patients avoid a return to the hospital after discharge.
"The acute myocardial infarction READMITS score (renal function, elevated brain natriuretic peptide, age, diabetes mellitus, nonmale sex, intervention with timely percutaneous coronary intervention, and low systolic blood pressure) is the best at identifying patients at high risk for 30‐day hospital readmission; is easy to implement in clinical settings; and provides actionable data in real time," the researchers wrote.
The AMI READMITS risk model is superior to other models, they wrote. "The few currently available AMI readmission risk prediction models have poor-to-modest predictive ability and are not readily actionable in real time."
Key findings
The JAHA research, which examined health outcomes for 826 AMI patients at six hospitals in North Texas, has several key findings:
The AMI READMITS score accurately predicts which heart attack patients are at high risk or low risk of readmission. In the JAHA research, about one third of AMI patients that were deemed at high risk through the AMI READMITS score had a 30-day readmission. Only 2% of patients considered at low risk experienced a readmission.
The AMI READMITS score can accurately predict readmission risk during the first 24 hours of a hospital inpatient admission, which gives clinicians the ability to make timely interventions.
Clinical severity metrics such as shock, heart strain or failure, and renal dysfunction as well as timely percutaneous coronary intervention were strongly associated with readmission risk.
Why this model matters
Assessing the readmission risk of AMI patients during the first day of hospital admission is crucial, says Oahn Nguyen, MD, MAS, the lead author of the JAHA research and an assistant professor at UT Southwestern Medical Center in Dallas.
"[The model] gives you more time to intervene and try to prevent someone from having to come back to the hospital. It gives you more time to optimize someone's path to recovery," she told HealthLeaders.
She said development of the AMI READMITS risk model is the first step toward significantly reducing readmissions for AMI patients. "Studies of interventions to reduce readmissions for other conditions suggest that the earlier you can intervene the better. One caveat is those interventions have yet to be assessed in acute myocardial infarction."
The current primary strategy to prevent readmissions for heart attack patients is transitional care intervention, and the AMI READMITS score helps physicians target patients for this intervention, she said.
"Transitional care intervention is a bundle of care to promote a safe transition from hospital to home. One way I like to think of it is deploying a medical SWAT team in the hospital to make sure that everything you can do for a patient is being done to ensure the transition from the hospital to the community is as smooth as possible," Nguyen said.
A "SWAT team" approach to care is often costly, so the capability of the AMI READMITS score to target patients who are at high risk of readmission improves the cost-effectiveness of care.
There are several primary elements to transitional care intervention:
Medication counseling to make sure AMI patients know how to take them
Making sure patients get their medications when they leave the hospital
Connecting patients with the most appropriate outpatient care such as setting up clinic appointments
Conducting phone calls to the homes of patients to check on their health status after discharge
Major strengths of the AMI READMITS score include the risk model's simplicity and low cost, she said.
"Our goal in creating this model was creating something that was simple and pragmatic; so, it's parsimonious because there are only seven variables that go into it. The seven variables are also information that is commonly and routinely collected during most hospitalizations."
The AMI READMITS risk model does not require sophisticated support systems, Nguyen said.
"In an age when there is a lot of hype about machine learning and big data, we were able to distill the big data of an electronic health record down to small, simple, parsimonious data that is easily applied at the bedside by clinicians," she said.
Expense is minimal for the AMI READMITS risk model.
"It's low cost because a clinician could look at our [research], then see how many of the seven factors a patient has in the hospital. You can literally spend less than five minutes summing up the points in the model scale, add them up, and determine whether a patient is at high risk or not. It does not take a fancy new IT infrastructure to implement," Nguyen said.
Despite recommendations against screening low-risk patients for ovarian cancer, personal experiences with cancer can prompt physicians to act outside the guidelines.
Physicians who have had personal experiences with cancer have a higher likelihood than their peers of ordering ovarian cancer screening against established recommendations, new research says.
Unrecommended screening exposes patients to risks of harm associated with testing procedures as well as surgery following a false positive test, according to the research, which was published this month in the Journal of Women's Health.
The lead author of the research, Margaret Ragland, MD, MS, of the University of Colorado Hospital in Aurora, says physicians who have had cancer themselves or in their social circles are biased toward ordering too many preventative cancer services.
"My hypothesis is that a doctor's personal experience may influence their assessment of risk. You see a patient in front of you and you may assess the risk to be higher than it actually is," she said in a prepared statement.
Ordering ovarian cancer screening outside established guidelines is problematic, according to the U.S. Preventative Services Task Force:
USPSTF has given routine ovarian cancer screening a "D" grade—a designation for medical services deemed ineffective or unlikely to generate benefits that outweigh potential harms.
The tests for ovarian cancer—transvaginal ultrasound and cancer antigen 125—have low positive predictive value and high false positive rates.
There is scant evidence that screening improves morbidity or mortality.
Screening for ovarian cancer is not recommended for women at low risk or the general population of women.
Earlier research found significant risks of patient harm associated with ovarian cancer screening such as bleeding, fainting, nausea, and bruising. This research also found that 5% of women screened for ovarian cancer experienced false positive tests, which resulted in unnecessary major surgery for many patients.
Other earlier research questioned the cost of ovarian cancer screening because the low prevalence of ovarian cancer in the general population of women limits the cost-effectiveness of routine testing.
Bias found
The Journal of Women's Health research features survey data collected from 504 physicians. The survey included a vignette of a woman at average risk of ovarian cancer.
In an unadjusted analysis, 86.0% of physicians who lacked personal experience with cancer reported following ovarian cancer screening guidelines. Among physicians who had personal experience with cancer, 69.2% reported following the screening guidelines.
After adjusting the data for factors including patient age, race,
insurance status, and requests for ovarian cancer screening, physicians who had personal experience with cancer were 0.82 times more likely to order testing outside recommended guidelines.
Raising awareness of the potential for bias in ovarian cancer screening is the primary recommendation of the Journal of Women's Health researchers.
"Results from this study can increase physician awareness of and improve training about factors that may unintentionally influence their clinical practices," the researchers wrote.
New research sheds light on the characteristics of patients who are placed in physical restraint while receiving emergency room care.
Most patients restrained in emergency departments fall into two categories—a relatively young and predominantly male group presenting with alcohol or drug use, and an older group with medical complaints, recent research shows.
"Our data found strong association of alcohol or drug use with physical restraints and identified a unique elderly population with behavioral disturbances in the ED," the researchers wrote this month in Annals of Emergency Medicine.
Knowing which agitated patients in the ED could require restraint is valuable information because of a steadily growing number of behavioral emergencies and grave risks associated with restraint.
Behavioral emergencies in EDs have skyrocketed in recent years, with national estimates of a 50% increase in ED visits for behavioral disorders between 2006 and 2011 compared with an 8.6% increase in the total number visits. Agitation is often associated with behavioral ED visits, with 1.7 million events occurring annually.
Although the use of patient restraint is common in the ED setting, negative health outcomes and potential liability can be severe.
"Adverse events have been cited in the restraint process, including blunt chest trauma, aspiration, respiratory depression, and asphyxiation leading to cardiac arrest. In addition, a survey of ED patients found that 66% reported experiencing severe psychological distress and lasting consequences in regard to care-seeking behavior after physical restraint," the Annals of Emergency Medicine researchers wrote.
Restraint patients
The researchers conducted the first large-scale study to characterize the kinds of patients who are restrained in the ED setting. Their study features 3,739 patients who were restrained in the emergency rooms of five hospitals.
For the vast majority of patients in the study, the researchers found there were two groupings of restrained patients with significantly different characteristics:
The larger grouping accounted for two-thirds of restrained patients, with a median age of 39. The smaller grouping of restrained patients had a median age of 64.
About 70% of the larger grouping were men, compared to about 60% male sex in the small grouping.
About 30% of patients in the larger grouping were black, compared to 20% in the smaller grouping.
About 60% of patients in the larger grouping had Medicaid coverage, and about 49% in the smaller grouping had Medicare coverage.
Homelessness was much higher in the larger grouping at 8.9%, compared to 0.9% in the smaller grouping.
Chief complaints varied widely between the two patient categories, with about 50% of the larger grouping complaining of drug or alcohol use and about 80% of the smaller grouping presenting with medical complaints.
The researchers say ED staff should take a cautious approach when deciding whether to restrain both kinds of patients.
An earlier study showed ED staff had strong sentiments of frustration and resentment toward patients with alcohol or drug use, psychiatric illness, homelessness, and frequent ED visits—all qualities associated with the larger grouping of patients in the Annals of Emergency Medicine research.
"These negative sentiments highlight a potential pitfall for implicit bias and stigmatization by ED health workers of an already marginalized population because of their underlying health conditions," the researchers wrote.
The researchers say there is significant risk associated with restraining older adults.
"Two previous retrospective studies of elderly ED patients with behavioral emergencies reported significant rates of cognitive impairment and multiple comorbidities that may be affected by sedation and restraint use," the researchers wrote.
Best practices
The Joint Commission has 10 primary standards for restraint and seclusion of patients:
Restraint and seclusion should be used only when clinically justified or when patient behavior poses a physical danger to the patient or others.
Patient restraint or seclusion should be implemented safely based on hospital policy as well as laws and regulations.
Restraint or seclusion should be based on an individual order for specific patients, not standing orders. If the attending physician did not make the restraint or seclusion order, he or she should be consulted as soon as possible.
Medical staff should monitor restrained or secluded patients.
Hospitals should have written guidelines for restraint and seclusion.
Patients who are restrained or secluded should be evaluated repeatedly.
Patients who are both restrained and secluded should be monitored continually.
Use of restraint or seclusion should be documented.
Staff should be trained in the safe use of restraint and seclusion.
Deaths linked to restraint or seclusion should be reported to the Centers for Medicare & Medicaid Services.
After careful screening of patients in the emergency department, outpatient management of blood clots is less costly and more convenient for patients compared to inpatient care.
Acute pulmonary embolism patients deemed at low-risk for adverse events can be treated safely at home after receiving therapy in an emergency room, recent research indicates.
Acute PE is the third top cause of cardiovascular death, and inpatient treatment has been the historical standard of care for patients. However, a study in CHEST featuring 200 acute PE patients found they could be treated safely at home with outpatient management and anticoagulant medication.
The study's lead author, Joseph Bledsoe, MD, of Stanford University and Intermountain Medical Center, told HealthLeaders this week that home therapy is less costly and more convenient for patients.
"Home-based treatment is really about patient convenience and patient cost savings. Patients are able to sleep in their own beds, spend time with their families, eat their own food, and go to work. By not missing work, they don't have loss of income; and by avoiding the hospitalization, they avoid the associated bills," Bledsoe said.
Treatment at home also avoids risks associated with inpatient care, he said. "Medical errors and hospital acquired infections are an unfortunate complication of hospital admission that can be avoided by home treatment."
Bledsoe and his colleagues, who included researchers from the University of Utah, say their study's 200-patient sample size is small but significant because patients were drawn from five diverse hospitals. "Enrollment of patients from a large tertiary referral hospital and four suburban community hospitals suggests generalizability of our results," they wrote.
Screening patients
Thorough assessments of acute PE patients in the ER are crucial to determine which patients are safe to send home, Bledsoe said.
"PE can be safely treated at home for patients who have been appropriately risk stratified. Using mortality-risk prediction scores, echocardiograms, whole leg ultrasound, cardiac monitoring, and other risk stratification is important to ensure patients will be safely treated at home and minimize the risk of a complication."
Earlier research supports the safety of sending carefully screened acute PE patients home after treatment at an ER, the CHEST study says. "Retrospective analysis has suggested a low PE mortality rate among select patients with PE treated on an outpatient basis, and patients with PE with a good prognosis are unlikely to benefit from inpatient care."
Treating patients
Acute PE patients who participated in the home care study received standardized care.
Patients were observed for 12 to 24 hours either in an ER bed or a hospital bed under outpatient observation status
They underwent transthoracic echocardiography and compression ultrasound of both legs as well as compression ultrasound of symptomatic arms
Treatment featured therapeutic anticoagulation with medications such as enoxaparin and rivaroxaban
A physician specializing in thrombosis care consulted with each patient while they were under observation
Outpatient follow-up with a thrombosis physician or the patient's primary care physician was set up before patients were discharged
Follow-up appointments and patient education are key factors to ensure safety, Bledsoe said.
"Educating patients about their diagnosis and treatment, including the possible bleeding risks of treatment, as well as timely outpatient follow-up are important to ensure patient safety. Home treatment of PE is not as simple as identifying the disease, treating, and sending patients home. It takes a thoughtful approach and robust communication with patients."
The disparity between rural and urban cancer patients is best explained by differences in access to care, not demographics or lifestyle factors, recent research suggests.
Rural cancer patients generally have worse outcomes than their urban counterparts, and physician leaders seeking to address the disparity should boost access to care rather than focusing on other factors.
A study published this month in JAMA Open Network found similar outcomes between rural and urban patients enrolled in clinical trials, which suggests lack of access to high-quality care in rural areas is the reason for the outcome disparity.
"If rural and urban patients with cancer receiving similar care also have similar outcomes, then a reasonable inference is that the best means by which to improve outcomes for rural patients with cancer may be to improve their access to quality care," the researchers wrote.
The research examined mortality outcomes in 17 groupings of rural and urban cancer patients enrolled in clinical trials. Mortality outcomes between the patients only varied in one grouping, with rural patients experiencing higher mortality for adjuvant-stage estrogen receptor–negative and progesterone receptor–negative breast cancer.
The research featured nearly 37,000 patients from across the country enrolled in clinical trials over a 26-year period. Closely reflecting national demographics, 19.4% of the patients were from rural areas.
Clinical trials were the focal point of the research because they generally provide consistent high-quality care.
"Patients receiving care in this setting are uniformly staged, treated, and followed up under protocol-specific guidelines, reducing the potential influences of inconsistent pretreatment evaluation, care, and post-treatment surveillance," the researchers wrote.
Earlier research demonstrated a significant level of disparity in cancer mortality rates between rural and urban areas, with 180.4 cancer deaths per 100,000 people in rural areas compared to 157.8 cancer deaths per 100,000 in urban areas.
Closing the gap
The JAMA Open Network researchers made five recommendations for physician leaders and healthcare organizations to address the disparity in cancer treatment outcomes between rural and urban patients:
Improve access to affordable health insurance
Expand access to screening and prevention tools
Boost access to oncology specialists
Increase transportation resources for rural patients who travel long distances to access quality care
Adopt innovation care networks to give rural patients access to new treatments and clinical trials
The researchers say two network models for oncology care—one in the United States and another in Australia—could help address the rural-urban cancer care disparity in this country:
Australia's Regional Cancer Centers of Excellence are designed to offer multidisciplinary care, boost support services, and increase clinical trial participation. This program has improved access to care, with increased treatment of rural patients in their communities.
At physician practices affiliated with Virginia Mason Medical Center, effective workflow optimization addresses burnout challenges with a team-based approach.
Through workflow optimization, physician practices can create a team-based approach to care that alleviates physician burnout, a Seattle-based internist says.
Inefficient workflows contribute to physician burnout in several ways, says Richard Furlong, MD, an internist affiliated with Virginia Mason Medical Center.
"The elements of physician burnout that are impacted by a flow that is not optimized are waiting unnecessarily, having a visit that you are conducting not set up for you, having a schedule that is mismatched relative to the demands upon you, and having a sequence of tasks that you are burdened with that are not matched with your skill level," Furlong says.
Effective workflow optimization addresses burnout challenges with a team-based approach, he says.
"Optimization initiatives that address flow are usually targeted at those categories—lack of set up, mismatch of supply and demand, and poor skill-task alignment."
Furlong and his care team colleagues have focused primarily on three workflow optimization tactics that foster team work: spreading the work burden among physicians, adoption of standardized work roles, and colocation of team members when feasible.
"We have team members who can help us, but we have to organize the work so that can happen," he says.
Data collected by The Advisory Board indicate that the workflow optimization efforts are having a positive impact on the employment satisfaction of physicians, advanced registered nurse practitioners, and physician assistants at Virginia Mason Kirkland Medical Center, where Furlong is based.
For the past two years, 100% of physicians, APRNs, and PAs surveyed have reported they were engaged or content with their workplace. Engagement is considered an indication of a staff member's dedication to the organization and willingness to go above and beyond on the job.
Spreading responsibilities
To prevent physicians from burning out, and to help them work at the top of their license, patients in Furlong's practice are often seen by caregivers other than the physicians, including clinical pharmacists, care managers, RNs, physician assistants, and nurse practitioners.
For example, diabetic patients can be seen by care managers and nurses who can help the patients manage their chronic condition.
"We have a process in place where the patient can be referred to a care manager, and the care manager becomes a co-owner of that patient. We'll make phone calls in between visits, and patients will have nurse-only visits for insulin teaching and lifestyle modification," Furlong says.
"The physician is not out of the loop but is not involved in every one of the care touches. When the patient comes back after three months to have their A1C checked and their meds reviewed, we have done some focused training with our APs to handle those follow-up visits," Furlong says.
Clinical pharmacists have been playing an increasingly important role in spreading the workload, he says.
"What a lot of clinics have not done is to take some of their staff—especially the clinical pharmacists—and plug them into the workstation of the provider who is out of the office on any given day. That has been successful for us because a lot times the clinical pharmacists have capacity in their day to help physicians," Furlong says.
The role of clinical pharmacists has been expanding steadily at Furlong's practice.
"They are involved in seeing patients in face-to-face, direct care. They started out seeing our coagulation patients—our patients on Warfarin. Then we had them see our hypertension patients. Now, we have them seeing patients on antidepressants and chronic opiates," he says.
Most primary care practices could benefit from utilizing clinical pharmacists, Furlong says. "They are in the mix in primary care in a big way. A lot of other healthcare institutions are getting onboard with using clinical pharmacists; and if you are not, you are behind."
Standardized roles
Establishing standardized roles can ease the workload burden on physicians, Furlong says.
For example, his practice has established new standardized roles to limit the number of patient portal and phone messages that are handled directly by physicians.
"The intent was to discern which messages could be handled by someone other than the physicians. So, we had a meeting with the pharmacists and asked them what kind of questions they would be willing to field and bypass the physician," Furlong says.
Medical assistants have also adopted a new standardized role to help manage patient messages, he says.
Colocation
Having care team members located at the same site can enable workflow optimization and ease physician workload, Furlong says.
Having pharmacists on-site can be particularly helpful in giving physicians timely support. For example, they can help review the medications of patients after discharge from a hospital.
"The patient could have 15 medications and there is often confusion about what they were discharged on. The pharmacists are good at digging in and sorting all that out. Sometimes, they can jump in and help on the spot," Furlong says.
And if it isn't possible to have all team members on-site? From a workflow optimization standpoint, it is possible to overcome the lack of care team colocation, he says. "Every health system has an electronic health record, so there are communication tools within the EHR."
For women aged 30 to 65, new national recommendations could mean end of Pap smear tests.
New recommendations for cervical cancer screening feature a significant change—giving women aged 30 to 65 the option to undergo one test every five years.
Screening every three years with cytology alone. Cytology is also known as Pap smear testing.
Screening every five years with testing for high-risk human papillomavirus (hrHPV) alone.
So-called cotesting for cervical cancer with both cytology and hrHPV techniques every five years.
This is the first time women have been given the option to be screened with hrHPV testing alone. The recommendations, which were published this week in JAMA, replace guidance issued in 2012.
A JAMAarticle accompanying the new guidance says the option of hrHPV testing alone reflects a trend toward less frequent testing. "These recommendations continue the trend of decreasing participant burden by lengthening screening intervals, making the 'annual Pap' a historical artifact," the article says.
The hrHPV test detects the DNA of human papillomavirus strains that have been linked with cervical cancer.
Weighing trade-offs
According to the new recommendations, cytology alone every three years or hrHPV testing alone every five years are the preferred cervical cancer screening methods for women aged 30 to 65 years.
Cotesting with cytology and hrHPV exams is considered an "alternative strategy" under the recommendations, but cotesting could result in more tests and procedures than either cytology or hrHPV testing alone.
Physicians and patients face sorting through trade-offs to determine the best screening strategy.
The recommendations estimate that hrHPV testing alone and cotesting would avoid about one additional cancer case per 1,000 women screened compared to cytology alone for a "very small" gain in life years. However, hrHPV testing and cotesting expose women to more tests and procedures than cytology alone.
The JAMA accompanying article says there is a similar trade-off between cotesting and hrHPV testing.
"Cotesting is slightly better than primary hrHPV testing at detecting precancerous lesions but is associated with increased tests and diagnostic procedures that may not benefit the patient and that have real costs to the health system," the article says.
Cytology is the lowest cost option and could be the best fit for public health systems, according to the article.
"Public health systems in general will more explicitly face trade-offs between less expensive techniques (cytology every three years) involving more clinician visits and more expensive approaches with substantially fewer patient touch points," the article says.
With more screening options available, physicians and healthcare organizations need to increase educational efforts for patients.
"What is clear is that new strategies will be needed to assist healthcare consumers in making informed choices from a broader range of options. New risk communication tools and messaging strategies will be needed to promote adherence and to increase acceptance of the lengthened intervals," the article says.
Cost and value
While cytology is the lowest cost screening method, the new recommendations do not address the comparative cost or value of cytology, hrHPV testing, and cotesting.
However, a JAMAeditorial accompanying the recommendations shows how healthcare organizations and researchers can assess the cost and value of the cervical cancer screening options.
One method to assess cost effectiveness and value is quality-adjusted life-years (QALY) analysis. The metric features both benefits and harms to estimate total costs per strategy and cost-effectiveness. Under QALY analysis, high-value screening strategies maximize benefits while minimizing harms and cost.
Physicians will have to help their patients assess value, the editorial says.
"If it is left to individuals to decide whether hrHPV testing or cotesting provides an appropriate balance of benefits and harms as compared with cytology, user-friendly educational tools will need to be developed to assure that women are making informed choices reflective of their preferences," the editorial says.
The Institute for Healthcare Improvement is launching a three-year effort to help decrease maternal mortality and morbidity.
The Institute for Healthcare Improvement (IHI) has launched a three-year initiative to address alarmingly high rates of maternal mortality and morbidity.
IHI, which launched the effort this month with support from the Merck for Mothers $500 million program, is focusing first on designing an approach to improving maternal health, says IHI Executive Director Jill Duncan, RN, MS, MPH.
"It is our commitment to build partnerships with those whose life work is to address women's health—specifically the racial disparities that exist around maternal mortality and morbidity. We are doing outreach and building partnerships," she says.
Among high-resource countries, the United States has the highest maternal mortality rate, according to the Washington, D.C.–based Alliance for Innovation in Maternal Health (AIM). Worldwide, only Afghanistan, Sudan, and the United States are experiencing rising rates of maternal mortality, AIM says.
Best practices
One of the top priorities of IHI's maternal health initiative is promoting the adoption of maternal safety bundles, Duncan says.
"There are safety bundles that organizations are adopting to address hemorrhage, hypertension, C-section rates, and blood clots. They are part of the AIM initiative and have been adopted by several states."
Prevention of retained vaginal sponges after birth
Reduction of peripartum racial and ethnic disparities
Safe reduction of primary Cesarean birth
Severe hypertension during pregnancy
Severe maternal morbidity review
Support after a severe maternal event
IHI is building on Merck's efforts to promote maternal safety bundles, Duncan says.
"Part of our interest is to work with partners who have found some success in spreading those bundles. We want to tie the bundles with our work in scaling best practices with improvement methodologies and accelerate the spreading of those bundles at the state level and at health systems."
Tackling disparity
Racial disparity is among the most vexing problems associated with maternal health, with black women experiencing mortality and morbidity at rates three to four times higher than other mothers, according to IHI.
There is a complex mix of medical and social reasons for the racial disparity, Duncan says.
"Black women are more likely to be uninsured. We are also recognizing the urgency of health systems and other organizations to grapple with unconscious biases—both institutional and structural racism—and the impact that has on black women in this country. It impacts the care that they get and the outcomes they experience."
She says there are several strategies that can be pursued to address the racial disparity in maternal health:
Improving treatment of health conditions and pregnancy complications
Adopting evidence-based methods to decrease complications
Advancing the understanding of the experience of black women
Reducing risk factors
Increasing protective factors such as the support women receive before, during, and after pregnancy
Addressing racial disparity in maternal health will take inspired leadership, Duncan says.
"It takes bold, courageous, and creative leaders in health systems and communities to act in new ways and radically redesign the way they think, the way they work, and the way they connect."
Tobacco use is associated with several negative surgical outcomes, including impaired wound healing, increased infection, and poor lower joint replacement results.
Tobacco smokers who have orthopedic surgery face higher risks of complications and should be enrolled in smoking cessation programs, research shows.
A recent review of 26 scientific articles on smoking and orthopedic surgery found significant risk of negative outcomes for patients.
"People who smoke heavily before orthopedic surgery may have more nonmedical complications than nonsmokers. Therefore, all orthopedic surgery patients should be screened for tobacco use," wrote the author of the review in Hospital Practice, E. Carlos Rodriguez-Merchan MD, PhD.
Smoking cessation
Rodriguez-Merchan says surgeons should help patients stop smoking before and after orthopedic surgery.
"The adoption of smoking cessation methods such as transdermal patches, chewing gum, lozenges, inhalers, sprays, bupropion, and varenicline in the perioperative period should be recommended. Perioperative smoking cessation appears to be an efficacious method to decrease postoperative complications even if it is implemented as late as four weeks before surgery."
Research published last year examined an online smoking cessation program used by smokers undergoing orthopedic trauma surgery. The study showed both strengths and weaknesses of the cessation program.
The study featured 31 orthopedic trauma patients. Engagement in the online cessation program was high, with 28 of the patients using the program during their hospital admissions. In addition, 20 patients completed follow-up smoking cessation phone calls after discharge.
The patients reported several weaknesses of the online cessation program:
Lack of time
Desire for additional support
Computer illiteracy or technology issues
Feeling unprepared or too stressed to quit
Reaching the point where nothing more could be learned from the online program
Smoking complications
Rodriguez-Merchan found multiple scientific articles that concluded smoking increases the risk of complications after orthopedic surgery.
"Orthopedic perioperative complications of smoking include impaired wound healing, augmented infection, delayed and/or impaired fracture union and arthrodesis, and worst total knee and hip arthroplasty results," he wrote.
One fracture study found that a cessation protocol started in the inpatient setting and performed for six weeks decreased the risk of developing at least one postoperative complication. For the control group, 38% experienced at least one complication, compared to 20% of patients in the cessation protocol.
Spine surgery research determined that smoking has a negative impact on surgical outcomes after lumbar and cervical spine procedures.
A spinal fusion study showed smoking increases the rate of perioperative complications. Smoking cessation was recommended for four weeks following surgery.
In anterior cruciate ligament surgery research, smoking was linked to increased rates of infection and venous thromboembolism after ACL reconstruction.
With a shortage of pharmacists and clinicians in rural areas, telepharmacy and telehealth clinical pharmacy services can fill the gap.
Telepharmacy and telehealthapproaches to clinical pharmacy services are helping to address pharmacist and clinician shortages in rural areas of the country.
Telepharmacy, which features the dispensing of medications and other pharmacy services, has allowed Scotland County Hospital in Memphis, Missouri, to establish a 24/7 pharmacy after years of being limited to a part-time service.
"We tried to hire a full-time pharmacist for about a year to have an on-site pharmacist. We knew it would create a larger cost center, but we also knew it would improve care. We had one or two people interview, and neither one took the position," says Randall Tobler, MD, CEO of Scotland County Hospital.
In September 2017, the hospital launched a hybrid pharmacy model, with a part-time pharmacy director and a telepharmacy service provided by San Francisco–based PipelineRx.
"Decisions related to formulary are done with our pharmacist of record. Pipeline certifies and validates oncology orders, checks for drug interactions, and makes dosing adjustments," Tobler says.
At the University of Iowa in Iowa City, the College of Pharmacy is operating a telehealth clinical pharmacist service called Centralized Healthcare Solutions. CHS is under the umbrella of the College of Pharmacy and any revenue generated flows to the university.
"We expand the types of clinical services to rural communities that they either don't have access to, can't afford, or can't staff," says Christopher Parker, PharmD, executive director of operations at CHS.
CHS, which started out focusing on patients with cardiovascular disease, was launched in November 2016.
"We would work with patients who had a past history of cardiovascular disease—a previous heart attack or a previous stroke—and we would help to lower their risk by getting their blood pressure under control and making sure they were on the right medications," Parker says.
Telepharmacy service
Contracting with a telepharmacy provider has helped Scotland County Hospital fill a critical need, Tobler says.
For several years, the hospital had relied on the local retail pharmacy to also serve as the hospital's pharmacy. "The pharmacist did the best he could to meet our 24/7 needs such as reviewing orders, but he wasn't a 365/24/7-guy-in-town all the time," he says.
The lack of continuing coverage created a compliance problem.
"Many times, we had to invoke the emergency rule to have orders reviewed after the fact. Under Medicare, all first-dose orders—whether it is the patient's own medication or something a doctor prescribes—have to be reviewed by a pharmacist unless there is an emergency," Tobler says.
"When I took over here about three years ago, I just felt that was not optimal, and we looked for ways to make it work financially. The way we made it work was by employing PipelineRx as a telepharmacy service," he says.
The telepharmacy service works on a daily basis with pharmacy technicians at the hospital.
"The techs have a daily call with Pipeline and they discuss whether ordered medications have been administered," Tobler says.
Although the critical access hospital is too small to generate statistically significant data about the telepharmacy service, he says gains have been realized.
"In general, we have stepped up the scrutiny of our prescribing. In essence, it gives me and our physicians a sense that there is someone looking over our shoulders to give a second opinion on prescribing," he says.
Pharmacy technicians are also functioning in a more optimal manner, Tobler says.
"The pharmacy techs have always been conscious of which drugs are going in the bins, but some of the burden of the pharmacist role has been taken off of them. They also have a new backstop that gives them peace of mind to focus on their core duties for patients," he says.
Patients have definitely benefited, Tobler says. "The turnaround times are much better. Now, the nurses can take routine orders, and they are not waiting. Patients are not getting delayed dosing because they are waiting for verification."
Telehealth service
CHS has expanded its clinical pharmacy services far beyond lowering the cardiovascular risk of patients.
"We have expanded to areas like focusing on tobacco cessation. We are working now to set up a contract to provide a tobacco cessation program for patients at high risk for hospitalization because of COPD," Parker says.
"We also focus on targeted disease interventions. In the rural settings, a lot of the clinics have trouble focusing in certain areas—uncontrolled blood pressure, diabetes, asthma. We will help them identify where they are struggling clinically, then figure out ways for our team to help," he says.
In addition to expanded services, CHS has expanded the number and variety of its clients.
"We have the gamut. We have privately owned rural primary care clinics. We have rural health systems that have hospitals and clinics. We have larger health systems that have rural clinics as part of their systems," he says.
Although CHS does not provide dispensing, it does ease staffing shortages at rural clinics, Parker says.
"The feedback we have gotten from the clinics in rural settings revolves around them not being able to hire enough primary care physicians. When we work with these clinics, the providers can refer patients to us for chronic diseases like diabetes. Then the patient may only need to see a primary care physician once or twice a year," he says.
Based on research conducted at rural clinics, Parker says CHS has generated several positive results:
Diabetes patients were able to achieve lower hemoglobin A1C values compared to patients in a control group.
Patients who were on guideline adherence for their disease state achieved double adherence compared to patients who did not work with CHS pharmacists.
Some clinics allowed CHS to manage patients independently. In those situations, CHS had a greater impact on lowering cardiovascular disease risk.
CHS is offering health systems, hospitals, and clinics an unconventional service, Parker says. "This model expands the role that a pharmacist plays."
