Low-acuity coronavirus patients can be safely monitored remotely at home.
A Denver-based health system has used remote monitoring to care for coronavirus disease 2019 (COVID-19) patients who do not require hospitalization.
Although there are therapeutics for treating seriously ill COVID-19 patients in the inpatient setting—remdesivir and dexamethasone—there are no therapeutics that have been found effective in treating coronavirus patients in the outpatient setting. Given that limitation, monitoring low-acuity COVID-19 patients at home is a viable option.
Denver Health created its Virtual Hospital at Home (VHH) program to care for COVID-19 patients who do not require inpatient care. "A remote home monitoring program can provide a safe care mechanism for a diverse population of COVID-19 infected patients who do not meet admission criteria, yet have risk factors for severe COVID-19 complications. Remote monitoring may also be beneficial in managing future surge hospital capacities," a recent research article written by Denver Health clinicians says.
The research article, which was published by Infection Control & Hospital Epidemiology and features data from more than 200 patients, includes several key data points.
81.5% of the patients in the VHH program were successfully discharged
13.3% of the patients in the VHH program required a higher level of care, with 38.7% of those patients admitted for hospitalization
The majority of the VHH patients were either uninsured (28.3%) or covered by Colorado Medicaid (38.2%)
"The VHH provided a safe and effective mechanism to remotely monitor a population that has been disproportionately affected by the COVID-19 pandemic. As 95% of patients referred participated, it seemed to be well received by patients, and successfully managed the majority of patients within their own homes," the research article's co-authors wrote.
Virtual Hospital at Home benefits
The VHH program has four primary advantages in the care of low-acuity COVID-19 patients in the outpatient setting, according to the research article.
The VHH program helps manage hospital-based resources in two ways. First, VHH allows emergency department clinicians to send low-acuity patients home rather than admitting them to an observation inpatient stay. Second, hospitalists can use the VHH program to safely discharge recovering COVID-19 patients to home, where they receive outpatient oversight and care guidance.
VHH COVID-19 patients receive at least two phone calls per day—once from a clinician and once from a nurse. So, the telehealth approach allowed Denver Health to conserve personal protective equipment supplies.
Many of the VHH participants were members of ethnic minority groups who were either uninsured or on some form of government insurance. These patients demonstrated an acceptance of the novel telehealth program.
The VHH provided Denver Health with an opportunity to connect patients with primary care providers if they did not have an existing relationship with a primary care clinician.
Keys to home monitoring success
The daily calls to VHH patients were a crucial element of the program, two of the research article's co-authors told HealthLeaders.
"The intent was for patients to receive one clinician call daily and one nurse call daily. We tried to make one call in the morning and one in the afternoon. The ability to have an ongoing dialogue all day allowed us to have a lot of back-and-forth interaction. Patients could sound very different in the morning vs. the afternoon," said Jeremy Long, MD, MPH, medical director of the Intensive Outpatient Clinic at Denver Health.
"The biggest piece of advice that I would offer to other health systems is making sure that they have a sustainable way to have frequent touches with the patient. The patients can have big swings in their course—even within the same day. So, you need to make sure there are multiple touches with the patient throughout the day to make sure this is a safe program," said Patrick Ryan, MD, medical director of the Hospital Transitions Clinic at Denver Health.
Targeting low-acuity patients also was pivotal for the VHH program's success, Ryan said.
"For COVID-19 hospital admissions, it came down to whether patients needed supplemental oxygen or if the clinicians found reasons for the patients to receive IV antibiotics, IV fluids, or intensive cardiac monitoring such as telemetry. Those are services we would not be able to offer through our Virtual Hospital at Home program. With our Virtual Hospital at Home program, we are only able to monitor pulse, pulse oximetry, blood pressure, and temperature. With those limitations, patients who needed more intensive monitoring helped guide clinicians to admit patients for hospitalization rather than sending them home with Virtual Hospital at Home," he said.
Ensuring that payers would support the VHH program also was important, Long said. "Another important piece is to be aligned with your payers. You need to be talking with the Medicaid program in your state and the Medicare Advantage companies to be sure there is alignment in terms of reimbursement. That is one of the things that helped us with this Virtual Hospital at Home program. We were doing provider visits over the phone and receiving reimbursement."
In addition, effective internal communication at Denver Health was essential, Ryan said. "Our team communication was critical to ensure that this was a safe program for patients. Through our electronic health record, we have a chat function, so all members of the team on a given day can chat constantly to give updates on their phone calls with patients. This chat function helped monitor changes in the courses of patients at home, and it helped make decisions about whether patients could continue to be safely monitored at home or admitted to the hospital."
Finally, having a narrow focus on COVID-19 patients helped achieve success in the VHH program, Long said.
"If we just wanted to shorten length of stay across the board in inpatient admissions through Virtual Hospital at Home, that would be hazardous. Focusing on a single disease process boosts safety. For example, with the right expertise and the right technology, heart failure patients could be good candidates for a Virtual Hospital at Home program. Other examples include emphysema, community-acquired pneumonia, and some infections, where patients can safely receive a transition from intravenous to oral antibiotics."
The more physical and occupational therapy visits pneumonia patients receive while hospitalized, the lower the risk of readmission or death, study finds.
Physical and occupational therapy for pneumonia patients in the acute care setting lowers hospital readmission and mortality risk, a recent research article says.
For adults, pneumonia is a leading cause of mortality and hospitalization. The respiratory condition also is a common reason for hospital readmission. Since 2012, Medicare has been penalizing hospitals financially for readmissions linked to several targeted conditions including pneumonia.
The recent research article, which was published by JAMA Network Open, is based on information collected from more than 30,000 patients with pneumonia or influenza-related conditions at a dozen acute care hospitals in Pennsylvania. The number of physical and occupational therapy visits provided during hospitalizations was categorized as none, low (1-3), medium (4-6), or high (greater than 6).
The study features several key data points:
18.4% of patients had a hospital readmission within 30 days of discharge
3.7% of patients died within 30 days of discharge
Compared to no therapy visits, risk of 30-day readmission or death decreased as therapy visits increased: low visits, odds ratio 0.98; medium visits, odds ratio 0.89; and high visits, odds ratio 0.86
The inverse relationship between therapy visits and risk of 30-day readmission or death was stronger in patients with low functional mobility and individuals discharged to a community setting
Receiving both physical and occupational therapy visits was associated with a decreased risk of 30-day readmission or death (odds ratio 0.90)
Compared to having no therapy visits, patients discharged to home who had at least 7 therapy visits had a decreased risk of hospital readmission or death within 30 days of discharge (odds ratio 0.68)
"In this study, we examined the association between therapy visits and the risk of 30-day readmission or death in adults hospitalized with a diagnosis of pneumonia or influenza-related conditions. We found that the number of therapy visits received was inversely associated with the risk of readmission or death. This association was greater in the subgroups of patients with lower mobility and patients discharged to the community," the research article's co-authors wrote.
Interpreting the data
The study's co-authors speculated about why the association between therapy and positive outcomes was strongest for patients who had lower mobility or were discharged to home.
"These findings make theoretical sense given that individuals with lower mobility are likely to benefit from therapy. Contact with a [physical therapist] or [occupational therapist] for individuals discharged to the community with functional limitations may also ensure that the patient receives appropriate follow-up care in a timely manner," they wrote.
Readmission risk may have been reduced because therapy decreased the level of functional decline patients experienced during their hospitalization, the co-authors wrote. "Because pneumonia and influenza-related conditions are likely to resolve with appropriate medical management, therapy may be particularly useful in targeting impaired function, a modifiable risk factor for hospital readmission."
The number of therapy visits received was a key factor in reducing the risk of hospital readmission or death, the co-authors wrote. "Our findings also suggest that it is the number of therapy visits received, more than the types of therapists seen, that was associated with the risk of readmission or death."
Rapid diagnosis and treatment of sepsis saves lives.
In recent years, HCA Healthcare and OhioHealth have been able to reduce sepsis mortality significantly.
September is Sepsis Awareness Month. Sepsis and the body's response to the infection is one of the deadliest medical syndromes in the United States, according to the Centers for Disease Control and Prevention. About 1.7 million adult Americans develop sepsis annually and the condition claims about 270,000 lives each year. About one-third of patients who die in hospitals succumb to sepsis.
Decision support tool
HCA Healthcare has developed a computer-based decision support tool called Sepsis Prediction and Optimization of Therapy(SPOT), and it can detect sepsis 18 hours earlier than the best clinicians, says Jonathan Perlin, MD, PhD, president of clinical services and chief medical officer at the Nashville-based health system.
"This is the future. Military fighter planes can't fly without decision support. Healthcare is equally complex. To think that we can manage all the variables without assistive technology is inconsistent with how we think about high-reliability endeavors like aviation and healthcare," he says.
HCA Healthcare started adopting elements of the Surviving Sepsis Campaign in 2013. From 2013 to 2017, sepsis mortality at the health system's hospitals fell 39%. HCA Healthcare launched the SPOT initiative in 2018. From 2017 to 2018, sepsis mortality at the health system's hospitals dropped nearly 23%.
SPOT features an algorithm embedded in HCA Healthcare's electronic health record that was built with Red Hat open source software. To indicate the onset of sepsis, the SPOT algorithm combines factors such as patient demographics data and medical history with continuous monitoring for signs and symptoms of sepsis as well as key elements of clinical care:
Body temperature
Blood pressure
Heart rate
Platelet count
Medications
Laboratory tests
Patient transfers such as moves to an ICU
"The SPOT algorithm surveils 24 hours a day, seven days a week to look for the signs and symptoms of sepsis. When those signs are found, they are teed up and presented to the caregivers," Perlin says.
When the algorithm detects a likely case of sepsis, SPOT initiates an alert similar to a heart attack or stroke code that prompts clinical care teams to take action. Caregivers who receive the alerts include telemetry units, nurse leaders, sepsis code teams, and rapid response teams.
An essential component of the SPOT initiative is the algorithm's diagnostic accuracy, Perlin says.
"We were able to train the algorithm to be more than 100% sensitive—we picked up cases of sepsis that the care providers did not see, and our rate of false positives was half that of care providers. So, the specificity was twice as good as clinicians. It not only improved care but also the efficiency of doctors and nurses," he says.
OhioHealth's approach
At OhioHealth, a systemwide initiative involving physicians, nurses, laboratory operations, and pharmacists has helped the Columbus, Ohio-based health system reduce its sepsis mortality rate.
Starting in July 2015, OhioHealth reduced sepsis mortality by educating staff members, utilizing a rapid diagnostic test, reducing the medication response time from hospital-based pharmacists, and creating a clinical culture that tolerates false diagnosis.
The effort required engaging thousands of health system workers about sepsis and highlighting an opportunity for care improvement, says James M. O'Brien Jr., MD, MSc, system vice president for operations and population health. "A big piece has been making the case that this work is important to us as an organization by looking at the underlying data of what our baseline mortality rate was and how many people it was affecting across our health system."
When OhioHealth launched the sepsis effort in 2015, the sepsis mortality rate was 24.3%. In 2018, mortality in sepsis patients was 20%.
Rapid sepsis testing reduced the laboratory time required to diagnose sepsis and narrow down the best antibiotic treatment from a day or more to a couple of hours, O'Brien says.
The previous generation of sepsis tests required a lengthy two-step process. First, a blood culture test would determine whether a patient was positive for sepsis, then the blood culture would be challenged with multiple antibiotics to see which antibiotic would be best for treating the patient.
With the rapid testing technology, once a blood culture tests positive for sepsis, molecular testing quickly narrows down the best antibiotic to treat the patient.
Once an OhioHealth clinician has prescribed an antibiotic, pharmacists are expected to have the medication at the bedside in less than an hour, O'Brien says. "In pharmacy, you need engagement with the medication safety pharmacist and the antibiotic stewardship pharmacist. They are the folks who tend to be most in tune with our pattern of resistance to antibiotics and what is appropriate."
Achieving rapid treatment for sepsis patients requires creating a clinical culture that does not penalize clinicians for "false-alarm" diagnoses, O'Brien says. "We have to be really careful to understand that clinicians are doing a difficult task in trying to figure out what to do, because this is a disease for which there is no single test that says, 'This is absolutely sepsis.' They are making decisions with uncertainty."
Anil Keswani, MD, discusses the outpatient setting, patient safety, and value-based care.
Scripps Health has split the health system's chief medical officer position into two roles.
In August, Anil Keswani, MD, was appointed as chief medical officer for ambulatory and accountable care at the San Diego–based health system. He had previously led population health efforts at Scripps and earlier served as vice president of medical management at Chicago-based Advocate Health Care.
Also in August, Ghazala Sharieff, MD, MBA, was appointed chief medical officer for acute care, clinical excellence, and experience.
Keswani recently talked with HealthLeaders about the outpatient setting and value-based care. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary strategies to manage the shift of treatment from the inpatient setting to the outpatient setting?
Anil Keswani, MD: First, we are creating ambulatory facilities and hubs that provide primary care as well as specialty care, imaging, infusion centers, and much more. In essence, we have created hubs of care that can do a lot more than a primary care clinic.
The most recent supersite we created in Oceanside has primary care, specialists, an ambulatory surgery center, and an infusion center with beautiful views. It is really a health center with everything built into it. This kind of site not only helps prevent people from getting sick, but also eliminates the need to go to a hospital for services that can be done on the outpatient side such as colonoscopy and orthopedic procedures.
The second strategy involves moving from hospitals and even ambulatory centers to the home. Last year, we launched a program in conjunction with our physicians that allows us to do house calls. These are not the house calls of years ago; they are house calls with a system of support built around them to make sure that the patients who are most vulnerable or frail receive care in the home for everything from the primary care they need to advanced care planning. It is a way to keep people happy and healthy in their home, and to prevent the need to go to an acute care setting.
The third strategy is a digital strategy with remote patient monitoring. This is incredibly important for us to be sure when people are at home that we have a continuous touch point with them. Again, this helps prevent patients from needing care in an acute care setting.
HL: What is a primary strategy for ensuring patient safety in the outpatient setting?
Keswani: Epic is our electronic health record, and we have Epic wall-to-wall throughout our clinics and our hospitals. When we look at patient safety, breakdowns are often related to breaks in continuous information or communication between people.
One of our primary patient safety strategies is to use Epic appropriately and properly to make sure that we have connected our entire system of care. We want information to flow from imaging to doctors and everything in between. We use MyChart to make sure we are transparent in sharing results with the patient.
This has become a different way of engaging the patient in their healthcare. It provides another set of eyes to make sure that patients are also ensuring their own safety.
HL: Where are the biggest opportunities to improve the value of medical care?
Keswani: There are three hot opportunities, and they probably are timeless.
One is access. As long as I have been in leadership, we have always had a focus on access. Years ago, the focus was on primary care access, then the focus was on specialty care access. Now, the focus on access is not just on the ability of a patient to physically come in for a visit—it is how we use care coordination, how we use remote monitoring, how we connect with people by email, and how we connect with patients where they want to be.
Access is an important process measure that speaks to the Triple Aim.
The second hot opportunity to improve the value of medical care is the patient experience. At Scripps, patient experience is deeply rooted in our culture—we want to improve how patients are heard and their connection to the health system.
For example, more than a year ago, we created Scripps Health Express, which is express clinics built within our health centers using our existing electronic health record. Scripps Health Express is not just a pop-in-and-pop-out setting to get an antibiotic. It has everything from nurse triage by phone before a patient comes in, to being seen the same day, to 100% of patients getting a follow-up call the next day.
Scripps Health Express is an access measure, but it is also off the chart as a patient experience measure.
The third hot opportunity for improving value is making healthcare affordable. Years ago, healthcare professionals were not interested in talking about the total cost of care. Now, Scripps is looking at total cost of care as an access measure—meaning that if we are unaffordable people cannot come to us.
So, whereas quality and experience are absolutely important, they have to be balanced with whether we are providing an affordable total cost of care. We need to make sure we are using the right generic medications and we are using the right protocols.
HL: From the healthcare provider perspective, what are the keys to success in value-based contracting?
Keswani: First, you must have a health system aligned and committed to want to deliver on value. It takes executive leadership and physician leadership to say, 'Yes, we are going to lead toward value.' Doing the value-based contracting without a value-based culture is a fool's errand.
I also have found that bringing the operations team and physician leadership to the table in the contracting is incredibly important. When we talk about value-based contracts, if there is a quality metric, it is important to know whether that quality metric is valuable and measurable. Oftentimes, it will be our physician leaders and operational leaders who will guide us through these contracts.
You also need a strong contracting team to make sure we are successful in the contracting process. Then you need to deliver on the contract, with the infrastructure set up well to make sure you can deliver.
The Merit-based Incentive Payment System may give a payment edge to health system-affiliated outpatient clinicians compared to independent clinicians.
Clinicians affiliated with health systems have posted significantly better performance ratings in the Merit-based Incentive Payment System (MIPS) compared to independent clinicians, recent research found.
Most clinicians participate in MIPS, which is a value-based payment system created by the Centers for Medicare & Medicaid Services (CMS). The first payment year for MIPS was 2019, with payment based on 2017 performance. Last year, clinicians participating in MIPS received payment bonuses or penalties as high as 4% of Medicare reimbursement based on performance scores for quality and cost metrics.
The recent research, which was published by the Journal of the American Medical Association, features data collected from more than 630,000 clinicians working at outpatient clinics across the country. Nearly half of the clinicians were affiliated with a health system.
The study features several key data points:
The mean final MIPS performance score for clinicians affiliated with health systems was 79.0 vs. 60.3 for independent clinicians. The final MIPS performance score ranges from 0 to 100, with higher scores indicating better performance.
The percentage of clinicians who received a penalty payment adjustment was 2.8% for clinicians affiliated with a health system vs. 13.7% for independent clinicians.
The percentage of clinicians who received a positive payment adjustment was 97.1 for clinicians affiliated with a health system vs. 82.6% for independent clinicians.
The percentage of clinicians who received a bonus payment adjustment was 73.9% for clinicians affiliated with a health system vs. 55.1% for independent clinicians.
"For clinicians participating in the 2019 MIPS, health system affiliation was associated with substantially better performance scores. Health system affiliation was also associated with more favorable value-based reimbursement," the study's co-authors wrote.
Interpreting the data
The study speculates the technological advantages that health systems hold over most independent physician practices may account for the better MIPS performance by clinicians affiliated with health systems.
"Clinicians who were affiliated with health systems had higher rates of reporting and performance on technology-dependent measures, such as providing patients access to their health records or electronic prescribing compared with their unaffiliated peers," the study's co-authors wrote.
In addition, two MIPS performance measurement domains are dependent on technology—meaningful use of electronic health records and practice process improvement activities. "Thus, health system affiliation may provide needed technology and management infrastructure that helps clinicians succeed across a range of metrics under value-based payment," the study's co-authors wrote.
Beyond a technological advantage, health systems may generate other MIPS benefits for their clinicians compared to independent clinicians, according to the study.
"Integration in the healthcare delivery system is associated with higher screening rates, better quality on process of care measures for chronic conditions such as diabetes, improved meaningful use of electronic health records, and more use of care management. In addition, practices affiliated with health systems may have more resources to support the measurement, selection, and reporting of quality measures to the CMS."
The study did not reach a conclusion on whether clinicians affiliated with health systems provide a higher level of quality care to patients compared to independent clinicians.
Telemedicine adoption has increased for both physicians and patients since the coronavirus pandemic began, a new Doximity physician network report says.
The volume and financial value of telemedicine visits will increase significantly in 2020 due to the coronavirus disease 2019 (COVID-19) pandemic, according to a new report.
The COVID-19 pandemic has spurred widespread adoption of telemedicine along several fronts at health systems, hospitals, and physician practices—primarily over concern about the spread of the novel coronavirus in healthcare settings. Telemedicine visits for nonemergency care also have been shown to be efficient and effective from both the healthcare provider and patient perspectives.
The new report, which was published last week by the Doximity physician network, is based on three resources: a randomized survey of 2,000 American adults to collect patient data, Doximity network data to reflect "physician adoption insights," and data from the Medical Expenditure Panel Survey and commercial insurance claims to gauge the telemedicine market.
"Physicians have found telemedicine has served as a vital lifeline for practices negatively impacted financially by the pandemic. In our view, the rapid uptake of telemedicine has important structural implications for the U.S. healthcare system," Christopher Whaley, PhD, lead author of the report and assistant adjunct professor at the University of California's Berkeley School of Public Health, said in a prepared statement.
Telemedicine market
The report features three data points on the telemedicine market:
About 20% of all medical visits will be conducted via telemedicine this year
The financial value of telemedicine visits this year will be more than $29.3 billion
The financial value of telemedicine visits is projected to be $106 billion by 2023
Physician perspectives
The report includes three data points on physician adoption of telemedicine:
In a telemedicine report Doximity published last year, the number of physicians who self-reported telehealth as a skill increased annually by 20% between 2015 and 2018. From 2019 to 2020, the number of physicians reporting telehealth as a skill increased 38%.
Female physicians are adopting telemedicine at a higher rate than their male colleagues. In last year's Doximity telemedicine report, female physicians engaged in telemedicine job ads at a rate 10% higher than male physicians. This year's report found female physicians are using telemedicine at a rate 24% higher than male physicians.
This year, the top two specialties using telemedicine are endocrinology and rheumatology. "Treating long-term chronic conditions like diabetes and arthritis require frequent patient visits, but they don’t always need to be in-person. For patients that require long-term care, telemedicine tools can reduce taxing trips to hospitals or clinics," the new report says.
Patient perspectives
The new report includes several data points on patient utilization of telemedicine:
Before the COVID-19 pandemic, 14% of Americans had participated in a telemedicine visit at least once.
Since the COVID-19 pandemic began, the number of Americans participating in at least one telemedicine visit has increased 57%. The number of Americans with chronic conditions who have participated in a telemedicine visit at least once has increased 77%.
Once the pandemic has passed, 23% of survey respondents report they plan to participate in telemedicine visits.
Since the pandemic began, 27% of survey respondents report feeling more comfortable using telemedicine.
More than a quarter of survey respondents reported feeling telemedicine visits have the same or better quality compared to in-person doctor visits. More than half of survey respondents with chronic conditions reported telemedicine visits have the same or better quality compared to in-person doctor visits.
Nearly half of survey respondents reported cell phones are the preferred device for conducting telemedicine visits, with 39% preferring laptops.
A new journal article highlights three challenges in accounting for coronavirus deaths and offers solutions.
The number of deaths directly and indirectly associated with the coronavirus disease 2019 (COVID-19) pandemic is probably higher than has been reported, a new journal article says.
The United States has had the highest number of reported COVID-19 cases and deaths. As of Sept. 18, there were more than 6.8 million COVID-19 cases and more than 202,000 deaths reported in the United States, according to worldometer.
The co-authors of the new journal article, which was published in Annals of Internal Medicine, wrote that it is essential to have an accurate count of COVID-19 deaths. "Estimates of direct, indirect, and excess deaths are critical to our understanding of the pandemic and its effect on human life. They also illuminate the weaknesses in our health system and societal structures. It is imperative to get them right."
The journal article focuses on three challenges to determining COVID-19 mortality and offers solutions for each.
1. Direct deaths
For a death to be directly associated with a disaster, the cause of death must be listed on the deceased person's death certificate. However, the new journal article points out that the Council of State and Territorial Epidemiologists did not set a case definition for COVID-19 until April 5, which was nearly three months after the first reported coronavirus case in the United States.
"Early in the pandemic, when the understanding of the clinical presentation of COVID-19 was still developing and testing rates were very low, it is likely that practitioners in the United States and elsewhere did not attribute all deaths in patients infected with SARS-CoV-2 to COVID-19," the journal article's co-authors wrote.
The Centers for Disease Control and Prevention (CDC) took action to avoid under-counting COVID-19 deaths, the journal article's co-authors wrote. "To account for possible underestimation from underdiagnosis of deaths attributable to COVID-19, the CDC began counting all deaths from pneumonia, influenza-like illness, and COVID-19 and subtracting the expected seasonal number of cases of pneumonia and influenza computed from trends in the previous 5 years."
To achieve a more accurate count of deaths directly associated with COVID-19, the journal article calls for stepping up efforts to educate physicians about CDC guidelines—particularly for documenting presumed cases.
2. Indirect deaths
There are several forms of indirect causes of death associated with COVID-19, including psychological distress prompting suicides, the journal article's co-authors wrote.
"In the context of the COVID-19 pandemic, this would include loss of wages or housing, disruption to medical care from temporary suspension of outpatient facilities, hospital or emergency department avoidance, postponement of surgeries or chemotherapy, and loss of health insurance, all of which could result in premature deaths," they wrote.
There are three challenges in accounting for indirect deaths associated with COVID-19, according to the journal article.
The complexity of the intersection between economic and social disruptions
Lack of consensus about the timescale for measuring deaths after a disaster
Interpreting the CDC's "but for" principle, which in this instance holds that "but for the [pandemic], would the person have died when he/she did?"
To account for indirect deaths associated with COVID-19, the journal article calls for improving death certificate reporting at the institutional, city, and state levels. "Applying the CDC's 'but for' test to include 'COVID-19' in part II or question 43 [of death certificates] is therefore a simple and feasible intervention that may greatly improve the reporting of indirect death," the journal article's co-authors wrote.
They also call for physicians to receive "refresher training" on how to fill out death certificates.
3. Excess deaths
In addition to accounting for direct and indirect deaths associated with a disaster such as the coronavirus pandemic, disaster mortality can estimated by comparing observed deaths with the expected mortality rate based on the experience in prior years, the journal article says.
Calculating excess deaths is an imprecise science and should be set in a range, the co-authors wrote. "The estimation of excess mortality requires both modeling and timely data from reliable civil registries and vital statistics records, and it may be associated with significant margins of uncertainty."
To rise to this challenge, timely access to baseline and mortality-range data is essential, the co-authors wrote. "These data would ideally be available in near real time from the states before being sent to the CDC or Department of Health and Human Services for further coding or analysis, allowing scientists prompt access to the most up-to-date information from each state."
Accounting for COVID-19 deaths
At this point in the coronavirus pandemic, it is difficult to determine the extent of the understatement of COVID-19 deaths, a co-author of the journal article told HealthLeaders.
"Given the pandemic is still raging across the United States, testing continues to vary widely, and because the impact of indirect deaths will not be immediately obvious, it is not yet possible to estimate how high the true mortality will be," said Satchit Balsari, MD, MPH, an assistant professor of emergency medicine at Harvard Medical School and Beth Israel Lahey Health in Boston.
Balsari discounted media reports that have claimed the number of COVID-19 deaths have been overestimated.
"The reports make this claim on the basis that some deaths may be wrongly attributed to COVID-19 when the patient died of something else just because they also had COVID-19. There is no evidence so far that the number of such cases is statistically significant. In fact, there are peer-reviewed research articles that demonstrate how mortality rates reported early in the pandemic are lower from a combination of decreased testing, evolving understanding of the disease (missed diagnoses), and sometimes simply delays in reporting," he said.
Photo: The bodies of deceased COVID-19 patients are moved into a temporary morgue in New York City. Lev Radin/Shutterstock
Tait Shanafelt, MD, has written more than 150 peer-reviewed articles on the topic of physician burnout.
One of the top physician burnout researchers in the country is expecting a new national survey will show a significant uptick in clinician burnout due to the coronavirus pandemic.
Burnout is one of the most vexing challenges facing physicians and other healthcare workers nationwide. Research published in September 2018 indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October 2018 found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
Tait Shanafelt, MD, who is the chief wellness officer at Stanford Medicine and a professor of medicine at Stanford University in Palo Alto, California, has written more than 150 peer-reviewed articles on physician burnout.
He has helped lead several national surveys of physicians to gauge the level of clinician burnout across the country—most recently in 2017 and the latest survey is being conducted this month. In 2008, Shanafelt became the first director of Mayo Clinic's Department of Medicine Program on Physician Well-Being, where he launched an effort to address physician burnout through programs focused on physician autonomy, efficiency, collegiality, and a sense of community.
He earned his medical degree at the University of Colorado and performed his residency in internal medicine at the University of Washington Medical Center.
Shanafelt recently talked with HealthLeaders about a range of issues related to physician burnout. The following is a lightly edited transcript of that conversation.
HealthLeaders:Gauge the extent of physician burnout during the coronavirus pandemic.
Tait Shanafelt, MD: Overall, we are probably higher in physician burnout than we have been in the past. In addition to the challenges in healthcare settings, society is dealing with challenges linked to sheltering in place and a lack of outlets for relieving stress such as connections with friends or family, going to the gym, or going to the theater. Whatever your main stress reliever was, you probably can't do it now.
In healthcare settings, there have been many challenges, including susceptibility to becoming infected, being a portal of transmission to your family, and a lack of answers for caring for patients with this disease. I am anticipating that we may see higher prevalence of physician burnout in the survey this month compared to 2017, which showed a slight improvement compared to 2014.
Although burnout has been the dominant occupational form of distress over the past decade, with other dimensions such as fatigue and problems with work-life integration, the pandemic has also caused an uptick in PTSD-like phenomena for physicians who went through events such as what happened in New York. There has been depression, anxiety, and sleep disorders. So, the pandemic is associated with a category of more traditional mental health disorders that probably have been exacerbated more than burnout has been exacerbated.
HL: What has inspired you to devote much of your professional career to studying and addressing physician burnout?
Shanafelt: It has been the witnessed suffering of colleagues. I have watched a dedicated and altruistic group of people become discouraged, demoralized, and sometimes worse. I have had colleagues consider leaving the profession or experience personal life repercussions because of some of the challenges in the work environment and healthcare delivery system. Witnessing these things made me care and want to drive change. We can certainly do better.
HL: When it comes to addressing physician burnout, which is more important—organizational approaches such as improving the work environment or individual approaches such as resilience training?
Shanafelt: First, we know that burnout is an occupational syndrome caused mainly by characteristics and stressors in the work environment, not deficits in individual resilience. About 80% of the burnout challenge is triggered by characteristics of the work environment, organizational culture, and professional culture. So, we certainly need to focus a lot of effort as a healthcare delivery system and healthcare organizations on addressing the primary problems.
That said, I encourage individual physicians that we are not victims and there is a component of burnout that includes choices we can make about integrating our personal and professional priorities, optimizing our own sense of meaning and purpose in work by shaping our career, and making sure that we are attending to personal things around self-care that we can control.
HL: In the United States, how does the culture of medicine impact physician burnout?
Shanafelt: It is a huge factor.
It is easy for us to point to some of the tangible manifestations of inefficiency, administrative burden, loss of control and flexibility, and a productivity-based reimbursement system, then say, "These are the problems." Those are problems; but in many ways, those problems are really manifestations of much deeper issues in the culture of our healthcare delivery systems and the view of the role of the physician in healthcare organizations.
In that sense, we often have incongruities between what we claim and our actions. We claim that physicians are professionals who are highly trained, and we want to minimize administrative burden. We claim that quality of care is our top priority, along with serving our communities. But oftentimes, we have a healthcare delivery system that operates in a way that is the antithesis of those things.
We have preauthorization and a whole bunch of documentation that is required to support billing, which says, "We do not trust you as a physician." We have administrative burdens that say, "We do not value your time." We have short visits that may not allow physicians to deliver optimal care. In a sense, we are suggesting that our economic priorities are more important than our quality priorities, our social justice priorities, or treating our physicians as professionals.
HL: If there were two causes of physician burnout that could be eliminated, which ones would you choose?
Shanafelt: For organizations, one of the most important things to think about initially is to address the loss of control and lack of flexibility. These are things that show up in many ways—physicians feel that they have no control and that they have no input in the way that their practices run.
Restoring a sense of control brings about the sense that physicians can drive change. When change seems possible, it brings a sense of hope, which can be a powerful first step on the journey to improvement.
At the level of individual doctors, we need to get rid of the mindsets of perfectionism and harsh self-criticism. What we find is that physicians are very compassionate with others but very critical and harsh in the way they treat themselves. They expect nothing but perfection in themselves.
For physicians, being compassionate with themselves is a skill that can be learned. Instead of a mindset of being perfect, there needs to be a mindset of always learning and getting better, and that is how we can get to being a better physician a year from now than we are today. It is a commitment to excellence and a growth mindset, rather than a self-critical mindset.
A national push involving more than two dozen organizations is seeking to ramp up patient safety efforts.
A coalition of 27 organizations convened by the Institute for Healthcare Improvement has launched an initiative to improve coordination of patient safety work nationwide.
Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark reportTo Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
The new initiative is detailed in an "action plan" published on Sept. 14. The document was crafted by the National Steering Committee for Patient Safety, which was formed in May 2018. There were 27 organizations represented on the steering committee from the following groups: healthcare organizations and healthcare systems; patients, families, and care partners; professional societies; safety and quality organizations; regulatory and accrediting bodies; and federal agencies.
The action plan has four focal points and 17 recommendations.
1. Culture, leadership, and governance
The action plan calls on healthcare leaders, governance bodies, and policymakers to demonstrate a commitment to safety as a core value and to foster cultures of safety. There are four recommendations related to culture, leadership, and governance.
Healthcare leaders and governance bodies must demonstrate that safety is a top priority and part of their organization's mission and values. Organizational cultures should embrace trust and transparency, ensure physical and psychological safety for healthcare workers, and promote joy in work.
Healthcare leaders and governance bodies must regularly assess capabilities and devote resources to promote safety at the personal and organizational level. Assessments should include the core competencies of every employee in the organization.
Healthcare leaders and governance bodies must encourage sharing of information about safety such as near misses and harm incidents. This transparency should include timely sharing of information across organizations as well as with patients, families, and care partners.
The quality and patient safety competencies of healthcare leaders and governance bodies should be assessed during onboarding and throughout their tenure. These competencies include knowledge, skills, and characteristics needed to promote patient safety.
2. Patient and family engagement
The action plan calls for propagation of effective patient and family engagement. Specifically, healthcare organizations should include patients, families, and care partners in the design and delivery of care. There are five recommendations related to patient and family engagement.
Healthcare organizations should set competencies for all healthcare workers to engage patients, families, and care partners. All healthcare workers should be capable of forming equitable and effective partnerships with patients, families, and care partners.
Healthcare leaders and workers must enlist patients, families, and care partners in the design and delivery of care.
Patients, families, and care partners should be included in leadership and governance of safety and improvement initiatives.
In their engagement efforts, healthcare leaders should actively and equitably work with patients, families, care partners, and community organizations.
Healthcare leaders must ensure that all healthcare workers are respectful and transparent in their interactions with patients, families, care partners, and each other.
3. Workforce safety
The action plan says patient safety and workforce safety are linked closely. To boost workforce safety, healthcare organizations should take a unified and total-systems approach. There are three recommendations related to workforce safety.
In a systems approach to workforce safety, all healthcare organizations should have comprehensive workforce safety programs. A systems approach includes leadership and engagement, safety management systems, risk reduction, and performance analytics.
Healthcare organizations should hold themselves accountable for the physical and psychological safety of healthcare workers as well joy in the workplace.
Healthcare leaders should create and implement programs to prevent healthcare worker injuries.
4. Learning system
The action plan calls on healthcare organizations to foster networked and continuous learning such as promoting the sharing of information and improvement efforts. There are five recommendations related to a learning system.
Learning should be promoted inside and between healthcare organizations. Methods to achieve collaborative learning include using high-reliability principles as well as creating local, regional, state, and national learning systems.
Promote safety learning networks and adoption of best practices.
Improve safety education and training for all healthcare workers.
Healthcare leaders should develop shared goals for safety in all healthcare settings and disseminate these goals widely.
Promote coordination, collaboration, and cooperation on safety across the healthcare sector. "Modelling leaders in civil aviation, healthcare leaders representing all stakeholders must actively develop a public-private partnership to use the power of data sharing and cooperative learning to identify and solve the most urgent and emerging patient safety problems," the action plan says.
Call to action
During a press conference yesterday, the co-chairs of the National Steering Committee for Patient Safety urged healthcare organizations to redouble their patient safety efforts.
Coordinated work is required to re-energize patient safety improvement and accelerate change, said Tejal Ghandi, MD, MPH, senior fellow at the Institute for Healthcare Improvement.
"In the United States, there are many organizations that work on patient safety—multiple federal agencies, hospitals and health systems, accreditation groups, associations, foundations, patient advocacy groups—the list goes on and on. But we don't tend to work together in a coordinated and collaborative way, which often results in the frontline getting recommendations and advice coming at them from many different directions. We believe that if we all work together and are synergistic rather than uncoordinated, we can go further faster," she said.
Even the safest healthcare organizations in the country can benefit from following the action plan's recommendations, said Jeffrey Brady, MD, MPH, director of the Center for Quality Improvement and Patient Safety at the Agency for Healthcare Research and Quality.
"In these high-performing organizations, delivering care is a team effort and safety is a shared value. When it comes to safety, no one sits on the sidelines. People who work in these organizations also trust that their own safety is important to leadership. Clinicians feel safe, and they work with patients and families to keep them safe. That is the kind of care that we want for ourselves and our families, but we all know that many obstacles stand in the way. Even the best organizations in the country struggle with these barriers, and they know the job of ensuring safety is never done."
Reduction in the number of days seriously ill coronavirus patients are on mechanical ventilation can reduce respiratory complications.
Dexamethasone treatment for coronavirus disease 2019 (COVID-19) patients with moderate or severe acute respiratory distress syndrome (ARDS) reduces the number of days patients spend on mechanical ventilation, a recent research article shows.
Earlier research has found that as many as 12% of hospitalized COVID-19 patients require invasive mechanical ventilation, with most of those patients developing ARDS. Mechanical ventilation is associated with several respiratory complications such as barotrauma, ventilator-associated lung injury, and ventilator-associated pneumonia.
The recent research, which was published by JAMA Network Open, gathered data from 41 ICUs in Brazil. There were nearly 300 COVID-19 patients in the study, with 151 randomly assigned to receive intravenous dexamethasone and standard care, and 148 in a control group that only received standard care. For the treatment group, patients received 20 mg of dexamethasone intravenously daily for five days, then 10 mg of dexamethasone daily for five days or until ICU discharge.
The study generated several key data points:
Patients in the dexamethasone group had a mean of 6.6 ventilator-free days during their first 28 days of hospitalization, compared to a mean of 4.0 ventilator-free days in the standard care group.
Sequential Organ Failure Assessment (SOFA) mean scores, which range from 0 to 24 with higher scores indicating greater organ dysfunction, were lower in the dexamethasone group (6.1) than in the standard care group (7.5) at seven days.
There was no significant difference between the two groups in all-cause mortality at 28 days, ICU-free days during the first 28 days of hospitalization, or a six-point ordinal scale measuring clinical status.
"Among patients with COVID-19 and moderate or severe ARDS, use of intravenous dexamethasone plus standard care compared with standard care alone resulted in a statistically significant increase in the number of ventilator-free days (days alive and free of mechanical ventilation) over 28 days," the recent research article's co-authors wrote.
The decrease in ventilator days for seriously ill COVID-19 patients is a significant benefit for patients and healthcare providers, they wrote. "This reduction is relevant in the context of a pandemic, in which an inexpensive, safe, and widely available intervention like dexamethasone increases even modestly the number of ventilator-free days and may reduce the risk of ventilatory complications, ICU length of stay, and burden to the healthcare system."
Remdesivir is the only other drug that has been shown to generate improved clinical outcomes in seriously ill COVID-19 patients.
