New research indicates that increases in minority students who are applying to and enrolled in medical school are not keeping pace with increases in minority populations nationwide.
Despite a decade-long effort to racially and ethnically diversify medical school graduates to reflect the diversity of the general population, underrepresentation of minority groups in medical schools remains problematic, new research shows.
Earlier research has demonstrated that demographic representation in the physician workforce has multiple benefits, including better healthcare access for underserved populations, better cultural effectiveness among physicians, and better medical research and innovation for all populations.
In 2009, the Liaison Committee on Medical Education created accreditation guidelines mandating medical schools to develop programs or partnerships that would open up medical education to more students with diverse backgrounds.
A co-author of the new research, which was published in the Journal of the American Medical Association, told HealthLeaders that boosting physician diversity is beneficial at the patient bedside and at healthcare organizations more broadly.
"Oftentimes, we talk about diversity at the frontlines of healthcare because we want to make sure that we have diverse providers engaged with diverse patients because it will mitigate interpersonal bias or individual biases. The truth of the matter is that we need a diverse medical workforce not just at the frontlines but also among those generating the science of tomorrow and generating the systems in which we deliver care," said Jaya Aysola, MD, MPH, an assistant professor of medicine at the University of Pennsylvania's Perelman School of Medicine and executive director of the Penn Medicine Center for Health Equity Advancement.
Medical school diversity by the numbers
Aysola and her JAMA co-authors examined data from 2002 to 2017. The primary metric was representation quotient (RQ), which is a ratio that shows the proportion of a particular subgroup among the total population of medical school applicants or enrollees relative to the proportion of that subgroup in the U.S. population. An RQ greater than 1 indicates overrepresentation. An RQ less than 1 indicates underrepresentation.
The researchers generated several key data points:
The main finding is that the overall numbers and proportions of black, Hispanic, and American Indian or Alaska Native (AIAN) medical school enrollees increased from 2002 to 2017, but the increases did not keep pace with increases of these minorities in the general population.
For minority medical school applicants from 2013 to 2017, Hispanic female applicants were the only minority group that showed a statistically significant increase in representation, with RQ rising from 0.29 to 0.34. For the same time period, the RQ for Hispanic male applicants was relatively constant at 0.28.
For medical school enrollees from 2012 to 2017, there were no significant RQ increases or decreases for any racial or ethnic group. For example, the RQ for male and female Hispanic graduates was relatively constant at about 0.30.
"Black, Hispanic, and AIAN students remain underrepresented among medical school matriculants compared with the U.S. population. This underrepresentation has not changed significantly since the institution of the Liaison Committee of Medical Education diversity accreditation guidelines in 2009. This study's findings suggest a need for both the development and the evaluation of more robust policies and programs to create a physician workforce that is demographically representative of the U.S. population," Aysola and her co-authors wrote.
Addressing underrepresentation
Aysola told HealthLeaders that the underrepresentation problem cannot be solved by just focusing on societal factors such as educational disparities early in life.
"When we consider the pipeline in isolation as the only contributing factor, we are ignoring the system inequities that also play a big role in underrepresentation. I'm interested in what is intrinsic to the system that makes a difference in who is selected to attend our medical schools. What are the systematic biases that exist that prevent professional diversity?" she said.
One policy change that could make a difference at medical schools is already in place at many commercial businesses, Aysola said. "We want to test the priming technique, where you can prime interviewers and selection committees to consider their biases before an interview and after an interview, then determine whether biases are playing a role."
"For example, after you are done conducting an applicant interview, the interviewer considers whether there is anything about the applicant that they see in themselves. Is there anything in the applicant's CV that resonates with the interviewer? You are encouraging interviewers to screen themselves for their own personal biases, so they become more self-aware."
AbleTo Medical Director David Whitehouse shares the potential and best practices for providing behavioral health services through telemedicine.
David Whitehouse MD, MBA, the new medical director at AbleTo, a provider of virtual behavioral health services, says telemedicine is a 'particularly good fit' for behavioral health.
Telemedicine is one of the most significant growth areas in healthcare around the world. Last year, the value of the global telemedicine market was estimated at more than $38 billion, and the market is expected to be valued at $130 billion by 2025. With a high degree of anonymity and convenience, telemedicine has gained significant traction in the provision of behavioral health services.
Whitehouse was recently picked to serve as the medical director at New York–based AbleTo Inc. He earned his medical degree from Dartmouth College's Geisel School of Medicine. His professional background includes serving as chief medical officer for Aliso Viejo, California–based UST Global and working as CMO for strategy and innovation for Optum Behavioral Health Solutions.
HealthLeaders spoke with Whitehouse recently to get his perspectives on the potential of telepsychiatry and best practices for telepsychiatry visits. Following is a lightly edited transcript of that conversation.
HL: Why is telemedicine a good fit for providing behavioral health services?
Whitehouse: It is an especially good fit.
When the Internet was getting started, an observation that was made quickly was that among social groups and chat groups the largest number of users were people who had behavioral health issues. What they loved about the Internet was the anonymity. The other thing the Internet provides is a treatment process that can be less demanding in terms of time and energy commitment.
For example, let's take a mother with postpartum depression. Part of the stresses for her are not sleeping at night and dealing with a crying child. If you tell her that she must find baby-sitting arrangements to see a therapist on a weekly basis, you are just going to add to her stress. The ability to make treatment available conveniently to her in her home or some other private place at moments when she can best use it is incredible.
In rural situations, you have the same ability and can overcome shortages of child psychiatry, shortages of opioid addiction treatment—not just medication but also ongoing therapy. All of these services can be provided through telemedicine to people privately and conveniently.
Another thing is that stigma is a huge issue. People have been reluctant to get treatment because they do not want to be seen going into an office. People don't want to be seen going into the employee assistance program office at work because it will be presumed that they have a drinking problem or a marital problem or something else is going wrong in their life.
There is shame in admitting that your emotional life is not totally under your control. If we can do anything to reduce that stigma and tell people that seeking help when they are emotionally challenged is acceptable, it would go a long way toward helping people.
HL: Give an example where technology is driving change in the mental health field.
Whitehouse: In more serious mental illness, there are new technologies that monitor people's movements and activities. For serious and chronic conditions such as schizophrenia and psychotic depression, people become reclusive and cut themselves off from the world. Now, we can do things like use cell phones to monitor social interactions, monitor affective tone, and monitor movement. With this technology, we can have a better sense of how these people are doing.
HL: What are the best practices for conducting behavioral health visits through telemedicine?
Whitehouse: Good telepsychiatry generally should start with an excellent screening process to choose patients who are most likely to benefit from telemedicine. That first screening session is probably one of the most important things that we do.
There are some cases that should not be handled in telemedicine—certain personality disorders have a high degree of intensity in emotional and behavioral interactions. For these patients, the day-to-day flareups are not handled well at a distance.
There also is a different skill related to the way you appear when you conduct a telehealth session. Whether it is just voice-to-voice or a telehealth presence, therapists must present themselves professionally. Probably even more so than a medical doctor, a therapist is part of the therapy—the eye contact they have on the screen, the way they look interested in the patient, how they dress, how their office looks—all these factors create an ambience in which you are creating a sense of safety for the patient. It can be unconscious to the therapist, and it can be unconscious to the patient, but its power is dramatic.
HL: How are AbleTo's telemedicine visits financed?
Whitehouse: The model at AbleTo is primarily geared to health plans and insurance companies. Our telehealth visits are generally considered a payable service. In most cases, we work with patients who pay with their behavioral health insurance benefit.
In commercial insurance, there usually is a copay. Behaviorally, we like the copay because psychologically, when you make something tremendously convenient for people, you want people to have an interest in the therapy themselves. The copay is an indicator that the patient is willing to make an investment in themselves.
HL: Is it particularly challenging when you are working as a telepsychiatry provider and you have a patient who slips into crisis?
Whitehouse: There are two considerations.
One, in the screening process, you want to determine who is a high-risk patient and who is not. If a patient has a history of past suicide events or a history of psychosis, they are not going to be a good candidate for telepsychiatry. They should be handled by a team of people who can be much more readily available.
Two, everyone with a behavioral health issue can experience a crisis, and every telehealth service should have a capability that is available 24/7 for both the intake team as well as therapists out in the field.
What happens when someone has a crisis is there needs to be a way over the computer, or text message, or over the phone that you can alert someone in the organization that the patient is in crisis. The one thing you don't want to do is get off the phone or break the human contact in any way. You then start to assess the crisis; and if you are the therapist in the field, you hand over the patient to the professional crisis team, whether it's over the phone or over the computer. Then the situation is exactly the same as if the patient was connected to the national suicide hotline.
Basically, a crisis worker is trained to perform a series of protocols that will first assess and try to de-escalate the situation. Often, when psychiatric patients are in crisis, the one thing they are most afraid of is loss of autonomy. You try to maximize their autonomy and try to find out what resources are available. Is there someone else in the house? Can you get a close friend on the phone?
If someone is suicidal and they have a gun, you are going to keep them on the line, and you will generally have a text-messaging capability to text a colleague. You will text that colleague and get them to contact the crisis team in the local community. Every telehealth crisis team should have the numbers for local resources. The local crisis teams deal with these situations often, and they can determine who should go out to the patient—whether it is a mental health crisis team or the police in a highly escalated situation.
You need to have not only a series of protocols in place and access to a crisis intervention system, but you also need to make sure that every provider who is engaged internally and every provider who is engaged externally is fully aware of the crisis services and trained in how to use them. That's one of the things that we take seriously at AbleTo.
Most hospitals and physician practices do not screen for all five of the social determinants of health featured in the federal Accountable Health Communities model.
Most healthcare organizations are not screening for the primary social determinants of health, recent research shows.
Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address SDOHs and working with community partners, healthcare organizations can improve patient health in profound ways beyond the traditional provision of medical services.
"The association of patients' social needs, such as food insecurity, housing instability, utility needs, transportation needs, and experience with interpersonal violence, with health outcomes and costs is increasingly recognized by the medical community, and an increasing amount of evidence documents that physician- and hospital-led interventions addressing patients' social needs can produce improved health outcomes and less costly medical care," wrote the co-authors of the recent research, which was published in the Journal of the American Medical Association.
Prevalence of SDOH screening
The researchers examined data from more than 2,000 physician practices and more than 700 hospitals.
The primary focus of the research was the prevalence of screening for the five social needs highlighted in the Centers for Medicare & Medicaid Services (CMS) Accountable Health Communities model: food insecurity, housing instability, utility needs, transportation needs, and experience of interpersonal violence.
The research generated several key data points:
24.4% of hospitals and 15.6% of physician practices reported screening for all five SDOHs
8.0% of hospitals and 33.3% of physician practices reported no screening for SDOHs
The most commonly screened SDOH was interpersonal violence, at 75.0% of hospitals and 56.4% of physician practices
The least commonly screened SDOH was utility needs, at 35.5% of hospitals and 23.1% of physician practices
At physician practices, the highest rates of screening for all five SDOHs were at federally qualified health centers (29.7%), Medicaid accountable care organizations (21.8%), bundled payment participants (21.4%), and primary care improvement model participants (19.6%)
Among hospitals, the highest rate of screening for all five SDOHs was conducted at academic medical centers (49.5%)
"This study’s findings suggest that most U.S. physician practices and hospitals do not report screening patients for key social needs, and it appears that practices serving more economically disadvantaged populations report screening at higher rates," the researchers wrote.
Interpreting the data
Availability of resources is the most likely explanation for why hospitals are more likely to screen for SDOHs than physician practices, the researchers speculated. "Hospitals may have more resources, including staffing, financial, and technological, as well as more processes, protocols, and standardization in care delivery."
Regulatory considerations are another likely factor driving higher screening rates at hospitals, the researchers wrote. "Hospitals may also be more likely to screen patients for transportation and housing needs as part of their discharge processes because they are subject to federal regulations on patient safety as part of their certification from CMS."
Lack of financial resources was reported as a major barrier to screening at both physician practices and hospitals. At physician practices that conducted no SDOH screening, 51% reported lack of financial resources as a major barrier. At hospitals that conducted no screening, 60% reported lack of financial resources as a major barrier.
Increased financial support will likely be needed to increase screening for SDOHs at hospitals and physician practices, the researchers wrote.
"Payers could allow physicians and hospitals to bill for evidence-based programs, such as FoodRx, that have been shown effective at addressing needs and improving outcomes. The CMS could consider expanding care management billing to include managing care for patients who are both at risk or have clinically complex conditions in addition to social needs."
Researchers have associated metabolic surgery with lower risk for all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy, and atrial fibrillation.
Metabolic surgery in patients with obesity and type 2 diabetes results in significantly lower risk of major adverse cardiovascular events, recent research indicates.
From 2015 to 2016, 39.8% of Americans over age 20 were obese, according to the Centers for Disease Control and Prevention (CDC). For the same time period, 20.6% of adolescents were obese, the CDC says. In 2008, the estimated annual medical cost of obesity was $147 billion.
The stakes are high for people with obesity and type 2 diabetes, according to the co-authors of the recent research, which was published in the Journal of the American Medical Association. "In patients with obesity and type 2 diabetes, weight and glycemic goals are difficult to achieve through usual care including lifestyle modifications and pharmacotherapy. In patients with obesity and diabetes, cardiovascular disease is the major cause of morbidity and mortality," they wrote.
Cardiovascular impact of metabolic surgery by the numbers
The recent research features data collected from more than 13,000 patients—2,287 patients who underwent metabolic surgery and 11,435 patients in a control group that did not have surgery. The primary focus was the incidence of six major adverse events: all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy, and atrial fibrillation.
30.8% of patients in the metabolic surgery group experienced major adverse events after their operations compared to 47.7% in the nonsurgical control group
All-cause mortality occurred in 10.0% of patients in the metabolic surgery group compared to 17.8% in the nonsurgical group
After following patients for eight years, mean body weight was reduced by 29.1 kg in the surgery group and 8.7 kg in the nonsurgical group
Utilization of noninsulin diabetes medications, insulin, hypertensive medications, lipid-lowering therapies, and aspirin were significantly lower for the surgery group compared to the nonsurgical group
Complications after metabolic surgery were relatively low, including bleeding requiring transfusion in 3.0% of patients, pulmonary adverse events in 2.5% of patients, venous thromboembolism in 1.0% of patients, cardiac events in 0.7% of patients, and renal failure requiring dialysis in 0.2% of patients
"All six prespecified outcomes were significantly lower in the surgery group, including all-cause mortality, coronary disease events, cerebrovascular events, heart failure, atrial fibrillation, and nephropathy," the JAMA researchers wrote.
Interpreting the research
The research team speculated that substantial and sustained weight loss after metabolic surgery led to a lower prevalence of major adverse cardiovascular events. "It's the most obvious conclusion," one co-author told HealthLeaders.
"You do metabolic surgery, and people lose a lot of weight. We know obesity is associated with cardiovascular risk enhancement from increased cholesterol, increased blood pressure, and higher incidence of diabetes. So, if you make the obesity better, it stands to reason that you would expect rates of cardiovascular disease to go down," said Steven Nissen, MD, professor of medicine, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland.
The magnitude of the cardiovascular benefits of metabolic surgery was unexpected, he said.
"This is a huge treatment effect. It was possible that the adverse cardiovascular prognosis from obesity would be largely irreversible. In other words, once people were obese, you would have a hard time reversing their cardiovascular event rate. That was not what we saw. There was a 39% reduction in six component adverse cardiovascular events and a 41% decreased risk of all-cause mortality. Those are really large effects," Nissen said.
Despite the eye-popping results, it is unreasonable to expect that metabolic surgery alone can end the country's obesity epidemic, he said.
"There are tens of millions of people in America who have severe obesity, and we cannot do surgery in all of them. Last year, about 250,000 people underwent bariatric surgery. Studies like ours will increase the number of people who are offered the operation. … It is a therapy that can be utilized in more people, but it is not going to completely fix the obesity epidemic because it just is not practical to do the operation in everybody who is obese."
More research is needed to confirm the JAMA study's findings, Nissen said.
"We recognize there are limitations of our study. It is an observational study, not a randomized controlled trial. We think that our findings make it imperative that we do a large randomized controlled trial, and we are working on securing the necessary funding to do that. We need to nail down for certain what these benefits are and what the risks are in a randomized controlled trial."
The initiative is designed to improve care for the 46 million Americans over age 65—a population that is growing by 10,000 people daily. The primary focus of the initiative is promoting evidence-based care for this vulnerable population.
"What's drawn health professionals to the Age-Friendly Health Systems movement is that it offers an organizing framework of evidence-based care that can be practiced reliably. And it all starts with knowing and acting on what matters to the older adult," IHI Senior Director Leslie Pelton said in a prepared statement.
Four-component framework
The IHI initiative, which was launched in early 2017, features the 4Ms:
1. What matters to the patient: With a potentially dramatic impact on medical decisions, determining what matters to patients may be the most momentous of the 4Ms, Kedar Mate, chief innovation and education officer at Boston-based IHI, told HealthLeaders earlier this year. "Improving medical decision-making is a key element of attaining value. Of all the interventions, the first M—what matters—gets you to high value as defined by the patient. It gets you to services that offer value in the patient's eyes."
2.Medication: Managing medications is crucial for achieving therapeutic benefits and avoiding adverse drug reactions, which cause harm and costly complications. Annual costs in the United States associated with adverse drug reactions have been estimated at $30 billion, according to a December 2013 article in the Journal of Pharmacology & Pharmacotherapeutics.
3. Mentation: Addressing delirium in the inpatient setting generates significant mentation benefits, Mate said. "Delirium is extremely common among older adults in inpatient settings, and it is extremely costly both on the human cost side with complication rates and lengths of stay, and the financial side. Length of stay is often 20% to 30% longer with delirium."
4. Mobility: Maintaining mobility also generates clinical and financial benefits, he said. "The data on functional impairment is stark. If you have a patient with one or two chronic conditions, then you add on functional impairment, the cost of care roughly doubles. Functional impairment is a big impediment in older adults' lives in achieving what matters to them, and it costs us a ton of money as a society."
Gaining recognition
Last week, IHI recognized 162 hospitals and physician practices for their Age-Friendly Health Systems initiative adoption efforts.
Eighty-five of the healthcare organizations were designated as "Age-Friendly Health Systems—Committed to Care Excellence" for reporting the number of older adults reached with the 4Ms over at least a three-month period. The remaining 77 organizations were recognized as "Age-Friendly Health Systems Participants" for showing commitment to put the 4Ms into practice and submitting their plans for IHI review.
Recent research highlights the difficulty of maintaining adequate clinical team staffing at rural hospitals. Four recruitment tactics could help change that.
Staffing clinical teams at rural hospitals can be a daunting human resources challenge, but there are effective strategies to address the problem.
Retirements and a declining number of young physicians choosing to practice in rural areas of the country is graying the rural physician workforce, according to U.S. Census data. From 2000 to 2017, the total number of rural physicians grew 3%, but the number of doctors under age 50 fell 25%. In 2017, more than half of rural doctors were 50 or older, and more than a quarter were at least 60.
Recently published research highlights the difficulty of maintaining adequate clinical team staffing at rural hospitals.
An article published in TheNew England Journal of Medicine includes a dire forecast for the rural physician workforce:
From 2000 to 2017, the rural physician workforce was stable at approximately 12 doctors per 10,000 population in rural communities. But the rural physician workforce is expected to decline 23% by 2030.
Nearly all of the expected decline is attributed to a drop in the number of rural physicians who are currently 45 or older because many of these doctors are likely to retire by 2030.
In contrast, the number of nonrural physicians is expected to drop slightly over the same time period—from 30.7 doctors per 10,000 population in 2017 to 29.6 doctors per 10,000 population by 2030.
The co-authors of the NEJM article call the forecast for the rural physician workforce troubling. "In 2030, residents of rural areas will have access to one third as many physicians per capita as their suburban and urban counterparts will. Yet rural residents are likely to be older, poorer, and in worse health than city dwellers, with a lower life expectancy, and they are more likely to be uninsured," they wrote.
Recruiting physicians at rural healthcare organizations
A survey report published by Alpharetta, Georgia–based Jackson Physician Search also includes a gloomy view of the rural physician workforce. "From 2013 to 2015, the overall supply of physicians in the United States grew by 16,000 but the number of rural physicians declined by 1,400. These facts compound the problem that while 20 percent of the U.S. population is rural, only 12 percent of the primary care physicians work in a rural area," the survey report says.
The survey report, which is based on data collected from more than 150 physicians and 105 rural health system administrators, says four factors were found to be particularly effective in the recruitment of doctors in rural areas.
1. Autonomy: The survey found 43% of physician respondents consider autonomy as a significant goal in their careers. The physician survey respondents say they value practicing medicine without undue influence from executives. "Healthcare professionals—both nurses and physicians—want to have their voices heard, especially when it comes to issues affecting their practice of medicine. Rural hospitals have the advantage here when compared to a large bureaucratic health system," Tony Stajduhar, president of Jackson Physician Search, tells HealthLeaders.
2. Team-based culture: Physician survey respondents say they enjoy working at healthcare organizations that have strong teamwork and collaborative decision-making. "Culture and fit are widely discussed as important factors for physicians in feeling engaged in the workplace," the survey report says.
3. Recruit the family: Physician and administrator survey respondents say a family-friendly environment is a desirable aspect of a healthcare organization. "Highlighting the best aspects of the community and involving community leaders in the process will go a long way in demonstrating the community's value to the physician. Specifically, taking time to ensure that spouses and significant others are engaged in the process can be a deciding factor once an offer is being considered," the survey report says.
4. Administrator role in recruitment: With physicians ranking culture high as a desirable attribute at healthcare organizations, rural hospital CEOs and other top administrators can be a decisive factor in the recruitment of doctors, Stajduhar says.
"Based on our survey, a well-designed, on-site visit that makes the physician and their family feel welcome and highlights the community culture is the No. 1 factor in picking a practice location. They need to be able to see themselves as part of an active and vibrant community, and to enjoy working in the organizational environment. Painting a picture of the vision of the organization and how they fit into building the future is essential. The senior leadership of the organization must be involved and take a lead role in the process," he says.
Avoiding recruitment and retention perils
On the other hand, Stajduhar and Lucy Skinner, lead author of the NEJM study and a rural health scholar at Dartmouth College's Geisel School of Medicine in Hanover, New Hampshire, say there are several pitfalls to avoid when trying to recruit and retain clinical team members.
Financial incentives may be helpful in recruiting but not necessarily in retention, Skinner says.
"One thing we have been focusing on is economic incentives such as signing bonuses and loan forgiveness, which can be effective in recruiting physicians to work in a rural area, but the problem is retention. Often, physicians will take these incentives then only stay for a few years—if they don't feel integrated into the community, they leave."
Particularly during the recruiting process, physicians and their family members should never feel unwanted or unwelcomed at rural hospitals, Stajduhar says. "They never meet the hospital president, CEO, board members, or senior medical leadership. You have a lot of no-shows at the physician dinner, or the staff is not friendly or welcoming during their visit. In addition, the family is largely ignored or forgotten."
The interview process for clinical team members must be well-orchestrated, he says. "Clinicians often leave an interview experience feeling that the organization doesn’t care whether they join them or not. They have unanswered questions or vague answers that don't inspire confidence in making a major life decision."
New research indicates that healthier areas of the country are healthier across all dimensions.
In a finding that expands on social determinants of health research, a new study shows that older adults with low incomes are healthier if they live in affluent communities.
Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address SDOHs and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.
The new study, which was published in Annals of Internal Medicine, examined data from nearly 6.4 million Medicare beneficiaries who had participated in the Medicare Part D prescription drug program. The researchers focused on more than 700 U.S. "commuting zones," which are groupings of counties developed by the federal Department of Agriculture that show economic and social activity as opposed to political boundaries.
The study's data features the prevalence of 48 chronic conditions in commuting zones. The research's key finding is that the prevalence of chronic conditions for older adults with low incomes is significantly lower in affluent commuting zones. "Low-income, older adults living in more affluent areas of the country are healthier, and areas with poor health in the low-income, older adult population tend to have a high prevalence of most chronic conditions," the researchers wrote.
The overall prevalence of the 48 chronic conditions ranged from 72.2 per 100 adults for hypertension to 0.6 per 100 for post-traumatic stress disorder. In addition to hypertension, the five most prevalent chronic conditions were hyperlipidemia, anemia, rheumatoid arthritis and osteoarthritis, ischemic heart disease, and diabetes.
Interpreting the findings
Social and other community-related factors are likely responsible for the study's findings rather than access to healthcare services, the report's lead author told HealthLeaders.
"Differences in the social fabric, peer effects, health literacy, community resources, and lifestyle more generally could contribute to this pattern. Many conditions that we examined are chronic, lifelong diseases related to daily health investments throughout someone's life, so it is very unlikely that differences can be attributed to differential availability or access to formal care. Interestingly, we actually find that health is better in rural areas of the country that have traditionally faced challenges in ensuring easy access to formal healthcare," said Maria Polyakova, PhD, assistant professor of health research and policy, Stanford University School of Medicine, Stanford, California.
The primary finding of the study is that healthier areas of the country are healthier on all dimensions, she said.
"There is no one condition that drives geographic health disparities. This points to the idea that policymaking that aims to address health disparities needs to address systemic, root-cause problems of why some areas are less healthy than others. This means spending resources on particular areas and addressing all types of health conditions in those areas, rather than focusing on one condition across many different areas," Polyakova said.
The study is a step forward in understanding the impact of SDOHs on older adults with low incomes, she said. "We use clinical rather than self-reported measures of diagnoses and report this group's variation in morbidity across local areas of the country, rather than nationally. Our results raise the bar for quantifying the importance of social determinants of health and figuring out what factors drive health disparities."
The primary goal of Working to Fight AMR is closing the gap between the increasing number of drug-resistant infections and production of new antimicrobials.
A new coalition of biotechnology stakeholders has formed to promote development of new antibiotics to fight antimicrobial resistance.
The Centers for Disease Control and Prevention estimates more than 2 million Americans experience a drug-resistant infection annually, with at least 23,000 deaths. A new estimate from the Washington University School of Medicine in St. Louis puts the annual death toll as high as 162,000.
Working to Fight AMR launched in August to close the gap in the pharmacological arms race between deadly microbes and antibiotic treatments, the new coalition's director told HealthLeaders last week.
"Many procedures are only possible because of the ability to treat infection, including cancer therapies, transplantation, complex surgeries, and Cesarean sections. Unfortunately, our use of antimicrobials has prompted an evolutionary response, and we are now in a phase where we are behind the curve. Resistance is increasing, and we are not producing enough new drugs to keep pace," said Greg Frank, PhD, director of Working to Fight AMR, and director of infectious disease at the Biotechnology Innovation Organization in Washington, DC.
Several biotechnology industry leaders have joined the new coalition:
Aleks Engel, PhD, director of the REPAIR Impact Fund at Novo Holdings
Julie Louise Gerberding, MD, MPH, former director of the Centers for Disease Control and Prevention and executive vice president and chief patient officer at Merck
The economics of antibiotics development is dysfunctional, Frank says.
"When someone develops a brand new, innovative antibiotic, the product will be reserved for the worst of all cases only when no other treatments work. You do not want to use these products indiscriminately because every time you use a product, new resistance develops. This makes it hard for industry to generate a return on investment. What we have been seeing over the past two decades is an exodus of the large pharmaceutical companies from developing antibiotics. And many of the small biotechs that are developing these products are struggling to raise the capital that they need."
The recent bankruptcy of South San Francisco, California-based Achaogen illustrates the economic problem.
Achaogen developed plazomicin, an innovative antibiotic with infection and antiterrorism applications that received government approval in 2018. The company filed for bankruptcy protection in April.
"They received approval for their antibiotic last summer and filed for bankruptcy earlier this year because they could not survive in the market given how little their antibiotic was used. They are not the only company that is in trouble. There are several other biotechs that have recent approvals that are also experiencing similar commercial challenges," Frank says.
Antibiotics are losing the antimicrobial arms race, he says. "We have a pipeline of very few products relative to the need to keep pace with resistance. There are only about 43 antimicrobials under development right now. Only a handful of those will actually reach patients given the trials and tribulations of clinical development. That is not nearly enough to stay ahead of antimicrobial resistance."
Antimicrobial policy prescriptions
Working to Fight AMR is calling for two federal policy initiatives:
1. Developing an Innovative Strategy for Antimicrobial Resistant Microorganisms (DISARM) Act: Introduced by Sens. Bob Casey and Johnny Isakson, this bill aims to address some of the reimbursement challenges for new antibiotics, which are more expensive than most established antibiotics, Frank says.
"It creates a separate payment for qualifying innovative antimicrobials outside of bundled payments, so the hospital is made whole regardless of whether these innovative antibiotics are used. In their clinical decision-making, it will allow the people in charge of an antibiotics stewardship program at a hospital to prescribe antibiotics based on whatever they think is best for the patient rather than the cost."
2. Pull incentive: Working to Fight AMR is advocating for new financial incentives in antibiotics development.
"The new incentives would aim to provide some level of substantial financial reward to a company that develops an innovative antimicrobial that meets an urgent unmet public health need. This would be reserved for the best-of-the-best products to provide sustainable return on investment. You don't want these products to be used widely. You want to find a way to generate a return on investment that is not driven by utilization of the product," Frank says.
One of these "pull incentive" concepts is a market entry reward, where regularly installed payments would be given to a company for a period of years after approval of an antibiotic. The payments would be linked to obligations to make sure that the antibiotic is accessible, used appropriately, and produced through a stable supply chain.
"By creating a reward, it pulls products through the pipeline," Frank says.
The new chief medical officer at Kindred Healthcare, with a background in emergency medicine and health plan management, is focused on payer-provider relations and managing costs of care.
Kim Perry, DO, would like to "close the gap" in understanding about the roles of long-term acute care hospitals and inpatient rehabilitation facilities, and bring payers and providers closer together.
Perry is the new senior vice president and chief medical officer of Louisville, Kentucky-based Kindred Healthcare, LLC. Kindred, which has annual revenue of about $3.3 billion, has more than 34,000 employees in 46 states at facilities including 71 long-term acute care hospitals and 22 inpatient rehabilitation hospitals.
Most recently, Perry served for three years as a multistate chief medical officer at UnitedHealthcare, where her responsibilities included initiatives related to clinical affordability, quality of care, population health, and growth. Prior to joining UnitedHealthcare, she worked for nearly a decade at St. Louis-based BJC Healthcare, where her leadership roles included chief of emergency medicine.
Perry received her osteopathic medicine doctorate from A.T. Still University's Kirksville College of Osteopathic Medicine in Kirksville, Missouri.
HealthLeaders spoke with Perry recently to get her perspectives on issues ranging from payer-provider relations to managing costs of care. Following is a lightly edited transcript of that conversation.
HL: Why did you pick emergency medicine as your specialty?
Perry: I like diversity. I like to do different things. When I considered going into emergency medicine, I was drawn by the procedures. I am very hands-on and procedure-driven. I like the challenge of complex patients, and always liked the challenge of not knowing who was coming in.
I wasn't as interested in spending day after day with the same patient because it made me get emotionally attached to patients. In emergency medicine, patients are short term, so emotions are not overwhelming, but you get challenging patients to take care of.
I also like to partner with teams—care management teams and other physicians. I don't like to be a solo person. I like to collaborate with a lot of other people, and emergency medicine offers that.
HL: How will your background in emergency medicine and health plan management help you as the new CMO at Kindred?
Perry: In addition to emergency medicine, I have done a lot of things. I have been a chief of emergency medicine. I have been a dean of clinical education. I have been in managed care organizations, where I got to know several of the issues that providers were having. As the chief medical officer at UnitedHealthcare over the past three years, my role was to develop relationships with providers and hospitals. The managed care background is going to be particularly helpful at Kindred.
HL: Why is your managed care background valuable in your new role at Kindred?
Perry: Kindred was wise to seek a chief medical officer with managed care experience. Managed care is growing—it's definitely in the Medicare and Medicaid realms but also in the commercial realm with accountable care organizations. We're basically moving from fee-for-service to value. Under value-based care, you can't just provide services—you have to provide care well and meet quality measures and meet evidence-based measures. Having the knowledge of what that means to the payer is helpful to the provider. Kindred is a provider and I have insight into what the payers are looking for in a partnership and what value means to them. I'm trying to bring them closer together.
HL: Payers and providers have historically had an adversarial relationship. How do you bridge the gap between payers and providers?
Perry: We need to work with the payers and show what Kindred can do for health plan members. With our patients, we often focus on the total cost of care and chronic disease management. At Kindred, we take care of medically complex patients on a day-to-day basis.
It may be a little more expensive upfront than having a patient stay in a short-term acute care facility, but our focus is total cost of care. So, within 30 days, within 90 days, or within a year, we provide care to keep health plan members healthier and reduce total cost of care.
We get patients functionally and medically stable enough to be successful at home. And we help with chronic condition management—we get patients to the point where they can be independent or be at a lower level of care. We also make sure patients are strong enough that they do not have a fall or any other incident in the first year of care that could cause them to have to go to a higher level of care or have an expensive intervention. So, we just don't take care of an episode of care and let the patient go. They become part of our family, and we keep an eye on them for years.
HL: What are your top goals as CMO at Kindred?
Perry: I have two major goals that I am focused on currently.
First is to improve relationships such as relationships in our patient experience—we want patients to have the best possible experience they can have given the situation. I want to collaborate better with providers—not only hospital providers but also primary care physicians, accountable care organizations, and anyone else who touches patients, so we can work collaboratively with the patients and their lifelong journey. It's not just the episode of care—we used to get paid to provide services, but it's not like that anymore. We have to provide care well, and we have to prove to our patients and our providers that we offer the best services for complex patients.
I also want to improve relationships with the payers. They are more focused now on value and the total cost of care, and we're here to help solve some of those issues for them. We can also help with the more mundane things—care gap closures, making sure women get their mammograms, and other things that complex patients may not follow through and do.
My second goal is to develop a value story for Kindred, both on the rehab side and the long-term hospital side. I want to make sure that people understand what we do, why we do it, and the difference between an acute hospital stay and a long-term acute care facility.
HL: What are the key factors in developing relationships between acute care hospitals and postacute care facilities?
Perry: There are four keys: trust, communication, respect, and mutual understanding of what each of us do. There are still many people in healthcare, including physicians in short-term care hospitals, who do not understand what a long-term acute care hospital or an inpatient rehab facility does, and how they can benefit patients. I want to close that gap.
A big job for me is to educate, communicate, and develop these relationships so that we can get the trust, respect, and understanding to work more collaboratively. All of us—the payers and the providers—want to do the right thing for the patient while being sustainable and reducing the total cost of care. We have to collaborate more, and we have to share data more, and we can only do that when we have trust, communication, respect, and understanding.
Care team factors associated with patient safety include teamwork, a multidisciplinary approach, knowing each other, and openness to questions from staff members.
There are more than a dozen care team factors associated with patient safety on hospital wards for older patients, recent research shows.
The number of Americans over age 65 is expected to double to nearly 100 million by 2060. With multiple chronic conditions and high costs of care at the end of life, older adults have relatively higher healthcare costs compared to younger Americans. In 2010, citizens over age 65 were 13% of the population but accounted for 34% of healthcare spending.
The recent research published in BMJ Quality & Safety features data collected from 70 staff members working on eight hospital wards for older patients, including 23 nurses and 10 doctors. The researchers found there were 14 care team factors that contributed to patient safety on the wards:
Knowing each other
Trust
Multidisciplinary approach
Integratingallied health professionals throughout ward activities
The BMJ Quality & Safety researchers highlighted five of the care team factors:
1. Knowing each other: Familiarity with coworkers helped staff to support each other in providing safe patient care.
"Friendly, personal connections between staff members were perceived to facilitate communication, influence their ability to contribute different perspectives, encourage them to work beyond silos and to be more broadly involved in patient care. The importance of knowing each other was apparent across professional grades and roles regardless of whether staff were permanent or temporary team members," the researchers wrote.
2. Multidisciplinary approach: Establishing a multidisciplinary care team encourages staff to get involved in all aspects of patient care and blurs the lines between care team roles.
"Everyone's contributions were encouraged and valued; staff felt listened to, were actively involved in ward activities and were kept informed of the bigger picture rather than just being told essential information. This created a shared awareness about a patient's care plan and the risks they faced, and it engendered a sense of responsibility towards patients and the team. Positively deviant wards particularly emphasized the importance of involving non-professional staff such as healthcare assistants and domestics in ward activities," the researchers wrote.
3. Integrating ward-based allied health professionals: Most of the wards in the study had allied health professionals such as physiotherapists and occupational therapists assigned to work in single wards. Integration of these staff members into the wider team was associated with higher degrees of patient safety.
For example, two wards created dedicated workspaces to allow therapists to complete all of their tasks such as documentation on the ward, which promoted communication between the allied health professionals and the rest of the staff. Another ward crafted its pharmacist's work schedule to allow participation in daily safety meetings.
4. Teamwork: Working together as a team promoted collaboration between staff from different professional groups and experience levels.
"Staff worked beyond silos contributing to multiple aspects of patient care and they trusted one another's judgments. Although this was considered to make their teams more effective, staff often struggled to describe how, referring to a 'feeling they got' and a lack of distinction between 'them and us,'" the researchers wrote.
5. Openness to questions from staff members: Establishing an open environment for asking questions promotes an emotional lift from being able to approach other staff members without concern.
"This ensured that problems were raised with the wider team and it enabled information to be checked immediately and/or passed on to others without delay. Again, this was apparent across staff grades and professional groups and was particularly evident for new team members such as rotating doctors or student nurses," the researchers wrote.
Traits of successful care teams
Effective care teams that work with older patients achieve a comfort level in working with each other and have shared objectives, the researchers wrote. "Together, some of the findings suggest that staff within positively deviant teams experience high levels of psychological safety (which facilitates interpersonal risk taking) and possess shared mental models (a common understanding of shared goals, roles and how to achieve these)."
The study calls into question patient safety initiatives that focus only on discrete aspects of safety such as ward-level efforts to address specific errors and harm, the researchers wrote. "That focus should also be dedicated to improving the cultural contexts that underpin a range of safety outcomes. Although this proposition is unsurprising, the balance is yet to be struck—healthcare organizations do not typically facilitate relationships, integration and multidisciplinary working as a means to promote safety."
