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."
Researchers call for early warning system to improve the care of cancer inpatients.
Several factors are associated with clinical deterioration of hospitalized cancer patients, with implications for patient monitoring, allocation of care resources, testing, and early warning systems, recent research shows.
Hospitalization is a leading contributor to cancer-related healthcare spending. Hospitalizations for cancer involve longer length of stay and higher costs than inpatient care for other conditions.
The recent research published in Journal of Oncology Practice was based on data collected from more than 21,000 hospital admissions at Barnes-Jewish Hospital in St. Louis. Clinical deterioration of cancer patients was defined as a composite of oncology ward death and intensive care unit transfers.
The research features several key data points:
Clinical deterioration of cancer patients was relatively common, at 9.2% of admissions
6.4% of cancer patients admitted to the hospital experienced at least one ICU transfer
2.7% of cancer patients admitted to the hospital died in an oncology ward
Factors associated with clinical deterioration included age, comorbidities, illness severity, emergency admission, bacteremia, and administration of antimicrobials and transfusions
The relatively high rate of clinical deterioration among cancer patients calls for an increased focus on high-risk patients, the researchers wrote. "Our findings suggest that inpatients with active cancer are at increased risk for clinical deterioration. This risk is particularly important, because prior work has shown that patients with cancer who develop critical illness may have worse outcomes than patients without cancer whose health deteriorates similarly."
Identifying cancer patients who are at high risk of clinical deterioration can generate significant care benefits, the researchers wrote. "Identification of patients on the wards before deterioration may offer the opportunity for interventions aimed to prevent ICU transfer, cardiopulmonary arrest, and death. Early intervention has been associated with improved short-term and long-term outcomes among patients with cancer whose health is deteriorating."
Early warning system
Cancer inpatients at high risk for clinical deterioration should be targeted for enhanced monitoring such as telemetry and differential vital sign monitoring, the lead author of the research told HealthLeaders. There are three reasons to establish early warning systems to monitor the health status of cancer inpatients, said Patrick Lyons, MD, a fellow in the Division of Pulmonary and Critical Care Medicine at Washington University School of Medicine, St. Louis, Missouri.
"First, their higher baseline risk means a well-performing early warning system would generate fewer false positive results, which are known to be harmful. Second, some literature suggests that subjective triage of oncology patients is uniquely challenging, so an objective risk prediction score might be able to help with triage. Finally, certain groups oncology patients—especially those with hematologic malignancies and recipients of stem cell transplants—commonly experience reversible deterioration, like sepsis, and ultimately recover good functional status. This suggests that some aspects of their critical illness might be modifiable if caught earlier," he said.
Lyons and his research colleagues are in the process of developing an early warning system for cancer inpatients, he said. "We are working to create an oncology early warning system and intend to test its performance, issues related to implementation and workflow integration, and ultimately patient outcomes. So, I am hopeful that our work will help develop a broad field of inquiry into how best to deliver inpatient care to such an important patient population."
Top areas where AI can have a significant effect on primary care include risk prevention and intervention, population health management, and device integration.
Artificial intelligence (AI) is poised to have a transformative impact on primary care, a recent journal article says.
AI technology is starting to be applied across the healthcare sector, including digital clinical decision support tools and natural language processing. With more than 500 million patient visits annually, primary care is a prime area for AI to have a revolutionary effect on healthcare.
"Primary care is where the power, opportunity, and future of AI are most likely to be realized in the broadest and most ambitious scale," the authors of the recent article in Journal of General Internal Medicine (JGIM) wrote.
The journal article identifies 10 primary care areas where AI is either already generating benefits or expected to gain traction.
1. Risk prevention and intervention: Potentially preventable medical conditions account for $1 in every $10 of hospital spending, so millions of hospital stays and billions of dollars in care costs could be avoided with better risk prediction and interventions in the primary care setting. For example, Phoenix-based Banner Health is using BaseHealth AI technology to predict risk for 42 health conditions to reduce emergency room and hospital utilization through primary care interventions.
2. Population health management: AI has the potential to identify and close care gaps as well as to improve healthcare providers' performance in quality payment programs such as those established under the Medicare Access and CHIP Reauthorization Act of 2015. For example, IBM and Siemens have established a partnership to develop new population health tools for primary care clinicians using Watson Health AI technology.
3. Medical advice and triage: "AI doctors" can offer medical advice to patients who have common symptoms, which opens up primary care access for more complex cases. Examples of companies that have developed this AI technology include Babylon Health and HealthTap Inc. The JGIM article authors caution that AI doctors should not be deployed to supplant primary care physicians. "Rather than AI replacing real providers for some conditions, we believe that AI support can be integrated into team-based care models that make it easier for primary care physicians to manage a patient panel," they wrote.
4. Risk-adjusted paneling and resourcing: By setting panel sizes according to patient complexity, risk-adjusted paneling can help primary care physicians see patients in an efficient manner, which can boost patient satisfaction and curb physician burnout. For example, University of California-San Francisco is using electronic health record (EHR) data on healthcare utilization to train algorithms that assess primary care panel sizes.
5. Device integration: Nearly a quarter of Americans have wearable devices that collect health data such as vital signs, but this voluminous data is often unwieldy and incompatible with healthcare provider EHRs. AI technology such as Apple's HealthKit has the potential to tame this cumbersome treasure trove of wearable-device data.
6. Digital health coaching: Treatment of chronic illnesses account for most of healthcare spending in the United States, with the cost of care for diabetics alone estimated at more than $300 billion annually. Companies that have developed digital health coaching tools for diabetes, hypertension, and obesity include Glooko, Lark Health, Livongo Health, Omada Health Inc., and Virta Health Corp.
7. Chart review and documentation: EHR clinical documentation is a major factor in physician burnout, causing as much as $140 billion in annual lost physician time. Automatic speech recognition technology is being used at healthcare organizations including Pittsburgh-based UPMC, which has partnered with Microsoft to develop AI-powered digital scribes that can monitor patient-physician conversations and produce clinical notes.
8. Diagnostics: AI algorithms have made inroads for diagnosing several diseases, including skin cancer, breast cancer, colorectal cancer, brain cancer, and cardiac arrhythmias. When deployed in areas of the country that have shortages of medical specialists, these diagnostic technologies have the potential to expand the services provided by primary care physicians. For example, Iowa City-based University of Iowa Health Care is using IDx-DR to detect diabetic retinopathy.
9. Clinical decision-making: Several EHR companies such as industry leaders Epic and Cerner are adding AI to workflows to provide clinicians with digital clinical decision support tools. For example, Nashville-based HCA Healthcare has deployed an EHR-based clinical decision support tool called Sepsis Prediction and Optimization of Therapy (SPOT) that can detect sepsis about 18 hours earlier than the best clinicians.
10. Practice management: AI can automate repetitive clerical tasks that create administrative burdens at primary care practices For example, Olive uses AI technology to automate several clerical tasks, including insurance claims, prior authorizations, billing, and data reporting.
Keys to AI success in healthcare
Successful AI initiatives in primary care augment rather than subvert the physician-patient relationship, the lead author of the JGIM article told HealthLeaders.
"The key is to never lose sight of the patient-provider relationship as the single most important ingredient that makes everything else in healthcare possible," said Steven Lin, MD, vice chief and technology innovation medical director at Stanford Family Medicine, and executive director, Stanford Medical Scribe Fellowship, Division of Primary Care and Population Health, Stanford University School of Medicine, in Palo Alto, California.
"Technology like AI can help strengthen that relationship if it serves to free up providers' cognitive and emotional capacity to connect with their patients, such as relieving them of the burden of clinical documentation or supporting clinical decision-making to reduce decision fatigue," he said.
It is also crucial for healthcare organizations to try to ensure that primary care patients accept AI innovations, Lin said.
"Patients need to trust that AI is not replacing part of their care, and that they are still being cared for by human providers who know them and care deeply about them. AI should be introduced as an additional member of their care team, not replacing anyone already on it. AI should be invisible or in the background, helping human providers become more efficient and giving them more capacity for face-to-face time."
To remain financially viable, all health systems must generate a positive operating margin to reinvest in their organization, which can pose challenges to nonprofits from a mission perspective.
"There is natural tension with being a nonprofit and being able to maintain the organizational vitality to further our mission," says CFO Rob McMurray, MBA, CPA, of Wilmington, Delaware-based Christiana Care Health System.
While operating margin targets are in a "constant state of flux" depending on the capital needs of any given year, Christiana Care must generate a positive margin year to year, McMurray says.
"We know that we want to maintain a margin that will provide us with the resources to continue to invest in our infrastructure to deliver optimal services. And we need to continue to invest and develop the people who will lead us in our strategic aims as well as continue to invest in innovative tools and strategic partnerships. It requires a certain margin to do those things," he says.
The necessity to post a positive operating margin can be a hard sell to board members who are laser-focused on nonprofit status, McMurray says. However, Christiana Care's board recognizes the importance of both fulfilling the nonprofit mission and business needs. "We spend a lot of time educating the board and ensuring that we have a board with the proper level of sophistication to understand how our business strategies support our mission. It's critical."
Mary Ann Freas, senior vice president and CFO of Southwest General Health Center in Middleburg Heights, Ohio, says the financial reality of operating a hospital "muddies the water" at nonprofit organizations.
"I'm the CFO. I'm always worried about making sure we have the resources available to stay viable, to make sure we have a steady workforce, to have the ability to reinvest, and to do all the things that are necessary to maintain ourselves in perpetuity. I know that means my revenues must exceed my expenses."
"It gets fuzzy and it gets confusing trying to explain this to caregivers if I'm asking to cut their budget, or to live with the same budget they had last year. Reimbursement is not growing; if anything, it's flat or declining from year to year, so we have to become more efficient. Sometimes, it's a hard equation to articulate," she says.
Depending on patient volume, which varies from year to year, Freas says Southwest General sets an operating margin target from 2.5% to 4.0%. Meeting those targets can lead to hard choices and pointed conversations.
"Sometimes, I challenge some of the resources that clinical leaders want to bring on board. We can't be everything to everybody. There's more clarity in the for-profit world. They can say, ‘This is our business, and this is how we're going to do it.'"
Three strategies have helped Southwest General generate positive operating margins, says Freas.
First, Southwest General has a large outpatient footprint, including ambulatory facilities in Middleburg and Strongsville, Ohio, that feature physician offices and outpatient services. "That strategy has allowed Southwest to grow its outpatient revenues to a level that is nearly two-thirds of the total," she says.
Second, Freas says Southwest General's employed physician group has contributed to the organization's financial success. Third, Southwest General has made steady investments in new services such as hyperbaric wound care and outpatient physical medicine, she says.
Banking on growth
Growth has always been important at for-profit health systems because investors demand it, but growth has become equally essential at nonprofit health systems in recent years, says Paul Keckley, managing editor of The Keckley Report in Washington, D.C., and former executive director of the Center for Health Solutions at New York–based Deloitte.
"Even in a community where you are the only game in town, the declining reimbursement rates for your core services require you to find new sources of revenue to create any kind of operating margin," Keckley says.
