Diverting patients from emergency departments with telemedicine can save more than $1,500 per visit.
Telemedicine visits generate cost savings mainly by diverting patients away from more costly care settings, new research shows.
The primary market opportunity for telemedicine visits is the value proposition that they can both expand access to patients while also reducing costs compared to alternative care settings.
The new study is based on data collected from 650 patients who used the JeffConnect telemedicine platform at Philadelphia-based Jefferson Health.
"In our on-demand telemedicine program, we found the majority of health concerns could be resolved in a single consultation and new utilization was infrequent. Synchronous audio-video telemedicine consults resulted in short-term cost savings by diverting patients from more expensive care settings."
The cost of a JeffConnect visit was a $49 flat fee.
The bulk of the cost savings from the telemedicine program was generated in diverting patients from emergency departments. Each avoided emergency department visit garnered cost savings ranging from $309 to more than $1,500. Cost savings from other alternate care types was below $114 average savings per visit.
"The net cost savings to the patient or payer per telemedicine visit of $19 to $121 represents a meaningful cost savings when compared with the $49 cost of an on-demand visit. The primary source of the generated savings is from avoidance of the emergency department, as this is by far the most expensive of the alternative care options provided," the researchers wrote.
Offsetting increased utilization
About 16% of the JeffConnect patients surveyed said they would have "done nothing" as an alternative to a telemedicine visit—representing potential increased utilization of services. But cost savings outweigh possible higher utilization of services due to telemedicine's easy access, the researchers found.
"A substantial shift would be necessary to outpace the savings from diversion. Conversely, this population of patients who would have done nothing may represent improved access and incorporation of patients into the healthcare system that might not have participated previously. This might actually prevent more costly care further down the line."
Most women who die of cardiovascular disease during pregnancy or the postpartum period were not aware that they had cardiac conditions.
Recently released guidelines for cardiovascular care of pregnant women have the potential to achieve significant reductions in maternal morbidity and mortality. The guidelines, which are detailed in a practice bulletin from the American College of Obstetricians and Gynecologists (ACOG), feature 27 recommendations.
Women face several cardiovascular disease risks during and after pregnancy, including heart rhythm abnormalities, heart valve conditions such as scarring, congestive heart failure, and exacerbation of congenital heart defects. From 2011 to 2014, cardiovascular disease was the leading cause of maternal mortality, according to the Texas Department of State Health Services.
"Cardiovascular disease is a major problem in obstetrics-gynecology," James Martin, MD, chair of the ACOG Pregnancy and Heart Disease Task Force, said during a May 3 conference call highlighting the new guidelines.
Cardiovascular care is critically important during and after pregnancy, he said. "The risk for cardiovascular disease can accelerate during pregnancy, and it can persist postpartum."
"There is a great need to follow-up with these patients and be very careful with postpartum care. As many as 40% of pregnant women do not return for postpartum care. That is a very sad statistic and reflects some of the need to change our payment models, so physicians and patients realize the importance of coming back for continuing care. If these patients have cardiovascular disease, it is likely to become worse during their lifetime."
Detection improvement needed
Screening for cardiovascular disease is another opportunity to reduce maternal morbidity and mortality, Pregnancy and Heart Disease Task Force executive member Afshan Hameed, MD, said during the conference call.
"The vast majority of mothers who die from cardiovascular disease either had undiagnosed cardiovascular conditions or had new onset of cardiomyopathy after their pregnancy. These are women who presented multiple times to healthcare providers for symptoms of shortness of breath, fatigue, or cough that were either dismissed or misdiagnosed," she said.
There is an urgent need to identify cardiovascular disease during and after pregnancy, Hameed said.
"We recommend screening all pregnant women and postpartum women to assess their individual risk for cardiovascular disease. This would allow for early diagnosis and treatment. … The overwhelming majority of women who die of cardiovascular disease during pregnancy or during the postpartum period were not aware that they had cardiovascular disease."
Team approach to care
Care teams should be assembled for women who are at risk of cardiovascular disease during and after pregnancy, Janet Wei, MD, said during the conference call. "A pregnancy heart team is multidisciplinary, with a minimum requirement of an obstetrics provider, a cardiologist, and—in moderate to high-risk patients—a maternal fetal specialist, and an anesthesiologist."
Pregnancy heart teams take a broad approach to care, said Wei, who is liaison for the American College of Cardiology on the Pregnancy and Heart Disease Task Force.
"The pregnancy heart team should have a comprehensive plan established for the pregnancy, delivery, and postpartum period. The plan should include the review of cardiac medication safety for the mother and the fetus, and the risk to the fetus from congenital and genetic conditions."
Top recommendations
The first 10 ACOG recommendations drawn from consensus and expert opinion feature advisories for maternal health as well as fetal and neonate care.
1. Knowledge: Clinicians should be familiar with signs and symptoms of cardiovascular disease.
2. Assessment: Ideally, a cardiologist should evaluate women with cardiovascular disease before pregnancy or as early as possible during the pregnancy for diagnosis, assessment of the effect pregnancy will have on cardiovascular conditions, risks to the woman and fetus, and treatment of underlying cardiac conditions.
3. Patient management: Women with cardiovascular disease risk should be managed through pregnancy and the postpartum period by a pregnancy heart team.
4. Patient engagement: Women with cardiovascular disease should be advised that pregnancy can contribute to a decline in cardiac status, risk of maternal mortality or morbidity, and fetal risks such as preterm birth.
5. Individualized care: To support the mother's decision making, the care team should take a personalized approach that accounts for maternal and fetal hazards linked to specific cardiac disorders and the patient's pregnancy plans.
6. Assessment tool: The California Improving Health Care Response to Cardiovascular Disease in Pregnancy and Postpartum toolkit should be used to assess all pregnant women for cardiovascular disease.
7. Ongoing evaluation: A pregnancy heart team should conduct ongoing evaluation of all pregnant and postpartum women with known or suspected cardiovascular disease.
8. Testing protocols: For women with cardiovascular disease and symptoms such as shortness of breath, chest pain, or palpitations, testing of cardiac status during pregnancy and the postpartum period is warranted.
9. ECG testing: Pregnant and postpartum women with known or suspected congenital heart disease, valvular and aortic disease, cardiomyopathies, and a history of cardiotoxic chemotherapy should have echocardiogram examination.
10. Fetal testing: For women with congenital heart disease, there should be fetal echocardiography. Conversely, when congenital heart disease is found in a fetus or neonate, screening for parental congenital heart disease could be warranted.
Vision impairment poses multiple challenges for hospitalized patients, including the inability to perform simple tasks such as locating call buttons.
Vision-impaired hospital patients have worse clinical outcomes, more readmissions, longer length of stay, and higher costs of care than non-vision-impaired patients, recent research shows.
Vision impairment including blindness affects nearly 4 million U.S. adults, and the figure is expected to increase significantly with rising rates of macular degeneration, glaucoma, diabetic retinopathy, and other eye conditions.
Compared to hospital patients without vision impairment, the recent research found vision-impaired Medicare beneficiaries and patients with commercial health insurance had significantly higher healthcare utilization and costs during and immediately after hospitalization.
"Extrapolating these findings to older adults suggests that hospitalization of patients with vision loss is associated with excess estimated healthcare costs of more than $500 million annually," the researchers wrote.
The research features data collected from more than 12,000 patients with and without vision impairment. The study, which was published in JAMA Ophthalmology, includes several key data points:
Compared to hospital patients with no vision impairment, Medicare beneficiaries with severe vision loss had longer mean lengths of stay, 6.48 days vs. 5.26 days.
Medicare beneficiaries with severe vision loss had a 23.1% readmission rate, which was 4.4% higher than patients with no vision impairment.
Medicare beneficiaries with severe vision loss had 12% higher costs of care compared to patients with no vision impairment.
For older patients with vision impairment, the total excess cost of hospital care was estimated at more than $580 million.
"These findings suggest that identifying the presence of vision loss during hospitalization or the discharge-planning period and employing strategies to assist these patients may be associated with improved outcomes, fewer readmissions, shorter LOS, better patient satisfaction, and (if applied across the United States) a cost savings of more than $500 million annually," the researchers wrote.
Vision-impairment challenges
Vision-impaired hospital patients are not typically targeted for special attention, which contributes to negative consequences, the researchers wrote. "Empirical evidence suggests that persons with vision loss may have difficulty following hospital routines and, once discharged, may struggle to read discharge orders and medication instructions, which may result in poor outcomes."
Hospitalization pose challenges for vision-impaired patients.
Documents such as consent forms, preadmission protocols, and post-discharge instructions are often inaccessible to vision-impaired patients. Many healthcare organizations are ill-equipped to address the needs of vision-impaired patients such as providing documents in larger fonts or braille. In an earlier study, only 23% of physician offices and hospitals offered large-print documents.
In the hospital setting, simple tasks can be daunting for vision-impaired patients, the researchers wrote.
"Indicating food choices, locating nursing call buttons, or identifying support staff can be difficult for hospitalized patients with vision loss. Ambulation is generally desirable during hospitalization to reduce risk of venous thrombosis and pressure ulcers. Yet for many patients with visual impairment, ambulation requires assistance from someone to address possible obstacles in hallways and patient rooms, which may increase the risk for injuries."
Caring for vision-impaired patients
The researchers say there are several measures that hospitals can deploy to meet the needs of vision-impaired patients:
Patients should be evaluated during the admission process for their ability to read documents
Patients who are identified with vision impairment should receive a hospital bracelet similar to bracelets provided to indicate fall risk that alert staff members to the need for additional assistance
Visual impairment should be noted in the electronic health record to make sure proper accommodations are provided during hospitalization and discharge
Care instructions should be provided to patients in accessible formats such as documents with large-font text
Patients should receive referrals for eye-care follow up for newly identified vision impairment during hospitalization
"Although some costs may be incurred to make facilities and hospital personnel better equipped to care for these patients, the potential savings and improvement in quality of care may make this undertaking a good investment," the researchers wrote.
In this inpatient program, patients are weaned off opioid medications while participating in a wide range of therapy and coping skills training.
An inpatient chronic pain program for children and adolescents in New Jersey has been adopted by Rady Children's Hospital-San Diego.
More than 10% of hospitalized children show signs of chronic pain, and approximately 3% of pediatric chronic pain patients need intensive rehabilitation. The annual total costs to society to care for children and adolescents with moderate to severe chronic pain has been estimated at $19.5 billion.
In April, the Rady Children's inpatient program was launched in partnership with New Brunswick, New Jersey-based Children's Specialized Hospital. The RWJBarnabas Health children's hospital has had an inpatient program for children and adolescents with chronic pain for six years.
"The goal of our program is to increase function, decrease pain, and promote the use of adaptive coping skills so our patients can return to functioning lives. We work on reducing the use of pain medications—any pain medications but specifically opiates," says Katherine Bentley, MD, director of the pain program at Children's Specialized Hospital.
The chronic pain program, which is targeted at patients age 11 to 22, has generated positive results at Children's Specialized Hospital:
In a 2016-2017 patient survey, participants reported knowledge of their condition improved 81%, quality of life improved 41%, compliance with care improved 89%, and depression improved 57%.
A Children's Specialized Hospital outcomes report found that from admission to discharge patients' average pain level dropped from 6.6 to 3.9 on a 10-point scale.
"We evaluate the patient before they enter the program. We have an open and honest discussion—our program is a functional program where we use the body to get better as opposed to outside factors," Bentley says.
Treating chronic pain in children and adolescents
Broad scope has been the key to success of Children's Specialized Hospital's chronic pain program, Bentley says. "It's interdisciplinary and comprehensive."
The inpatient program offers a wide range of therapy and training in coping skills:
Physical therapy
Occupational therapy
Child, life, and recreational therapy
Meditation
Yoga
Aqua therapy, with pool activities and games offered five days a week
"We work on diaphragmatic breathing. We have biofeedback in our program, so patients can see the mind-body connection. We work on coping strategies. We work a lot on home exercise programs—for many people with amplified pain or who have a bad pain day, exercising is the best thing for them," Bentley says.
The inpatient program takes a sophisticated approach to weaning patients off pain medications, she says.
"What we do is develop a safe weaning schedule, but the great part of the program is weaning is not done in a vacuum. Patients get physical therapy, occupational therapy, coping strategies, and meditation. So, weaning is done in a safe way that is both physiologically safe and psychologically safe."
Allowing autonomy for advanced practice practitioners continues to be contested state by state.
At the beginning of this year, the National Commission on Certification of Physician Assistants predicted that the reform of scope of practice, supervision, and delegation of authority legislation would be a top trend regarding physician assistants.
The NCCPA's expectation seems to be correct as more states are pushing for legislation to expand scope of practice for advanced practice practitioners.
But expanded scope of practice for advanced practice practitioners has been contentious. Physician groups have insisted on medical-doctor supervision of advanced practice practitioners. For example, in 20 states, a physician must co-sign a percentage or number of physician assistant charts, according to the American Medical Association. In 39 states, there are limits on the number of physician assistants a physician can supervise or with whom a physician can collaborate.
However, advanced practice practitioners have been equally insistent on gaining expanded scope of practice across the country. For example, in several states, laws that expand scope of practice for physician assistants (PA), nurse practitioners (NP), and advanced practice registered nurses (APRN) have already been adopted.
Twenty-two states and the District of Columbia allow NPs to function in a "full practice environment," which includes evaluating patients, ordering and interpreting diagnostic tests, managing treatments, and prescribing medications.
Now the decades-long struggle over regulation of advanced practice practitioners is playing out in Rhode Island and Florida.
Efforts to change state law
In Rhode Island, legislation would allow physician assistants greater autonomy from physicians, with the creation of a more collaborative model. The legislation also would end physician legal liability for the work of physician assistants.
In Florida, Florida House Bill 821 and its Senate companion, SB 972, are moving through the state legislature and would grant expanded scope of practice to PAs and APRNs.
The Florida legislation would allow PAs and APRNs to work independently of physicians as long as they had not been disciplined in the previous five years, had accrued at least 2,000 clinical practice hours within a three-year period, completed graduate-level courses in pharmacology, and maintained specified levels of professional liability coverage.
However, the legislation is not expected to become law this year, says Deborah Gerbert, PA-C, co-chair of the Legislative and Governmental Affairs Committee at the Florida Academy of Physician Assistants.
The legislation has passed the Florida House, but it has not passed the state Senate and this year's legislative session is set to conclude on May 3.
"I never say never until the last gavel is put on the table, but the fact that it has not been heard at all in the Senate committees has been a deliberate block of the legislation by the chairman of the Health Policy Committee and the president of the Senate. They do not want this issue heard," Gerbert says.
If the state Senate does not pass the legislation this week, advocates of the scope-of-practice expansion would have to start over next year, she says.
Weighing educational requirements
Representatives of physicians and nurse practitioners have starkly different views on the proposed Florida legislation's clinical practice hour requirement.
Jay Epstein, MD, a practicing anesthesiologist and chair of the American Society of Anesthesiologists' Florida chapter Committee on Governmental Affairs, says the training of physicians is superior to the training of advance practice practitioners.
"I had to do 12,000 hours over a three-year anesthesiology residency. I then passed my anesthesiology boards to be board-certified in anesthesia, then I passed my boards in critical care medicine. So right off the bat, I had six times the clinical hours of this legislation's requirement," he says.
Epstein says the proposed Florida legislation should have more specificity about the level of clinical practice hours and the specificity of those hours.
"My 12,000 hours over three years were in the operating room, in the labor suite, in the pain clinic, in the intensive care unit, and in the cardiac catheter lab—wherever the patient required surgical or procedural sedation. Florida House Bill 821 does not define where those 2,000 hours are going to come from," he says.
However, Taynin Kopanos, DNP, NP, vice president of state government affairs for the American Association of Nurse Practitioners in Austin, Texas, says the proposed Florida legislation's clinical practice hour requirement is overkill.
"AANP believes that these requirements are unnecessary for safe practice by nurse practitioners and can impede direct access to patient care. We understand that some state legislators find that this is a political compromise option that they are willing to move forward from," Kopanos says.
"Nurse practitioners follow the literature on evidence-based outcomes and the evidence supports that care provided by nurse anesthetists is safe, high-quality care and the patients have the same outcomes as they do from physicians. So, the evidence on patient outcomes do not support that there is a difference in quality of care between the two providers," she says.
Addressing physician shortages
Part of Kopanos' argument for scope-of-practice expansion is that it could help ease the country's physician shortage, she says, making it essential for advanced practice practitioners to work independently of physicians and to bring their full knowledge and skill set to the treatment of patients.
PAs are widely viewed as part of the solution to the country's physician shortage.
"A clarifying point around this issue is the word independent. What we are looking at in Florida is whether it is legal for an NP to provide care to patients outside of a relationship with a physician. Right now, it is illegal for nurse practitioners to bring their knowledge and expertise to provide care to patients based on existing licensure laws," she says.
Kopanos says HB 821 and SB 972 are a step in the right direction to not only improve access to care but also focus on other challenges. "These bills are about making it legal for people to practice their profession and help address healthcare shortages and disparities, provide better choices, and address healthcare costs in the state."
However, Epstein says requiring advanced practice practitioners to work under the supervision of a physician is the safest way to help address physician shortages.
"APRNs and physician assistants working in a care team would be ideal. That is the model we have had for a long time in anesthesia, and it's a model that can be widely applied to other specialties. It gives you the benefit of the physician being present for preoperative optimization, intraprocedural care, and postoperative complication management," he says.
Epstein says supervision of advanced practice practitioners is essential for patient safety in acute care situations, making an analogy to the aviation industry.
"Things go quite wonderfully most of the time; but the minute there is a problem, you need the education, the background, and the experience to make critical decisions. We are always going to have a situation where physicians are needed to be available for immediate rescue. There are cases in the hospital that are less acute where we can start talking about broadening the supervision ratio to something higher than 1 to 4," he says.
Resolving the controversy?
Kopanos says states that have expanded scope of practice for advanced practice providers have shown that NPs, PAs, APRNs, and physicians can cooperate effectively and safely as equals.
"For example, there are networks in Washington state where pharmacy boards, nursing boards, physician boards, and their associations get together and craft legislation on how those providers who are going to write controlled substances manage them, and all of those providers are treated equitably," she says.
The struggle over scope of practice should be viewed as an effort to modernize licensure laws, Kopanos says.
"It really is incumbent on states to move forward with full practice authority. With 50 years of evidence for safe, quality NP care, this is not a turf war. This is about recognizing that healthcare has evolved and grown, and that NPs have expertise in health disciplines that can help address patient care needs in the country," she says.
However, Epstein says legislators should not take a one-size-fits-all approach to scope of practice for healthcare providers.
"As a first step, we should determine what is appropriate for a given situation because nothing is ever black and white, it's always gray. We should determine where it makes sense to use physician extenders without physician supervision or with limited supervision, or with full physician supervision," he says.
Patient safety should be the paramount concern, Epstein says.
"If we also start with the safety of the patient and what's in the best interest of the patient, we'll settle this controversy quicker. It will help turn down the heat on the discussion if we have a rational dialogue on differentiating between an acute care specialty like anesthesiology and the practice of other specialties in medicine like family practice, where the decisions are not as acute."
New research indicates incentives for clinician assessments of hospital-discharged skilled nursing facility patients should be strengthened.
At skilled nursing facilities, hospital-discharged patients who are not visited by a clinician are nearly twice as likely to be readmitted to a hospital as patients who receive visits, recent research shows.
About 20% of hospitalized Medicare patients are discharged to a skilled nursing facility (SNF). Readmissions have become a crucial metric for hospitals, with quality and financial dimensions. For example, Medicare has been penalizing hospitals financially for readmissions linked to several conditions such as pneumonia since 2012.
The recent study, published in Health Affairs and LDI Research Brief, found clinician visits to hospital-discharged patients at SNFs were strongly associated with readmission and mortality rates:
SNF patients who received at least one clinician visit had a 14.3% hospital readmission rate. SNF patients who received no clinician visits had a 27.9% readmission rate.
SNF patients who received at least one clinician visit had a 7.2% mortality rate. SNF patients who received no clinician visits had a 14.2% mortality rate.
The researchers examined data from more than 2 million Medicare fee-for-service SNF stays.
"Patients transitioning from hospitals to SNFs are often medically complex and at high risk of poor outcomes, with one in four of these patients deceased or re-hospitalized within thirty days. Results from this study suggest that missing and delayed care from physicians and advanced practitioners occurs during this vulnerable time," the study authors wrote.
Improving care at SNFs
Better incentives are needed to promote clinician assessments of hospital-discharged SNF patients, the researchers wrote. "Current regulatory and payment policies do not incentivize timely physician assessment of patients discharged from hospitals to SNFs. Medicare requires only that a physician complete an initial assessment within 30 days of SNF admission."
The lead author of the study, Kira Ryskina, MD, MS, told HealthLeaders that some new payment models are promoting enhanced SNF care. "Payment reform such as bundled payments that penalize hospitals for their patients' postacute care outcomes aim to encourage hospitals to invest more resources in SNFs."
Medical assessments of patients at SNFs generally feature three elements, she said.
"Typically, an effective assessment has an admission history including a review of medical records from the preceding hospitalization and medication reconciliation, physical examination, and delineation of plan of care," said Ryskina, an assistant professor of medicine at the University of Pennsylvania's Perelman School of Medicine.
The primacy of online reviews in the marketing of medical practices is the 'new normal,' according to a recent survey.
Online reviews are playing a pivotal role in how patients pick their healthcare providers, a recent survey shows.
For clinicians, online reviews should be a primary concern for several reasons: review websites such as HealthGrades and Vitals are collecting information and posting it across the country, online reviews can be robust marketing tool, and reviews can help hone clinician performance.
"This is the new normal for medical practices in 2019. Choosing a doctor based on online profiles and patient reviews is the old word-of-mouth at today's scale and speed. Number of reviews, average star rating, and convenient hours and locations are essential 'shopping' details that patients expect to find before stepping foot into a waiting room," the recent survey's report says.
The survey, which features responses from more than 800 people about online reputation and patient reviews, generated several key data points:
74.6% of respondents had researched doctors, dentists, or medical care online
69.9% said a positive online reputation is very or extremely important in selecting a healthcare provider
51.8% of patients who had submitted negative online reviews about a medical practice had not been contacted to address their concerns
Patient satisfaction doubles when a medical practice addresses a negative online review
"While satisfied patients are more prevalent online than unhappy ones, the fact remains more than 1 in 3 patients who've shared their experience online have submitted a negative review. Negative reviews are going to pop up—they're an unavoidable aspect of customer service for any business, in any industry," the survey's report says.
Responding to negative reviews
The survey—which was conducted by Santa Monica, California-based PatientPop—shows the key role online reviews are playing in patients' selection of healthcare providers.
"This illustrates just how influential reviews are in patients' decision-making process. If a doctor or practice isn't making a strong first impression with online reviews, that's the difference between a newly acquired patient and a lost one," says Joel Headley, director of Local SEO and Marketing at PatientPop.
The powerful impact of addressing negative reviews was an unexpected finding of the survey, he said.
"It was surprising to see just how much patient satisfaction can increase—99%—following a negative review based on just one action: practices reaching out to address the patient's concerns. We assumed that good common courtesy and customer service would bump up respondents' satisfaction rates, but I don't think we expected they would double."
There are a handful of best practices when responding to negative reviews, Headley says.
"First, being prompt is critical—practices should respond to any negative review by the next business day. Second, whomever is responding for the practice should keep it short and professional, being clear that the patient's concerns are important and stating they want to help remedy the issue. They should also offer to reach out directly to the patient and take the conversation offline. Finally, practices must keep HIPAA compliance in mind, never including any personal health information or care details within the response even if the patient does."
Prompt identification of patients who are at high risk of sepsis could be the difference between life or death.
Emergency department crowding leads to a significant increase in door-to-antibiotic time for septic patients, recent research shows.
On an annual basis, sepsis affects about 1.7 million American adults and the infection is linked to more than 250,000 deaths. Prompt administration of antibiotics is the standard of care for patients who have been identified with sepsis.
The recent research found only 46% of emergency department sepsis patients received antibiotics within 3 hours of ED arrival when the emergency room was crowded compared to 63% receiving timely antibiotics when the ER was not crowded.
The researchers examined data collected from more than 3,500 sepsis patients.
"We observed a consistent association between increased ED crowding and decreased antibiotic timeliness. When ED occupancy rate was in the highest quartile, the adjusted probability of starting antibiotics within 3 hours was more than 50% lower than when ED occupancy rate was at or below the 25th percentile," the researchers wrote.
Achieving standard of care under crowded ER conditions
Even in a crowded ED and with the diagnostic challenges of sepsis, meeting the 3-hour standard of care for administration of antibiotics to sepsis patients is a reasonable expectation, the lead author of the research told HealthLeaders.
"Myocardial infarction treatment and stroke treatment also require a team evaluation and multiple aspects of clinical evaluation—there is intensive resource mobilization. However, for MI or for stroke, we don't say, 'The ED was overcrowded, so it's OK that we didn't achieve our one-hour time to treatment goals,'" said Ithan Peltan, MD, MSc, an attending physician in the Department of Medicine at Intermountain Medical Center, Murray, Utah.
EDs should have a similar approach to sepsis treatment as MI and stroke treatment, with the acknowledgement that sepsis diagnosis is definitely not as clear cut, he said. "We should determine how we can achieve our treatment goals for sepsis without increasing harm to patients—without increasing overtreatment or giving antibiotics unnecessarily to patients."
Accelerating sepsis assessment
Peltan's research team found that delayed administration of antibiotics results mainly from challenges in the early stage of patient care.
"Crowding-associated antibiotic delays resulted from delays in initial patient assessment (patient triage, evaluation by a clinician, and diagnostic data collection) rather than delay occurring between initial assessment completion and antibiotic initiation," the researchers wrote.
There are methods to improve early-stage care of sepsis patients in crowded EDs, Peltan told HealthLeaders.
"One factor is that the earliest stages of sepsis treatment are critical. You need to recognize the patients who might have sepsis. That is not to say we are going to diagnose sepsis right away, immediately start treatment, and give antibiotics indiscriminately. That is clearly not the right thing to do," he said.
In the early stage of patient care, identifying patients who are at high risk of sepsis is pivotal, Peltan said. "Identifying patients who are at increased risk for sepsis can be based on clinician suspicion with increasing education of our frontline providers and more advanced sepsis prediction models."
Once an ED patient has been identified as high risk for sepsis, the assessment process should be accelerated, Peltan said.
"The next step is to do what we have done for stroke and MI, which is to take measures that expedite the assessment that is necessary before the treatment decision can be made for patients. We should bring all of the resources into the room, we should get the blood tests done quickly, we should conduct point-of-care tests, we should have the nurses getting IV access, we should get a basic chest X-ray done, and we should collect a urinalysis sample."
Although speeding up the assessment process is challenging in a crowded ED, it is an essential step to reach an initial decision on whether sepsis is present or more assessment is necessary, he said. "This approach is helpful when there is ED crowding. One of the big challenges that ED crowding poses is for the physician at the bedside to have all of the data needed to make decisions."
New research indicates comprehensiveness in primary care could be just as significant as care access and coordination.
Patients who receive comprehensive primary care have lower Medicare expenditures, fewer hospitalizations, and less emergency department visits, recent research shows.
More comprehensive care has been linked to improved care coordination; reduced diagnostic tests, medications, and interventions; health gains; lower costs; and improved equity.
"Our findings, when taken in the context of prior literature, suggest that promoting comprehensiveness of primary care could avert preventable ED visits and hospitalizations and lower overall costs," the authors of the recent study published in Health Services Research wrote.
The researchers examined three measures of comprehensiveness:
Involvement in patient conditions: This new metric gauges the comprehensive of clinicians based on their involvement in the care of a broad range of patient health conditions.
New problem management: This new metric measures how much a clinician manages a patient's new symptom or problem rather than making a referral to a specialist.
Range of services: This previously established metric shows the range of services that a clinician provides to all patients.
The research is a leap forward in the ability to examine the comprehensiveness of primary care, the lead author of the study, Ann O'Malley, MD, MPH, told HealthLeaders.
"This work helps us assess comprehensiveness more deeply than prior work by adding two new measures—new problem management and involvement in patient conditions—and we demonstrate that both are important dimensions of primary care clinician comprehensiveness," she said.
O'Malley's research team found a high degree of new problem management was associated with reduced total Medicare expenditures, hospitalizations, and ED visits.
The research shines a light on comprehensiveness of primary care—an issue that has received insufficient attention in the past, O'Malley said.
"To date, comprehensiveness has received less attention than other key elements of primary care, such as access or continuity, which are more easily measured, and coordination, which is now the focus of a variety of new payment models. Without explicit measurement and support for its improvement, comprehensiveness may wither as other aspects of primary care such as access and coordination receive more resources and attention."
Expanding knowledge about comprehensiveness of primary care
The new study builds on earlier research about comprehensiveness of primary care and outcomes, she said.
"This work shows that particular aspects of primary care physician comprehensiveness—in particular the primary care physician's management of patients' new problems and the primary care physician's involvement in the care of a broad range of a patient's conditions—are associated with lower rates of emergency department visits, lower hospitalization rates, and lower total Medicare expenditures."
The new study also advances the understanding of how comprehensiveness impacts care, O'Malley said.
"This work adds to prior efforts, which have chiefly focused on comprehensiveness in terms of the types of services a primary care practice offers. Our analyses suggest that, for Medicare beneficiaries, high physician comprehensiveness on our two new measures is as important as assessing the range of services they provide."
She cautioned that the study's findings are useful to primary care researchers but have limited utility for applications such as payment models. "These claims-based measures are not suitable for high-stakes performance metrics for individual primary care clinicians or practices."
CEO Pat Basu speaks on a range of opportunities to defeat cancer.
Pat Basu, MD, MBA, has been on a quest to cure cancer since he decided to go to medical school.
"I went into medicine in the first place to become a radiologist, in large part, due to cancer being one of the great battles that humanity is fighting today, and has been fighting for many centuries," Basu, the new president and CEO of Cancer Treatment Centers of America (CTCA), told HealthLeaders recently.
Cancer claims the lives of more than 600,000 Americans annually, according to statistics from the National Cancer Institute.
The University of Chicago Pritzker School of Medicine graduate brings an extensive professional background to his new role.
He has worked as a physician at Stanford University Medical Center; a partner at Chicago Pacific Founders Private Equity and at Pritzker Group Venture Capital; senior vice president at Optum; a White House fellow; and president, chief operating officer, and chief medical officer at vRad, a provider of radiology services.
Basu is also one of the founders of Doctor On Demand, a telehealth video visit company.
"I have been privileged to work at organizations that are at the forefront of some of the major transformations in healthcare—technology and data, value-based care, and healthcare reform working in the White House," he says.
HealthLeaders spoke with Basu, who is succeeding Rajesh Garg, MD, JD, to find out about his vision for CTCA. Following is a lightly edited transcript of that conversation.
HealthLeaders: What are the biggest challenges facing cancer treatment providers such as CTCA?
Basu: Clinically, we have amazing potential clinical tools that are on the verge of breakthrough such as precision medicine and immunotherapy. But cancer is still an unbelievable plague on our society, with one-out-of-three Americans who will be diagnosed with cancer during their lifetime.
From a care delivery standpoint, cancer care providers face similar—and in some instances extenuated—versions of what other healthcare providers in America are experiencing. On the one hand, cancer care providers are delivering very complex care despite an accelerating decline in reimbursement. At the same time, cancer care providers are dealing with increasing input expenses such as pharmaceutical costs.
There are also challenges throughout the American healthcare system that are highly relevant to cancer care providers. There are changes in care models—there are shifts from treatments that used to be inpatient therapy that are now outpatient therapy and may soon be shifted to telehealth. That sounds nice; but as an organization, those shifts are challenging operationally.
There are shifts in the marketplace in terms of value-based care and increasing patient deductibles. There is the impact of technology, which is a good thing, but technology in and of itself is not a solution. You need to have solutions that deploy technology, not technologies that deploy solutions.
HL: What is an example of a new business venture at CTCA that is designed to expand access to higher-quality cancer care?
Basu: We have incredibly big opportunities in the data space, where we are working with pharmaceutical companies and biotechnology companies. At CTCA, we have been treating patients end-to-end, with holistic, integrated care for more than 35 years. So, we have lots of data from the time that patients came to us, to the time they were treated and went home, and everything in between.
So, we have clinical trials with pharmaceutical companies to use that data to unlock better cures.
HL: Why is data such a valuable commodity in medicine?
Basu: How many times in our profession have we said that something works, then we came back later and said it doesn't work? You just don't use the latest and greatest because it is the latest and greatest. You have to think about whether you are adding value to the patient, and you need data that says one therapy is better than another.
History is littered with medical treatments that we thought were great, but they ended up not great and actually harmful.
HL: What would you pick as the most promising technologies in cancer care?
Basu: In the purely clinical axis, I hold a lot of faith in precision medicine and immunotherapy.
Precision medicine is based on the idea that each of us have unique factors that—to date—have not been taken into account. American medicine has been monolithic—if you take a certain dose, I take a certain dose. Immunotherapy is also powerful because it is unlocking the body's own powerful defenses.
On the technology axis, I am most excited about what data can unlock. In cancer care, which is a highly complex disease and a highly prevalent disease, we have lots of data. We should be able to unlock treatments, wisdom, and nuances.
On the care delivery axis, I am excited about the notion of getting care out to the patient in terms of telehealth and remote monitoring and other things that allow us to come to the patient instead of the patient always having to come to us. That has relevance in primary care, and it has relevance in oncologic care.
