A new collaborative approach is designed to improve birth outcomes, decrease cesarean section procedures, and increase patient engagement.
Maternal morbidity and mortality continue to be a devastating trend in U.S. healthcare, as reported in The Washington Post last November.
Complications from C-sections such as hemorrhaging are widely considered to be a contributing factor to the country's high maternal mortality rate. The federal Centers for Disease Control and Prevention have been monitoring maternal mortality since 1986. The number of pregnancy-related deaths has risen steadily since the monitoring effort began, from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014.
In December, the federal government took a step toward addressing maternal mortality with passage of the Preventing Maternal Deaths Act.
To decrease C-sections and improve birth outcomes, Ariadne Labs, a collaborative of Brigham and Women's Hospital and the Harvard T.H. Chan School of Public Health in Boston, launched the Team Birth Project in 2018 at a handful of sites across the country to recast the hospital-based birthing process.
The Team Birth Project features two primary elements: efforts to improve communication between the mother, the family, and the clinical care team; and a pair of decision-making tools.
1. Create a labor storyboard and implement team huddles
Under the Team Birth Project model, birth plans are living documents throughout the birth process, says Margie Bridges, DNP, a perinatal clinical nurse specialist at Overlake Medical Center. The Bellevue, Washington, facility is one of the pilot sites for the initiative.
"Historically with birth plans, the patient and the family may have talked to their doctor during an office visit then brought it to labor, when it got tucked into a chart. It wasn't a living document that got changed as conditions changed," she says.
To make sure birth plans are considered during labor, the Team Birth Project calls for clinical care teams to mount a whiteboard in the birthing room that reflects the mother's preferences. At Overlake, 24 x 36-inch whiteboards are affixed to a door facing the mother.
Information on the whiteboard has crucial information such as the birth team, which includes the mother; a plan for the baby such as monitoring; a plan for the mom such as pain management; and a plan for labor progress.
The whiteboard is the "story of the labor," says Lisbeth Jordan, MD, a hospitalist and OB Hospitalist Group site director at Overlake. "It is updated regularly—what's going on with the baby, how the labor is progressing, and next steps with the provider. It's a storyboard to help the family be aware of what they want, how the baby is doing, and how the labor is going."
Birth plan huddles are held at key points during labor, Bridges says. "The huddles get the core team together when decisions are being made. Huddles are held when you would normally consult the doctor, and you include the patient."
The huddles can be held even when the physician is unable to be at the bedside, the nurse specialist says. "We get them on the phone for a conference call in the birthing room. We put the doctor on the speakerphone, and we go over the whiteboard to review changes in preferences, give status reports on the mom and the baby, and raise concerns."
Boosting communication can help avoid C-sections, Bridges says. "Sometimes, it's tricky to understand why a mom has a C-section. There are so many variables and variation. If we look very clearly at the three lanes—mom, baby, and labor progress—and have a plan, we can avoid some cesarean births."
Open communication can be pivotal in avoiding a cesarean birth, Jordan says. "There is a shared understanding of what is going on. So, the story plays out, and the provider checks in with the nurse and the family. The idea is that it is a collaborative, team effort that can reduce unnecessary C-sections because there is shared knowledge about the whole process of labor."
2. Use admission decision and C-section criteria tools
The Team Birth Project has a duo of decision-making tools to help reduce C-sections, Bridges says.
"There is an admission decision aid that helps us decide whether a patient needs to be admitted to the hospital. We know if we admit someone too early—the mother is well and the baby is fine—it starts the clock ticking and increases the rate of cesarean sections. If the patient is hospitalized, we start to intervene."
The second decision-making tool helps determine whether conditions for ordering a C-section are present, she says. "We also have an aid that we can use during the process of labor that focuses on the mom, the baby, and labor progress that tells us whether we have met the minimal criteria to even consider a C-section. It tells us whether it is safe to keep going with a vaginal birth."
Generating results
While the Team Birth Project pilots are in their infancy, the early results are promising.
In February, Boston 25 News (WFXT-25) reported that South Shore Hospital in South Weymouth, Massachusetts, had achieved a 4% reduction in the facility's C-section rate through Team Birth Project implementation. South Shore was the first hospital to launch in the initiative in April 2018.
Patient experience gains are also evident, Jordan says. "The initial motivation of this initiative was to decrease C-section rates and the research outcomes are pending, but we are finding the increased communication has transformed the relationships in the entire team. Communication improves outcomes, so it may be that the most significant outcome is not decreased C-sections but a better experience for the family."
Happier families have also been noted at another pilot organization: Kirkland, Washington-based EvergreenHealth.
"We are seeing amazing things in terms of patient satisfaction—they leave the hospital feeling that they understand what happened to them. They get to write their own birth story. It's an important change in how we deliver care because we are providing care with the patient and not giving care to the patient," says Angela Chien, MD, an obstetrician-gynecologist at EvergreenHealth.
Inappropriate electrocardiographic monitoring results in wasteful spending and decreased quality of care.
Following practice standards through an electronic order set boosts the appropriate use of electrocardiographic monitoring without increasing adverse events, recent research shows.
Earlier research demonstrated that inappropriate use of cardiac telemetry results in significant wasteful spending. Over monitoring has also been associated with quality and safety concerns such as clinician alarm fatigue.
In findings published this month in the American Journal of Critical Care, researchers conclude that ECG monitoring should only be used in situations specified under American Heart Association (AHA) guidelines.
"ECG monitoring should be restricted to patients who might benefit from it and should be discouraged in patients at low risk for arrhythmias that require treatment. ECG monitoring is often not ordered for a specific clinical concern, but instead is used as an extra patient-safety mechanism or as a substitute for frequent monitoring of vital signs," the AJCC researchers wrote.
The research was based on data collected from nearly 300 patients hospitalized in medical, surgical, neurological, oncological, and orthopedic care units. Order sets based on the AHA guidelines were placed into the hospital's electronic health record and education about appropriate use of telemetry was offered to hospitalists and medical residents.
The intervention resulted in an increase of appropriate ECG monitoring from 48.0% to 61.2%, with no significant increase in adverse patient events. Medical residents received the most education on appropriate ECG monitoring, and they showed higher adherence to practice standards compared to hospitalists, increasing their appropriate use of telemetry monitoring from 30.8% to 76.5%.
"Use of electronic order sets is an effective and safe way to enhance appropriate electrocardiographic monitoring," the researchers wrote.
The lead author of the AJCC research told HealthLeaders there are five primary considerations when implementing ECG electronic order sets.
1. Gathering the right team
"Involve end-users of the order set, including staff nurses, hospitalists, intensivists, and cardiologists. As the results of our study demonstrated, education is an important component of the practice change, so it's important to have a team member with knowledge and skill in education," said Kristin Sandau, PhD, RN, professor of nursing at Bethel University in St. Paul, Minnesota, and staff nurse, at United Hospital, Allina Health, St. Paul.
"Clinical nurse specialists are a critical part of the team as they bring not only clinical expertise in the content area but also skills and knowledge of practice changes at the nurse and system levels. The experts from our informational technology team included a nurse who is a key member of our EHR staff," she said.
2. Setting baseline metrics
"Allow adequate time to prepare and obtain baseline measures. Preparation time should include pilot-testing at a small site and revising. What are the best feasible ways for you to measure pre- and post-implementation outcomes? This can be challenging because some outcomes are very difficult to measure, such as wait times for an ICU, ED, or telemetry bed," Sandau said.
3. Embedding leadership
"Be sure to have physician and nurse champions who are ready to receive both positive and constructive feedback as the team works to make technology an asset rather than burden to busy clinicians. You should expect that adjustments and tweaks will be ongoing as you face new challenges," she said.
4. Impacting staff members
"It is critical that you consider scope of practice and direct impact on clinicians. Other sites have implemented practice standards in the EHR that require the staff nurse to answer a series of questions about a patient then make a choice to discontinue telemetry based on a set of parameters. We made a dedicated effort at our site to avoid putting the responsibility on the staff nurse," Sandau said.
Sandau's team assigned responsibility for discontinuing ECG monitoring to clinicians. "We've built prompts for nurses and prescribers to share, but we felt it was ultimately the responsibility of the prescriber to discontinue telemetry."
5. Sharing the implementation experience
"By sharing what works and what was not as helpful, we can help smooth implementation for others and shorten the time it takes for research to be integrated into day-to-day practice," she said.
New research helps identify which breast cancer patients are likely to quit going to follow-up visits.
Within the five years following a diagnosis for Stage I or II breast cancer, 21% of patients stop seeing physicians for follow-up care, a recent study says.
Breast cancer is the second most common form of cancer for American women, with about 12% of women developing the condition, according to the American Cancer Society. Breast cancer has a high level of lethality—only lung cancer kills more women annually.
The corresponding author of the recent research, which was published in the Journal of Oncology Practice, told Healthleaders that there are several reasons why follow-up care is crucial for recovery.
"It is important for patients to know that during follow-up appointments they are being evaluated for recurrence, evaluated for early detection of new primary tumors, and to make sure they are up to date with other cancer prevention activities. In addition, information is rapidly changing, so keeping up with the oncologist is important to make sure the care is current," said Dawn Hershman, MD, MS, a professor of medicine and epidemiology at Columbia University Medical Center in New York.
Hershman's research team examined data from more than 30,000 patients who were 65 and older. They found several key points.
In the first year after diagnosis, 85.8% of patients saw a medical oncologist and 71.9% saw a radiation oncologist in addition to a surgeon
Two-thirds of the patients visited all three kinds of providers in the first year after diagnosis
In the five years after diagnosis, 21% of patients stopped follow-up visits
Factors predictive of discontinued follow-up care included older age, single relationship status, patients with low-grade tumors, and patients with hormone receptor-negative breast cancer
Encouraging follow-up care
Surgeons and oncology specialists can take steps to increase follow-up care for breast cancer, the researchers wrote.
"Coordination of follow-up care between oncology specialists and other providers may reduce discontinuation rates as well as the redundancy of visits, thereby increasing clinical efficiency. Identifying patients who are at risk for early discontinuation of follow-up will eventually allow for the promotion of public health initiatives to improve access to care," they wrote.
Hormone therapy should be a focal point of public health efforts, Hershman told HealthLeaders. "The most important thing we do during follow-up is to make sure women on hormone therapy stay on their hormone therapy. Making sure these treatments are available to everyone is an important public health initiative."
Educating breast cancer patients about the seriousness of follow-up care is essential, she said. "As a provider, it is hard to know when patients stop following up. Sometimes, patients move or change providers. Patients need to be active in making sure they follow with at least one provider."
Engaging patients and family members is crucial when there are documents specifying physician directives for life-threatening conditions.
For clinicians, there are a handful of approaches to working with physician orders for life-sustaining treatment (POLST) documents in the emergency department setting, according to a recent article in the Annals of Emergency Medicine.
POLST forms are available across the country. Compared to living wills and durable power of attorney documents, POLST forms have been associated with significantly higher decreased odds of resuscitation attempts in the field and increased odds of out-of-hospital death for patients with "comfort measures only" directives.
"POLST forms are more useful than CPR directives in that they describe important broader end-of-life treatment choices than just whether to receive CPR attempts. For example, some patients may not want to go to the ICU; they may not want intubation," the author of the Annals of Emergency Medicine article, Jean Abbott, MD, MH, wrote.
Clinicians should take five approaches to working with POLST forms in the emergency department setting, according to Abbott, who is a professor emerita at the Center for Bioethics and Humanities, Department of Emergency Medicine, University of Colorado, Aurora.
1. Supporting emergency medical service workers
Abbott recently told HealthLeaders that EMS personnel are obligated to honor POLST documents but emergency departments are better equipped to interpret the forms as well as the care preferences of patients and family members. "When a family is overwhelmed enough to call 911, EMS should respond and bring the patient to the hospital. The ED is the place to sort out how to best honor a patient's wishes," she said.
The goal for EMS and ED staff should be to narrow the gap between the care that is provided and the patient's care preferences, Abbott said. "I have done a significant amount of training both with EMS and the ED to get them to a better place than, 'Well, I'll just do everything and if the patient survives, they can just figure out what to do upstairs.'"
2. Honoring POLST orders for CPR and airway management
Even in crisis conditions, ED clinicians should check the "yes" and "no" orders at the top of POLST documents for CPR and intubation, Abbott said. "Though not usually part of the ED situation, there are starting to be lawsuits when clear advance directives—usually in the form of the orders associated with POLST rather than more vague wishes expressed in other advance directives—are ignored."
3. Using POLST information to engage the patient and family members
After the initial crisis has been stabilized, ED clinicians should use POLST forms to engage patients and family members in a discussion about care preferences, Abbott said.
"There is no substitute for a conversation with patients and families to discern the meaning behind various choices—would they want antibiotics for an episode of presumed sepsis, would they want vasopressors for low blood pressure, etc. Much of those choices depend on where the patient is in the arc of their life—do they want a robust attempt to restore them to their pre-crisis state, or was their life already very difficult and they would lean more toward gentle interventions."
4. Considering disposition strategies that align with patient wishes
Based in information in POLST forms, ED clinicians can help patients or their surrogates to establish an action plan for hospital-based care, Abbott wrote in her Annals of Emergency Medicine article.
"Broaching the concept of, for instance, a time-limited trial or of revisiting interventions started in the ED may help the admitting team to later suggest stopping interventions that are not successful in restoring the patient to an acceptable quality of living," she wrote.
5. Preparing patients and families for difficult intervention questions
ED clinicians are well-suited for laying the foundation for discussions about intervention dilemmas, Abbott wrote.
"The ED role includes good documentation and robust communication with admitting teams. The electronic health record note should include topics broached, who was present, and what wishes and intent might have been clarified by the ED team. Palliative care consultation can and should be initiated when appropriate from the ED," she wrote.
Components of Johns Hopkins' SNF collaborative include a rigorous process for selecting partner facilities and establishing a management framework.
Johns Hopkins Medicine has established a skilled nursing facility collaborative to improve the quality and cost effectiveness of postacute care for its patients.
Transferring patients to skilled nursing facilities shortens length of stay in acute care settings but low quality of care at SNFs can lead to hospital readmissions. This dynamic is reflected in a 2013 Institute of Medicine report that found postacute care accounted for 73% of the variation in Medicare spending.
"One mechanism employed to improve transitions to SNFs and reduce associated readmissions is to create a preferred provider network. Increasing the concentration of hospital discharges to higher performing facilities is associated with lower rehospitalization rates, particularly during the critical days following discharge," Johns Hopkins staff members wrote recently for an article published in the Journal of Hospital Medicine.
There are three primary steps to establish a SNF collaborative, the article says.
1. Select appropriate SNF partners
The best SNF partners for health systems and hospitals are high-quality facilities and/or SNFs with historically high volume. In the latter case, the SNFs' name recognition with patients and providers can be capitalized and quality can be boosted through improvement initiatives if necessary.
There are several possible quality and clinical outcome criteria for picking preferred SNF partners:
Centers for Medicare & Medicaid Services quality star ratings and Long-Term Care Minimum Data Set measures
Rate of 30-day readmissions
Satisfaction ratings from patients and family members
Emergency department visits
Primary care follow-up within seven days of hospital discharge to the SNF setting
The Johns Hopkins Medicine Skilled Nursing Facility Collaborative features a management framework that established a system-level approach to SNF partnerships based on the shared goals of improving care and reducing costs.
The framework includes three primary elements:
A steering committee that functions as the collaborative's governing body was drawn from all participating Johns Hopkins Medicine (JHM) players. When the collaborative was launched, the steering committed targeted three dozen SNF chains and freestanding facilities to participate in the initiative.
A stakeholder group was formed with broader representation from JHM, including leaders with postacute care expertise such as rehabilitation and emergency medicine. The stakeholder group also included SNF partners and the local CMS-funded Quality Improvement Organization.
Dedicated workgroups lead protocol-based initiatives, data management, and analytics. The initial protocol-based initiative for the collaborative was transitions of care, which featured all affiliated hospitals focusing on a harmonized approach to care transitions. Representatives on the workgroup included members of hospital leadership, Johns Hopkins HealthCare, Johns Hopkins Medicine Alliance for Patients, the JHM home care division, and members of SNF leadership.
3. Foster physician leadership
Enlisting physician leaders to help guide meaningful and broad change is an essential ingredient of an effective SNF collaborative, the Journal of Hospital Medicine article says.
"When devising system-wide solutions, incorporation and respect for local processes and needs are paramount for provider engagement and behavior change. This process will likely identify gaps in understanding the postacute care patient's experience and needs. It may also reveal practice variability and foster opportunities for provider education," the article says.
Investing resources
The lead author of the journal article told HealthLeaders that JHM invested considerable resources to build an effective SNF collaborative.
"The greatest upfront investment was likely the time and effort of individuals across our organization who crafted the vision for this collaborative in alignment with the institutional priority," said Sarah Johnson Conway, MD, medical director of the Johns Hopkins Infusion Center and an assistant professor of medicine at the Johns Hopkins University School of Medicine in Baltimore.
"The coordinating team had representation from population health, care management, hospital administration, health plan, and skilled nursing facility medical leadership. Once the framework was in place, initial investments went toward administrative infrastructure with project management, data and analytics, and medical oversight."
Workplace violence against healthcare workers by patients and patients' family members has reached epidemic proportions at hospitals, but there are strategies hospital leaders can implement to cope with the problem.
Hospitals carry a heavy workplace violence burden, with about three-quarters of U.S. workplace assaults occurring in healthcare settings, according to a report by the Occupational Safety and Health Administration. Workplace violence is prevalent in emergency departments—78% of emergency physicians have reported being targets of workplace violence in the prior 12 months.
The scope of the peril for healthcare workers is so immense that hospitals have an obligation to address assaultive behavior in the workplace, says Laura Monaco, JD, an associate in the Employment, Labor, and Workforce Management practice at Epstein Becker Green in New York.
"We're not just talking about punching or hitting—it's also things like spitting, biting, and shoving. Employers have to be mindful this is an urgent situation that they need to be on top of and have a laser-focus on because it is such a large threat," she says.
There are six steps hospital leaders can take to manage workplace violence against healthcare workers.
1. Know your jurisdiction
The first step for hospital leaders is knowing the applicable laws in their state, Monaco says. "The first thing to consider is where are you—what is your jurisdiction? Many states have specific laws that provide for enhanced criminal penalties when a healthcare worker is assaulted similar to assaults on police officers or firefighters."
It is essential for hospitals to have policies and protocols established to deal with violent episodes at their facilities, Monaco says.
"The employer should have a policy and protocol for investigating incidents—especially when you are dealing with patients. They should develop standard questions: Was the patient on medication? What medication were they on? Was there a normal or adverse reaction to medication?"
Consistency is crucial, she says. "There need to be procedures in place where—on a standardized basis—the employer can investigate and ask questions because these are case-by-case decisions."
Policies and protocols should promote peaceful resolutions to violent situations, says Sarah Swank, vice chair, Educational Programs, In-House Counsel Practice Group, at the American Health Lawyers Association in Washington, D.C.
"The policies should be based on de-escalation because violence in the workplace can come from different sources. It can come in different levels of intensity. Training and policies based on de-escalation can be very successful," Swank says.
To be effective, policies and protocols for workplace violence should be widely disseminated throughout a hospital's staff, she says. "Training and policies should not just be focused on the hospital security team but also on clinicians and other frontline employees because they can be part of the de-escalation process."
3. Mandate assault reporting
Hospital employees should be required to report workplace violence incidents, Monaco says.
"Anything an employer can do to encourage reporting of these assaults is important—having clear procedures, explaining how employees can make these reports and who they can go to, having steps for managers and supervisors to take once they receive a report of an assault, and knowing how to contact law enforcement authorities. These things should be planned out in advance and streamlined."
Hospital leaders must assure healthcare workers that they will not face retaliation for reporting workplace violence, Monaco says.
"Policies should make it clear that there will be no retaliation against an employee who reports an assault. Nurses and other healthcare workers have a concern that they will be retaliated against—either by patients' family members or other staff who may not agree with the assault reporting. If you mandate reporting and there is no retaliation, then you are encouraging people to come forward when they are assaulted."
Some states require employers to report assaults on healthcare workers to law enforcement, Monaco says. "For example, Connecticut has a law that requires assaults to be reported within 24 hours whether or not charges are pressed."
4. Investigate violent incidents
Hospital-led investigations of workplace violence episodes are opportunities to reduce future assaults on healthcare workers, Swank says. "After a violent incident, The Joint Commission recommends doing a root-cause analysis, which can be helpful in process improvement and improving policies."
To promote effective investigations, hospitals can create dedicated teams to probe workplace violence incidents, Monaco says. "One approach is having an emergency response team—people who respond when these types of issues come up. There can be representatives from the legal department, from HR, and from administration who make decisions in a uniform way about whether to press charges and how to proceed."
5. Enforce policies
Having an emergency response team can boost enforcement of workplace violence policies, Monaco says.
"When you formalize procedures, it's easier to follow through. If there is an emergency response team, and the task of the team is to address workplace assaults, it becomes more difficult to sweep these situations under the rug. There is accountability, which is one way to make sure these kinds of policies are enforced."
Adherence to policies is fundamental to successfully addressing workplace violence, Swank says. "Once a hospital sets a policy, it's important for the hospital to follow the policy. A policy should not be aspirational—it should be easy to follow, easy to understand, and reflective of the hospital's culture."
6. Press charges
For hospital leaders, deciding whether to press charges against patients or their family members who have assaulted healthcare workers can be a daunting challenge, Swank says.
"Oftentimes, it is not the hospital that presses charges against family members or patients who have had a violent incident. The hospital needs to balance supporting its employees without creating a chilling effect on those who want to seek care at the hospital. Achieving this balance is especially difficult when patient violence is part of a patient's medical condition."
If hospital officials decide not to press charges, they can still help staff members who have been assaulted, Swank says. "A hospital can support its employees. For example, if there has been an assault and an employee has pressed charges, the hospital can provide information as part of the charges or the employee can be given time off from work to testify in the criminal case."
Assistance should not be limited to legal aid, she says. "It should be addressed with compassion and sympathy for the people who were injured or were part of the incident."
It is important for hospital leaders to participate broadly in what happens after a workplace assault, Monaco says. "Policies should not forget about the employee once the decision is made whether to press charges. If an employee has been assaulted, they are going to need support and they could need counseling."
Leaders who raise awareness at their hospitals about the potential for pressing charges against patients who have assaulted healthcare workers can have a significant impact, Monaco says.
"Sometimes, the deterrent affect can be achieved even if you don't press charges. It can help to have administrative action ready to go. If a patient commits an assault but it's in a gray area, you can flag the file not only as a warning for other staff members but also as a record that the patient is assaultive. It can be made clear to the patient and family members that if it happens again the hospital will press charges," she says.
The overall disparity between male and female physicians decreased from 2017 to 2018, but there was wide regional variation.
From 2017 to 2018, the national divide between male and female physician compensation eased, a report published today says.
In recognition of the ongoing disparity, the American Medical Association last year adopted several policy prescriptions to help close the gender gap in physician compensation, including a call for pay structures that are objective and gender-neutral.
According to today's report from San Francisco-based Doximity, the chasm between male and female physician compensation dropped below the six-figure mark for the first time last year.
"In 2017, the physician gender gap was at 27.7%, when female doctors earned $105,000 less than their male counterparts. In just one year, the gender pay gap in 2018 dropped to 25.2%, or $90,490 less than the average male doctor," the report says.
Doximity has collected compensation data from nearly 90,000 physicians over the past six years.
While there was significant variation in physician compensation by gender in markets across the country, female physician pay could be trending upward compared to their male counterparts, the report says.
"Financial compensation for men stagnated while female compensation grew by 2%. After years of examination, the gender wage gap is now demonstrating a downward trajectory, suggesting that the industry is moving toward equally compensating female physicians."
The report focused on 50 metropolitan areas across the country. Diminishing the gender wage gap has been uneven. "Despite the progress in the overall gender wage gap, most metro areas with larger gaps saw an increase between 2017 to 2018. However, metro areas with smaller gender wage gaps saw the gap improve," the report says.
The headway in moving toward gender parity in physician compensation is heartening—to a point, Mandy Huggins Armitage, MD, director of medical content at Doximity, told HealthLeaders last week. "One of the important findings is the gender gap has decreased. Obviously, there is more work to be done."
Compensation by the numbers
The report generated several other key data points.
The Top 5 metropolitan areas for physician compensation were Milwaukee at $395,363; New Orleans at $384,651; Riverside, California, at $371,296; Minneapolis at $369,889; and Charlotte, North Carolina, at $368,205
The Bottom 5 metropolitan areas were Durham, North Carolina at $266,180; Providence, Rhode Island at $267,013; San Antonio, Texas, at $276,224; Virginia Beach, Virginia, at $294,491; and New Haven, Connecticut, at $295,554
The Top 3 specialties for annual compensation were neurosurgery at $616,823; thoracic surgery at $584,287; and orthopedic surgery at $526,385
The Bottom 3 specialties for annual compensation were pediatric infectious disease at $185,892; pediatric endocrinology at $201,033; and pediatrics at $222,942
"In 2018, medical specialties that require more advanced training continue to have higher salaries and distinct specialties earn significantly higher income than the average annual compensation," the report says.
Compensation growth levels off
Physician pay plateaued last year, the report says. "Nationally, wages were flat with less than 1% decrease in physician compensation between 2017 and 2018."
The slowdown in wage growth was modest, according to the lead author of the report. "It's a relatively minor change—it's not like a 10% decrease. It's more of a leveling off, Christopher Whaley, PhD, an adjunct assistant professor at the University of California's Berkeley School of Public Health told HealthLeaders last week.
The flat wage growth last year is probably a reflection of consolidation in the healthcare sector, he said. "In the past couple of years, there has been a wave of physician practices being bought by health systems. So, if you are working for a larger company like a hospital or health system, you may have less agency over your pay."
The concept of moral injury expresses the systemic nature of the strain on physicians and the need for a comprehensive approach to address the problem.
A pair of doctors believe they have pinpointed the cause of physician burnout symptoms.
Research indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.
The root of the problem is "moral injury" resulting from the multiple roles physicians are playing in contradiction to their moral imperative to take care of patients, Simon Talbot, MD, and Wendy Dean, MD, wrote this month in a blog post published by Medical Economics.
"The underlying problem is, we are being pulled in too many directions. We took oaths to put the needs of our patients above all else, but over time that priority has eroded in the face of economic drivers in healthcare and competitive realities. Too often now, physicians must choose between the needs of their patients and the demands imposed by their employers, productivity metrics, insurance companies, mandates to reduce 'leakage,' and satisfaction surveys," they say in the post.
Measures vs. mainspring
The commonly cited Maslach measures of physician burnout do not illuminate the causes of the condition, Talbot and Dean told HealthLeaders recently via email.
"As healthcare has become increasingly driven by business requirements, physicians are facing a situation where they are unable to provide the best care possible because of the double and triple binds that get in the way. The crux of these binds is competing allegiances to the patient, the insurer, the hospital, and to themselves," they said.
In their email, Talbot and Dean gave several examples of competing priorities that are resulting in moral injury for physicians.
"Physicians may feel that their ability to provide the highest quality of care is limited by an expectation of seeing too many patients each day, generating an RVU target, completing insurance prior authorizations, and using a cumbersome electronic health record, just to name a few. This has been exacerbated with the corporatization of healthcare, increased profit-drivers, and a move away from the traditional doctor-patient relationship," they said.
Healing moral injury
Fundamental changes are required to limit physician moral injury, Talbot and Dean told HealthLeaders.
"Breaking down the competing allegiances that face physicians requires refocusing the goal of healthcare to ensure the needs of the patient are central to all parties involved. It requires that health system leadership have deep roots in patient encounters, and a vast reservoir of empathy for how systems' decisions impact patients' experience of care, as well as the impact on physician distress."
In the current state of medical practice, business model imperatives are at odds with physician training and tendencies, they said. "When physicians cannot keep their Hippocratic Oath to put patient needs above all else, that is deeply troubling to them; they are forsaking deeply ingrained, over-trained patterns of selfless thoughts and behaviors in service of business motives."
Talbot and Dean gave five prescriptions to treat physician moral injury.
Replace the term burnout, which implies a locus of control within the individual, with the term moral injury, which expresses the systemic nature of the problem and the need for a comprehensive approach.
Develop physician leaders with first-hand experience of the problems and the solutions who have been chosen for their investment in improving clinical care and their abilities to lead.
Focus on physician agency and autonomy as well as maintaining relationships—rather than transactions—that empower physicians to do what is right.
Deploy information technology that adds value to the patient-physician encounter, does not distract from the human connection, does not slow down physicians, and does not shift tasks such as billing to clinicians.
Talbot is a reconstructive plastic surgeon at Brigham and Women's Hospital in Boston and an associate professor of surgery at nearby Harvard Medical School. Dean is a psychiatrist and senior vice president of program operations at the Henry M. Jackson Foundation for the Advancement of Military Medicine in Bethesda, Maryland.
The new care model recognizes that family dynamics impact health and cost of care.
Healthcare providers and payers should adopt integrated family care to boost clinical outcomes and generate return on investment, a United Hospital Fund reportreleased this week says.
Families can have a major impact on an individual's good health, including caregivers easing stress on family members who face serious illness and caregivers supporting the physical and mental health of children. Families can also contribute to an individual's poor health such as dietary habits that lead to obesity.
"Focusing on these dynamics yields an opportunity to invest in supporting families as an effective means for improving population health," the UHF report says.
There also is a strong business case for having a family focus in healthcare delivery and reimbursement. The report cites research published in 2007 by the National Business Group on Health that found four advantages for companies that use insurance benefit design and other tools to foster good maternal-child health: lower healthcare costs, increased worker productivity, employee retention, and a more fit workforce over the long term.
In addition, other research on child-parent psychotherapy estimated the return on investment at $15 for every $1 invested.
Integrated family care has several primary elements, the UHF report says.
Similar to behavioral health integration into primary care, integrated family care ensures all family members' healthcare is effectively coordinated
Healthcare delivery and payment models are crafted to promote family-based approaches to care that decrease care silos between family members
The approach integrates physical and mental health care as well as social services
There are three pillars in the framework for establishing integrated family care, the report says.
1. Insurance is foundational
Health insurance for both children and their parents is crucial for effective integrated family care, the report says.
"Insured children with uninsured parents are more likely to experience insurance coverage gaps, not have a usual source of care, have unmet health care needs, and miss preventive care services. Uninsured parents are also less likely to receive care for their own medical conditions, such as mental health disorders, that when left untreated can adversely affect their child's health."
2. Family-centered care approach
Integrated family care shares principles with the patient centered medical home model of care, the report says.
"The model stresses partnership with families and a continual effort to be responsive to their needs. The primary care team is expected to encourage and support the patient and his or her family in making decisions about treatment and in developing and implementing the plan of care. The PCMH practice also takes on a major responsibility for coordinating care with other providers on behalf of its patients."
3. Building bridges
Practitioners of integrated family care identify health conditions of family members that affect a patient's health and they strengthen family bonds, the report says.
"The best-known example of 'bridging efforts' may be the implementation of maternal depression screening during well-child visits and the billing for such services under the child’s insurance plan. Other clinical interventions akin to this include detection of parental substance use disorder or significant parental stress."
Integrated family care openings
There are several opportunities to pursue the integrated family care model, the report says.
Providers and payers can increase awareness of evidence-based family interventions such as the Blueprints for Healthy Youth Development database and seek "braided funding" such as block grants from the federal Substance Abuse and Mental Health Services Administration.
Providers and payers should promote maternal depression screening in children's primary care.
Collecting and examining state data on complex families can identify risk factors facing children.
Payers should offer planning grants to providers that want to develop integrated family care through new partnerships such as behavioral health providers in New York that received grants to increase readiness for value-based payment.
Payers and providers can use the Center for Medicare & Medicaid Innovation's Integrated Care for Kids and Maternal Opioid Misuse demonstration projects to test integrated family care models.
Health plans can work with providers to test new payment models that encourage collaboration between providers that care for different members of the same family.
Many hospitalized patients are reluctant to raise concerns about their care, which reduces opportunities for improvement.
Encouraging patients to speak up about problems that occur during hospitalizations can improve patient experience and safety, recent research indicates.
Patients are uniquely qualified to raise concerns about care because they are present for the entire episode of care. Earlier research has shown most patients do not raise concerns or file formal complaints, with hesitancy to speak up linked to several factors such as an expectation that complaining will not make a difference.
The lead author of research published this month in BMJ Quality & Safety told HealthLeaders that health systems and hospitals have nothing to lose in asking patients about their concerns.
"From an institutional perspective, I don't think there is a downside to encouraging patients to speak up. However, institutions that do this should be prepared to take the next step and respond to patients who bring up concerns," said Kimberly Fisher, MD, an associate professor in the Department of Medicine at the University of Massachusetts Medical School in Worcester, Massachusetts.
Fisher's research team, which examined data from more than 10,000 patients, published several key findings.
48.6% of patients reported experiencing a problem during their hospitalization
30.5% of patients did not always feel comfortable raising concerns
Patients who had the highest likelihood of not speaking up were older, had worse overall and mental health, were admitted from the emergency department, and did not speak English at home
Mental health was a strong predictor of unlikelihood to speak up, with patients who had poor mental health nearly four times as likely to not feel comfortable raising concerns compared to patients who had excellent mental health
Patients who were not always comfortable raising concerns gave lower ratings for nurse communication, physician communication, and the hospital overall
"The most common type of problem that patients report is inadequate communication—they didn't get the information that they wanted, they didn't get their questions answered, or things were not explained to them in a way that they could understand," Fisher said.
Taking an active approach
To maximize the number of patients who raise concerns, health systems and hospitals should take an active approach, she said.
"Directly asking patients whether they have any concerns and conveying a sincere desire to hear from patients is essential in encouraging patients to speak up. We learn about many more—by an order of magnitude—concerns and problems in care with an 'active outreach' approach in which someone inquires of patients as to whether they've had any problems, as compared to just setting up and publicizing mechanisms—websites, phone numbers, or email addresses."
Care team members are well-positioned to ask patients whether they have concerns, Fisher said. "If it comes from someone on the care team, you are not fragmenting care by introducing yet another cook into the kitchen."
Health systems and hospitals need to be prepared for patient feedback, Fisher said. "When you ask a patient if there is a problem and a concern is raised, the response cannot be saying nothing. You can't ask people to raise their hands and speak up about something and not be ready to respond."
Rising to mental health challenge
Encouraging patients with poor mental health to speak up is daunting and will require further research, she said.
"In conditions that require patient activation and engagement, it's clear that poor mental health can be a barrier to doing what they need to do to take care of themselves. It's a cross-cutting problem. It's not just about speaking up—it affects managing diabetes, heart failure, and other conditions. Mental health can impact many health management behaviors."
Enlisting friends and family members could be an effective technique to help patients with poor mental health speak up, Fisher said.
"One approach that we have found helpful in getting patients' concerns heard that could be useful for patients who have a mental health barrier to speaking up is having friends or family members involved and available to speak up on their behalf."
In earlier research that she conducted, Fisher found patients were much more likely to express concerns if a friend or family member was in the room than if the patient was alone.
"We often think of people who are unable to advocate on their behalf as impaired, but there are a lot of people who are not particularly impaired but still find speaking up a hard thing to do."
