Millennials are becoming increasingly important for physician practices seeking to maintain or grow their market share.
Millennials are playing a leading role in the transformation of the practice of medicine.
"Over the past 10 years, there's been a move out of the hospital. There has been a shift away from having a big physician office at the hospital to having offices in the suburbs to make healthcare convenient. That's what the millennials require," says Louis Levitt, MD, vice president of The Centers for Advanced Orthopaedics in Bethesda, Maryland.
The baby boomer generation's predilection for primary care and hospitals is not shared by millennials, he says.
"Millennials tend to go to a clinic system—either acute care clinics or chronic care clinics—to treat acute processes before they will consider going to an orthopedist or other specialist for care," he says.
"They are very cost conscious, and clinics are less expensive for them than going to an expensive physician office," Levitt says.
For specialists, millennials have upended the traditional approach to generating referrals, Levitt says. Under the traditional approach, specialists build a reputation for excellence that, in turn, draws physician referral sources such as primary care practices.
He says millennials require more direct engagement.
"We have to go out and meet millennials in their work and play environments. They are not going to come into an office based on a relationship, and most millennials don't have primary care physicians," Levitt says.
Levitt is retooling his practice, Orthopaedic Medicine and Surgery Care Center in Washington, D.C., to cater to millennials. The practice has taken four approaches.
1. Online presence
Making a practice accessible online is essential to attract millennial patients, Levitt says.
"We make online booking a top feature in the office. Millennials don't have any patience—certainly not for hanging on a telephone line for 10 or 15 minutes waiting for someone to make an appointment. So, we have to have easy access for them to get into the office," he says.
In addition, online tools ease administrative burdens on millennials, he says. "We also use tech to allow patients to fill out forms in advance of showing up at the office."
Social media is also one of the keys to engaging millennials.
"There is a huge shift to relying on social media as a form of advertising—going right to the sites where millennials seek information and enticing them to come to your practice. You let them know they can been seen quickly," Levitt says.
2. Convenient location
To help provide easy access for millennials, Levitt's practice has opened its first satellite office in 35 years of operation.
"I have spent a great deal of time and energy avoiding doubling up on expenses and personnel with two offices. I always believed that if patients wanted to see me, they would come to my office," he says.
The new office was targeted specifically at millennials.
"This year, we opened our first ancillary office in an area around Capitol Hill in Washington, D.C., that is a growing gentrification area for the city. It's the site where all the millennials are focused. So, we felt we had to open an office there to be convenient for millennials," Levitt says.
3. Patient experience
Millennials insist on good service, Levitt says.
"If millennials spend more than 30 minutes waiting for you in the office, they will believe they had a bad healthcare experience no matter how good the healthcare delivery was during the visit," he says.
To rise to the customer service challenge, Levitt's practice has focused on the efficient use of patient time.
"We have gone to great lengths to cut down on the wait times and any other difficulties getting into the office. We are aware that we are no longer going to be judged on healthcare alone. Patients are judging based on the entire patient experience," he says.
4. Embracing change
To appeal to millennials, established physician practices must be open to new ideas and new approaches to providing care, Levitt says.
"I can't hang on to my old ways. So, when my junior partners come to me looking for help managing their email and text messaging with patients, I can't deny that we need this kind of help just because we didn't have the need before," he says.
The Arizona-based health system's new chief clinical officer is committed to sharing data with patients and curbing medical staff burnout.
Banner Health has promoted Marjorie Bessel, MD, to serve as the organization's new chief clinical officer.
Bessel, who most recently served as Banner's vice president and chief medical officer for community delivery, is succeeding John Hensing, MD. He retired last month.
At Banner, one of the unique aspects of the chief clinical officer position is direct oversight of the information technology department, Bessel says.
"IT reports up to this role, which is responsible for care delivery and making sure information flows. There is a lot of technical support to make sure all of that is happening," she says.
HealthLeaders Media spoke recently with Bessel. Following is a lightly edited transcript of that conversation.
HLM: Why do you have a passion for healthcare transparency?
Bessel: Part of it is personal. One of my brothers was diagnosed with Hodgkin's lymphoma six years ago. He does not live in Phoenix, where I live.
It was really important to both of us—him as a patient and me as a close sister—that the University of Rochester where he got care had a fabulous patient portal. My brother is an engineer and it was very important to him to know everything that was about to happen to him. He wanted to know all his data.
When you are in a situation like that, it can be overwhelming and life-altering. You want to feel that you have some control over what is happening to you. For my brother and patients like him, that control comes from access to their own data.
HLM: How did your brother's experience influence your approach to transparency at Banner?
Bessel: That portal experience was important to my brother and important for me at Banner. When I looked at what we had at Banner, I did not see the same level of transparency or sharing data with our patients. We did not have the same level of sophisticated tools to enable that to occur.
I worked on a very large change management initiative to make sure information was flowing to Banner's portal without delay and without embargoing test data. That resulted in a lot of changes to workflows all the way down to the provider level.
HLM: You also are an advocate for medical staff wellness. Give an example of a burnout initiative you have helped lead at Banner.
Bessel: I am responsible for burnout across the organization, in partnership with our chief human resources officer, Naomi Cramer. We have a balanced approach to put up programs so we can support all of our providers across the organization.
When you think about safety, the patient is front-and-center. They may have been harmed by the care that was delivered by Banner. Their friends and their family and their support network around them also suffer when an error happens.
We know there is a whole other circle of people suffering. These are second victims, and they are the people who delivered the care. It could be the nurse. It could be the pharmacist. It could be the physician, it could be a therapist, or someone else.
We are making sure that we are having excellent conversations with the patient, and with the patient's family and friends. We are also making sure we are supporting the staff involved in the event because they suffer as well.
Bessel: As humans, we all are going to make mistakes. What we experience in healthcare is when we put processes into place, when we put programs into place, when we put safeguards into place, we have drift over time from those best practices because we are human.
Because we have drift, we experience errors that programs or processes were supposed to mitigate.
Some of the solution is going back to basics, which is something we do at Banner. We have to make sure that when we put a program into place that we are consistent and focused on monitoring it.
Some of the challenges we have also are very basic. A lot of errors are related to infection such as post-operative infection. The solutions can be very basic like remembering to wash your hands.
At Banner, we are going back to revisit programs and processes that we have put into place. We are correcting drift. We are also working on the basics that all of us should do like hand washing.
The new measurement set is designed to generate valuable clinical care and outcome data without placing a crushing administrative burden on physicians and their organizations.
The American Medical Group Association has endorsed 14 metrics as a value and quality measurement set for data reporting in payer contracts.
Widespread adoption of the new measurement set would address the administrative burden and burnout associated with the current patchwork of reporting regimes, says Jerry Penso, MD, MBA, president and CEO of the AMGA.
"Our members told us that the burden of reporting the current quality measures was great; mainly, time to run the measures and time out of clinical practice for physicians to input the data," he says.
The AMGA, which is based in Arlington, Virginia, represents physician groups and health systems nationwide. More than 175,000 physicians practice at AMGA member organizations.
"Reporting is also a factor in physician burnout," Penso says. "That's a flaw in the current measurement system. There are too many measures, and they are not harmonized between the different insurance programs."
In 2016, Health Affairs published research that shows the costly consequences of the current reporting system. The study found that physician organizations spent $15.4 billion annually to report quality data and the average physician worked for 785 hours yearly on reporting.
The AMGA's 14 measures feature both process measures such as cancer screening and outcome measures such as hospital readmission rates:
Admissions for acute ambulatory sensitive conditions composite
HbA1C poor control
Depression screening
Diabetes eye exam
High blood pressure control
CAHPS, health status, and functional status
Breast cancer screening
Colorectal cancer screening
Cervical cancer screening
Pneumonia vaccination rate
Pediatric well-child visits through age 15 months
A task force drawn from the AMGA's 22-member Public Policy Committee used multiple criteria to select metrics for the new measurement set, Penso says. "They were aiming for a smaller set—14 to 25 measures—as their final target."
He says there were seven primary selection criteria:
Measures had to be clinically relevant and impactful on patient lives
Measures had to be evidence based, with scientific evidence of care improvement
Claims-based measures were preferred because of the ability to report from claims data
Track records were required—measures needed to demonstrate an ability to improve quality through past performance
Measures that accounted for patient experience were preferred because a patient's perception of care is an important outcome
Metrics needed to have a large enough sample size to be statistically valid for performance comparisons
The current reporting system is overkill, Penso says.
"The way many people use quality measures is for external reporting—it could be part of a value-based contract or public reporting for patients. Our point is that all of the measures that are out there do not need to be used for this purpose."
The AMGA is not seeking to replace or abolish metrics that were not included in the new measurement set, he says.
"A lot of other quality measures can be used for internal improvement. Physician groups can use our measures, then use other quality measures for internal benchmarking and internal management of performance improvement initiatives."
Taken as a whole, the new measurement set gauges not only quality but also value, Penso says.
"Quality is important to all of us, our patients, our families, and our providers. But our value measure set has other metrics that are important like utilization, cost, and patient safety."
The next steps in collecting patient experience data include gathering information in real time and aligning patient experience surveys with a healthcare organization's primary goals.
Patient experience officers are seeking to enhance the timeliness and value of the data collected from patient surveys and other sources.
Upgrades are overdue, according to a recent report from Boston-based Chilmark Research.
"Traditional patient experience survey solutions suffer from three clear shortcomings: They are too long, they capture retrospective data, and they use outdated phone- and paper-based methodologies to gather data," the report says.
The report is based on interviews of a dozen chief experience officers (CXOs), who said their most pressing need is gathering data in real time before patients leave care settings such as inpatient wards, emergency rooms, and laboratories.
"Among the CXOs interviewed, the most pressing need is insight into the patient experience at the point of care," the report says.
For more than a decade, healthcare providers have been collecting valuable patient experience data through Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys required by the Centers for Medicare & Medicaid Services. However, time lag is a major shortcoming of HCAHPS data, the report says.
"Today's CXOs increasingly need near-real-time information about patient sentiment in order to improve the care experience while someone is still in the hospital or within days (and not weeks) of discharge."
The report makes five recommendations for healthcare providers seeking to upgrade their patient experience data capabilities:
Align surveys with organizational goals: Healthcare providers often focus on two or three primary goals for improving the patient experience. Survey solution questions and answers should align with these goals and the metrics such as HCAHPS that measure progress toward meeting those goals.
Account for employee satisfaction: Burnout has cascading impacts—successively degrading care delivery, care quality, and patient experience. Employee satisfaction surveys should gauge burnout levels and enable sentiment analysis that can provide insight on curbing burnout.
Real-time capability: CXOs interviewed for this report wanted to understand how individual business lines and departments perform without waiting weeks for HCAHPS survey results.
Qualitative data analysis: Surveys should have open-ended questions, not just yes or no queries that generate quantitative data. Patient experience data collection also should include phone calls to administrative offices and call centers.
EHR integration: Including patient experience surveys in electronic health records allows physicians or nurses to discuss surveys with patients, then administer the survey during the care episode. This approach can appeal to patients who dislike automated text or email messages.
The National Steering Committee for Patient Safety seeks to recast siloed approaches to safety, create measurable goals, and promote the total systems approach to safety.
A national coalition of healthcare organizations is seeking to jumpstart patient safety efforts.
The National Steering Committee for Patient Safety is tasked with crafting an action plan to reduce patient harm by early 2019 and generating measurable results within the next three years.
In 2016, Johns Hopkins safety experts reported that more than 250,000 deaths in the U.S. were linked to medical errors annually.
The new patient safety panel is striving to slash that mortality figure by breaking down safety siloes, creating measurable safety goals, and taking a systematic approach to improving safety.
Boston-based Institute for Healthcare Improvement (IHI) is the prime organizer of the steering committee. Twenty-four organizations are represented on the panel, including:
The scale and reach of the steering committee's membership bodes well, says Tejal Gandhi, MD, MPH, chief clinical and safety officer of IHI, and cochair of the steering committee.
"We need to percolate everything we are doing to the local level. The organizations we have pulled together all have interconnections with the frontlines," says Gandhi.
The steering committee has three primary objectives.
1. Break down safety silos
The steering committee seeks to promote coordination and cooperation among healthcare organizations, Gandhi says.
"There are many organizations working on patient safety, ranging from hospitals to health systems, primary care practices, associations, foundations, and government agencies. But what has become apparent is that there are often different agendas," she says.
A siloed approach to safety is inefficient and limits progress, she says.
"You can have two or three organizations working on similar safety topics but doing it in different ways without coordinating. The risk is that at the frontline the messaging can become complicated. One organization can want you to do five things, and another organization can want you to do another five things," she says.
To increase cooperation, the steering committee is drawing on the public health model, Gandhi says.
"As we have tackled public health issues over the years, we have had national coordination for these issues, whether it has been smoking, seat belts, or another public health issue. That kind of approach was the impetus behind the National Steering Committee," she says.
2. Create unified and measurable safety goals
A top objective of the steering committee will be selecting strategies to strengthen the foundation of patient safety such as leadership, organizational culture, and patient engagement.
"The hope is we will be able to create a national action plan with three or four significant goals related to safety that can be measured," Gandhi says.
Setting metrics will be a challenge, she says. "There has been a lot of debate about how you measure patient safety and harm; so, getting several organizations to come to a consensus on what we are going to measure and what we are going to improve is a key piece."
The steering committee's goals likely will be measured on a case-by-case basis. "There are many metrics, but the ones we choose are likely to be a combination of structure, process, and outcome measures. We will work that through for every one of the areas we pick," Gandhi says.
Leadership and culture are tempting targets for improvement.
"Leadership needs to be fully engaged in patient safety and see it as a core value for their organization. They set that vision and goal for the entire organization," she says.
Culture also is crucial for safety.
"Culture is foundational in terms of creating a culture where people feel comfortable talking about errors; and they know if they do talk about errors, they won't be punished. That culture is critical in advancing efforts for patient safety," Gandhi says.
3. Promote a systematic approach to safety
The steering committee, which held its first meeting in May, is promoting the total systems approach to healthcare safety.
The total systems approach is comprehensive rather than piecemeal, Gandhi says.
"You might have a medication error issue and a falls issue, which are important issues to address; but if you focus on them one at a time, you may improve them without achieving success across the board," she says.
Components of the total systems approach include ensuring that leaders foster a safety culture; creating centralized oversight of patient safety; addressing safety across the entire continuum of care; and partnering with patients and families.
Engaging healthcare leaders is essential to promoting the total systems approach to patient safety, Gandhi says.
"The governance and leadership of health systems need to understand the total systems approach. We are working on leadership and culture with the American College of Healthcare Executives. We are working on a project to better educate boards about total systems safety," she says.
In a clinically integrated supply chain, physicians play formal and informal roles in decision-making for changes in supplies, devices, and equipment.
Supply chains generate high value for health systems and hospitals when physicians are engaged at key points in decision-making.
Physicians have become a crucial element of supply chain success, says Frank Eischens, RN, director of supply chain, University of Iowa Hospitals & Clinics, Iowa City.
"A supply chain needs to be built on a foundation of data analytics, point-of-use management and strategic contracting, but those three things do not do anything by themselves. You need relationships with clinicians in a way that allows them to see the outcome of their choices," he says.
In May, Eischens and three other panelists participated in a HealthLeaders Media Executive Roundtable event in Nashville. Vizient sponsored the panel discussion, "Optimizing Clinically Integrated Supply Chain."
Medical director role
At Cleveland Clinic in Ohio, the health system has placed physicians in a senior supply chain role, says Allen Passerallo, MBA, senior director of supply chain management.
"We have medical directors that are part of our supply chain department. So, we align with our medical operations division, and they help fund the medical directors to be a part of our department. That gives us credibility with the physicians throughout the enterprise," he says.
Cleveland Clinic has four medical directors working in supply chain—two orthopedists, a general surgeon, and an anesthesiologist.
The supply chain medical directors benefit the health system with their knowledge and influence among their medical peers, and they benefit from deepening their professional experience, Passerallo says.
"Another form of engagement is acknowledgment and credit. One of our supply chain medical directors just became vice chair of surgical operations. Another one just became chairman of vascular surgery. Being a medical director in supply chain is a stepping stone."
Advocate for change
Other health systems have a less formal supply chain role for physicians.
"We do not have medical directors in supply chain, but we take a very similar approach. Working with our service line leaders and executives at each of our facilities, we identify physician champions," says Trisha Gillum, MBA, director of supply chain management at Kettering Health Network in Dayton, Ohio.
At Kettering, the physician champions help advocate for supply chain changes, she says.
"We usually spend time sitting down with them reviewing data, reviewing the value proposition both from a research basis as well as the financial contract offering. Then we look to those physician champions to help with the communication as we reach out across the various facilities and physician meetings."
Physician engagement
Trust is the key to engaging physicians in supply chain decision-making, Gillum says.
"We can't underestimate the trust factor. Physicians need to have a full seat at the table, you have to earn their trust, and they have to trust the data you are using," she says.
Giving physicians formal roles in supply chain decision-making is an effective engagement strategy, says Martin Lucenti, MD, PhD, senior principal at Vizient Advisory Solutions.
"The best way to engage the clinicians is to put them in charge. Make it their responsibility. It is always incredibly painful for the supply chain to try to take out $20 million in costs while coercing a group of doctors. Give the doctors $20 million of cost reductions, and they will figure out a way to take that out without consequence to their patients," he says.
Convincing physicians to support supply chain changes requires focusing on the clinical impacts, Passerallo and Gillum say.
"You try to put change in physicians' words, so they understand it more. If you put a business side to it, they immediately push back," Passerallo says.
"Some of the trust you can gain is by leading with the quality, the outcomes, the elimination of variability, and creating standardization," Gillum says.
"Other industries have shown that if you can eliminate variation you can improve quality. As opposed to leading with a financial case, you can show that you are considering other interests as well. Your end goal may be reduction of costs, but that can't be what you are leading with," she says.
View the complete HealthLeaders Media Roundtable report: Optimizing Clinically Integrated Supply Chain.
As the national physician shortage worsens, areas of the country with aging OB-GYN clinicians and high OB-GYN workloads are expected to face a high risk for physician shortfalls.
With a severe shortage of OB-GYN clinicians forecasted, some metropolitan areas are more prone to crisis-level conditions than others, according to research released today.
The stakes for women's health are high, according to Amit Phull, MD, vice president of strategy and Insights at San Francisco-based Doximity, which conducted the research.
"We're facing a national physician shortage in the years to come. OB-GYNs are one of the top specialties at risk and are central to women's healthcare in the U.S. The emergence of a significant shortage in this specialty could be terribly problematic from a women's health standpoint," Phull said in a prepared statement.
The American Congress of Obstetricians and Gynecologists (ACOG) estimates there will be a shortage of up to 8,800 OB-GYNs by 2020, with the shortfall approaching 22,000 by 2050.
The Doximity study includes data from the Centers for Medicare & Medicaid Services, board certifications, and self-reported information from about 43,000 OB-GYN clinicians. The research, 2018 OB-GYN Workforce Study, focused on the largest 50 U.S. metropolitan statistical areas by population.
One of the key features of the Doximity study is a risk index designed to identify which cities could feel the brunt of the OB-GYN shortage first. The risk index has two factors: the average age of the local OB-GYN workforce and the workload they carry based on births per OB-GYN per year.
"In the metropolitan areas with older OB-GYNs and higher workloads, we expect that they have a greater risk of shortages. In the metropolitan areas with younger OB-GYNs and lower workloads, we expect that they have a lower risk of shortages," the Doximity researchers wrote.
The Top 5 cities considered at high risk for an OB-GYN shortage are Las Vegas; Los Angeles; Miami; Orlando; and Riverside, California.
The Top 5 cities considered at low-risk for a shortage are Ann Arbor, Michigan; Birmingham; Portland, Oregon; San Jose; and Baltimore.
The Doximity study features several other key findings:
In the study's 50 metropolitan areas, the number of OB-GYNs was compared to the number of annual births. St. Louis posted the highest workload, with 247 births per OB-GYN. Ann Arbor had the lowest workload at 32 births per OB-GYN. With service-volume capacity, low-workload areas should be resistant to physician shortages.
Retirements are a key driver of the OB-GYN shortage. The average age of OB-GYNs was 51, with Pittsburg posting the oldest age at 52.32 and Houston posting the youngest at 48.38. The median retirement age for OB-GYNs is 64, according to ACOG.
More than a third of OB-GYNs were 55 or older. In 32 out of the 50 metropolitan areas in the study, at least one third of the OB-GYNs were 55 or older.
Only 16 percent of OB-GYNs were 40 or younger. In 12 of the metropolitan areas, less than 15% of OB-GYNs were 40 or younger.
Metropolitan areas with large OB-GYN workloads also tended to have the highest number of women who were uninsured or covered by Medicaid. With Medicaid reimbursement trailing private insurance, these areas have downward pressure on OB-GYN compensation.
Successful concierge medicine practices have a patient-centered philosophy, small scale, financial strength, strong care coordination, and focus on prevention, a concierge physician and author says.
Embracing patient-centered care is an essential ingredient for success at concierge medicine practices.
"We are focused on doing everything we can do to exceed the expectations of the patient," says David Winter, MD, a concierge medicine physician in Dallas and chairman and president of HealthTexas Provider Network, a physician group affiliated with Baylor Scott & White Health.
Concierge medicine is based on a membership model, where the concierge physician receives a monthly or annual fee to subsidize amenities not offered in most primary care offices. Those amenities include 24/7 access to a physician, same-day appointments, and the ability to have lengthy office visits if necessary.
There are five best practices to operate a successful concierge medicine practice, says Winter, who recently published a book, ServiceExtraordinaire: Unlocking the Value of Concierge Medicine.
1. Primacy of Patient Experience
Well-run concierge medicine practices provide an excellent patient experience, he says.
"You have prompt access, 24/7; phone, text, or email communication at the patient's choice; and our office visits are unrushed and lengthier than standard clinics."
Concierge medicine is the antithesis of the past's practice of medicine, Winter says. "In many of the old practices, it was built for the physician—the schedule was set for the physician, the parking places were closer for the physician. We've switched all of that. Our patients get valet parking, and we pay."
At Winter's practice, BSW Signature Medicine - Tom Landry, efforts to enhance the patient experience start the moment a patient comes through the door, he says.
"We'll serve them water, coffee, or soft drinks. We'll update their records. They don't have any idle time. We don't want them to wait. In fact, we don't call our entry room a waiting room, we call it a greeting room."
2. Less is More in Scale
The optimal scale for a concierge practice is a single physician, Winter says. "The ideal way to run a concierge practice is with a physician who has been in practice [for a] while and has a relationship with patients."
Establishing relationships with patients enhances care, he says. "It's about a one-on-one relationship between a patient and a physician—a trusting relationship. That augments the care of the patient."
3. Retainer Fee Financing Model
Monthly and annual patient retainer fees help finance concierge practices. There are two approaches, Winter says.
"You can charge a retainer fee and bill people for billable events, which is the way we do it. If you come in with bronchitis, we will send a bill to the insurance company or Medicare. The other way is to have a higher retainer fee, with no billing for anything."
For Winter's practice in the Dallas market, the blended approach made more sense. "People have the insurance anyway. Patients need it in any concierge practice for specialty care and hospitalization. They had the insurance anyway, so we felt that was the easier way to go."
In North Texas, retainer fees range from $1,800 to $18,000. Winter says his practice's retainer fee is at the low end of that scale.
The retainer fee financial model helps concierge practices generate more income than many standard primary care practices. "If the patients are paying annual retainer fees, then the physician does not have to see 20 or 25 patients per day to pay overhead and generate income," Winter says.
Time is a precious commodity at a physician practice, he says.
"I was in practice for 20 years, had a very busy practice, and I went from one patient to the next. I would focus very intently on my patients; but once a patient was out of the exam room, you forgot about them and were on to the next one. With concierge medicine, you can think about patients, do research, and call them back to see how they are doing."
4. Care quarterbacks
Most concierge practices offer primary care, and the best ones prioritize care coordination, he says.
"They are the quarterback of a patient's medical team. They will get the specialists they need to take care of the patient, but the care all runs through one physician," Winter says. "How you coordinate care is a key factor in concierge medicine—you want to make sure you are doing all you can do for the patient. You use specialists as necessary to augment the care."
5. Promoting preventive care
The best concierge practices also focus on preventive care, he says.
"Every afternoon when I am working in my administrative role, my nurse goes through our patients to see who is behind on colonoscopies, mammograms, and vaccinations," he says. "My nurse calls patients to get them into the office, so our quality scores are very high."
In quality scores, Winter's concierge practice consistently ranks in the top of Baylor Scott & White Health's 340 primary care practices, he says.
The luxury of time is critical in preventive care, Winter says. "When we were working together in my standard practice, we didn't have the time to do preventative services work. … When you do all of these things properly, you can save lives. People who get colonoscopies get less cancer."
Winter is trying to bring elements of concierge medicine to the physician practices in the HealthTexas Provider Network. "We're working on access, consumerism, same-day scheduling, and online scheduling—all things that I have been doing for a long time in concierge medicine."
For surgical patients who received nutritional intervention in the hospital, the 30-day readmissions rate was cut nearly in half.
Compared to hospitalized medical patients, surgical patients benefit more from malnutrition screening and intervention, researchers say.
The study, which collected data from 1,269 patients in a nutrition-focused quality improvement program and 1,319 control patients, found the 30‐day readmission rate for surgical patients dropped nearly in half, falling from 19.6% to 10.4%.
"Malnourished hospitalized surgical and medical patients experienced improved readmission rates and length of stay. However, surgical patients saw a significantly greater reduction in the readmission rate," the researchers wrote.
For surgical patients, the readmissions rate was 22.3% for the control group and 17.7% for the quality improvement program patients.
Length of stay reductions were also greater for surgical patients, with LOS for surgical patients dropping 2.7 days, from 9.3 days to 6.6 days. Medical patients experienced a 2.1-day LOS decline, from 7.1 days to 5.0 days.
As many as 50% of patients are malnourished or at risk of malnutrition when they are admitted to a hospital. Surgical patients face high risk, the researchers wrote. "Surgical patients in particular are vulnerable to a decline in nutrition status during hospitalization."
The researchers say surgical patients face four primary nutrition-related risks during their hospitalization:
Delayed wound healing
Postoperative complications such as surgical site infections
Longer LOS
Higher readmission rates
Hospitals and surgeons should intervene when a surgical patient is malnourished, the researchers wrote. "The avoidance of nutrition therapy bears the risk of underfeeding, which will in turn result in significant postoperative complications."
For this study, which was published in the Journal of Parenteral and Enteral Nutrition and funded by Lake Bluff, Illinois-based Abbott, the nutrition-focused quality improvement program had four primary elements:
Malnutrition screening
For malnourished patients or patients at risk of being malnourished, oral nutrition supplements were provided in less than 48 hours
Nutrition information was provided for both the patient and caregivers
The electronic medical record triggered dietitian consultations and specified oral nutrition supplements depending on a patient's condition
With health outcomes and cost savings on the line, the researchers urge surgeons to embrace nutritional interventions for their patients.
"We particularly call surgeons to action—to raise awareness of the importance of nutrition on surgical outcomes, to partner with hospital administration to obtain appropriate support for nutrition care processes, and to expand nutrition education and training in residency and continuing medical education programs."
Training is a weak link in efforts to address malnourishment among medical and surgical patients, the researchers wrote.
"In a recent survey, 72% of managers of U.S. medical residency programs stated that an advanced course in nutrition should be required of residents. However, only a quarter of residency programs include a formal course in nutrition, and half of those are taught to family practitioners, not surgeons."
With an increasing volume of mental health visits at emergency rooms, telemedicine has the potential to improve clinical care and ER operations.
Researchers are calling for the expansion of telepsychiatry services in the country's emergency departments (EDs).
In an article published this month in the American Journal of Emergency Medicine, the researchers found multiple benefits from ED telepsychiatry.
"The development of novel patient platforms such as telemedicine may offer an innovative approach to mental health care in the ED that may optimize and improve patient outcomes while also helping to reduce challenges such as ED overcrowding and limited specialist availability," the researchers wrote.
Earlier research has shown a pressing need to boost mental health services in emergency rooms. One study showed that 1 out of 8 ED visits involves mental health as the chief complaint.
There are two main clinical benefits from enhancing ED mental health services, the corresponding author of the American Journal of Emergency Medicine research, Bernard Chang, MD, PhD, told HealthLeaders this week:
The ED allows clinicians to intervene in the ultra-acute setting, when a psychiatric event has occurred or is at greatest risk of occurring
The ED can help offer seamless integration with behavioral health specialists that patients may otherwise have challenges coordinating on their own
Anxiety and depression appear to be particularly well-suited for ED telepsychiatry, Chang says. "Many of the assessments and treatments can be done remotely."
He says telepsychiatry can spare anxiety and depression patients the stress associated with busy EDs. "The acute care environment may sometime exacerbate psych complaints. So, the less time patients can be in that chaotic environment, the better, particularly those with anxiety or depression."
Several healthcare organizations have published positive results from using a telemedicine platform for psychiatry, Chang and his coauthor wrote. In addition to treating depression and anxiety, those programs reported success in cognitive behavior therapy as well as supportive therapy for PTSD patients.
Telemedicine programs such as telestroke care have been adopted at many EDs, but ED telepsychiatry is relatively rare. Financial factors are among the obstacles, the American Journal of Emergency Medicine researchers wrote.
"In a survey of several ED telepsychiatry programs, researchers found that key challenges included financial sustainability of such programs ranging from initial upfront startup costs to ongoing carrying costs associated with maintaining such a program."
Despite the challenges, the potential benefits of ED telepsychiatry are significant, the researchers wrote.
"ED overcrowding has been associated with multiple negative outcomes from patient satisfaction, medical errors, and patient perceptions of clinician communication. ED telepsychiatry may help offset patient burden in the ED and improve overall length of stay and patient satisfaction."
