Balcezak says that at Yale New Haven Health "nothing has been as powerful as changing behavior and changing culture for how we behave as clinicians and caregivers."
Thomas Balcezak, MD, MPH, chief clinical officer of Yale New Haven Health, recently talked with HealthLeaders on a range of issues, focusing primarily on physician burnout and workforce shortage issues, while expressing how the organization is moving healthcare forward in the communities it serves with patient safety initiatives and hospital acquisition goals to provide higher-quality care.
The transcript below has been edited for clarity and brevity.
HealthLeaders: Yale New Haven Health is in the process of acquiring three hospitals in Connecticut. What are you plans for clinical care at these hospitals?
Thomas Balcezak: We have acquired other hospitals and integrated them into the health system. For example, in 2012, we acquired the Hospital of Saint Raphael. In 2016, we acquired Lawrence and Memorial Hospital and Westerly Hospital. And in 2019, we acquired Milford Hospital. In each one of those transactions, our goals were straightforward. Connecticut is a parochial state—we like our healthcare local, and we like access to high-quality services. In these transactions and the proposed transactions for the three other hospitals, our goals are to broaden access to high-quality clinical services, to keep care to whatever extent possible local, to improve the quality of care, and to reduce the cost of care.
It comes down to cost, quality, and access. If all goes well as in the previous transactions, we believe we have an opportunity to do all three.
HL: How do you lower the cost of care in these transactions?
Balcezak: There are a couple of different ways. One is to take advantage of being a relatively large organization—we are almost $6 billion in revenue. That gives us good power in negotiation for products. It gives us access to competitive pricing on things such as drugs and supplies. So, we have some opportunities in supply chain savings.
The other way we can lower cost of care is in economies of scale for back-office services. Healthcare in general and hospitals in particular are human capital—intensive. We do not believe there is an opportunity to reduce direct caregivers—we have enhanced the staffing on the clinical side at the institutions we have acquired and integrated into the health system. There is opportunity in management structure, span of control, and back-office services.
HL: What is the status of physician burnout at Yale New Haven Health?
Balcezak: We are in a similar position as other health systems and hospitals across the country. Burnout is an issue beyond physicians—it is all of our clinical caregivers such as nurses, respiratory therapists, and pharmacists. We are seeing an epidemic of burnout in U.S. healthcare. It is something we are taking a lot of steps to address, but we do not have all of the answers.
The steps are relatively simple, but they are nuanced with a lot of efforts that are bolstering those steps. One step is making sure that we have adequate staffing, which has been a challenge. We have staffing shortages in virtually every area of our institution; just like you are seeing in other industries, we have seen growth in open positions.
Addressing staffing shortages goes well beyond salary and benefits. People want to work where they feel they are doing important work that is contributory to society. That is where healthcare has an advantage over many other industries. People go into healthcare because they want to help people—they want to help communities. It is important to be grounded in that as a health system. We need to spend more time focusing on what we are doing to improve the lives of the patients we serve and the communities we serve.
Another step is supporting the caregivers—giving them the tools that they need to deliver good care as well as reducing the barriers and the excess work that they do such as difficulties with documentation or use of the electronic medical record. There is a whole stream of work that we have been engaged in to improve day-to-day work effort, while providing employee and health resources support, so that staff have opportunity to express where their concerns are.
Pictured: Thomas Balcezak, MD, MPH, is the chief clinical officer at Yale New Haven Health. Photo courtesy of Yale New Haven Health.
HL: Give an example of an initiative you have put in place to address physician burnout.
Balcezak: One of the initiatives that we have is spearheaded by our chief medical information officer, and it is called Building Against Burnout. This initiative is specifically looking at how much time physicians are spending using the electronic medical record, particularly the "pajama time" outside of standard work hours. We have had a reduction in pajama time that can be tied directly to what our CMIO and his team has been doing to make the electronic medical record more streamlined and easier for physicians to use.
The electronic medical record is a big complaint by physicians, and it is appropriate that they are complaining about it. Technology is supposed to make lives at work easier, but what we often hear from physicians is that technology has made their work more onerous. In healthcare, we need to make documentation easier and use things such as virtual scribes to make the amount of time that physicians are spending on the electronic medical record go down.
HL: What have been your primary efforts to address workforce shortages?
Balcezak: We have made a multi-pronged effort. One of the efforts has been to make sure that we can offer a competitive salary and benefit package. We need to be competitive with more than other hospitals. We need to be competitive with other industries because it is not just healthcare that has a workforce shortage. We find ourselves competing with Amazon, retail outlets, and manufacturing organizations—we are competing at all levels of the workforce.
Right now, we have about 3,000 open FTEs that we are trying to recruit, and they are everything from pharmacists to respiratory therapists, nurses, environmental services, biomedical engineering, and clinical technicians. Virtually every position in our organization has open positions.
If you are a young person, and you are looking for a career in healthcare, the good news is there are lots of openings. There are openings at all levels, from physical therapists to occupational therapists, to all kinds of technicians, radiology, and the operating room. Every one of those positions has opportunities.
We have partnered with our local colleges to provide more educational opportunity such as scholarships for people to join the workforce. Some of our positions call for a high school diploma, and we are hiring people who do not have a high school diploma and allowing them to get a GED on the job. We have pathways for folks to get nursing degrees, and we are offering that with some tuition assistance at local colleges.
HL: What are your primary clinical challenges now that the crisis phase of the coronavirus pandemic has passed?
Balcezak: In many ways, it is getting back to basics. We have had growth in our length of stay. If you are not able to take care of patients in the acute phase of their illness in the most efficient way, and get their workup completed and their therapy completed in a timely way, that is a quality issue. So, we are attacking length of stay. We want to make sure that patients are not seeing delays in either diagnostics or therapeutics—that is a big deal for us now.
We are also still clearing the backlog of patients who had delays in care because of COVID. We have a backlog in screening exams—in colonoscopies. Those are burdens for population health that we are focusing on now. We are coming out of the other end of these backlogs, but we have not seen them completely cleared.
HL: Give an example of patient safety initiatives you have launched at Yale New Haven Health.
Balcezak: One of our most groundbreaking patient safety initiatives has been our work around becoming a high-reliability organization. We started this work about a decade ago—we were a relatively early adopter. The Connecticut Hospital Association created an initiative for hospitals, and we fully embraced it.
It was a galvanizing moment for our health system to get everybody involved in safety. Applying the principles of high reliability such as a deference to expertise has been permeating our organization. Rather than one initiative around falls, or one initiative around surgical-site infection reduction, we have implemented checklists and we have implemented technology for safety events. We have been addressing the most flawed part of our safety environment, which is the propensity of humans to make mistakes. The high-reliability work that we have done has taken direct aim at the frailty of humans and the fact that we are not perfect creatures.
We can talk about what we have done with technology and what we have done with human-factors engineering—those have been great individual efforts in individual error prevention. But nothing has been as powerful as changing behavior and changing culture for how we behave as clinicians and caregivers.
Outpatient practices can drive value, harness telemedicine, provide access, and promote equitable care.
Effective outpatient strategies are critical to the success of health systems, a top executive at NewYork-Presbyterian (NYP) says.
With an ever-increasing shift of care from the inpatient setting to the outpatient setting, ambulatory care has become an increasingly important sector of the U.S. healthcare industry. Annual revenue from ambulatory healthcare services is about $1 trillion, outpatient practices employ more than 7 million people, and there are more than 600,000 ambulatory care establishments, according to statista.com.
Outpatient care is essential to drive value in healthcare, says Tiffany Smith Sullivan, MPH, senior vice president and chief operating officer of physician services at NYP. "To drive value at its core, you need a patient-centered approach. We need to build teams for patients that manage complex types of care, so that we are aligned, we are communicating, and we are working with the patient to make sure that they have everything they need to remain healthy in the ambulatory setting. For example, we want a patient who is managing diabetes to not have to go to the emergency department or have an inpatient stay. That is a condition that we can manage in the ambulatory setting with community partners to help the patient get what they need to stay healthy."
Ambulatory practices have become leaders in telemedicine, she says. "You need to go back to 2020, when many of our outpatient practices were closed for in-person visits. Before 2020, we had been dragging our feet on telehealth options for our patients. We were still getting our technology up to speed. The pandemic accelerated the pace of building telehealth capabilities in the ambulatory space. While we were shut down for in-person visits, we were able to identify platforms for telehealth including phone calls and video. It was important to have telephonic visits as well as video visits for our patients who live in areas where access to high-speed Internet was not available for them. The pandemic gave us an opportunity to shift to telehealth platforms and be safe in how we provided care for patients."
NYP is committed to telemedicine in the outpatient setting, Smith Sullivan says. "We are going to continue to offer telehealth—we have about 20% of our patients wanting that option for care."
Outpatient care is essential for efficiency and access to care, she says. "Our outpatient strategies to increase efficiency include opening up access to care so that patients do not need to seek care in high-acuity settings such as the emergency department. If we are only open Monday through Friday, 8 a.m. to 5 p.m., then we are leaving out a segment of our patient population. Sickness does not only happen Monday through Friday, 8 a.m. to 5 p.m. So, we are making sure that we have extended hours and weekend hours to make sure we can provide access to our patients whenever they need care. We want them to be able to seek care in an outpatient practice, rather than seeking care in the emergency room."
NYP is trying to schedule outpatient visits within at least seven days, Smith Sullivan says. "We are identifying opportunities for expansion of primary and specialty care in areas where we see lag times. That means if you call today, how long does it take us to get you into an appointment? We have metrics for that, and we want to make sure that if we see a community that has a high lag time, we look at those trends to address where we need to place primary and specialty care resources."
The health system is expanding its ambulatory care network to improve access, she says. "We are making sure that we understand where we have significant lag times by using trend data. It can mean increased staffing such as more advanced practice providers including nurse practitioners and physician assistants in our practices. We are looking at not only the structure of the type of caregivers we have in our practices to address the needs we see in our communities but also looking at where the need is growing and shifting related to primary care and different types of specialty care."
Using ambulatory care to promote equity
Equity is one of the goals of NYP's outpatient care strategy, Smith Sullivan says. "Each community in New York City has its own different flavor and has its own underpinning resources. So, we need to make sure that we have strong partnerships in our communities and strong relationships with our patient population. We need to streamline what it takes to get in and see a provider such as having a centralized contact center, which is a process in place at NYP starting with primary care. That improves access for all of our patients."
NYP's ambulatory practices are closely linked to the community, which supports equity in care, she says. "Our strongest opportunity with our socioeconomically disadvantaged populations is to understand the community, to understand the pain points in the community, and to work with community-based organizations. For example, we have strong partnerships with faith-based organizations, school-based health centers, and programs that help people obtain healthy food. So, integrating with those programs and organizations is part of building trust in the community and making sure that care is equitable in terms of access and being able to see a provider of your choice. We need to be embedded in our communities, to be tied in with community-based organizations, and to have partnerships that are meaningful."
Expanding ambulatory care
Opening new outpatient practices remains a cornerstone of expanding ambulatory care at NYP, Smith Sullivan says. "Brick and mortar is still our biggest play in terms of the volume of patients that we see. So, we spend a lot of time and energy on where we are having bottlenecks and where we are having access issues in terms of patients not being able to get an appointment in seven to 14 days, which can mean we need an additional brick and mortar location. We also want to look at how we can open up our schedules to accommodate those patients."
Data drives decisions on opening new outpatient practices, she says. "There are several metrics that help us decide whether we should expand, where we expand, and what type of services we expand in a community. We look at lag time—how long it takes a patient to get an appointment. We look at the comments from our engagement surveys such as how long patients are staying on the phone. We look at our quality metrics to make sure our patients are getting high-quality care. If we see our physicians are overloaded, we often see a correlation to some of our quality metrics."
Recruitment statistics from 2021 show strong demand for physicians and advanced practice providers.
The market to fill physician and advanced practice provider positions is extremely competitive, according to a recent report from the Association for Advancing Physician and Provider Recruitment (AAPPR).
There are widespread workforce shortages across the country at health systems, hospitals, and physician practices. Clinical leaders say labor shortages are the Number One challenge facing their organizations.
The recent report is based on 2021 data collected from more than 175 AAPPR member organizations representing more than 23,000 employment searches. More than half of the searches were specific to physicians. The report includes several key findings:
The percentage of physician searches filled decreased for the fourth straight year
The most sought-after physician specialties were family medicine, internal medicine, and hospital medicine
The physician specialty positions that were least likely to be filled included otorhinolaryngology, dermatology, and urology
Nearly half of all physician searches were to replace a departing physician—this turnover rate has increased 16 percentage points since 2018
The proportion of clinician searches open at year end spiked in 2021, reaching 47% for physicians and 32% for advanced practice providers (APPs)
At 10% in 2021, APP turnover increased to a six-year high
The top three active searches by provider category were physician (52.0%), nurse practitioner (26.5%), and physician associate (11.2%)
The primary reasons for physician turnover at organizations with 300 to 999 providers were leaving for a similar position (74.6%), retirement (67.3%), geography (50.9%), burnout (34.6%), and compensation (30.9%)
The primary reasons for APP turnover at organizations with 300 to 999 providers were leaving for a similar position (91.7%), compensation (68.8%), geography (43.8%), burnout (33.3%), vaccination or testing requirement (18.8%), and retirement (12.5%)
Interpreting the data
The extent of clinician shortages is mainly dependent on geography and specialty, says Carey Goryl, MSW, CEO of the AAPPR. "The shortage of physicians is impacting different communities differently. If you look at rural communities, that is where we are going to see the physician shortage being felt most acutely. It also depends on the specialty. We are already starting to see certain specialties with serious shortages such as urology, where they have an aging provider workforce. When you look at the data to see who is going into urology residencies, there are not big enough numbers to have enough providers five to 10 years from now."
Future clinician shortages will be driven by geography, specialty, and burnout, she says. "The trend is taking us into an area where different patients in different communities will feel the physician shortage differently. It is going to depend on where you are and what type of provider you are trying to see. The future trend is also associated with burnout. If you have a specialty that is already stretched thin, the challenges to impact burnout, engagement, and retention point to a looming storm."
For health systems, hospitals, and physician practices, there are three primary consequences associated with physician turnover, Goryl says.
"The first impact is cost to the organization. It is very expensive to replace a physician and it is also expensive to have a physician position vacant for long periods of time. The cost to recruit and the lost income from vacant physician positions can be millions of dollars. The second impact of physician turnover is continuity of care. It hurts patients when their provider leaves and they have to create a relationship with a new physician. They may have been seeing a provider for several years, and there is a lot of historical information and relationship building that can be lost when there is this break in the continuity of care. The third impact of physician turnover is the impact on their colleagues. When a provider leaves, that means their colleagues might need to pick up additional patients or call coverage. It stretches everyone even thinner and adds to burnout."
There are no easy fixes for high clinician turnover and increasing job openings, she says. "We must look at provider retention programs that address physician concerns. We must look at why physicians and APPs leave their positions. And we need to invest in workforce planning. We must get ahead of these numbers, so they do not continue to increase. In workforce planning, we need to look at everything from retirements to employee engagement data. We need to try to forecast what is going to happen because the sooner we can start developing relationships and start recruiting to fill openings, the easier it will be to address these turnover statistics."
In a new study, deaths in U.S. emergency departments were estimated to account for 11.3% of total deaths from 2010 to 2019.
Death during or shortly after an emergency department visit is relatively common, and EDs should be prepared to provide better end-of-life care, according to a new research article.
From a patient experience point of view, it is unlikely that most EDs are a good setting for an unanticipated death. Earlier research on patients with cancer who die in an ICU shows there is a lower quality experience such as physical distress than patients who die at home.
The new research article, which was published by JAMA Network Open, features information drawn from the Optum clinical electronic health record data set from 2010 to 2020. Data was also used from the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample and U.S. Census.
The study features several key data points:
Among more than 104 million patients with more than 96 million ED visits, 205,372 ED deaths were found in the Optum data set, with a median age of 72
Deaths in EDs were estimated to account for 11.3% of total deaths from 2010 to 2019
A third of people who died nationally visited an ED within one month of their death
The proportion of deaths occurring in the ED decreased 0.27% annually but the proportion of people who died within one month of an ED visit increased by 1.2% annually
Compared to all ED visits, patients with ED visits resulting in death were older, male, and had higher Charlson Comorbidity Index scores
Among patients older than 80 who had ED visits, nearly 1 in 12 died within one month
"This retrospective cohort study found deaths during or shortly after ED care were common, especially among patients who are older and with chronic comorbidities. EDs must identify patients for whom end-of-life care is necessary or preferred and be equipped to deliver this care excellently," the study's co-authors wrote.
Interpreting the data
The data suggest approaches to end-of-life care in the ED setting, the study's co-authors wrote. "We found that more than 1 in 3 U.S. residents come to the ED within 1 month of their death, a proportion that has increased 42% over a decade. Moreover, nearly 300,000 U.S. residents die in the ED annually. Taken together, these findings highlight a pressing need to develop systems and resources to support end-of-life care in the ED. Unsurprisingly, we find that patients with death proximate to their final ED encounter are older and have significantly more comorbidities compared with the overall ED population. … These patients may exhibit identifiable trajectories of dying that offer an opportunity to avoid unwanted aggressive care or hospitalization at end of life."
The quality of end-of-life care in the ED is generally suboptimal, the study's co-authors wrote. "There is general consensus that delivering high-quality end-of-life care in the ED is an unmet need. Compared with dying at home or in a hospice facility, quality of dying in the hospital is worse and may lead to protracted grief and psychological distress for families. Time constraints, patient volume, and environmental factors may contribute to suboptimal patient care and family experience."
The study's co-authors offer suggestions for improving end-of-life care in EDs. "Development and implementation of policies, structural changes, and allocation of additional resources can improve delivery of care to these patients. ED programs should clearly include grief and bereavement resources. Practitioners and staff in the ED should have core primary palliative care skills, including symptom management for actively dying patients, the ability to give serious news, and focus on talking to patients and families about goals of care."
EDs should be prepared to connect patients near the end of life with palliative care and hospice care, the study's co-authors wrote. "ED practitioners and systems of care should consider developing relations with community palliative care and hospice programs to follow up with the large number of patients who, although they will survive their acute encounter, have impending or ongoing palliative care needs."
Some medical device supply chain challenges at hospitals are foundational such as determining what they own and establishing a comprehensive inventory.
Medical devices are one of the most challenging facets of supply chain management at health systems and hospitals.
Medical devices include a range of equipment from monitors, to IV pumps, to million-dollar magnetic resonance imaging machines. Hospitals not only need to acquire medical devices but also need to keep track of them and maintain them in good working condition.
This equipment is high in the supply chain hierarchy, says David Klumpe, PharmD, president of clinical asset management solutions at Indianapolis-based TRIMEDX. "Medical devices are an important part of the hospital supply chain. On the capital side, medical equipment represents 20% to 25% of what the hospital is spending every year on capital equipment. It is a major driver of organizational spending for capital on an ongoing basis."
He says there are four primary supply chain challenges related to medical devices:
"The first challenge is gaining visibility to what you own. We find that many of our clients do not fully understand everything that they own. When we help them complete an inventory, there is a pretty big difference between what they think that they own and what they actually own—they can be off as much as 30%," he says.
"The second challenge is measuring device utilization. Hospitals own thousands of devices and they need to know how many they are using on a regular basis. Nearly every hospital struggles with this challenge because it is very difficult for hospitals without technology to monitor device utilization. A typical hospital is only using 40% to 50% of the equipment that they own on any given day. So, asset utilization can be far less than what they might expect," Klumpe says.
"The third challenge is that many hospitals lack comparative benchmarks—how much equipment does a hospital own compared to similar hospitals. For example, how many ventilators does a hospital own and how many IV pumps does a hospital own? Many hospitals do not have comparative benchmarks to gauge the level of investment they have made in their equipment," he says.
"Lastly, like a lot of things in a hospital, there are many stakeholders for medical devices—many people involved in decisions about clinical equipment. There is the administrative point of view, the frontline caregiver point of view, the finance point of view, the regulatory point of view, and the infection control point of view. So, because there are many stakeholders involved, there can be complex decisions that need to be made with input from many individuals," Klumpe says.
There are strategies to rise to these challenges, he says. "The first strategy is to create and maintain an accurate single source of truth. A hospital should have a comprehensive inventory of all the equipment that it owns in one location, where they know everything about that equipment. There should not only be an inventory of equipment but also how much of it is utilized, and an accounting of how old it is and whether parts are available."
The second strategy is to establish effective governance over medical devices, Klumpe says. "There is governance over pharmaceuticals and supplies, and there should be the same level of governance over the ongoing investment in clinical assets. You should get all of the stakeholders around the table, get alignment around goals, and establish accountability for who can make decisions and how decisions are going to be made."
The third strategy involves technology, he says. "If you are going to try to do this work with manual processes, it is going to be very difficult. So, you need to seek solutions that can automate the collection and maintenance of the data. You need to automate the understanding of utilization. You need to automate infusion of benchmarks into conversations about medical devices."
Managing medical devices
Hospitals need to establish the useful life of medical devices to help maintain the equipment in good condition, Klumpe says. "Many hospitals rely on the equipment manufacturers to make recommendations about replacement intervals, but there are many pieces of equipment that have useful life far beyond what the manufacturer may suggest through a robust clinical engineering program. Often, hospitals find a partner who can help bring insight to useful life beyond what the manufacturer might suggest is the useful life, which is a way for hospitals to stretch their capital."
There are two primary strategies to extend the useful life of medical devices, he says.
"One approach is to have a quality clinical engineering program. You should have a team of highly trained, disciplined clinical engineers who are able to do repairs on the equipment in a timely way. These engineers can keep the equipment functioning past what the manufactures have suggested as the useful life of the device," Klumpe says.
The other approach, which goes hand-in-hand with a quality clinical engineering program, is an advanced supply chain, he says.
"There are parts available for clinical devices after the manufacturers have stopped manufacturing parts. There are several firms that provide 'aftermarket' parts. You need to understand that market and be thoughtful about who you are going to buy aftermarket parts from. An advanced supply chain will conduct rigorous supplier management and make sure parts are coming from qualified suppliers. This supplier management ensures that the device is safe and continues to function as it needs to for the care of the patient."
"This system has failed many patients awaiting organ transplants due to the lack of oversight and accountability," says one health system executive.
Leaders at AdventHealth are calling for improvements in the U.S. organ transplant system—the Organ Procurement and Transplantation Network (OPTN), the federal government agency that oversees organ transplants in the country, and the United Network for Organ Sharing (UNOS), the nonprofit organization that manages the organ transplant system under a contract with the OPTN.
The organ transplant system needs to be reformed, Barry Friedman, BSN, executive director of the AdventHealth Transplant Institute, recently testified before the U.S. Senate Finance Committee. "Families in need of life-saving organs have no other choice but to trust the organ transplant system that is in place. This system has failed many patients awaiting organ transplants due to the lack of oversight and accountability. Approximately 23% of kidneys procured from deceased donors are not used and discarded, resulting in preventable deaths. It is our responsibility to address this issue."
Transportation of organs also needs to be improved, he said. "Organ transportation is a process left to federally designated organ procurement organizations (OPOs). Currently, they develop their own relationships with curriers, [and] rely on airlines, charter flights, ground transportation, and federal agencies to facilitate transportation. In many cases, organs must connect from one flight to another, leaving airline personnel responsible for transfers. While anyone can track their Amazon or FedEx package, there is currently no consistent way of tracking life-saving organs. … Currently, there is no requirement for OPOs to use tracking systems. Data availability and transparency are key to improving organ procurement, and UNOS has not proven capable in providing this function."
Also, OPTN technology needs to be updated, Friedman said. "OPTN technology has significant interoperability challenges and lags behind other technology platforms. This contributes to a fractured flow of information between OPOs, donor hospitals, and transplant programs."
UNOS should be taking advantage of electronic medical records at health systems and hospitals, Bobby Nibhanupudy, MD, a transplant surgeon at AdventHealth, told HealthLeaders.
"We need to have more integration of EMRs with the database at UNOS, so we can transfer information more easily. Right now, a lot of information is entered on donors in the hospital EMRs and the database at UNOS. There is also information in EMRs and the UNOS database on outcomes. But a lot of that data is given secondhand through forms that are entered physically. UNOS needs to catch up to the capabilities of EMRs and their interfaces. They just do not have a large enough information technology department, which is probably a financial issue, but it needs to be more robust than it is now," he said.
In addition, UNOS is not effectively screening organ donors so that they can be quickly directed to transplant programs, Friedman said. "UNOS asks centers to voluntarily opt out of certain organs via a filtering process. As a result, OPOs waste valuable time making organ offers to centers that will never accept them. Time wasted equates to prolonged cold ischemic time, and organs not placed resulting in lost organ transplant opportunities. This creates a vicious cycle that disadvantages patients on the wait list."
The shortcomings of UNOS are that the complexities of the organ transplantation system have outgrown some of the abilities of the organization, Nibhanupudy said.
"UNOS has been great responding to the transplant community for many years. But over the past five years, UNOS has become more of an executive board-driven entity rather than listening to the transplant community. This has led to a couple of problems. In information technology, the needs of the transplant community have outgrown the abilities of UNOS. That has hindered the ability of UNOS to respond quickly to what the transplant community needs. Secondly, the executive board driven–approach has led to one-blanket-fits-all allocation changes; and no matter how noble the intent was, it has led to decreased transplants in the state of Florida, organs are not being utilized, and there have been increases in costs for the transportation of organs," he said.
Perspective at UNOS
Before his departure from UNOS at the end of September, former CEO Brian Shepard, told HealthLeaders that the organ transplant system is functioning effectively. "The United States has the largest and most productive organ transplant system in the world. Nobody touches our numbers—we have set records for nine consecutive years. We had 40,000 transplants for the first time last year, which is a number that no other country has come close to meeting. Some of that performance is our size—we are a big country—but if you adjust for population, we are still the largest organ transplant system in the world."
UNOS is committed to having effective technology capabilities, he said. "We have constantly updated our technology, and technology accounts for nearly half of UNOS' budget. We spend almost $30 million a year upgrading, improving, and advancing technology. We are always adding new features to help transplant hospitals do their job better such as providing predictive analytics. We provide screening tools that help them target the right organ to the right candidate faster. So, improving the system is an ongoing and continuous process."
Although UNOS is not in charge of organ transportation, the organization does provide a tracker that OPOs can use, Shepard said.
"We do provide a GPS tracker that folks can choose to use. But there are other commercial trackers that people can use—not everybody uses our tracker. We have a couple of committees—our policies always arise from experts in the field—that are looking at questions such as mandating that everyone uses a tracker or mandating that everyone uses the same tracker so it can be monitored through the same interface. These committees are also considering whether it is OK not to use a tracker when the surgeon is traveling with the organ. So, we have committees looking at how we can make the tracking of organs better."
There is not a conflict of interest in having the OPTN and UNOS share board members, he said. "We look for specific issues to see if there is a certain policy we can adopt or a certain information technology programming plan. I don't see a conflict of interest. We are a mission-based nonprofit whose goal is to increase the number of transplants performed in the United States."
Migraine can be safely diagnosed in the primary care setting and advanced medications are available.
There is a shortage of neurologists nationwide, and primary care physicians can help fill the gap in migraine care, a headache expert says.
Migraine is one of the most common disabling medical conditions, according to the American Migraine Foundation. In the United States, 1 in 4 households has a family member who suffers from migraine, and migraine affects 1 out of 7 people globally, the foundation says.
Recent advancements in migraine care and research make treating migraine in the primary care setting easier, says Loretta Mueller, OD, a headache specialist and family physician at Cooper University Health Care, which is based in Camden, New Jersey. "There has been a boom of new therapies in recent years and a lot more research going on. It is a good time to be treating headache and researching headache. The newer medications that are out generally are tolerated better than the older medications, and many of them work much quicker than the older medications."
Primary care physicians have several medication options for migraine that have become available over the past four years, she says. "The newer ones that have come out since 2018 include injected monoclonal antibodies that target the calcitonin gene-related peptide, which is migraine specific. We also have new oral medications called gepants that also target the calcitonin gene-related peptide. Two of the oral treatments are for as-needed use once a headache starts—rimegepant, which is Nurtec ODT, and ubrogepant, which is Ubrelvy. We also have a new medication that is only for headache prevention—atogepant, which is Qulipta. Nurtec ODT can also be used for prevention, when taken every other day."
Detecting migraine in the primary care setting
Diagnosing migraine is appropriate for the primary care setting, Mueller says. "It is not a procedural field, so every primary care physician who has an interest in headache should be able to treat migraine. It is just a matter of having the time to sit down and provide the care as well as having the education about what to look for. The reality is that most of what you are going to see in a primary care practice is migraine. So, if primary care physicians were taught to start with the diagnosis of migraine and work backwards from there, we would have a lot more patients who could be easily treated for migraine."
To diagnose migraine, primary care physicians should review the patient's medical history and schedule a visit to focus on the patient's headaches, she says.
"The medical history is key as well as dedicating an office visit specifically for headaches rather than just having a by-the-way complaint when a patient is in the office for high blood pressure or another condition. The primary care physician should focus only on headache during a visit. I see nothing but headache patients on a hospital's neurology floor, and it takes me an hour with a new patient, but we do have migraine identifiers such as ID Migraine, which is only three questions: Have you not been able to function at least one day out of the past three months because of your headaches? Do you ever get nauseous with your headaches? Do you ever get light sensitivity with your headache? If two out of those three are positive, there is about a 93% chance that the condition is migraine. If all three are positive, there is a 98% chance that the condition is migraine."
Primary care physicians can use tools to rule out more serious causes of headache such as SNOOP, Mueller says.
'S' is for systemic symptoms such as cancer.
'N' is for neurologic abnormalities.
The first 'O' is onset of rapid escalation of pain within seconds or the so-called thunderclap headache that can be a marker for aneurysm or brain bleed.
The second 'O' is for onset of new headache over the age of 50.
'P' is for prior headache history, where a change in headache history such as increased severity or frequency could be signs of a serious condition.
Treating migraine in the primary care setting
The treatment of migraine requires a holistic approach to care, Mueller says. "It comes down to a clinical judgment call. There is no single algorithm as is the case for other conditions such as a diagnosis of Lyme disease calling for a specific antibiotic. There is some art in the treatment of migraine because many of these patients have other comorbidities such as depression and anxiety. You look at the whole picture."
Migraine treatment can be complicated, she says. "There are many treatment options. For example, how many medications do you go through or how many classes of medications do you go through with the patient in shared decision-making. A lot of migraine care requires shared decision-making. Some patients definitely have a preference as to what they are looking for or side effects that they do not want. Some migraine medications have weight gain associated with them."
Compared to other hospitalized patients, patients with diabetes have longer lengths of stay and higher readmission rates.
Hospitals could save millions of dollars with better glycemic control of patients with diabetes.
In 2017, per capita healthcare expenditures for hospital care were estimated at $4,966 for patients with diabetes and $1,202 for patients without diabetes, according to the American Diabetes Association. Riverside Healthcare found that better management of hypoglycemic patients at their facility led to an estimated savings of $544,756 annually, and that by reducing length of stay in critical care units due to the implementation of a computer-guided insulin protocol they achieved a $2.1 million in savings in a year.
"There are high healthcare costs with the poor management of blood sugar. Costs associated with diabetes in hospitals include length of stay—these patients tend to stay in the hospital longer than other patients. They need more treatments—insulin management is a major cost for these patients. They need more interventions. They also have more readmissions than other patients," says Betsy Kubacka, MSN, an endocrinology advanced practice registered nurse at The Hospital of Central Connecticut in New Britain, Connecticut.
There are two primary elements of caring for patients with diabetes in the hospital setting, she says. "When a diabetic patient is admitted to the hospital, they are primarily treated with insulin, which is the safest modality and has the least amount of side effects. We can get blood sugar control of the patient and maintain it throughout the hospitalization. When they are under control, patients can recover quicker and have less of a risk for infection. For most patients, we want to keep their blood sugar between 100 and 180 milligrams per deciliter throughout the hospitalization. We also want to ensure that our diabetic patients have adequate diabetes education to manage their diabetes when they are back home. We provide chronic disease management education."
Diabetes management is a challenge in the inpatient setting, Kubacka says. "Resources such as endocrinology are often limited at hospitals, so it is often a challenge getting our patients under control within the hospital setting. With insulin, you must give the right amount. If we don't give the right amount, you either have blood sugar that is too high or too low, both of which can lead to adverse outcomes."
In the hospital setting, there are adverse outcomes for patients with diabetes who have low blood sugar and high blood sugar, she says. "The adverse outcomes of low blood sugar include hypoglycemia, which can make the patient feel shaky and dizzy. In severe cases where the patient's blood sugar goes below 40, they can have altered mental status or hypoglycemic coma. Those patients have a longer length of stay at the hospital. Low blood sugar is the biggest concern for hospital staff. The adverse outcomes of high blood sugar—above 180 during hospitalization—include bacterial infections. Among COVID-19 patients, those who had uncontrolled high blood sugar while hospitalized have had higher mortality rates."
Managing hospitalized diabetic patients
Expert resources for patients with diabetes are often lacking in many hospitals across the country, and technology can fill the gap, Kubacka says. "We have a shortage of endocrinologists. We have a shortage of nurses who specialize in diabetes to help support team members in managing diabetic patients in hospitals. With a shortage of expert resources, we must look at things like technology to improve glycemic care. That is something that we implemented within Hartford HealthCare to assist our staff in calculating insulin doses by using Food and Drug Administration-cleared computerized algorithms."
The Hospital of Central Connecticut has launched three primary initiatives to improve glycemic care, she says.
"There has been a lot of work in order set design. Within the electronic health record, we provide guidance to our physicians, nurse practitioners, and physician assistants in how to prescribe insulin. So, although endocrinology may not be their specialty, information on how to prescribe for a patient is at their fingertips."
"We have ensured through our nutrition services that diabetic patients are getting the correct diet. We ensure that we have a process, so the nurse knows when a meal is delivered, and the nurse can check the patient's blood sugar before the meal and administer insulin in a timely manner. We have put processes in place and support the staff as best as we can."
"We have an endocrine council that meets monthly, and I serve on that council. We look at any adverse event that occurs in the hospital and do root cause analysis on those events to see if there is anything within our processes that we can do differently to prevent adverse outcomes in the future."
Researchers found that completion of the primary series of COVID vaccination before acute COVID-19 illness was associated with a lower risk of long COVID.
A new research article gauges the prevalence of long COVID symptoms among U.S. adults and examines the effectiveness of vaccination for averting long COVID.
The World Health Organization has definedlong COVID as a syndrome that occurs three months after a COVID-19 infection, with symptoms that last for at least two months. Long COVID symptoms include cough, shortness of breath, anxiety, depression, cardiac issues, and fatigue.
The new research article, which was published by JAMA Network Open, features survey data collected from more than 16,000 adults who experienced a test-confirmed COVID-19 illness. The study includes several key data points:
Among the 16,091 survey respondents, 2,359 people (14.7%) reported long COVID symptoms. When this data was reweighted for national sociodemographic distributions, these long COVID patients represented 13.9% of patients who had tested positive for COVID-19.
Completion of the primary series of COVID vaccination before acute COVID-19 illness was associated with a lower risk of long COVID (odds ratio 0.72).
Older age per decade above 40 years was associated with higher risk of persistence of long COVID (adjusted odds ratio 1.15).
Female gender was associated with higher risk of persistence of long COVID (adjusted odds ratio 1.91).
People with a graduate education versus high school or less were associated with a lower risk of persistence of long COVID (adjusted odds ratio 0.67).
People who lived in urban versus rural areas were associated with a lower risk of persistence of long COVID (adjusted odds ratio 0.74).
Among long COVID patients, fatigue was the most common symptom (52.2% of patients), followed by loss of smell (43.7%), brain fog (40.4%), and shortness of breath (39.7%).
"This study suggests that long COVID is prevalent and associated with female gender and older age, while risk may be diminished by completion of primary vaccination series prior to infection," the study's co-authors wrote.
The data estimates the prevalence of long COVID among adults who test positive for COVID-19, they wrote. "In this cross-sectional study of a cohort of 16,091 adults surveyed between February 2021 and July 2022 in all 50 states in the U.S. and the District of Columbia, we estimated that 14.7% of those who reported a positive COVID-19 test result more than 2 months previously continued to describe symptoms that they associated with acute infection, or 13.9% after reweighting to reflect the U.S. adult population."
To help address healthcare workforce shortages in western Kentucky, Owensboro Health has led an effort to open a staff development innovation center in Owensboro, Kentucky.
Many healthcare executives say workforce shortages are their top challenge as the country emerges from the crisis phase of the coronavirus pandemic. Health systems, hospitals, and physician practices nationwide are struggling with workforce shortages in clinical and nonclinical roles.
Mark Marsh, president and CEO of Owensboro Health, says workforce shortages have affected the entire organization. "Throughout the country, workforce shortages are impacting our ability to provide care. It is affecting clinical roles such as nursing, respiratory therapy, and physical therapy, but we are seeing shortages throughout our organization including the support staff, dietary staff, and housekeeping. With COVID, we had a lot of retirements. We are seeing shortages on the inpatient and the outpatient sides."
Owensboro Health has launched the Commonwealth West Healthcare Workforce Innovation Center (CWHWIC), which was formed in collaboration with nine regional colleges and universities. The Kentucky General Assembly approved $38 million to establish the innovation center and develop a curriculum.
Owensboro Health got involved to spearhead the CWHWIC to meet a critical need, Marsh says. "We knew we were facing workforce hardships, including burnout from COVID. I am on a collaborative with the other nine big health systems in Kentucky, including Norton Healthcare. We were all facing workforce hardships. With traveling nurses, we have just been swapping nurses. So, we have been trying to put a plug in the problem, but even with the travelers, it has not been enough."
Working in collaboration with the colleges and universities is a critical component of the CWHWIC, he says. "We are blessed—we have nine colleges and universities in the western part of the state. When I first got here—I have been at Owensboro Health for about 16 months—I pulled those nine colleges and universities together and said, 'Here is what we are confronting.' I said, 'How can we put our collective resources together to address workforce shortages?' I came to the conclusion that we are going to be a lot better off trying to solve for this problem ourselves rather than rely on state or national resources. CWHWIC is an attempt to grow our own staff."
Owensboro Health worked with state legislators to establish the CWHWIC, Marsh says. "That was the exciting part. … Lawmakers love collaborative efforts. They saw nine public and private institutions come together with a solution. Lawmakers had been hearing about workforce shortages from the health systems in Kentucky. It made it easy for me to work with some of our local politicians. One was state Rep. Suzanne Miles. We had the chance to put our story together, and we went to the capital to meet with politicians. What was initially designed just to present the concept and how the innovation center would help moved so quickly that it went up for a vote in the appropriations committee."
Owensboro Health has invested heavily in the CWHWIC, says Bart Darrell, vice president of the innovation center. "Owensboro Health did not just go to the legislature and make a request for money. It has made a significant investment in everything from personnel to auxiliary services and the human resources piece. Owensboro Health is all in. This would not have moved forward if the state legislature and the governor did not believe that Owensboro Health was going all in. There is a significant $10 million–$12 million investment from Owensboro Health, which makes a great point to everybody that this is not just an idea. This has been researched and we have the right people involved."
How the CWHWIC will work
Owensboro Health has made a facility available to house the innovation center, Marsh says. "We have a facility that serves as our business office in the heart of Owensboro. It is about 48,000 square feet. We needed space to create the simulation labs and the innovation center. We were able to have some people work from home, and we have some other facilities throughout the area where we can relocate some of our personnel. It gave us the freedom to go ahead and convert and retrofit our business office into this new innovation center. That was a great speed to market for us and we are investing those resources."
The contribution of space for the innovation center was crucial for the initiative, Darrell says. "If Owensboro Health was not willing to contribute this building, you could not build a similar facility with the money that is coming from the legislature. Without that facility, this initiative would not be happening. It is going to be a state-of-the-art facility. It will have the cutting edge in technology as it relates to simulation."
Simulation labs are the key component of the CWHWIC, he says. "Anything that we do here is going to be done with excellence. So, we are making sure that we are being smart on how we start down the road. We anticipate offering simulation lab training in nursing, respiratory therapy, radiology, and lab techs initially."
The simulation labs will provide essential training at the innovation center, Marsh says. "We are putting together 13 simulation labs—those simulation labs are going to provide real-life scenarios where participants can see what an operating room nurse is or an ER nurse is. We are trying to role-play and provide real-life scenarios, so when participants get into the workplace setting, it will reduce the orientation and allow them an easier transition. It will give innovation center participants a better understanding of what their jobs entail."
Collaboration with the colleges and universities is also crucial, Darrell says. "Another piece is when we collaborate with the colleges and universities. Each one of them has their own niche or specialty. We know where we are going for the first three to five years, but we are also ready for whatever the healthcare environment presents to us and whatever technological advances arise. We believe we will be well-positioned to take advantage of change."
