Compared to 21 other high-income countries, the United States has the highest per capital cancer care spending but has a cancer mortality rate higher than six countries.
In comparison to 21 other high-income countries, the United States spends more on cancer care but does not have the best cancer outcomes, a new research articleshows.
The United States spends more on healthcare than any other country. Despite the high level of U.S. healthcare spending, the country lags behind other high-income countries in several health outcomes such as maternal mortality.
The new research article, which was published by JAMA Health Forum, compares U.S. cancer care spending and mortality rates to 21 other countries in the Organisation for Economic Co-operation and Development in 2020. The study includes three key data points.
The median cancer mortality rate was 91.4 per 100 000 population. The U.S. cancer mortality rate (86.3 per 100 000) was higher than that of six other countries.
Median per capita spending for cancer care was $296. U.S. per capita spending for cancer care was $584, which was higher than any other country.
Smoking is a strong factor associated with cancer incidence, and the United States has a relatively low smoking rate. When adjusting for smoking rates, nine countries had lower cancer care spending and lower mortality rates than the United States.
"In this cross-sectional study of 22 high-income countries, cancer care spending was not associated with age-standardized cancer mortality rates. Although the U.S. spent more on cancer care than any other country, this expenditure was not associated with substantially lower cancer mortality rates. Understanding how other countries achieve lower cancer mortality rates at a fraction of U.S. spending may prove useful to future researchers, clinicians, and policy makers seeking to best serve their populations," the research article's co-authors wrote.
The study's findings provide more evidence that the United States does not generate high value from the country's high health care spending, co-author Elizabeth Bradley, president of Vassar College and a professor of science, technology, and society, said in a prepared statement. "The pattern of spending more and getting less is well-documented in the U.S. healthcare system; now we see it in cancer care, too. Other countries and systems have much to teach the U.S. if we could be open to change."
Factors driving U.S. cancer care spending
Several factors account for why U.S. cancer care spending is higher than that found in other countries, according to the research article.
The United States spends more than other countries on cancer drugs
The prices of U.S. cancer drugs are relatively high, particularly for new drugs
The U.S. Food and Drug Administration grants earlier and wider access to new drugs compared with other countries' regulatory agencies
U.S. cancer care includes interventions for low-risk tumors such as early-stage prostate cancer, which is unlikely to cause harm if left untreated
End-of-life care in the United States is relatively intensive compared to other countries, with one study finding that U.S. cancer patients are admitted to intensive care units at twice the rate found for cancer patients in six other developed countries
Clinicians and patients are being encouraged to use the "in between" care offered in the health system's hospital at home and post-acute care at home programs.
Michigan Medicine is pursuing two primary pathways to offer home-based medical care.
Healthcare organizations are reimagining how they provide care to patients, increasingly looking beyond the walls of hospitals and other facilities to find new ways to provide medical services. Home-based medical care such as hospital at home programs have shown promise in improving clinical outcomes and reducing cost of care.
Michigan Medicine and the University of Michigan have a strategic initiative called Care at Home, says Grace Jenq, MD, associate chief clinical officer for post-acute care at Michigan Medicine and a clinical associate professor at University of Michigan Medical School.
Jenq says there are two key pathways in the Care at Home initiative—a hospital at home program called Hospital Care at Home and a post-acute care program called Completion at Home.
"With Hospital Care at Home, we take patients from the emergency department and enroll them directly into Hospital Care at Home. They go from the emergency department straight home, and we bring the nursing, the doctors, the medications, and the technology to monitor vital signs to the patient's home, so, they avoid admission to the hospital. We also have within Hospital Care at Home a way to get patients out of a hospital bed a little bit earlier. These patients get into the hospital, cool down a little bit, but they still need acute care—whether it is IV medication, IV fluids, nursing, or doctors to check their labs. We will transfer them to their home, then take care of them through the Hospital Care at Home program," she says.
Completion at Home is a program designed for high-risk patients after hospital discharge, Jenq says. "These are patients who are discharged from the hospital, but our intent is to try to provide wrap-around services with visiting nurses, our house call program, and our technology for monitoring. We try to keep our attention on these patients after they have been discharged from the hospital, so they do not get readmitted or come back to the emergency department. It is like a glide path—we do not just discharge patients anymore who are at high risk for readmission, we provide a glide path."
Hospital Care at Home
Michigan Medicine started building the infrastructure for Hospital Care at Home in 2018, with Blue Cross Blue Shield serving as an essential payer partner. The coronavirus pandemic accelerated the program, with the Medicare Acute Hospital Care at Home waiver program providing a new reimbursement mechanism for Medicare patients.
Hospital Care at Home is designed for patients who need acute care services at a level below the 24-hour care provided in the hospital setting, Jenq says. "No. 1, the patient and family have to understand there is not 24-hour care at home. There is a nurse who comes out to the home twice a day. If the patient has an emergency, they can reach a doctor immediately and we can send a paramedic out to the home for urgent issues that can be addressed within 30 minutes. … Doctors also go out to the home—the first visit, which includes a physical, must be conducted in person. About 80% of doctor visits are in person and 20% are virtual. These visits are daily."
Patients are carefully screened for enrollment in the Hospital Care at Home program, she says. "The types of patients we look for are patients who do not want to be in the hospital, but they want to get high-level services such as IV medications if they need them. The kinds of conditions are wound infections, cellulitis, mild pneumonia that requires oxygen, congestive heart failure that requires diuretics, and urinary tract infection. So, it is bread-and-butter medicine that does not require 24-hour-a-day nursing and monitoring. They still need medications. They still need laboratory tests. They are still acute patients—this is not outpatient care where you manage your condition with a primary care provider and get medications from CVS."
Completion at Home
The Completion at Home program was launched in 2020, in part as a response to the coronavirus pandemic.
Completion at Home services are not as intensive as Hospital Care at Home services, Jenq says. "With Completion at Home, we will have the nursing come out to you at home every couple of days, and we have the technology so the patient can take vital signs. We also have a way for the patient to reach a nurse or a doctor immediately if there is an issue with medications or a worsening of symptoms. Our intent with this glide path with Completion at Home is to make sure the patient has necessary resources, so they do not come back to the hospital for readmission."
The Completion at Home program is basically three services bundled together, she says. "The nurses go out through Michigan Visiting Nurses. We have a patient monitoring kit, which includes a cellular tablet, blood pressure cuff, and daily symptoms survey. Then we have our house call program, which includes physicians and nurse practitioners who provide virtual and in-person visits to make sure the patients are OK."
Completion at Home patients do not need daily visits by a nurse or a doctor, Jenq says. "We have this program to provide wrap-around services after a patient gets discharged. In the first week after hospital discharge, a nurse will visit the patient about three times and a doctor will visit the patient about two times. We are making sure that these patients have what they need at home—they are eating and drinking well, they have the medications that they need, and they are improving."
For Completion at Home, 80% of doctor visits are virtual and 20% are in person, she says.
The Completion at Home program has generated positive results, she says. "We have had a 50% reduction in emergency department utilization and 50% reduction in readmissions for patients who have been on the Completion at Home pathway."
Culture change required
Growth of home-based medical services requires a cultural change for both clinicians and patients, Jenq says. "We are changing a culture. Doctors and patients usually think about care as you are either in the hospital or you are at home with no services. There is nothing in between. What we are trying to tell them is there is 'in between' care—we can provide hospital-level care in the home and generate good outcomes. We have to sell this to the public, and we have to sell this to our nurses and doctors."
Processes have been put in place to encourage clinicians to use home-based medical care, she says.
"We now have mechanisms within our electronic medical record that can flag patients who are in the right geography and right payer mix for home-based services. We have asked the care managers to work with the physicians on the hospital floors or the emergency department to screen patients for home-based services. Part of the process is educating the medical providers that these programs exist. We also provide feedback to physicians about how many patients could have been eligible for home-based care, and we ask why they did not refer patients or ask why they declined to refer patients for home-based care," Jenq says.
In some pain interventions, contrast media is used for imaging that visualizes the needle tip location for clinicians.
The temporary closure of a contrast media manufacturing facility in China for a COVID-19 lockdown is impacting some pain interventions, a pain medicine expert says.
The closure of the GE Healthcare facility in Shanghai, which makes iodine-based contrast media, is having a more widespread impact on radiology such as CT scans. The American College of Radiology has made several recommendations for imaging that requires iodinated contrast media.
The contrast media shortage is a concern in pain medicine, says David Dickerson, MD, chair of the American Society of Anesthesiologists Committee on Pain Medicine. He is also medical director of the Anesthesia Pain Services Department of Anesthesiology, Critical Care, & Pain Medicine at NorthShore University HealthSystem in Evanston, Illinois.
"In interventional pain care, we use contrast to visualize our needle tip location during procedures that are targeting inflamed or dysfunctional nerves, joints, or muscles. So, contrast is often used in spinal procedures to make sure that we are near the target that we want to be treating such as a nerve root before we deliver the medication. We want to make sure that our medicine goes to the right place and that the needle tip is not somewhere that can cause harm. Contrast is used with X-ray-guided procedures," Dickerson says.
The American Society of Regional Anesthesia and Pain Medicine has made several recommendations for pain interventions during the contrast shortage. One of the recommended alternatives to using contrast for pain interventions is using ultrasound, Dickerson says. "With ultrasound, you can visualize all of the soft tissue and you are able to see where your needle is in real-time. So, you can forgo using contrast with an ultrasound-guided approach."
Pain medicine specialists should not switch to gadolinium contrast for spinal procedures, he says. "We cannot switch from iodinated contrast to the gadolinium contrast used in MRI scans, which has not been affected by the contrast shortage. There have been cases of patients who have had injury from gadolinium getting into their spinal fluid during a spinal injection. Patients have lost consciousness, experienced confusion, and suffered neurologic injury."
Some procedures can be modified to use either approaches or drugs that do not require contrast as a part of the procedure, Dickerson says. "You might change your image guidance, or you might change your needle approach to be not in an area where blood vessels are located—you can use an alternative approach to get to the same target. That approach can avoid using contrast, and the efficacy or safety of the procedure is not compromised."
Epidural procedures
Contrast is required for one kind of epidural procedure, Dickerson says. "When doing something like a transforaminal epidural steroid injection, which is a nerve root injection for a herniated disc or disc bulge, there are a couple of different approaches to get steroid into the epidural space around the nerve root. One approach is to put the needle right next to the nerve root and introduce a small amount of medicine around the nerve root and the epidural space as well. That epidural is very targeted to the nerve root of interest, but it is also in a very vessel-rich area. So, contrast lets us know that we are in the right spot and that we don't need to move the needle tip a couple of millimeters to avoid putting the medicine into a wrong location."
He says two other epidural approaches achieve the same effect but do not require contrast: caudal or interlaminar epidurals. "Those approaches have us placing a needle tip or a tiny microcatheter that advances to the target and avoids being near blood vessels. That is one of the recommendations—if you do not have contrast available, consider using a caudal or interlaminar epidural, where you avoid the need for contrast."
Shortage expected to ease soon
There should be adequate supply of iodinated contrast soon, Dickerson says.
"The Shanghai facility that was shut down for a COVID lock down is back up and running. We have been told that by the end of June, we should have restoration of the supply chain. However, that assumes that there are no other hiccups. This is where we need to think about having redundancy in our supply chains."
Federal action may be required, he says. "We may need to work with members of Congress to ensure that we require the companies that import contrast have diversification of their supply chain. The companies that import iodinated contrast are exclusively bringing in the contrast from one facility in China. We could end up with geopolitical issues that affect that supply chain with very little room for flexibility or adapting outside of rationing."
A new study found female physicians and racial and ethnic minority physicians are at highest risk for mistreatment and discrimination by patients, families, and visitors.
Physicians who experience mistreatment and discriminatory behaviors by patients, families, and visitors have higher odds of burnout, a new research article says.
Physician burnout was a concern before the coronavirus pandemic, which has exacerbated the problem. Earlier research has linked physician burnout to negative personal and professional consequences.
The new research article, which was published by JAMA Network Open, is based on data collected from more than 6,500 physicians. The study has several key findings.
In the previous year, 29.4% of physicians had experienced racially or ethnically offensive comments by patients, families, or visitors. This mistreatment was more prevalent among female physicians (34.7%) than male physicians (26.0%).
In the previous year, 21.6% of physicians had a patient or family refuse to allow them to provide care because of the physician's personal attributes.
In the previous year, female physicians (odds ratio 2.33) and Black physicians (odds ratio 1.59) were more likely to report mistreatment or discrimination.
Offensive racial or ethnic comments by patients, families, or visitors in the previous year were experienced 55.8% of Black physicians and 55.4% of non-Hispanic Asian, Native Hawaiian, of Pacific Islander physicians. These experiences were reported by 22.0% of White physicians.
In the previous year, 28.7% of physicians reported offensive sexist remarks by patients, families, or visitors, with this mistreatment reported by more female physicians (51.0%) than male physicians (15.1%).
In the previous year 20.5% of physicians reported unwanted sexual advances by patients, families, or visitors, with this mistreatment reported by more female physicians (29.6%) than male physicians (15.0%).
At least once in the previous year, 14.8% of physicians reported physical harm by patients, families, or visitors. Physical harm was reported by 31.8% of non-Hispanic male physicians of two or more races, a rate more than twice that of other groups.
The researchers scored mistreatment on a scale from 0 (no mistreatment) to 3 or greater. Higher scores were associated with higher odds of burnout: score of 1 odds ratio 1.27, score of 2 odds ratio 1.70, score of 3 or greater odds ratio 2.20.
"In this study, mistreatment and discrimination by patients, families, and visitors were common, especially for female and racial and ethnic minority physicians, and associated with burnout. Efforts to mitigate physician burnout should include attention to patient and visitor conduct," the research article's co-authors wrote.
Compensation for most physician specialties saw modest increases between 2019 and 2021, according to new MGMA data.
It appears that medical practices are rebounding from the coronavirus pandemic, with most physician specialties reporting compensation levels that are the same or in excess of pre-pandemic levels, according to new data from MGMA.
The first year of the pandemic took a heavy financial toll on physician practices and physician compensation. An American Medical Association survey conducted from mid-July through August of 2020 found a 32% average drop in revenue at physician practices.
The 2022 MGMA Provider Compensation and Production report has data from more than 192,000 providers at more than 7,700 healthcare organizations. The report, which focuses on 2021, features several key data points.
Nonsurgical specialist physicians experienced the biggest percentage decline in median total compensation from 2019 to 2020. These physicians experienced a 3.12% increase in median total compensation in 2021, and a 1.79% increase over the 2019 compensation level.
Surgical specialist physicians experienced the second biggest percentage decline in median total compensation from 2019 to 2020. These physicians experienced nearly a 4% increase from 2020 to 2021, with median total compensation reaching $517,501.
In 2021, primary care physicians experienced compensation gains slightly below figures in 2020, with median total compensation reaching $286,525.
Work RVUs reflect clinician productivity while taking into account visit complexity. From 2020 to 2021, the average percentage increase in median wRVUs for all provider types was 14.3%. Advanced practice providers experienced the largest percentage gain at 16.58%.
The Top 3 specialties that posted total compensation gains from 2019 to 2021 were ophthalmology at 6.97%, general orthopedic surgery at 6.88%, and family medicine without obstetrics at 5.60%.
The Bottom 3 specialties that posted weak total compensation changes from 2019 to 2021 were neurological surgery at -0.23%, diagnostic radiology at -0.14%, and emergency medicine at 0.78%.
Interpreting the data
The 2021 data bodes well for 2022, Michelle Mattingly, senior manager of data solutions at MGMA, told HealthLeaders. "With the compensation and work RVU data from 2021 being at or greater than levels in 2019, there is a very strong case that the pandemic is less of a cause for concern as we look forward to 2022."
Physician productivity appears to have returned to pre-pandemic levels, she said.
"The work RVU growth in 2021 is reflective of the decrease in 2020 due to the pandemic. Work RVU volumes dropped by more than 10% in 2020. The volume in 2021 is in line with pre-pandemic levels. Surgical and nonsurgical specialty physician productivity is reported about the same as it was before the pandemic. Primary care physicians report a slight increase (1.16%) in productivity compared to 2019."
Regarding patient volume, MGMA examined data for total encounters, which reflect the number of direct provider-to-patient interactions regardless of setting, including telehealth visits. This data shows that the pandemic is still having a negative impact on physician practices, Mattingly said.
"Total encounters increased between 2020 and 2021, signaling that patients are more comfortable being seen than they were in the height of the pandemic. However, the total encounters data is still down from pre-pandemic levels in 2019. For example, primary care physicians had 2.69% more encounters in 2021 than 2020; however, the 2021 level was still 7.73% less than what it was in 2019. Likewise for surgical specialty physicians: encounters were 5.89% more in 2021 than 2020; however, the 2021 level was still 4.85% less than what it was in 2019," she said.
Compensation for most physician specialties saw modest increases between 2019 and 2021, according to the MGMA data. Mattingly said setting expectations for 2022 and beyond is difficult because there are several factors that could affect a practice's productivity and have a downstream effect on physician compensation. Three of those factors are as follows:
Short staffing: Many practices are struggling to maintain necessary staffing levels. Without the right number of staff, practices may not be able to handle higher patient volumes.
Inflation: As the cost of goods and services increases, some patients may struggle to keep up financially and put off care.
Physician Well-Being: Burnout was problematic before the pandemic, and there are indications that the pandemic may have added fuel to the fire. Without enough providers in the workforce, it may be difficult to keep up with the demand.
Shared accountability between providers and care settings is a critical element of quality in behavioral health care.
Overcoming a fragmented system is the key to effectively measuring the efficacy of behavioral health care, a healthcare quality expert says.
Eric Schneider, MD, MSc, is executive vice president of the Quality Measurement and Research Group at the National Committee for Quality Assurance (NCQA). Before joining the NCQA staff in January, he worked at The Commonwealth Fund as senior vice president for policy and research focusing on quality measurement. Prior to his tenure at The Commonwealth Fund, he was principal researcher at the RAND Corporation. As a professor at the T.H. Chan Harvard School of Public Health and Harvard Medical School in Boston, Schneider taught health policy. He began his career as a primary care physician and practiced primary care internal medicine for 25 years.
HealthLeaders recently talked with Schneider about a range of issues related to achieving quality in behavioral health care, including the role of quality data in promoting health equity and behavioral health care, the importance of achieving shared accountability in behavioral health, and the value of using standard quality measures in behavioral health. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of measuring the efficacy of behavioral health care?
Eric Schneider: The biggest challenge is the fragmentation of behavioral health care across the United States. Primary care does a large amount of behavioral health care, but primary care physicians do not have the capability to manage all behavioral health problems. The behavioral health professional sector has been chronically underfunded, so the availability of practitioners is also a challenge. When it comes to the measuring of efficacy, in a fragmented system it is difficult to have the data systems in place that enable the collection of data on performance—particularly measures that can be reported by all of the settings and providers that contribute to behavioral health care.
Data availability is a primary challenge, but it is driven by the fragmentation of the existing system. The fragmentation means there is not a consistent set of data systems across the providers and settings to report on services for behavioral health.
HL: Why is quality data vital to promoting health equity and behavioral health care?
Schneider: One of the things we know about behavioral health—and it is true of primary care services for other chronic diseases as well—is that care is paid for by three major payers: commercial payers, Medicare, and Medicaid. Those payers are not equally generous in paying for behavioral health services. The inequities that result from that situation include lack of access to meet the demand, especially for people living in poor communities and people of color. Without sufficient funding, there is even more fragmentation of the data.
The way we can understand the lack of access and understand how needs are not being met is to do quality measurement at the payer level. So, Medicaid, Medicare, and commercial health plans all have something to contribute in terms of understanding whether people have access to behavioral health services and whether provider networks are adequate to provide services. Without shining light on where access is better or worse, it is difficult to figure out how to intervene to improve health equity.
HL: Why is shared accountability a problem in behavioral health care?
Schneider: The shared accountability model is important because without the sense of shared accountability, providers tend to just operate in their silos and manage their piece of the puzzle without being able to support the other providers in their recommendations and treatment plans.
HL: Define shared accountability in behavioral health.
Schneider: In behavioral health, it can be voluntary shared accountability to optimize the treatment plan of the patient, but that is difficult to do without either a management infrastructure or direct financing of that shared accountability. So, value-based contracting is a mechanism for trying to create shared accountability—if each of the providers who are participating are getting paid based on whether they are participating in shared accountability, that tends to be a strong incentive.
Shared accountability can also be accomplished by creating management systems such as business process management systems that specify how providers in one part of a system communicate with providers in another part of the system. It is a set of expectations or protocols. If a patient is seen in an emergency room, the primary care provider is notified and the behavioral health professional responsible for that patient is notified. If a person is in crisis and appears in a community health center, other providers will be notified. That's the kind of shared accountability that can be created by management systems that groups such as accountable care organizations or payers or care managers can provide.
HL: Why is it important to have consistent use of standard quality measures in behavioral health care to increase shared accountability and promote quality improvement efforts?
Schneider: Without a shared understanding of what represents a good outcome, it is difficult for the providers to navigate to a good outcome or help the patient navigate to a good outcome. There are several standard quality measures, and they are a mechanism for helping providers to share accountability—they can all see the metrics, preferably on a dashboard. Then they can adjust their approach over time for the populations they are seeing—they can adjust their approach to improve quality.
We think about standard measures in two categories. First, there are measures on the outcome side such as symptom reduction and functional improvement, whether patients can attain their goals, social outcomes in terms of school and employment, and family outcomes. Second, there are several measures on the process side such as whether behavioral health is being well integrated, whether goals are being set effectively, and whether there is an evidence-based care plan.
HL: How can you establish and use health information systems to capture patient-reported behavioral health outcomes?
Schneider: This is a game changer. This type of data collection for patient-reported outcomes has traditionally been done through paper-based surveys, but we are moving to a digital world. People are used to receiving surveys on their smartphones. That technology is enabling us to do much better real-time collection of data from people who are experiencing behavioral health problems. You can capture their current symptomatic state, then share and analyze the data to understand whether a patient is improving or getting worse.
After surgery for hip replacement, we would want to measure how many steps a patient can go day-by-day. If someone has a behavioral health crisis, we want to measure or understand through a standardized tool how they are doing at the time of the crisis and how they are doing after treatment is initiated. Health information systems enable much more efficient capture and analysis of that data.
There is a huge opportunity here. We still do not have digital standardization, but that is something NCQA is working on. There are also several companies that are creating electronic health records or other platforms that can enable the collection, storage, and analysis of patient-reported outcome data. Once we have the protocols in place to share that data and we have behavioral health quality frameworks to align clinical treatment settings, payers, and state and federal regulators, then we will have a much better chance of understanding a patient's journey with their behavioral health issues.
Nurse training has been a critical element of an ongoing initiative to improve the screening of new mothers for mood disorders.
A postpartum depression screening, education, and referral program at Cedars-Sinai Medical Center has generated positive results.
Perinatal mood and anxiety disorders are relatively common, and they can complicate pregnancy, delivery, and the postpartum period. Despite these risks, many hospitals have difficulty identifying and supporting patients with perinatal mood and anxiety disorders.
Cedars-Sinai launched its postpartum depression screening, education, and referral program in 2017. The initiative featured four interventions, Eynav Accortt, director of the hospital's Reproductive Psychology Program, told HealthLeaders.
1. Nurse champions: The hospital identified about 20 nurses who showed an interest in mental health. These nurse champions received a full day of training, including instruction in conducting mental health screening.
2. Mental health screening: The hospital shifted from only querying mothers on the first two items of the Patient Health Questionnaire-9 (PHQ-9) to covering all nine items. More importantly, the hospital moved PHQ-9 screening out of the admission phase of a new mother's care, Accortt said.
"For our population, it is inappropriate to do the questionnaire in triage. Women are coming in in pain, with contractions, with water breaking, and they are overwhelmed. So, one of the main elements of our quality improvement initiative was to stop asking the PHQ-9 questions upon admission. We decided to get them in, get them the medical care they needed, let them have their baby, then ask all nine items on the PHQ-9 in the postpartum unit rather than asking when they were in labor and delivery," she said.
3. Nurse training: Hundreds of Cedars-Sinai nurses received hour-long, in-service, in-person training on how to conduct mental health screening of new mothers. The training sessions featured role playing, with Accortt or a social worker playing the role of a nurse conducting the PHQ-9 and a nurse playing the role of a depressed mother.
"That role playing allowed the nurses to feel more comfortable with some of the PHQ-9 items because some of the questions can be quite jarring the first time you say them out loud. For example, one of the items asks, 'Over the past two weeks, how often have you had thoughts that you would be better off dead or thoughts of hurting yourself?' The first time a nurse says that out loud, it can be uncomfortable, and they brace themselves for an answer," Accortt said.
4. Video training: Based on nurse feedback that there were traveling nurses and night nurses who could not be present for the in-service training, the hospital developed a 10-minute training video with a key partner organization, Maternal Mental Health Now.
The four interventions improved nurse screening, nurse comfort with screening, and nurse knowledge about depression, Accortt said. "The interventions also improved our screening rates. When we were screening in labor and delivery upon admission, we were only screening about 10% of our patients because for the others it was just inappropriate to ask questions. We went from a 10% screening rate to a 99% screening rate. In addition, our screen positive rates went from nearly negligible up to 2.9% of patients in the first year. Finally, and probably most importantly, the four interventions increased our rate of social work consultation from 1.7% of patients to 8.4%."
The initiative is the subject of a research article published by the American Journal of Obstetrics & Gynecology.
Social worker consultation
If a new mother screens positive for a mood disorder or anxiety, she is connected to a social worker, Accortt said.
"The social worker begins by being caring, nonjudgmental, and a listening ear. The social worker provides support, asks questions, and provides resources after a thorough assessment of the patient's needs. Sometimes, the social worker might need to consult psychiatry if a woman seems unstable and in need of a full psychiatric evaluation. Otherwise, the social worker might provide a referral to our Reproductive Psychology Program. We have an outpatient reproductive psychology program. We have an outpatient social worker—that way, the patient has a seamless connection to care from the inpatient setting to the outpatient setting," she said.
The inpatient social worker always reviews the mental health screening data and looks for red flags, Accortt said. "For example, if a woman answers with anything other than 'not at all' to the question whether there are thoughts of harm, that is something the social worker needs to inquire more about. Under those circumstances, the social worker will likely consult with an inpatient psychiatrist. It's important. Maternal suicide is one of the leading causes of death for women in the postpartum period. We do not take that lightly. We want to make sure we provide support for anyone in distress."
Recent protocol changes
In February, the hospital dropped using the PHQ-9 for new mothers and replaced it with the Edinburgh Postnatal Depression Scale. At the same time the PHQ-9 was replaced, the hospital introduced iPads to complete the screening process.
"Our nurses still do an excellent job of introducing the concept of family wellness and the importance of the need for screening, but now they just hand the patient an iPad and the more commonly used Edinburgh Postnatal Depression Scale (EPDS) is what we use now instead of the PHQ-9. This is wonderful news because the EPDS also asks about anxiety, which is more common than depression at this time of life, and the iPad allows for more privacy," Accortt said.
The National Steering Committee for Patient Safety sees several worrisome developments, including rise in hospital-acquired conditions and decline of workforce well-being.
Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark reportTo Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
Last week at the Institute for Healthcare Improvement Patient Safety Congress in Dallas, the 27 members of the National Steering Committee for Patient Safety (NSC) issued the Declaration to Advance Patient Safety. The NSC features healthcare organizations and healthcare systems; patients, families, and care partners; professional societies; safety and quality organizations; regulatory and accrediting bodies; and federal agencies such as the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention.
The Declaration to Advance Patient Safety calls on healthcare leaders to embrace three resources developed by the NSC:
Identify a senior sponsor and team to use the National Action Plan's Self-Assessment Tool, which helps healthcare organizations determine where to start in improving patient safety
Use the National Action Plan's Implementation Resource Guide to bolster and sustain efforts to enact the four foundational areas identified in the National Action Plan
NSC members felt compelled to issue the Declaration to Advance Patient Safety, Patricia McGaffigan, RN, vice president of the Institute for Healthcare Improvement and IHI senior sponsor for the NSC, told HealthLeaders.
"We focused on issuing a declaration to call attention to the important work that we felt was necessary because we were concerned that the coronavirus pandemic had been diverting attention away from safety. We also wanted to focus on the ongoing foundational work that is necessary for strong safety performance in healthcare organizations," she said.
Several specific factors spurred the declaration, McGaffigan said. "Some examples of what prompted the concerns that we had was that family members were often excluded from care settings because of pandemic-related limitations on visitation or accompanying patients to their visits—family members play a key role in supporting safety. Access to care was hampered during the pandemic and there were delays in care. There have been worrisome signals from the workforce around growing fatigue and frustration as well as decline of workforce well-being. In early September, a seminal publication confirmed some of the setbacks in hospital-acquired conditions such as catheter-associated infections and ventilator-associated events. We had begun to accumulate more data on how safety culture scores were declining in many organizations."
The National Action Plan's 17 recommendations are organized into four foundational areas. McGaffigan summarized why each of the foundational areas are critical to improving patient safety.
1. Culture, leadership, and governance
The NSC determined that safety is critically dependent on healthcare leaders and governance bodies as well as the positions they take on establishing safety for patients, families, and the healthcare workforce, McGaffigan said. "Safety is a system property, and it is important for us to keep in mind that even if we are focusing on specific projects such as reducing infections, there are many factors that influence whether that work will be successful. Those factors are grounded in the culture and the tone that leaders set in their organization."
The National Action Plan was built on the premise that focusing on culture, leadership, and governance had to come first because they are essential to attain and maintain safety, she said. "Ultimately, this work is preconditional for getting to safety. We know that leaders who are committed to safety are focused on building the conditions, experiences, and workplace considerations such as culture that encourage trust and transparency, as well as ensuring the physical and psychological safety for everyone who is a part of the organization."
2. Patient and family engagement
Engaging patients and family members is a vital component of safe care, McGaffigan said. "It is not only safer when individual consumers are more meaningfully engaged in their care, but it is safer in a broad sense when we are able to integrate patients and family members into codesigning our systems and processes for care. They should also be engaged in improvement initiatives overall."
For example, patient and family engagement can improve diagnosis, she said. "Over the past two years, IHI worked with leaders and experts including patient and family advisors to develop the Safer Dx Checklist. Organizations can use this tool to advance diagnostic excellence. There are 10 recommendations in the checklist and those recommendations reflect the foundational areas in the National Action Plan. One of the items on that checklist that relates to patient and family engagement is whether the healthcare organization is seeking patient and family feedback so they can identify and understand diagnostic safety concerns and address those concerns with patients being actively involved in the codesign."
3. Workforce safety
Patient and workforce safety are inextricably linked, McGaffigan said. "If we do not have a workforce that is physically and psychologically safe, the workforce will be unable to bring the best effort to their job on any given day. Long before the pandemic and long before the National Action Plan, we had ample data confirming that the incidence of illness and injury in healthcare exceeded that in other industries we would typically consider to be dangerous such as construction and manufacturing."
In recent years, many healthcare organizations have realized they need to place more emphasis on healthcare workforce safety and well-being, she said. "This has certainly been illuminated during the pandemic, particularly in areas such as workplace violence, burnout, and increases in depression and anxiety among providers and care team members."
4. Learning systems
Healthcare organizations cannot improve unless they are constantly learning, McGaffigan said. "Because safety is a dynamic property of the system, we cannot say we have reached safety if we sit on our laurels. This is the constant daily work of everyone in healthcare. The work is fostered when we have intentional design and implementation of learning systems that can systematically integrate internal data and experiences with external evidence that we know about any topic we are pursuing."
Learning systems generate key benefits, she said. "In organizations where we have well-established learning systems, we have patients who get higher quality, safer, and more efficient care. These organizations are better able to deliver on their mission to patients and families, and they are better places to work."
The negative consequences of unnecessary surgeries include avoidable complications, increased costs of care, and opportunity costs.
Unnecessary surgeries, which have plagued U.S. healthcare for years, persisted during the first year of the coronavirus pandemic, according to a new analysis by the Lown Institute.
Last year, the Lown Institute, a nonprofit healthcare think tank based in Needham, Massachusetts, reported that hospitals performed more than 1 million unnecessary tests and procedures on Medicare patients from 2016 to 2018. Unnecessary tests and procedures can put patients at risk of complications and drive up the cost of care.
The new analysis found that hospitals performed more than 100,000 low-value procedures on Medicare patients from March to December 2020.
Stents for stable coronary disease: 45,176
Vertebroplasty for osteoporosis: 16,553
Hysterectomy for benign disease: 14,455
Spinal fusion for back pain: 13,541
Inferior vena cava filter: 9,595
Carotid endarterectomy: 3,667
Renal stent: 1,891
Knee arthroscopy: 1,596
"The Lown Institute is the first to measure rates of hospital overuse during the COVID-19 pandemic. Overuse, or low-value care, refers to medical services that offer little to no clinical benefit or are more likely to harm patients than help them. … From June to December 2020, with no vaccines available to vulnerable older adults, hospitals delivered low-value services to Medicare patients at rates similar to 2019," the new analysis says.
These are the Top 5 hospitals for avoiding overuse of eight low-value procedures and four low-value tests in the 2022 Lown Hospitals Index for Social Responsibility (the ranking is based on Medicare claims data from 2018 to 2020).
1. Highland Hospital, Rochester, New York
2. Natividad Medical Center, Salinas, California
3. Kalispell Regional Medical Center, Kalispell, Montana
4. Beth Israel Deaconess Medical Center, Boston
5. Lahey Hospital & Medical Center, Burlington, Massachusetts
These are the Top 5 states ranked by average performance on avoiding overuse of eight low-value procedures and four low-value tests in the 2022 Lown Hospitals Index for Social Responsibility (the ranking is based on Medicare claims data from 2018 to 2020).
1. Oregon
2. Maine
3. Vermont
4. Minnesota
5. South Dakota
Dimensions of unnecessary care
There are three primary negative consequences of unnecessary surgeries, Vikas Saini, MD, president of the Lown Institute, told HealthLeaders.
"First and foremost, procedures of any kind carry risk, and this is particularly true for procedures that are unlikely to benefit the patient. The risk of complications, side effects, and harms is one of the consequences of unnecessary surgeries. Fortunately, most surgeries and procedures have complication rates in the single digits. So, most of the time you are going to be fine, but the fact is if you start multiplying unnecessary surgeries by large numbers of people there will be unnecessary harms."
"Second, there is the cost. Quite often, people with insurance do not face costs for unnecessary surgeries, but sometimes they do. There can be copayments, costs for complications, costs for new medications, and costs associated with follow-up care. Mostly, the costs are felt at the systemic level. In that sense, we all are paying for unnecessary surgeries."
"Third is the classic question of opportunity costs. If you can free up capacity to do other procedures that have more value, you can generate a bigger bang for the buck. Those procedures are being crowded out by low-value procedures. If you imagine a world where we are trying to be efficient and have a healthcare system that does not cost too much, then you want to be using doctors' time, nurses' time, and all staff time for its highest purpose."
In the first year of the pandemic, the rate of unnecessary surgeries initially fell then returned to pre-pandemic proportions, Saini said.
"When the pandemic first hit, many people speculated that it would cause a drop in unnecessary care because the pandemic caused a drop in all care. When we looked at this, what we found was that the factor that caused a drop in unnecessary care was the shutdown. In April and May 2020, rates of medical care in general plummeted, and the rates of unnecessary care also plummeted. After the shutdown as business returned to normal, the rates of unnecessary care came back, and eventually they returned to 2019 levels," he said.
The pandemic trends for unnecessary surgeries show that several change factors are needed to address the problem, Saini said. "The experience of the pandemic tells us it is going to take something stronger than exhortation or pointing to a study that shows a surgery is unnecessary to reduce unnecessary care. As with all change in a complex system such as healthcare, it is going to take multiple things all at once to reduce unnecessary surgeries."
For now, unnecessary surgeries are widely embedded in U.S. healthcare, he said. "Unnecessary surgeries are entrenched because they are part of the fabric of modern medical practice. … Among the Top 20 U.S. News & World Report recognized hospitals, some do well, and some do not do well. The fact that some of the top hospitals do unnecessary surgeries shows that it is entrenched."
The hospital's chief strategic integration and health equity officer says the coronavirus pandemic has opened eyes and made health equity a national priority.
To eliminate health disparities, it is essential to address "upstream" inequities, an experienced hospital health equity officer says.
Chris Pernell, MD, MPH, is the chief strategic integration and health equity officer at University Hospital in Newark, New Jersey. Additionally, she is a clinical assistant professor in the Department of Medicine at Rutgers New Jersey Medical School and a former adjunct associate professor at New York University College of Global Public Health.
HealthLeaders recently talked with Pernell about a range of topics, including how to address health disparities, health equity and health disparity initiatives at University Hospital, and the country's journey in tackling health equity and health disparities.
The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: What are the primary ways to address health disparities?
Chris Pernell: It is important to back up and go upstream before we talk about health disparities. We need to talk about health inequities—the structural conditions or determinants that are unfair and unjust, which lead to differences in health outcomes. Those structural determinants are issues around where people were born, where people work, and where people age. We need to talk about access to affordable housing, access to quality education, access to safe and equitable healthcare, and access to green spaces. We know that place-based factors drive health outcomes and the disparities that we see.
If we start with the COVID-19 pandemic, which in recent data is the third leading cause of death in America after heart disease and cancer, and we look at how COVID-19 disproportionately impacted the African-American community in particular, that shines a light on disparities. For example, if you go to the Centers for Disease Control and Prevention website, the CDC has been tracking the differences in COVID-19 infections, hospitalization, and death across different populations. There are differences across Black, Latino, Native American, and Asian populations that are distinct. In particular, there are differences in hospitalizations. In data from March, Black people were 2.4 times more likely to be hospitalized with COVID compared to White people. Native American people were 3.1 times more likely to be hospitalized. Latino people were 2.3 times more likely to be hospitalized.
If you start to talk about death from COVID-19, it is roughly 2 times more likely in the Black, Latino, and indigenous populations compared to White Americans. This is not because of biological reasons, rather the reasons are related to risk of exposure, access to care, quality of care received, and pre-existing chronic morbidities.
Health disparities are formed because there is differential access to care, there is differential access to the quality of care received, and there are unjust and unfair differences in access to life opportunities such as housing and education. At those three fundamental levels, we see disparities that are amplified and highlighted in the COVID-19 pandemic.
If we think about the Newark community, like in all of New Jersey, heart disease is the leading cause of death in the Newark community. Like in all of New Jersey, cancer is the second leading cause of death in Newark. But something that is unique in Newark is the prevalence of asthma. Approximately 32% of people living in Newark have asthma. If you look at Newark's county, which is Essex County, only about 6% of the people in the county have asthma. It begs the question—why are people in Newark having higher rates of asthma? You have to look at environmental injustice issues.
HL: What are other examples of health disparities in Newark?
Pernell: Newark has primarily a Black and Brown population. The Newark population hovers around 50% Black and 36% Latino. Asthma is only one example of unique health condition prevalence in Newark. With chronic obstructive pulmonary disease (COPD), 16% of Newark residents have COPD but only 5.1% of people in Essex County have COPD.
In Newark, 16.4% of residents have diabetes, but if you look at the prevalence in the state it is 9.6% of the population. Another disparity is in obesity. About 36% of Newark residents have obesity compared to 27% of New Jersey residents.
HL: What are some of the health equity and health disparity initiatives that have been launched at University Hospital?
Pernell: Through our population health department, we have focused a lot on clinical prevention and bringing care to people where they are situated in the community. That involves partnering with community assets to deliver health screenings, such as screenings for high blood pressure and diabetes. We do screenings in a consistent and regular fashion to emphasize the power of prevention.
We are ensuring that our ambulatory practices are accessible to the community—accessible with time and availability of appointments. Our community members can be serviced for primary care, which is fundamental to solving health equity. We have a robust network of primary care and people have access to longitudinal care; we offer primary care services as well as specialty and subspecialty services through our outpatient practices.
We are making sure our care is being delivered in a community-integrated fashion, so we can reach health inequities that cause health disparities. We are ensuring that care is situated in the community where people reside.
For example, we are undertaking a project with the state housing and mortgage financing agency, as well as a local developer, to develop affordable housing close to the hospital. There will be about 16 housing units specifically geared toward patients who have multiple medical and social complexities that drive poor health or poor management of chronic health conditions. People will be identified by eligibility criteria, and they will be able to screen into these supportive housing units. They will have access to wrap-around services that address social needs and social determinants of health that are driving their health outcomes. As part of this project, we will be building a primary care health center, which will be open for not only the residents of the development, but also all residents of the city to have access to primary care and some specialty care.
Another initiative we have is the use of community health workers or community healthcare chaplains. These are credible messengers who have lived experiences that are socially and culturally fluent with the patient populations that we serve. They help navigate patients with social and medical complexities. They help people to connect with appropriate care. They help ensure that people have their social needs met. They work with chronic high utilizers of the emergency department. They work with patients who have a particular payer such as Horizon Blue Cross Blue Shield of New Jersey and have identified social needs.
HL: As a nation, where are we in addressing health inequity and health disparities. How far have we come?
Pernell: I am a public health and preventive medicine physician by training, and as someone who has been working in this space for many years, I can say that prior to the pandemic the conversation about health equity and health disparities was conceptual. Since the beginning of the pandemic, we have been having a more honest, more robust, and more comprehensive dialogue and solution-generating process around tackling health inequities.
The pandemic has been the collision of multiple pandemics, such as the collision of systemic racism with the pandemic. With the coronavirus, we have been able to describe in compelling ways what disparities look like. Black, Latino, and Native American populations are dying of COVID-19 at two times the rate of White Americans. We all have to pause and ask, "Why is this happening?"
The pandemic has afforded a richer dialogue, and that has afforded more complex solutions, and that has afforded an imperative in priorities around health equity. Not only do you see healthcare leaders having a conversation around health equity, but also you see the American public having a more honest conversation about what is driving health inequities. People are looking for solutions in a collaborative, cross-sector matrix approach.
If you think about the summer of 2020, as we were coming out of one of the first waves of the COVID-19 pandemic, and the public saw the murder of George Floyd. We saw protests on the streets, and that allowed us to have a more transparent and authentic conversation around systemic racism.
We are poised to do something about health equity. These next few years and decades will determine how sustained the efforts will be. I believe that we cannot turn back. Racism wastes human resources and wastes our potential. We cannot be as prosperous, we cannot be as great, and we cannot solve the dilemmas that we need to solve in the 21st century if we are not taking care of all of our communities. We will never achieve our full greatness it we do not make health equity front and center of our priorities.
