Cesarean section births can have dangerous complications such as hemorrhaging.
The years-long effort to reduce unnecessary Cesarean section births in the United States is coming to fruition, an obstetrics expert says.
Complications from C-sections such as hemorrhaging are widely considered to be a contributing factor to the country's high maternal mortality rate. The federal Centers for Disease Control and Prevention have been monitoring maternal mortality since 1986. The number of pregnancy-related deaths has risen steadily since the monitoring effort began, from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014.
"We are finally at the point where most hospitals are sharing their data and having conversations on an individual basis about C-section rates. We are having conversations about quality at labor and delivery units as well as about the quality of individual providers. It has taken more than a decade to get to this point," says Amy VanBlaricom, MD, vice president of clinical operations for western states at Greenville, South Carolina-based Ob Hospitalist Group.
VanBlaricom says she is optimistic about the ongoing effort to limit unnecessary C-sections. "I would not say that we are at the finish line, but we are definitely in the home stretch. Reducing C-sections is on everyone's radar screen. Everyone who is in the practice of obstetrics knows that this is a problem, and they understand that there are medical complications that are happening to women that are avoidable because many C-sections have been done historically for less than medically sound reasons."
Roots of the problem
Both clinicians and patients are responsible for unnecessary C-section births, VanBlaricom says.
"From the physician side, there is fear of medical-legal risk. There is an old adage that obstetricians say, 'You never regret the C-section that you do, but you regret the C-section that you did not do.' There are many obstetricians who are fearful of being sued if they delay too long in performing a C-section, so they may call for a C-section sooner than is medically necessary. There are also inconveniences in scheduling—obstetricians need to coordinate their day if they have other issues going on. An obstetrician can become impatient with how long it takes a labor to progress," she says
"On the patient side, there is a segment of the patient population that asks for a C-section when it is not necessarily medically indicated. Some mothers want a C-section because they want to schedule the day of their birth. Some mothers want a C-section because they are fearful of the process of vaginal delivery—they want to preserve the integrity of their pelvic musculature. They read articles in lay journals about how it is going to impact their body to have a vaginal birth, and they decide they want to try to avoid that impact," VanBlaricom says.
Financial incentives can also drive unnecessary C-sections, she says. "There is a concern that insurance companies pay more for a C-section than for a vaginal delivery. The worry is that there is the convenience factor and the medical-legal climate that makes obstetricians fearful, then the payers incentivize financially toward the surgical delivery. That creates an environment that leans many providers toward the surgical mode of delivery."
Avoiding unnecessary C-sections
Peer pressure can be an effective way to encourage clinicians to avoid unnecessary C-sections, VanBlaricom says.
"That means benchmarking C-section rates for all of the hospital providers and making it transparent. You need to champion those who are doing a good job at keeping their C-section rates low. You also want to allow the providers who have higher C-section rates to learn. They should find out the ways that a colleague, who is seeing patients from the same community and has a lower C-section rate, is doing their practice in ways that achieve a lower C-section rate," she says.
Benchmarking should focus on first-time C-sections because once a C-section has been performed on a mother, she is more likely to have a surgical birth in the future, VanBlaricom says.
"Most hospitals look at the rate of first-time C-sections. There are a couple of different ways to look at that. One is the NTSV C-section rate, which stands for Nulliparous, Term, Singleton, Vertex. This measure eliminates twin gestations, breach babies, and those kinds of situations where it can be a no brainer to conduct a C-section. This is all about avoiding the avoidable, first-time C-section and looking at that rate. A good number is somewhere around 23% of births—that is usually where the data has shown that an appropriate number of avoidable C-sections are avoided," she says.
Standardization of care is another approach to limit unnecessary C-sections, VanBlaricom says.
"A good standardization tool is a labor dystocia checklist. Many clinicians think that the most avoidable form of C-section is the one that is done for a slow labor process—what is called labor dystocia. It is a labor that is taking longer than you think it should take. This can be very subjective. It can be based on the clinician's patience level, it can be based on what the clinician is usually willing to tolerate over time, or it can be based on what the mother is willing to accept," she says.
Labor dystocia checklists are based on evidence and a stepwise approach to labor, VanBlaricom says. "The checklists account for the number of steps you have taken, the amount of time that you have let the mother labor in each section of the labor process, and how long it is safe to let the mother labor. For example, the checklists account for how long the amniotic sack has been broken and how long the mother has been on labor augmentation medications without having the appropriate amount of cervical change."
Including mothers in their care teams is another way to limit C-sections, she says.
"When the mother is included in the care team, she will be more informed about the process and ask appropriate questions. We as clinicians will be less likely to call for a C-section out of convenience or call for a C-section based on a nonstandard indication. At hospitals that involve mothers in the process of labor, what we see is each member of the care team is held accountable to each phase of the process. The physicians are less likely to recommend a procedure that is not medically indicated because the patient requires a level of information and being informed. The patient is more likely to feel empowered to say 'no' if there is not a medical reason to perform a C-section," VanBlaricom says.
C-sections by the numbers
Statistics indicate that unnecessary C-sections are becoming less common.
Ob Hospitalist Group's NTSV C-section rate for the deliveries their clinicians perform is 20.4% of all births.
The rate of low-risk C-sections spiked to 28.1% of all births in 2009 but the rate fell to 25.9% in 2018.
Healthy People 2030 set a national target for low-risk, first-birth C-section deliveries at 23.6% of all births and many states are making headway. For example, California reached a statewide average of 24.5% for low-risk, first-time C-section births in 2017.
Researchers found that some patients became sick after exposure to other patients with influenza-like illness in primary care offices.
There is a significant risk of spreading infection of influenza-like illness in primary care offices, a new research article shows.
The potential for the spread of respiratory illness in healthcare settings has been a primary concern during the coronavirus pandemic. To address this concern, many outpatient clinics closed their doors in the early phase of the pandemic and telehealth expanded tremendously to keep patients and their clinicians safely connected for care.
The new research article, which was published by Health Affairs, is based on information collected from a national electronic health records database for patient visits at more than 6,000 office-based primary care practices from 2016 to 2017.
The researchers focused on patient visits for influenza-like illness. Patients were considered potentially exposed to infection if another patient with influenza-like illness was seen in the same clinic as long as 90 minutes before an office visit. Patients who had office visits before another patient with influenza-like illness was seen in the same clinic were considered unexposed. The researchers sought to see whether exposed patients returned to the clinic within two weeks of exposure with influenza-like illness.
The research article features three key data points:
The researchers found 2.7 patients per 1,000 returned within two weeks with influenza-like illness, with exposed patients more likely to return with influenza-like illness (an adjusted difference of 0.7 per 1,000 patients)
Compared with the baseline rate of a return visit with influenza-like illness for unexposed patients, this change represented a 31.8% increase
With more than 7.3 million patients exposed in the study, about 5,140 excess influenza-like illness visits were potentially attributable to appointment timing
"In this study of a large, national EHR dataset, we found that in primary care offices, those seen after a patient with influenza-like illness were more likely to return with a similar illness in the next two weeks compared with nonexposed patients seen earlier in the day," the research article's co-authors wrote.
Policy implications
There are two primary healthcare provider policy implications from the study, the research article says.
"First, given that the presence of a symptomatic patient with influenza-like illness is associated with increased rates of likely infection among patients present in the clinic at the same time, healthcare facilities should consider explicit guidelines for the triage to telemedicine of patients with low-risk respiratory viral symptoms such as cough, runny nose, muscle aches, sore throat, or low-grade fever," the research article's co-authors wrote.
The second policy implication is that clinics should use strict infection control techniques if patients with influenza-like illness must be seen in person.
"Many infection control practices are standard expectations of care in outpatient settings, as outlined by recommendations from the Centers for Disease Control and Prevention, but compliance with even basic infection control practices such as hand hygiene is notoriously poor. Enhanced infection control practices could include strict requirements for patient mask wearing, which might not be a universal expectation among patients, and immediate cohorting of patients with influenza-like illness into reserved exam rooms that are not shared with other patients before decontamination," the research article's co-authors wrote.
The American Hospital Association award recognizes healthcare leadership and innovation in improving quality and advancing health in communities.
Yale New Haven Health System (YNHHS) has been named the 2021 recipient of the American Hospital Association Quest for Quality Prize.
The Quest for Quality Prize recognizes healthcare leadership and innovation in improving quality and advancing health in communities. The first Quest for Quality Prize was awarded in 2002, and the honor is sponsored by RLDatix.
YNHHS earned the Quest for Quality Prize based on three factors: addressing social determinants of health, using data to drive quality improvements, and engaging staff in quality improvement work.
1. Addressing social determinants of health
Steven Choi, MD, chief quality officer of New Haven, Connecticut-based YNHHS and Yale School of Medicine, says the health system has been working to address social determinants of health for several years. "We have supported efforts such as food pantries, Habitat for Humanity, college scholarships for those people who live in underserved areas and those people who are members of underrepresented minorities in the healthcare industry, job training programs, and transportation."
Part of the effort has been screening patients for social determinants of health, he says. "We screen patients in our emergency departments, primary care practices, and medical group practices for social determinants of health. We have been conducting this screening in an organized and structured way for about five years. We screen about 450 patients a month for social determinants of health. The screening involves assessing their ability to maintain financial means, food security, housing, utilities, and transportation needs to access healthcare."
YNHHS also partners with community-based organizations so the health system can refer patients for resources within their local communities, Choi says.
2. Using data to drive quality improvements
In the effort to harness data to drive quality improvements, YNHHS made a pivotal change about three years ago, he says. "We had plenty of outcome data to understand and monitor our patients' physical outcomes such as mortality, complications, readmissions, and medical errors. But we had very little data on the key drivers of outcomes."
YNHHS developed a "key driver" dashboard to help the health system determine the fundamental behaviors and processes that staff were executing to get patients their best outcomes, Choi says.
"For example, we are trying to prevent infections and we want to know that we are doing the right things. Now, we can monitor our quality improvement by measuring all of the key drivers for preventing infections, including glucose control for individual patients, monitoring patient temperature to make sure they do not get too hot or too cold, making sure patients get the right antibiotics at the right time, and making sure our providers are using checklists for patients with central lines," he says.
The key driver dashboard has been a powerful tool for frontline care teams because YNHHS leaders can avoid making blanket pronouncements to staff about quality improvements such as limiting infections and reducing readmissions, Choi says. "Instead, we ask them to focus more on making follow-up appointments with patients when they get discharged, we ask them to focus on antibiotic compliance for patients coming out of the operating room, or we ask them to focus on scrubbing the hub of a central line to avoid potentially life-threatening bloodstream infections."
3. Engaging staff in quality improvement work
To engage staff in quality improvement work, YNHHS has a dedicated quality improvement team at each of the health system's hospitals, he says. "We do the fundamental basics of staff engagement in making sure that we have a multidisciplinary team that represents critical service areas such as nursing, pharmacy, medical staff, housekeeping, information technology, food services, and transportation. All of these services are represented on the performance improvement teams."
The health system also uses rounding to engage staff in quality improvement work, he says.
"A fundamental change that we made is that we now round every week on medical units and other sites where care is delivered to talk about our quality improvement work to make sure that the staff is aware of the key drivers that help build success. We want staff members to understand how the things they do contribute to success. This is a process called Rounding to Influence, which is a model that many high-reliability organizations have adopted. We go around and ask specific questions about the key efforts we are striving for. We also ask the staff to give us feedback about what is prohibiting them from executing best practices."
Holston Medical Group has been able to reduce emergency department visits, hospitalizations, and readmissions.
A Tennessee-based physician group is utilizing care coordination and patient outreach to fill gaps in care and manage transitions of care.
Care coordination and patient outreach is a proactive approach to care management that can drive positive outcomes such as reduced emergency department visits, decreased hospitalizations, and fewer hospital readmissions. For example, Massachusetts General Hospital has deployed community health workers to conduct care coordination and patient outreach for inpatients after discharge, which has reduced readmissions 50%.
Kingsport, Tennessee–based Holston Medical Group has developed a robust care coordination and patient outreach program combined with data analytics to target individual patients. The physician group operates 50 clinics in eastern Tennessee and southwestern Virginia.
"We can identify when there are gaps in care. We utilize the OnePartner Insights analytics tool to close gaps in care. We can identify each individual gap, perform outreach to ensure that we are able to close those gaps, and increase our quality measure scores," says Samantha Sizemore, chief operations officer at Holston Medical Group.
The analytics tool allows Holston Medical Group to track patients, she says. "If a patient arrives in an emergency room or is admitted at a hospital system, we know in real time and we can outreach with the patient. We can provide education about the reason a patient arrived in an emergency room. We can provide alternatives for high-quality, low-cost options for care such as our group's urgent care extended hours. More importantly, we can direct access to the patient's physician office. We also schedule follow-up appointments immediately."
Care coordination and patient outreach
Holston Medical Group takes a team approach to care coordination and patient outreach, Sizemore says.
"We have a care coordination team that is centralized and focused on the acute setting outreach. Every morning, we get a list from OnePartner Insights of patients who have been discharged from hospitals. The centralized care coordination team performs immediate outreach to patients to ensure that they received their discharge summary, make sure they understand what their discharge summary encompasses, ask whether they have any questions, check whether they received their medications, and try to set up an appointment with their primary care physician within the next 72 business hours," she says.
Connecting with hospital inpatients quickly after discharge is crucial, Sizemore says. "The reason why our follow-up appointment goal is within three business days is we believe that if we can see a patient sooner rather than later and we can stabilize the patient's condition in an outpatient setting, then we have a better chance of preventing a readmission. We do that real-time outreach on a daily basis."
The administrative staff at Holston Medical Group physician practices also conducts care coordination and patient outreach, Sizemore says.
"For example, with L3 patients who have five or more chronic conditions, we want to touch those patients. We want to see those patients on a quarterly basis at the very minimum. If we see these patients often, we feel we can keep their conditions stable and prevent a future hospitalization. Every month, reports on L3 patients go out to our physician offices that list who has not been seen that quarter. Office managers conduct outreach to those patients. For example, the office manager will call and say, 'You have not seen Dr. Jones and we need to go ahead and schedule an appointment,' " she says.
Nursing staff also are engaged in care coordination and patient outreach, Sizemore says. "We have individual quality gaps that we have disseminated through our value-based coordinators, who are part of the nursing team. They focus on the individual quality gaps. For example, we have a gap list for breast cancer screening. The value-based coordinators will receive that list, conduct outreach to the patients, and educate the patients on why they are on the list. Then, they go ahead and get mammograms scheduled."
Holston Medical Group focuses on transitions of care, she says.
"We are reaching out to patients within 12 hours of their hospital discharge—in some cases on the same date of service. If a patient is discharged early in the morning, we reach out to them by the afternoon. We try to schedule an appointment with the patients' primary care physicians within three working days. What we find at that transition of care appointment is that the primary care physician often feels that the patient's condition is not fully stabilized and schedules another appointment for the following week," Sizemore says.
The care coordination and patient outreach effort is funded through value-based contracts, she says. "With our accountable care organization, we allot for care coordination—we allot a care coordination budget of $1 per attributed life for that population. In partnership with our value-based payers such as Medicare Advantage, we receive a care coordination payment each month that is spent for the centralized care coordination team."
Generating positive results
Statistics show that care coordination and patient outreach is achieving positive results for Holston Medical Group (HMG) and its patients.
125.7 emergency room visits per 1,000 patients for HMG compared to 192.8 for regional healthcare providers
For HMG, the overall average for ER visits were 131.8 per month in 2020 and 116.6 per month so far in 2021
In 2020, hospital admissions per 1,000 patients for HMG were 35.3 compared to 54.1 for regional healthcare providers
For HMG, the overall average for hospital admissions were 39.4 per month in 2020 and 29.9 per month so far in 2021
Teamwork and patient-centered care are the keys to success in care coordination and patient outreach at a physician group, Sizemore says. "It is very important to use teamwork, and the patient must be the central focus. If you can come at outreach and care coordination from different angles in a coordinated manner you can be successful. The last thing you want to do is have a fragmented approach, with the patient receiving three or four disjointed calls from the same organization. When it all comes together, that is when success will follow."
Right-sizing care coordination and patient outreach is also essential, she says. "We have achieved an effective balance. A lot of organizations fail because they try to overcompensate with the care coordination department, which is an enormous expense. So, rather than having 50 care coordinators for 170 providers, we have a minimal care coordination staff—six care coordinators for 170 providers."
Joseph Giaimo, DO, says osteopathic medicine is strong and getting stronger.
Osteopathic physicians are well-suited to rise to the challenges of the coronavirus pandemic, the new president of the American Osteopathic Association (AOA) says.
Joseph Giaimo, DO, was inaugurated as the 125th president of the AOA this month. He is board-certified in internal medicine, pulmonary medicine, and sleep medicine. Giaimo has been working in private practice in Palm Beach Gardens, Florida, for more than 30 years.
HealthLeaders recently held a discussion with Giaimo on a range of topics, including the pandemic, the future of telehealth, and the state of osteopathic medicine. The following is a lightly edited transcript of that conversation.
HealthLeaders: How is osteopathic medicine suited to treating the coronavirus pandemic?
Joseph Giaimo: Osteopathic medicine and our philosophy of the holistic approach to medicine is well-suited to COVID-19 because we emphasize a collaborative effort. COVID-19 patients do not only have a pulmonary problems, they have cardiac issues, they have hematologic issues, and they have psychological issues with neurologic problems such as brain fog and anxiety. These issues are compounded by what is going on in society—people are losing their jobs and businesses are closing. We live in a very stressful time.
In osteopathic medicine, because of the way we are trained and how we approach individuals with medical problems holistically, we have a unique perspective on these kinds of issues.
HL: What is your vision for telehealth after the coronavirus pandemic has passed?
Giaimo: There is an opportunity here to take advantage of. We have found that there are huge disparities in the healthcare system and COVID-19 has exposed those disparities. There are people who can benefit from telehealth now and in the future.
The face-to-face interactions that we have with patients are still a cornerstone for medicine moving forward. We need to interact with patients—we need to see them face-to-face. But telemedicine has a great capacity for patients who are unable to get to see a clinician in an office. So, I think telehealth is going to continue in the future, and it has improved access to care.
HL: What are the primary challenges facing physicians in this stage of the coronavirus pandemic?
Giaimo: We have gotten to the point where we have medications and protocols that are effective in the treatment of COVID-19. If we can get patients early on in their disease, that is very helpful.
We also have learned that preventive care is at the forefront of addressing the coronavirus. There are simple things like hand washing and wearing masks. And, most importantly, vaccination is key because we are seeing many people now with COVID-19 who are not vaccinated. We need to partner with our patients to make sure they have the tools that they need to stay healthy.
HL: How can physicians encourage their patients to get vaccinated?
Giaimo: It's about education; and, unfortunately, there is a lot of misinformation out there. We need to have patients have a transparent relationship with their healthcare provider. I have been in practice for more than 30 years, and often patients will come to you to get your opinion. The role of primary care physicians is to be able to educate patients.
There is a risk of becoming critically ill with COVID-19, especially with some of the new variants. The delta variant is highly contagious. I am seeing patients who end up on ventilators and who end up with protracted hospitalizations because they are not vaccinated. So, we need to educate patients. We need to tell them this pandemic is not over, and they need to maintain their due diligence.
HL: What are the primary elements of your AOA presidency agenda?
Giaimo: It is really about coming out of where we have been over the past 18 months—coming out of a pandemic that has shut down so much. So, I am focused on uniting the profession again and having the transition from where we have been in the past 18 months to where we are going to move forward in the future. We have a lot of challenges such as fighting for appropriate scope of practice issues to make sure that osteopathic medicine can move forward.
Healthcare disparities are one of the biggest things that we are looking at as a profession. We must help address those disparities, and we are well-positioned for that effort because of our training. We have been trained in rural areas and traditionally in smaller group practices. Our practitioners tend to lean into that type of care.
HL: How is osteopathic medicine well-positioned for addressing healthcare disparities?
Giaimo: We have more than 130,000 osteopathic physicians across the country, and one out of every four medical students in the country are studying osteopathic medicine. And there is a large percentage of female physicians who are coming into our profession.
We are trying to be more reflective of the general population—we are trying to be reflective of our patients. There is no better way to care for patients than when you have physicians who are from their community—somebody who has historical knowledge and relationships in the community. Osteopathic physicians have traditionally practiced in rural and underserved areas, which is where most of the disparities are.
HL: Characterize the status of osteopathic medicine in the United States.
Giaimo: We are strong and are getting stronger. My father was an osteopathic medicine physician in primary care; and when he started his practice, people's understanding of osteopathic physicians and their training was not as mature as it is now. There is a bright future for our profession. We have a lot of young minds who are coming into the profession and a lot of wisdom among the osteopathic physicians who have been practicing for a while.
HL: What is your vision for the future of osteopathic medicine?
Giaimo: I see osteopathic medicine continuing to grow. It has a wonderful opportunity to continue to move our philosophy forward of integration and a team approach to medicine. We are team-oriented in the way that we approach problem-solving and other things because of the nature of how we are trained. A team approach to medicine is what this country needs in the future. And osteopathic medicine focuses more on the overall maintenance of health as opposed to just treating disease.
Omnichannel platforms and virtual care have several potential benefits for healthcare providers and patients, Chilmark Research report says.
A new report from Boston-based Chilmark Research provides insights on the future of virtual care after the coronavirus pandemic has passed.
Virtual care has expanded rapidly and broadly during the pandemic, with a recent McKinsey and Company report finding that telehealth utilization has stabilized at levels 38 times higher than before the pandemic. But the future of virtual care after the crisis phase of the pandemic has passed is unclear.
The new report from Chilmark Research features three key takeaways:
1. Omnichannel platforms aspire to become the centerpiece of provider workflow
Omnichannel platforms have the potential to transform the electronic health record into just one of many data sources for workflows and analytics
New interoperability rules and growing adoption of application programming interfaces make developing and integrating new data sources easier than ever
Omnichannel platform solutions cross over from simple data aggregation and reporting to transform their breadth of data into automated activity and concise recommendations
2. Payers and employers are offering access to more virtual care than ever before
Payers and employers are the fastest growing segment driving adoption of omnichannel care management
Reduced costs and overall utilization are valuable to health systems, payers, and employers
Solutions must include tools for overall wellness, behavioral health, and an integrated care model to successfully impact patient health
3. Omnichannel care offers better tools for engaging and sustaining the health of chronically ill patients
Longitudinal monitoring and increased patient involvement in care dramatically improves health outcomes, and targeted use of virtual tools reduces the impact on providers
Creating and maintaining patient-provider trust and long-term relationships are key to both ongoing revenue and improved patient outcomes
The most successful vendors cover as many chronic conditions as possible and offer services for other types of virtual engagement
The definition of virtual and omnichannel care has six elements:
Simple and seamless integration with clinical workflows
Ease of patient and user experience
Workflows and pathways that are customizable
Application programming interface tools for integration and deployment
Potent data capture for billing and validation
Utilization of transparent artificial intelligence and machine learning for clinical effectiveness and efficiency
There are several potential benefits of omnichannel care management in four primary areas, according to the Chilmark Research report
1. Innovation
Creating infrastructure and workflows capable of supporting new virtual tools and modes of care
Allowing the use of more efficient care pathways
2. Access
Increasing responsiveness of care teams and clinicians
Reducing wait times for encounters and limiting unnecessary appointments
Creating easier contact and communication with patients and more transparency into health status
3. Healthcare provider and patient burdens
Relieving clinician and staff workflow
Maximizing clinical and administrative productivity
Improving patient experience
4. Finance
Increasing billable encounters
Reducing care gaps and improving value-based care metrics
Redirecting utilization to the most appropriate and cost-efficient settings
Reducing development and integration costs
The Chilmark Research report highlights the near-term and longer-term impacts of the coronavirus pandemic on virtual care.
1. Near-term impacts
Widespread acceptance of telehealth and remote care
Accelerated adoption of virtual care reimbursements for Medicare and private payers
Relaxed licensing and scope of practice rules
Spike in virtual care spending and investments
2. Longer-term impacts
Healthcare provider acceptance of remote patient monitoring and virtual home care services
Patient comfort with remote care is expected to drive utilization of payer- and employer-sponsored health apps
Centers for Medicare & Medicaid Services reimbursements and waivers for virtual care are likely to continue, but state exceptions and eased licensing are likely to expire
Sutter Health capitalized on functioning as an integrated network and effectively increased critical care capacity by more than 200%.
Sutter Health—an integrated network of hospitals and physician practices in Northern California—has successfully navigated several challenges during the coronavirus pandemic.
The pandemic is the greatest public health crisis in the United States in more than a century. As of July 20, there had been more than 35 million reported coronavirus cases in the country, with more than 625,000 deaths, according to worldometer.
Sutter Health, which features 24 hospitals and more than 12,000 employed physicians, has posted impressive performance metrics during the pandemic.
Acquired more than 35 million pieces of critical personal protective equipment, including masks, isolation gowns, and face shields for patients and healthcare providers
Increased systemwide critical care capacity by 200%–300% to care for patients during coronavirus surges
Doubled the capacity of the health system's electronic ICU program—providing all patients access to an ICU team regardless of hospital location
Rapidly expanded telehealth—conducting 1 million video visits in 2020
Reduced hospital length of stay for COVID-19 patients by 12 days—from 20 days at the start of the pandemic to eight days by the end of 2020
Provided COVID-19 testing with the capacity to test thousands of patients per day during surges—performing 700,000 tests in 2020
Integrated network advantages
In the Sacramento, California–based health system's response to the pandemic, functioning as an integrated network generated several advantages, says William Isenberg, MD, PhD, chief quality and safety officer.
"We have had the capability through integration to move around material resources such as personal protective equipment, ventilators, and reagents as well as the capability to move around patients. If one hospital was overrun with severely sick patients and another one had available beds and ICU capability, that gave us a lot of latitude. We were able to load-balance on both the support material as well as the patients. That gave us a lot more capability than a single hospital would have," he says.
Functioning as an integrated network generated supply chain benefits, Isenberg says.
This pandemic has highlighted just how vulnerable and integral the hospital supply chain is in the healthcare industry. To cover the pain points, lessons learned, and solutions for sustaining the supply chain, HealthLeaders is launching a monthly Supply Chain eNewsletter. Get your free subscription.
"We have a supply chain that is coordinated across the enterprise. So, this enables us to benefit from bulk purchase pricing—we do not have individual purchasing managers at every hospital. It is all managed through a centralized strategic sourcing supply chain group. Through their contacts that they have established through years of relationships and preferred customer pricing, they were able to get us things that we needed well in advance," he says.
The scale of Sutter Health's integrated network was an advantage in sourcing personal protective equipment during the pandemic, Isenberg says. "When you are a big, bulk buyer, you are considered a preferred customer at places such as 3M that make masks. We had an edge on individual hospitals that might make a purchase of one or two cases of masks every three months—that is nothing like getting a truckload of masks every other week like we do."
Integration played a key role in reducing hospital length of stay for COVID-19 patients, he says.
"Imagine an individual hospital with 100 beds. If I am a doctor at this hospital and read an article that remdesivir is a good drug to use with COVID patients, I can try remdesivir on one or two patients, but I have not amassed any data to understand whether the drug is safe or effective or understand the best treatment regimen. Because we are an integrated health system, we were able to combine data from across several hospitals. So, the doctors down in Modesto who were seeing a lot of COVID patients could share their experience with a smaller facility that had not seen many patients, and they could say, 'Stay away from hydroxychloroquine. We have already tried it and got no good results from it. But dexamethasone with remdesivir lowers the length of stay.'"
Sutter Health was able to achieve a dramatic reduction in length of stay for COVID-19 patients, Isenberg says. "The first COVID patients we saw in our hospitals were with us for about 20 days. Three months into the pandemic, we had that length of stay down to about seven or eight days. We achieved that through the sharing of information as well as the constant commentary and discussion among our various sites."
Increasing critical care capacity
To prepare for potential COVID-19 patient surges, Sutter Health assessed the health system's critical care capacity early in the pandemic, Isenberg says.
"Early on, we started working with our analytics team at modeling what would happen if the New York experience came to California. They looked at our resources such as how many ICU beds we had and what it would look like if the New York experience happened here. In looking at the models they created, they realized that to be successful we would need about three or four times the capacity of critical care beds that we currently had. We had about 300 critical care beds and needed to boost that up to about 1,200," he says.
To meet the potential need for more critical care beds, Sutter Health focused on supply chain and staffing.
"We immediately contacted our supply chain and put in orders for 900 more ventilators. Fortunately, as we continually monitored what was going on, we never got to a point where we needed that many ventilators. So, we were able to back off from those orders, which is a nice thing about having established relationships with vendors. We were able to throttle our purchasing and delivery for things such as ventilators as we needed them," Isenberg says.
The health system took two primary approaches to increasing critical care staffing.
"One, we flexed nurses from various areas. The governor had suspended elective surgery, and we have many ambulatory surgery centers that have critical care–capable nurses. We uptrained them so they could function in the role of an ICU nurse. Two, my office credentialled all of our ICU doctors and other physicians who were capable of managing ICU patients. These doctors were credentialled at all of our hospitals. So, I could call Davis and have a physician go down to Modesto to work for a week as an ICU doctor," he says.
Another important aspect of increasing critical care staffing was boosting the number of electronic ICU-capable beds, Isenberg says.
"We have hubs—one in Sacramento and one in San Francisco—where we have 24/7 ICU capability with ICU doctors who monitor patients. We have cameras in the ICU rooms so they can see the patients. There are microphones so ICU doctors can talk with the nurses and the patients. That gave the doctors who were physically in the ICU the capability of having ICU-trained physicians monitoring patients 24/7," he says.
The recovery phase of the pandemic includes leadership challenges such as balancing competing priorities, maintaining staff engagement, and avoiding burnout.
Three dozen healthcare experts from 17 countries have published a consensus statement on 10 healthcare organization leadership imperatives during the recovery phase of the coronavirus pandemic.
According to a novel model for the pandemic and other global crises, there are four progressive stages in a crisis: escalation, emergency, recovery, and resolution. The co-authors of the consensus statement say the pandemic has reached the recovery phase, which includes leadership challenges such as balancing competing priorities, maintaining staff engagement, and avoiding burnout.
The consensus statement, which was published by JAMA Network Open, features 10 leadership imperatives to rise to the challenges of the recovery phase of the pandemic.
1. Acknowledging staff and celebrating success
2. Supporting staff well-being
3. Developing an understanding of local and global pandemic conditions that includes informed projections
4. Preparing for future emergencies in areas including personnel, protocols, contingency plans, coalitions, and training
5. Reassessing priorities explicitly and regularly while providing purpose, meaning, and direction
6. Maximizing team and organizational performance while discussing enhancements
7. Managing the backlog of paused medical services while avoiding burnout
8. Sustaining innovation, learning, and collaborations while imagining future possibilities
9. Providing regular communication and engendering trust
10. Providing safety information and recommendations to government, other organizations, staff, and the community in consultation with fellow leaders and public health officials to improve equitable and integrated care as well as emergency preparedness
"The unprecedented and high stakes nature of this global phenomenon highlights an urgent need for clear guidance to support leaders at all levels in navigating the course of this crisis and in preparing for those to come," the consensus statement's co-authors wrote.
Keys to success
One of the co-authors, Jaason Geerts, PhD, of the Canadian College of Health Leaders in Ottawa, Ontario, and the Bayes Business School at the University of London in the United Kingdom, told HealthLeaders that there are five essential leadership qualities required during the recovery phase of the pandemic.
Healthcare leaders need to have humility to distribute leadership by enabling and supporting others. No leader can effectively master all 10 imperatives alone—trusting others is essential.
Healthcare leaders need to be able to accept a context that is volatile, uncertain, complex, and ambiguous (VUCA) as well as have the capacity to lead and prioritize effectively in this situation. In the recovery stage of a crisis, the context changes often. Even at times when things appear to not be changing, there is constant volatility.
Healthcare leaders need to be able to make clear decisions based on the best available information even though the volume of information can be overwhelming and conflicting.
Healthcare leaders need to have the vision to be able to anticipate future developments, including preparing for resurgences, and to imagine future possibilities and to support innovation. Healthcare leaders should not only react to immediate issues as they arise or focus exclusively on what is urgent in the present.
Healthcare leaders must be able to engage in effective communication, which is fundamental to all 10 imperatives. With so much uncertainty, frustration, fear, and burnout, it is essential to maintain open lines of communication. This involves listening to frontline workers and other leaders regarding required resources and recommended improvements, listening with empathy regarding how people are faring, celebrating staff and achievements, and communicating the evolving priorities and the constants.
Focusing on the well-being and morale of staff is critically important, Geerts said.
"In any organization, our people and those we serve are our Number One priority. This pandemic has been tough on a lot of people and has lasted so long that many healthcare professionals are burned out—many were burned out before the pandemic. It is essential that we give them the rest and support they need and to factor their well-being into decisions about re-introducing procedures that were paused during the pandemic," he said.
Reassessing priorities during the recovery phase of the pandemic is particularly challenging, Geerts said.
"Reassessing priorities during a crisis is an ongoing imperative according to the rapidly and constantly changing circumstances. Some tasks or procedures that were front and center yesterday may quickly have to change based on safety directives. This requires gathering information on an ongoing basis internally and from outside the organization through environmental scanning and strategic foresight. Reassessments should be informed by the input of those closest to the work and informed by input from the community. For many people, especially those with a strong proclivity toward predictability, processes, and routine, this situation is very challenging," he said.
There are several factors involved in engendering trust inside a healthcare organization, Geerts said.
"Trust is earned by respecting staff and trusting them to do their job without unnecessary restrictions, listening to and acting on their recommendations for improvements, and instilling in them the confidence that priorities are being decided and decisions are being made with their best interests at the forefront and that they are based on the best available information. This also involves transparency—admitting mistakes including what has been learned as a result, appropriately expressing the times when the situation is uncertain, and addressing the way in which decisions are being made," he said.
A new law in the Lone Star State grants automatic approval of medical orders for clinicians who have a track record of prior authorization approvals at a payer.
The effort to reform prior authorization of clinician orders has taken a step forward in Texas.
Reining in prior authorization of clinician orders by payers is a top priority of physician groups. They argue prior authorization delays or denies evidence-based care and places an onerous administrative burden on healthcare providers.
"Our effort at the AMA and the state medical societies is about right-sizing prior authorization. We do not expect it to go away entirely, but it has gotten out of control," says Jack Resneck, Jr., MD, president-elect of the American Medical Association and a practicing dermatologist in the San Francisco Bay Area.
In June, Texas adopted a new law that features "gold carding" clinicians to make the application of prior authorization more selective. Under the new law, if a clinician orders a medical service such as medication at least five times in a six-month period and at least 90% of the orders pass prior authorization muster, then the clinician is exempt from undergoing prior authorization for the particular medical service for the next six months.
"House Bill 3459 sought to diminish some of the burdens of the prior authorization process on Texas patients and physicians. It sought to do that by creating a path to gold carding or automatic approval when there is a study or service that is ordered by a doctor and the doctor has a track record of getting most of those studies or services approved when using a particular insurer," says Debra Patt, MD, a practicing oncologist at Texas Oncology in Austin, Texas, and immediate past-chair of the Texas Medical Association Council on Legislation.
She gave a theoretical example from her practice. "If I order a CT scan for the chest and abdomen, and I have ordered that exam five times in a six-month period and my history is that they get approved, then for the next six months all of my CT scans for the chest and abdomen through that same insurer will be approved. So, my CT scans will be gold carded."
Gold carding benefits patients and clinicians, Patt says. "The natural consequence of gold carding is that my staff will not spend five hours working on a prior authorization and patients will not have delays in care of two to three weeks to get authorization for appropriate care."
Gold carding only applies to payers that fall under the state's jurisdiction and are not state funded. The law is set to go into effect on Sept. 1.
The Texas law is only a first step in the journey to prior authorization reform, she says. "The truth is that utilization management has gotten more arduous—it has become very difficult for patients to receive guideline-based care. If the purpose of utilization management is to provide high-value care, insurance companies need to step up to the plate and work more collaboratively with physician groups to make sure that we have alignment in getting patients appropriate high-value care without the inappropriate delays and administrative burdens."
National drive for prior authorization reform
In January 2018, the AMA and other national organizations representing pharmacists, medical groups, hospitals, and health plans signed a consensus statement outlining a shared commitment to improving five key areas associated with prior authorization. That effort has not generated action, so prior authorization reformists have shifted their focus to legislative and regulatory changes at the state and national level, Resneck says.
"It is unfortunate that since that consensus statement we have not seen any significant progress at the major national health plans. That is why we have reached the point now where patients and physicians alike are looking to legislative and regulatory solutions to try to right-size prior authorization," he says.
The new efforts largely mirror the five reforms sought in the consensus statement, Resneck says.
Selective application of prior authorization: "If you are a doctor who is following evidence-based guidelines, and you are being asked to jump through hoops and fill out prior authorization paperwork, but 99% of the care you are providing with prior authorization is being approved, the health plan should not be placing an added burden on you or themselves to put you through the same process as somebody else who may be creating more challenges."
Prior authorization program review and volume adjustment: "We want to decrease the volume of prior authorizations. For example, medications that end up getting approved 99% of the time probably should not be on prior authorization lists. Generics should not be on prior authorization lists. Things where there is not alternative to treating a certain disease should not be on a prior authorization list."
Transparency and communication: "Some of the state legislation is just asking for the basics of public release of general statistics for prior authorization. For medications, how often are they approved, how often are they denied, how often are appeals filed, and how often are those appeals granted?"
Continuity of patient care: "We see a lot of patients who have a chronic disease, and you find the treatment that works well—they are stable, and their chronic disease is being held in check. Then, all of a sudden, the patient changes health plans or their health plan changes the formulary and the medication that did not require prior authorization now does require prior authorization. So, you have a patient who cannot get renewal of their medication without the prior authorization process."
Automation: "Patients are shocked to find out that when clinicians are sitting down at our electronic health record writing their prescription, we often cannot see what is on formulary and not on formulary, we cannot see what requires prior authorization, and we cannot see how much different medications cost. Physicians feel that we should have transparency about that data."
"The reform effort is requiring a piecemeal approach. The reality is, we are seeing interest at the Department of Health and Human Services, the Centers for Medicare & Medicaid Services, Congress, and state legislatures because everybody is a patient at one time or another and prior authorization has gotten to be so ubiquitous and a burden that patients are getting frustrated. Legislatures are hearing about it," Resneck says.
A practicing family medicine physician from South Carolina becomes 176th president of the American Medical Association.
The new president of the American Medical Association says physicians have a key role to play in the lives of their patients.
Gerald Harmon, MD, is a practicing family medicine physician based in South Carolina. He has been a member of the AMA board since 2013 and served as board chair from 2017 to 2018. Before his election to the AMA board, Harmon served on the AMA Council on Medical Service.
Harmon is a clinical professor at two South Carolina medical schools. He also is a member of the clinical faculty at the Tidelands Health MUSC Family Medicine residency program.
Harmon was inaugurated as the 176th president of the AMA in June, succeeding Susan Bailey, MD. He recently talked with HealthLeaders about a range of healthcare topics, including the pandemic, health equity, and physician burnout. The following is a lightly edited transcript of that conversation.
HealthLeaders: At this stage of the stage of the coronavirus pandemic, what is the primary pandemic-related challenge facing physicians?
Gerald Harmon: Physicians have always been shown to be one of the most trusted sources of information for patients. The patients get direct advice and recommendations from their physicians. Now, physicians need to encourage vaccine confidence and encourage improved access to vaccines.
Vaccine administration has slowed because it is not quite top of mind for a lot of folks. So now, it is critical for physicians to have the vaccines available to vaccinate their patients. We know physicians have been eager to vaccinate patients, and we are still trying to make sure that physician offices across the country have a vaccine supply.
So, it is important for physicians to serve as a source of vaccine information and encourage their patients to receive the vaccine, but it is also important for vaccine suppliers to get vaccines into physician offices and practices so they can give those vaccines to patients and reduce the spread of COVID.
HL: What can physicians say to their patients to increase confidence in the vaccines?
Harmon: There is some misinformation in the media and social media. I try to offer to my patients that there are proper vaccine protocols. I say these vaccines were developed rapidly but not by missing any scientific hurdles.
The messenger RNA and adenovirus technology was taken off the shelf. We did not have to go through funding hoops because the federal government applied funding upfront. The absolute rigor of the scientific process was followed, and these vaccines are among the safest and most effective ever developed. Patients should have every confidence that these vaccines are safe.
HL: How can physicians help to advance health equity?
Harmon: One of the things I get to be is the spokesperson for the AMA's health equity accelerator. Part of our mission statement is advancing the art and science of medicine and the betterment of public health. It is hard to do that without advancing health equity and addressing healthcare disparities. So, health equity is critical to our mission statement.
We released a plan in May with different actions on health equity. We want to promote equity and racial justice in the AMA itself. We want to expand the capacity to understand and implement anti-racism and equity strategies. We want to build alliances with other stakeholders. We want to look upstream to social determinants of health and root causes of inequities. We want to ensure there are equitable structures for providing healthcare such as broadband expansion into underserved and rural communities. Finally, we want to foster some pathways for truth, education, reconciliation, and transformation for AMA's past racial inequities.
It is a big deal. We have had policies established by the AMA House of Delegates establishing that race is a social determinant of health.
HL: Assess the impact of the coronavirus pandemic on physician burnout.
Physician burnout has worsened. Physicians and others absolutely stepped up during the pandemic. They had taken an oath to take care of people. They risked their lives and even the lives of their families by taking care of COVID patients.
A factor that has limited burnout during the pandemic is a renewed sense of purpose. We have done some surveys at the AMA during the pandemic that found that as many as 48% of doctors felt a renewed sense of purpose. They realized that the practice of medicine was a calling. We have had some psychological, emotional, and physical burnout, but we have had a renewed sense of purpose.
Now that the adrenaline is pulling back and we are getting into a post-pandemic steady state where we do not have the overwhelming burden of COVID disease, we still have barriers to physician satisfaction.
We have the barrier of electronic records not talking with each other. We have statistics that physicians spend many hours per year just waiting to log on to an electronic record. We also know that for every hour of direct patient care, physicians spend up to two hours documenting what they did—so it is a very inefficient system. Then we have the barrier of prior authorization, whether it is a prescription drug, a referral to a specialist, or an imaging procedure. We know that the average doctor has almost 40 prior authorizations to process every week. We consider prior authorizations to be barriers to care. We have a lot of disincentives for physician morale to stay high.
HL: What are some of the primary solutions for physician burnout?
The AMA has some prescriptions for physician burnout. If you have an energized and engaged workforce of physicians that is resilient, it is essential for achieving national health goals. We also know that burnout it is not only a physician workforce issue—a healthcare organization must become resilient itself.
For example, if I work for a large health system, I want the organization to develop a resiliency policy. The health system cannot just say that doctors need to be more resilient and work harder. Healthcare organizations can take a more systemic approach. They can focus on staffing and scheduling. They can focus on giving physicians the right tools. They can focus on getting better vendor support for electronic records. They can work with physicians to reduce the burden of credentialling. These irritators can be reduced without reducing quality of care.
HL: What advice would you offer to new physicians who are just beginning to practice medicine?
Harmon: Remember your opportunity to be a doctor. If you are a new doctor now, you have been given a gift. You can treat your fellow human with a level of trust that you have never had before.
To get to be a practicing doctor today, you have climbed a steep hill. You have gone through education in the twelve grades, then you qualified for a college-based degree, then you qualified for medical school. You have met all kinds of successful standards—you can take data, analyze it, and come up with a meaningful application to benefit humankind. You are an extraordinarily gifted person if you are a young doctor. Take that to heart without getting an artificial sense of self-importance. Apply your gift.
Whether it is me as a family medicine physician, an emergency room physician, a researcher, a pathologist, and all manner of physicians in practice, it is such an honor to be a doctor. I recommend to every doctor—take advantage of that honor and be proud of being a physician.
