An Ohio medical center's chief diversity officer discusses the origins of mistrust and strategies to overcome vaccine hesitancy.
As the coronavirus pandemic enters its second year, reaching the Black community has emerged as one of the daunting challenges of vaccinating as many Americans as possible.
Survey data indicate that COVID-19 vaccination hesitancy is high among Black Americans. A survey commissioned by the National Foundation for Infectious Disease found 51% of Black adults were not planning to be vaccinated for COVID-19. A survey conducted by the Urban Institute found 49% of Black adults said they were unlikely to get vaccinated, with 28% who said they probably would not get vaccinated and 21% who said they definitely would not get vaccinated.
HealthLeaders recently spoke with Leon McDougle, MD, MPH, chief diversity officer at The Ohio State University Wexner Medical Center in Columbus, Ohio, to get his perspectives on vaccination hesitancy among Black Americans. McDougle is president of the National Medical Association, the country's largest and oldest national organization representing African American physicians and their patients. He is also past chair for the Association of American Medical Colleges' Group on Diversity and Inclusion.
HealthLeaders asked McDougle about the origins of COVID-19 vaccination hesitancy among Black Americans and how healthcare providers can address vaccination hesitancy in this population. The following is a lightly edited transcript of that conversation.
HealthLeaders: Why is there vaccine hesitancy among Black Americans?
Leon McDougle: When it comes to vaccine hesitancy, we need to be careful not to place the blame on Black Americans themselves. We must acknowledge the history of the medical establishment's treatment of Black patients and the trauma that has caused. A revealing example is the Tuskegee syphilis study, in which public health officials worked with the Tuskegee Institute to study impoverished Black men who had syphilis, leaving them without treatment for the disease so that researchers could study its progression in the body over 40 years.
Even today, we know that many of the health disparities among people of color are a direct result of unconscious bias and racism. A 2019 study, for example, shows that Black women are considerably less likely to receive standard treatment for heart attacks than white women. When you or members of your community have experienced this kind of unequal treatment, it's understandably difficult to take the word of strangers in white coats who want you to try a vaccine that has been developed unusually quickly.
HL:What can physicians do to address vaccine hesitancy among their Black patients?
McDougle: Physicians need to earn the trust of their Black patients in the spirit of mutuality by having conversations with patients that are not dominated by the healthcare provider—understanding the perspective of the patient is key. Those in the Black community can be assured by knowing that they were adequately represented in the COVID-19 vaccine trials. Independent groups of scientists and physicians, such as the National Medical Association COVID-19 task force on vaccines, are providing extra vaccine reviews on their behalf.
Importantly, transparent communication must include listening to individual concerns and acknowledging that vaccine hesitancy, especially in the Black community, is valid. This pandemic and the COVID-19 vaccine are unprecedented, and it is reasonable and understandable to have questions.
Safe, convenient, accessible vaccination sites must be established to ensure that certain communities of color are also able to get the vaccine easily when they are ready.
Leon McDougal, MD, MPH, chief diversity officer at The Ohio State University Wexner Medical Center in Columbus, Ohio
HL: What steps has Ohio State Wexner Medical Center taken to address vaccine hesitancy among Black people?
McDougal: Among Ohio State's many health equity and anti-racism initiatives are efforts specifically designed to address COVID-19 vaccine availability, accessibility, and misinformation. Our Anti-Racism Action Plan includes periodic Roundtables On Actions Against Racism (ROAAR)—public panels that bring together institutional and community leaders and are led by the Ohio State Wexner Medical Center's Health Equity Steering Committee. Our most recent ROAAR addressed these health disparities and other race-specific issues laid bare by COVID-19.
A multifaceted COVID-19 Vaccine External Education Committee at the Ohio State Wexner Medical Center develops consistent, educational, accessible messaging targeted specifically to our most vulnerable communities, while providing transportation to vaccine sites and assisting with neighborhood-based, mobile vaccine distribution. Recent examples are public service announcements that aired during the Super Bowl, featuring a diverse group of Ohio State Wexner Medical Center staff who shared their personal reasons for getting vaccinated.
Recently, we also opened a dedicated vaccination site on Columbus' Near East Side, central to the city's neighborhoods that typically have the fewest resources available to them. Patients and community members in targeted ZIP codes can receive their COVID-19 vaccine at a closer, more convenient site at Ohio State's East Hospital, in addition to the option of traveling to Ohio State's mass vaccination site at the Jerome Schottenstein Center.
Digital tools can increase the capability to communicate with patients and boost the efficiency and safety of intake processes.
Digital tools for intake processes and patient engagement boost efficiency for hospitals, physician practices, and patients.
During the coronavirus pandemic, hospitals and physician practices have adopted new intake processes and patient engagement tools to increase safety and ease staffing shortages. For example, hospitals and physician practices have adopted new processes to limit the number of patients in waiting rooms.
Family Practice Associates of Lexington, which is based in Lexington, Kentucky, adopted digital intake processes and new patient engagement tools in April 2020. "Most healthcare providers who utilize these kinds of tools would implement gradually over months. We implemented these tools in four days because of the pandemic. It was difficult but very beneficial in the long run," says Virginia Burberry, director of clinical education at Family Practice Associates of Lexington.
The physician practice implemented several elements of Phreesia's suite of digital intake workflows and patient engagement tools. Phreesia is a software-as-a-service platform that integrates with practice management and electronic health record systems.
In addition to a telehealth scheduling feature built into Family Practice Associates of Lexington's website, Burberry says the practice uses five of Phreesia's tools:
1. Enhanced mobile: The practice uses this tool to send check-in forms to the patient's mobile device. "In the past, the patient would have to stand in line and wait for a pad that someone else had used before them. Now, having that registration form sent to the patient's personal device allows them to fill out the registration form remotely. It gives the patient peace of mind," she says.
2. Self-scheduling: "The self-scheduling allows patients to avoid standing in line to make follow-up appointments or waiting in line to schedule the bone density assessment their doctor said they needed. The self-scheduling is online, and it is easy for them to use," Burberry says.
Self-scheduling has been particularly beneficial during the pandemic, she says. "We often have been operating with skeleton crews. We have had a lot of staff that were either sick or had to quarantine because family members had been exposed."
3. Health campaigns: Health campaigns enable Family Practice Associates of Lexington to send targeted text messages or emails to update patients on important information or prompt them to schedule appointments. "We can ask patients whether they are due for their well visit, due for their Pap smear, or due for six-month follow-up to get lab work. We also use health campaigns for general education such as where we are at in getting COVID-19 vaccine, our safety precautions for patients, and how we are doing our no-waiting-room policy," she says.
"The health campaign tool was important for sending information out to the patients about the new digital features. Within seconds, we could send out emails to 38,000 patients."
4. Patient chat: "This feature allows us to communicate with patients via text. We can direct patients to their exam room and communicate with patients when they arrive and when they leave," Burberry says.
The patient chat tool plays a key role in operating the practice's no-waiting-room policy, she says. "We can work off a dashboard and broadcast to several patients at the same time. They are told that when they arrive for their appointment, they should text us that they have arrived and that we will send further instructions. That allows our waiting room to be completely empty and gives the patients the confidence that when they come in, they are not going to be exposed to other people."
5. Broadcast messaging: This feature allows the practice to communicate with specific segments of patients or all patients. "We recently had to close on a Tuesday and were able to click on the dashboard and broadcast to more than 400 patients within seconds that we were closed due to inclement weather. We included the self-schedule link to allow them to reschedule their appointments later in the week," she says.
RWJBarnabas Health moved forward quickly in treating COVID-19 patients with monoclonal antibody therapy, giving the medication to patients within 10 days of emergency use authorization.
RWJBarnabas Health has embraced monoclonal antibody therapy for high-risk COVID-19 patients, providing the medication at all 11 of the health system's hospitals.
On Nov. 9, bamlanivimab became the first monoclonal antibody to receive an emergency use authorization (EUA) for the treatment of COVID-19 patients. The EUA for bamlanivimab marked a milestone in the coronavirus pandemic because the monoclonal antibody became the first medication that could be administered to COVID-19 patients on an outpatient basis.
"On the outpatient side, we really did not have anything to manage COVID-19 before monoclonal antibodies. People were just doing supportive care at home. Now we have a therapy that can be used to prevent the progression of COVID-19 in an outpatient setting," says Indu Lew, PharmD, senior vice president and chief pharmacy officer at RWJBarnabas Health.
The West Orange, New Jersey-based health system moved quickly to treat eligible patients with bamlanivimab, she says. "The EUA for bamlanivimab came out on Nov. 9; and within 10 days of the EUA being approved, we were treating our first patients. Ten days is extraordinarily quick from EUA approval to actual implementation."
Monoclonal antibodies mimic the body's immune response, and they have been approved to treat COVID-19 patients who are at high risk of developing severe illness, according to an article published recently in the Journal of the American Medical Association. "An antibody is a protein that is naturally produced by the immune system in response to an infection. A monoclonal antibody is a molecule developed in a laboratory that is designed to mimic or enhance the body's natural immune system response against an invader, such as cancer or an infection," the article says.
Monoclonal antibodies limit the ability of the coronavirus to bind to human cells and replicate, Lew says. "It binds to the receptor binding part of the spiked protein of the COVID-19 virus. What it does is it prevents the attachment of the spiked protein with the human receptor cells. So, if you cannot have the spiked protein attach to the human receptor cells, it prevents the virus from replicating and going into the severe symptoms that you see with COVID-19."
Under the EUA, there are four primary eligibility criteria for COVID-19 patients to receive monoclonal antibody treatment. A patient must:
Test positive for coronavirus
Present for treatment within 10 days of COVID-19 symptom onset
Not be sick enough to require oxygen or hospitalization
Be at high risk for progression to severe illness such as being over age 65
Model of care
RWJBarnabas Health is administering monoclonal antibody therapy at emergency departments in all 11 of the health system's hospitals.
There are two pathways for patients to receive the treatment, according to Christopher Freer, DO, senior vice president for emergency and hospitalist medicine at the health system.
1. Referrals: "We can get referrals from our doctors in the community. They are calling us and having a conversation between the emergency department doctor and primary care doctor to see whether a patient is a candidate. If the patient is a candidate, they are sent into the emergency department for the therapy," he says.
2. Presenting at the emergency department: If an ill patient tests positive for the coronavirus in the ED, the patient is assessed for whether hospital admission is necessary. If hospitalization is not necessary and the patient meets the other criteria for monoclonal antibody therapy, the patient receives an infusion of the medication that takes about an hour. Then the patient is observed for at least an hour for any side effects such as an allergic reaction.
After the monoclonal antibody therapy has been administered, the patient is discharged from the ED with a pulse oximeter and is monitored via telemedicine, Freer says. "We do telehealth visits on day 1 and day 3. We have a core group of doctors who have become outpatient specialists in the three regions served by our 11 hospitals. They call these patients and know what to ask and what to look for to see whether patients are progressing in the right direction or are taking a turn for the worse."
Promising data
As of Feb. 11, the health system had administered monoclonal antibody therapy to about 3,200 patients. Among these patients, there was one fatality. "When you have 3,200 high-risk patients and you only have one death, that is a good number," Freer says.
For monoclonal antibody patients, the primary metric the health system has been following is whether any of the patients have required hospitalization. Out of the 3,200 patients, more than 95% have not required hospitalization.
The positive outcomes are good news for patients and the health system, he says. "Keeping people out of the hospital keeps our beds open for people who need it. Our supplies, our ventilators, our personal protective equipment, and our medications for the patients are conserved. It has been a welcomed change compared to early in the pandemic when we did not have this type of therapy."
As of Feb. 25, RWJBarnabas Health had provided monoclonal antibody therapy to 3,800 patients.
Successful program
Patients do not have to pay the cost of the medication, Lew says.
"Right now, the therapy we are using is provided by the federal Department of Health and Human Services. The monoclonal antibodies go from Health and Human Services, come to our state, then our Department of Health allocates the monoclonal antibodies to our facilities. So, there is no cost to the patient for the therapy because we are receiving it for free. There is a cost that goes through insurance for the actual administration of the therapy and the ED visit," she says.
All eligible patients can get the therapy, Lew says. "At the end of the day, regardless of insurance or not, if someone comes to our facility and they are a candidate for monoclonal antibodies, we will treat them."
RWJBarnabas Health is a national leader in monoclonal antibody treatment for COVID-19 patients, Freer says. "We are way ahead of other health systems. I am getting calls from other health systems to discuss how we rolled out this therapy."
Among vaccine-hesitant adults, most were concerned about side effects and vaccine effectiveness.
A significant number of Americans say they are unlikely to get vaccinated for COVID-19, a survey report from the Urban Institute says.
Vaccination is widely viewed as an end-game stage in the coronavirus pandemic. One of the primary goals of vaccination is to achieve herd immunity—a point at which enough of the country's population will have immunity to the coronavirus that community spread is unlikely. In December, leading infectious disease expert Anthony Fauci, MD, said herd immunity for the coronavirus will require 70% to 75% of the population having immunity.
The Urban Institute survey report, which was funded by the Robert Wood Johnson Foundation, features data collected from more than 7,500 adults ages 18 to 64. The survey report has several key findings:
35% of survey respondents said they were unlikely to get vaccinated, with 19% who said they would probably not get vaccinated and 16% who said they would definitely not get vaccinated
49% of Black adults said they were unlikely to get vaccinated, with 28% who said they would probably not get vaccinated and 21% who said they would definitely not get vaccinated
47% of Republicans said they would probably not or definitely not get vaccinated
25% of Democrats said they would probably not or definitely not get vaccinated
Among vaccine-hesitant adults, most were concerned about side effects and vaccine effectiveness
Among vaccine-hesitant adults, 57% said they did not need the vaccine
Among vaccine-hesitant adults who were Republicans, 63% said they did not need the vaccine
Among vaccine-hesitant adults, 51% said they trust their healthcare providers about the vaccine
Addressing concerns about safety and effectiveness of vaccines
When it comes to the safety and efficacy of vaccines, a primary concern is the speedy development and production processes, says Julie Morita, MD, executive vice president of the Robert Wood Johnson Foundation.
"The survey done by Urban Institute made it clear that there were some people who had concerns about the short timeframe in which the vaccines were developed and produced as well as concerns about the safety of the vaccines and how effective they could be given that the vaccines were produced so quickly," she says.
"You can address those kinds of concerns by talking through the manufacturing process. The reason that these vaccines were developed so quickly was because billions of dollars were pumped into the development and manufacturing. There was incredible coordination between the manufacturers, government agencies, and academic institutions to have these vaccines produced," Morita says.
Concerns about safety and efficacy also can be addressed by highlighting the review process, she says.
"The process for reviewing the vaccines was comprehensive and rigorous. The Food and Drug Administration has a process and an external body for reviewing the safety and efficacy of vaccines before they authorize them. The Centers for Disease Control and Prevention has a process and an external body that reviews the vaccines before making recommendations about them. So, the vaccines that are currently available have been demonstrated to have strong clinical trial data that supports the vaccine safety and efficacy."
Addressing concerns among Black Americans
To address vaccination hesitancy among Black Americans, the reasons for the hesitancy should be recognized, Morita says.
"It goes to the deep-seated distrust of the healthcare system and government based on historic and ongoing mistreatment and lack of access to services. There also has been a poor history of experimentation in the past. Those kinds of things are things that we need to confront and acknowledge when we are working with the African American community," she says.
"We need to say, 'We know that there have been reasons in the past for mistrust. You may not have gotten the services you needed. You may have mistrust because of historic or ongoing discrimination that you faced.' Then you need to listen to them and engage with them."
Building trust among Black Americans will take effort, Morita says. "Earning trust after years of discrimination and years of mistreatment cannot be done overnight. You need to work with the community and get information into the hands of people they do trust, so they can have confidence and faith in the vaccines."
Addressing concerns of Republicans
Skepticism about the severity of COVID-19 is a root cause of vaccination hesitancy among Republicans, she says.
"A high proportion of Republicans reported that they did not feel they needed to get the vaccine. That would suggest that they do not necessarily recognize the benefits of the vaccine versus the risk of the disease. That is where healthcare providers can play an important role in terms of making it clear that what we know about COVID-19 is that it can cause serious infections and it can cause long-term illness."
How healthcare providers can address vaccination hesitancy
Healthcare providers need to be good communicators to address vaccination hesitancy among their patients, Morita says.
"It is important for healthcare providers to listen. Healthcare providers are trained to listen to their patients in terms of understanding what their symptoms are, what they are experiencing, and why they are in for a visit. Healthcare providers need to ask questions. If you are offering the vaccine, and people refuse the vaccine, then you need to ask why. You need to spend the time to understand what the questions or the concerns are. You need to spend the time to find out what information is needed to reduce the vaccine hesitancy."
The ICU Survivor Center at Indiana University Health Methodist Hospital has treated about 100 COVID-19 patients who survived ICU-level care.
Indiana University Health is using an ambulatory post-ICU care clinic to treat COVID-19 patients who survived ICU care and are experiencing coronavirus symptoms after hospital discharge.
According to an article published by The BMJ, about 10% of all people who have COVID-19 become so-called long haulers, with symptoms that persist for weeks or months after the acute phase of their illness. The number of long haulers could be much higher among hospitalized COVID-19 patients. In an article published in the Journal of the American Medical Association, 87.4% of hospitalized COVID-19 patients reported the persistence of at least one symptom.
Since June 2020, the ICU Survivor Center at Indiana University Health Methodist Hospital in Indianapolis has treated about 100 COVID-19 patients who survived ICU-level care. The patients are experiencing a range of symptoms, according to Sikandar Khan, DO, medical director at the ICU Survivor Center and a research scientist at the Regenstrief Institute in Indianapolis.
60% of patients have had physical function issues such as muscle weakness or difficulty with balance
44% of patients have had sleep problems
38% of patients have had post-traumatic stress disorder symptoms
Other symptoms include fatigue, headache, anxiety, and depression
"Some are very fatigued even six months after hospital discharge. They may be having headaches. They might be having a lot of difficulty with sleep. So, virtually all of our patients have some complaint in terms of their general well-being and effects on quality of life," Khan says.
ICU Survivor Center care model
The ICU Survivor Center is an interdisciplinary clinic, Khan says.
"The goal of the clinic is to maximize the recovery of critical illness survivors. We know from scientific literature that patients who survive critical illness have symptoms of post-intensive care syndrome, which can be physical function problems, mental health challenges, and cognitive issues such as changes in memory. All of this leads to a quality of life impairment," he says.
The ICU Survivor Center's staff includes pharmacists, pulmonary critical care specialists, chaplains for spiritual support, ICU nurses, social workers, and rehab specialists. The ambulatory clinic also has referral partners such as psychiatrists and neuroscience faculty.
COVID-19 patients receive care similar to that given to other ICU survivors, Khan says. "It is a lot of the same specialties because we see the same burden in patients who have survived critical illness with COVID-19. These patients have fatigue, muscle weakness, muscle pain, headaches, and autonomic nervous system impairments such as palpitations and shortness of breath. These patients see me as well as a few of the specialists who are focused on rehab such as physical rehab and cognitive rehab."
The ICU Survivor Center also is treating COVID-19 patients with telemedicine, he says. "Our first preference is a video visit if a patient wants to have telehealth services. With video, you can really engage with the patient. If patients are not equipped with a camera—either on their phone or their computer—we will do phone visits. With the phone visits, we will usually recommend that they come in for one in-person visit, so we can get a full assessment."
The primary feature of the Moms2B program is a two-hour educational and interventional session held on a weekly basis.
A community-based interdisciplinary intervention program in Ohio has improved pregnancy and infant outcomes in neighborhoods at high risk for infant mortality, a recent research article shows.
The Centers for Disease Control and Prevention (CDC) defines infant mortality as the death of an infant in the first year of life. According to the CDC, the top five causes of infant mortality in 2018 were birth defects, preterm birth and low birth weight, maternal pregnancy complications, sudden infant death syndrome, and injuries such as suffocation.
A co-author of the recent research article who is the founder of the Moms2B community-based interdisciplinary intervention program at The Ohio State University Wexner Medical Center in Columbus told HealthLeaders that infant mortality is a significant problem in the United States.
"It is a critical measure of the health of our neighborhoods, our cities, our states, and our country. We lag way behind the other developed countries in our infant mortality rate. Most concerning is that two-to-three times more Black babies die in the United States as White babies," said Patricia Gabbe, MD. In addition to founding Moms2B, Gabbe is a professor of pediatrics and obstetrics and gynecology at The Ohio State University College of Medicine.
The recent research article, which was published by Maternal and Child Health Journal, features data collected from more than 2,000 primarily non-Hispanic Black women and their infants. There were 675 pregnancies that had been exposed to the Moms2B program and a control group of more than 1,300 pregnancies.
The study includes three key data points:
Pregnancies exposed to Moms2B were less likely to result in a neonate with low birth weight than the control group, 9.45% versus 12.00%, respectively.
Moms2B participants had an infant mortality rate of 0.75%, and the control group had an infant mortality rate of 1.67%
Moms2B participants had a preterm birth rate of 10.9%, and the control group had a preterm birth rate of 12.7%
"The biggest contributor to infant mortality in our Black families is very preterm birth. So, the Moms2B program's emphasis on promoting a healthy pregnancy is designed to get moms to a full-term pregnancy," Gabbe said.
Primary elements of Moms2B
The Moms2B program was launched in 2010, with Gabbe and an infant mental health specialist as the only staff members. "We started with two pregnant women at a church in a high-risk, high-crime neighborhood. In 2019, we had almost 800 moms. Last year, even with the pandemic, we had 629 moms. It is a testimony to how much interest and need there is for this program. We now have a staff of 25," she said.
The current staff includes child development and parenting specialists, community navigators and health workers, dietitians, fatherhood leaders, lactation counselors, nurses, obstetricians, pediatricians, and social workers. Moms2B now has sites in eight Columbus neighborhoods.
The primary feature of the Moms2B program is a two-hour session held on a weekly basis at each Moms2B site. The sessions begin with a "sister-brother circle," Gabbe said. "The men hear the same lessons on breastfeeding, good nutrition, co-parenting, and anger and emotional management. Then, our sessions break up into three groups: a Dads2B group that works with a fatherhood leader, a parenting group for women, and a pregnancy group for women."
Childcare is provided during the two-hour sessions so participating adults can focus on the program.
Gabbe said the two-hour sessions have several educational and interventional elements, including the following:
Nutrition: All moms get a healthy meal during the two-hour session and can take a meal home. As is the case for all lessons, food preparation and nutrition lessons are accompanied by short and colorful handouts. Moms are connected to the federal Supplemental Nutrition Program for Women, Infants, and Children (WIC), as well as food banks. Once a month, Moms2B brings a Mid-Ohio Foodbank truck to its sites, so moms can go home with fresh foods and staples.
Breastfeeding: For infants, breastfeeding is protective. "Our moms initiate breastfeeding in the hospital about 80% of the time. When we started, it was about 50%," Gabbe said.
Safe sleeping: Moms2B models safe sleeping techniques for infants. For example, one interactive exercise consists of placing a crib filled with inappropriate items in the center of the sister-brother circle. The moms and dads are then asked which items should not be in the crib. "In the end, you end up with an empty crib with a baby flat on their back," she said.
Reproductive health: Moms2B provides education about several different methods of birth control. "Our team has developed a game called Repro Bingo, where you call out different methods of birth control and show what is effective and what is not effective," Gabbe said.
Smoking cessation: Moms2B conducts smoking assessments with moms and dads. The organization also has a partnership with a Columbus Public Health program called Baby and Me Tobacco Free. "We do not want our babies to go home where the mom or dad are smoking," she said.
Stress reduction: Moms2B teaches moms stress reduction techniques. "Sometimes, we blow bubbles to reduce stress, and we teach moms how to take deep breaths to relax," Gabbe said.
Return on investment
The Moms2B program has an annual budget of about $1.6 million, with the funding drawn from Medicaid, the Governor's Office of Faith-Based and Community Initiatives, and The Ohio State University Wexner Medical Center, Gabbe said.
"The cost per baby is about $2,000, said Gabbe. "That is a small investment to save a baby and to save a mom. We are focused on achieving equity in health—equity in the population of moms and babies. So, we are making a modest investment given what we are trying to achieve."
Moms2B generates a positive return on investment, she said. "When I do a cost-saving analysis, Moms2B saves money. This investment reduces healthcare costs that have been devoted to infants who are born premature and spend a lot of days in a NICU."
A new automated contact tracing system precisely tracks healthcare workers' movements in hospitals.
In the hospital setting, automated contact tracing is far superior to manual contact tracing, a California-based hospital's chief medical officer says.
Since the beginning of the coronavirus pandemic, the healthcare workforce has been strained by coronavirus infections and workers sent home to quarantine after unsafe exposures to infected patients and colleagues. There have been more than 400,000 cases of COVID-19 among healthcare workers, according to the Centers for Disease Control and Prevention.
Methodist Hospital of Southern California adopted automated contact tracing in November. "With automated contact tracing, which we do with SwipeSense, we can get contact tracing information in about five minutes. It is a total game changer," says Bala Chandrasekhar, MD, CMO of the Arcadia, California facility.
Before the hospital started using automated contact tracing, the manual process took about two weeks and imprecision often resulted in healthcare workers being sent home for testing and isolation unnecessarily, he says.
The manual process had been administered by the hospital's Occupational Health Department. "The problem with the manual process is that it is very time consuming. I had one doctor come to me at the beginning of the pandemic who said, 'I just got contacted from occupational health that I had an exposure two weeks ago. What am I supposed to do?' I said, 'At two weeks, there is not much that you can do.' That was very unsatisfactory," Chandrasekhar says.
The two-week lag period in manual contact tracing could lead to the spread of coronavirus infection, he says. "A healthcare worker could be carrying the virus for a while and be asymptomatic, then expose other healthcare workers, patients, or their family."
And relying on the memory of staff members about exposures to infected patients and coworkers is imprecise, he says.
"With a manual contact tracing process, it is difficult to risk stratify. With COVID-19, the CDC says an unsafe close contact is someone who has had at least a 15-minute exposure within six feet of the infected person over a 24-hour period. The manual process cannot get you that information reliably. So, you might unnecessarily call people and tell them they have been exposed. If it is a healthcare worker, they are out of work in quarantine or isolation. That is a problem because we need healthcare workers during the pandemic—we cannot send a bunch of people home unnecessarily. It creates more of a crisis."
How automated contract tracing works
The SwipeSense technology uses badges to collect data on the movements of healthcare workers in the hospital, Chandrasekhar says.
"It is a radio frequency tag that you wear with your ID tag. The badge tracks where you have gone in the hospital; so, when it comes to contact tracing, we can easily figure it out in a very short period of time. Although data is collected continuously, contact tracing only gets turned on when there has been an unsafe exposure to an infectious disease. So, we are not actively tracking everybody all the time."
The automated contact tracing technology can tell whether a healthcare worker has had an unsafe exposure according to the CDC guidelines, he says. "We have complete information about everybody who has been in contact with an infected person, and we can risk stratify. Anybody who has had only casual contact with an infected patient or healthcare worker does not need to be notified or go into quarantine."
So far, Methodist Hospital of Southern California has used automated contact tracing for 41 patients and 114 healthcare workers.
Among COVID-19 patients hospitalized with severe acute respiratory infection, lung and functional impairments were found in half of them four months after discharge.
Many coronavirus patients hospitalized with severe acute respiratory infection experience significant respiratory, functional, and psychological symptoms four months after hospital discharge, a recent research article found.
Gary Rogg, MD, an attending physician in internal medicine and co-director of the Post-COVID-19 Recovery Program at Westchester Medical Center in Valhalla, New York, says coronavirus "long haulers" can have a range of long-term symptoms. Those symptoms include cough, shortness of breath, anxiety and depression, cardiac issues, constitutional symptoms such as numbness and tingling, deconditioning, and hair loss.
The recent research article, which was published by JAMA Network Open, features data collected from 219 patients at an academic hospital in Northern Italy. The researchers measured lung impairment, functional impairment, and posttraumatic stress symptoms.
Measurement of lung function impairment was based on diffusing lung capacity for carbon monoxide (DLCO). Lung function impairment was considered present if the DLCO level was less than 80% of expected value. Severe lung function impairment was considered present if the DLCO level was less than 60% of expected value.
DLCO was less than 80% of the expected value in 51.6% of patients
DLCO was less than 60% of the expected value in 15.5% of patients
Functional impairment was found in 53.8% of patients
Posttraumatic stress symptoms were found in 17.2% of patients
"We found that a significant proportion of survivors of COVID-19 experienced respiratory or functional impairment four months after hospital discharge, with clinically relevant psychological consequences," the study's co-authors wrote.
Among hospitalized patients with severe acute respiratory infection, coronavirus long haulers are relatively common, the lead author of the study told HealthLeaders.
"In our study, we confirmed that a relevant proportion of patients still complains of COVID-19 symptoms months after the acute phase of their illness. The most frequent symptoms were fatigue and reduced tolerance to exercise," said Mattia Bellan, MD, PhD, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy.
The severity and duration of COVID-19 symptoms after hospital discharge poses challenges to many patients and requires further research, Bellan said. "These symptoms have an impact on the quality of life of these patients since they often have the perception of being generally unwell. Whether these sequelae will persist over time is a major public health issue that needs to be assessed in the future."
CommonSpirit Health has a large and diverse physician enterprise, with more than 5,800 employed physicians, about 1,100 ambulatory care sites, and 21 value-based organizations.
Large health systems with far-flung physician practices benefit from creating a shared culture and utilizing effective communication strategies, the new physician enterprise leader of CommonSpirit Health says.
The Chicago-based health system has an expansive physician enterprise across 21 states. The organization has more than 5,800 employed physicians, about 1,100 ambulatory care sites, and 21 value-based organizations.
In December, CommonSpirit Health announced that Thomas McGinn, MD, MPH, had joined the organization as system executive vice president of physician enterprise. McGinn is succeeding Bruce Swartz, who retired in November.
Before joining CommonSpirit Health, McGinn served as the deputy physician-in-chief and senior vice president of physician network operations at New Hyde Park, New York–based Northwell Health. While at Northwell Health, he was also the founding chair and a professor at the Department of Medicine at the Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. Before working at Northwell Health, he was chief of the Division of General Internal Medicine at Mount Sinai Medical Center in New York City.
HealthLeaders recently had a conversation with McGinn about the challenges of managing a large physician enterprise. The following is a lightly edited transcript of that discussion.
HealthLeaders:What is your vision for physician enterprise leadership at CommonSpirit Health?
Thomas McGinn: The fundamental vision is to look at each of our medical groups and communities, then try to come together under one culture and one mission. That mission-driven culture should enhance efficiency and quality.
A first step is standardizing communication across different communities. We put forward our message about who we are, what we are doing, and what are our priorities. You cannot underestimate the importance of well-timed communication that is both supportive and defining.
Then, we have a lot of issues we are looking at across the board on creating standards. For example, quality standards such as blood pressure measurements in Tacoma, versus blood pressure measurements in Houston, versus blood pressure measurements in Fargo. It seems like a basic thing, but how you measure blood pressure and how you collect that data has a standard across our footprints. We have our quality standards that we are setting that people are following. We are benchmarking those standards and have dashboards for them.
We also have operational performance standards that we have created. There are all the basics such as revenue cycle, then we have interesting targets such as virtual health. In virtual health, we went from zero before the pandemic to about 20% of our volume now in virtual care. The standards for virtual care being created across the health system include what percentage of volume should be virtual.
There are also cost standards such as staffing ratios and provider incentives.
HL:What are two of the top goals in your new position?
McGinn: The underlying challenge in each of our communities is the evolution toward an integrated delivery network. Creating an integrated delivery network often comes down to the concept of network integrity. So, we are looking at each of our markets and trying to understand key elements that are missing across the care continuum. One of the biggest challenges in almost every market is the absence of a solid primary care base, which is a common problem among health systems. Most health systems grew out of hospital acquisition, and hospitals tend to have specialists, so there is an inverse proportion of specialty to primary care.
Virtual care is another top goal. We want to maintain the volume of our virtual care and to evolve virtual care into each type of specialty. We need to figure out how to use virtual care in specialties such as pediatrics, surgery, and rehab.
HL: How do you promote value-based care in an integrated delivery network?
McGinn: We need to go into each market and look at it through the lens of how our delivery network is doing rather than how our hospitals are doing. It is an evolutionary process, and each market is in a different stage of evolution in creating an integrated delivery network. You do not have to own everything in every market. You can develop partnerships in areas such as primary care and nursing homes, but partnerships need to be strategic and you need to monitor all of the pieces to make sure they are working.
I use the term ecosystem. Each patient lives in a healthcare ecosystem, and it is usually three or four ZIP codes. You want to know all the pieces in that ecosystem; and you want to pay attention to them, so you know how patients are navigating their healthcare ecosystem. Whether you own all of the pieces of the ecosystem or not, you want to understand how it works.
HL: What are the keys to building and strengthening provider networks?
McGinn: There are a lot of different pieces that go into this puzzle. One major piece is building a culture that people feel they belong to. Another major piece is interconnectivity and having the IT infrastructure so that referrals can happen in a seamless way, which can be a challenge when you have medical groups with different electronic medical records. It can take hard labor to fix IT infrastructure issues.
You need to have people who work to connect clinicians. You need to have people who are physically visiting doctors' offices—even doing social events or virtual events. There are a lot of different tactics that you have to use to bring doctors together to enhance network integrity.
Equity has been a longstanding issue in U.S. healthcare, but the coronavirus pandemic has heightened concern by exposing glaring disparity problems. In particular, African American and Hispanic people have experienced a disproportionate burden of illness and mortality during the pandemic.
Disparity is a major issue in sepsis care and outcomes, the president and CEO of the Sepsis Alliance recently told HealthLeaders.
"Sepsis is a huge burden on everyone. It is the No. 1 cause of death in hospitals. It is the No. 1 cost of hospitalization. It is the No. 1 cause of readmission to hospitals. Sepsis is a huge public health crisis. Then you magnify this crisis on certain minority communities, and you have something that is really dire," said Thomas Heymann, MBA.
The Sepsis Alliance has created a Sepsis and Health Equity Fact Sheet that highlights many racial, ethnic, and socioeconomic disparities related to sepsis. The fact sheet includes the following sepsis disparities:
Black and other nonwhite people have nearly twice the incidence of sepsis as whites
Non-Hispanic black children admitted to an emergency room are less likely to be treated for sepsis than non-Hispanic white children
Native Hawaiians have almost twice the burden of sepsis mortality compared to whites
Black children are 30% more likely than white children to develop sepsis after surgery
Children with severe sepsis or septic shock who are black or Hispanic are about 25% more likely to die than non-Hispanic white children
Adults below the poverty line have more than three to four times the risk of dying of sepsis compared to adults whose family income is at least five times the poverty line
"We understand equity as a systemic problem, so we cannot do a scatter-shot approach, which is what we had been doing in being more reactive than proactive in this area. Seeing the COVID-19 disparity data really brought it home to us. We got some funding to conduct a sepsis inequity literature review, and we saw startling differences in access, care, and outcomes," Heymann said.
Sepsis Alliance pledge
The San Diego-based organization adopted the following pledge last month: "Sepsis Alliance is committed to fostering equity, diversity, and inclusion (EDI) in our work and in the sepsis care community."
The Sepsis Alliance also adopted a three-point EDI plan.
1.Expand public education and provider training to close racial and ethnic gaps in sepsis awareness and ensure culturally responsive sepsis care: Goals for this part of the EDI plan include adding at least five new subject matter experts from communities of color to the organization's roster of presenters annually and providing implicit bias instruction in Sepsis Alliance Institute courses.
2.Pursue advocacy initiatives that further EDI goals and act as an EDI leader in healthcare: Goals for this part of the EDI plan include creating an industry EDI pledge by spring 2021 and creating an industry EDI reporting platform by spring 2021.
3. Boost diversity within the Sepsis Alliance to better reflect the communities that the organization serves: Goals for this part of the EDI plan include incorporating EDI into the Sepsis Alliance charter and conducting annual EDI training for the Sepsis Alliance's staff, board of directors, and advisory board.
Understanding and addressing sepsis disparities
Several factors are driving sepsis disparities, Sandy Cayo, DNP, vice president of clinical performance and transformation at the New Jersey Hospital Association and a member of the Sepsis Alliance Equity, Diversity, and Inclusion Steering Committee told HealthLeaders.
There is relatively less awareness about sepsis in minority populations compared to white Americans. In the Sepsis Alliance's most recent annual survey on sepsis awareness, only 5% of black respondents could identify the four most common sepsis symptoms and 18% of white respondents could identify the symptoms.
There is a higher incidence and severity of underlying health factors among minority populations. African Americans and Hispanics often have more comorbid conditions including diabetes, hypertension, and respiratory problems such as chronic obstructive pulmonary disease.
There are also "overlaying factors" such as lack of insurance and mistrust of providers that cause people of color to either not seek treatment soon enough or not get the proper treatment when they present to a healthcare provider with signs and symptoms of sepsis.
"There have been studies that show that when people of color show up in emergency rooms, providers may not listen to them in the same way they might listen to their white counterparts. So, they may not be believed," she said.
To address sepsis disparities, healthcare providers need to elevate their awareness of equity issues and bias, Cayo said. "We need to put a lens of equity on how we approach care. We need to look at whether there is bias inserted and whether we could have eliminated it or addressed it."
Healthcare providers also need to communicate openly and regularly about equity and bias, she said. "It is important that we start talking about equity and bias. We are talking about it more than ever this year. We need to have these conversations upfront—it cannot be just for diversity and inclusion officers. All clinicians need to have equity and bias awareness as a priority in their approach to care."
