Researchers call physician turnover costs and lost productivity a 'substantial economic burden.'
The annual cost of physician burnout is conservatively estimated at $4.6 billion, research published this week shows.
A national survey conducted in 2014 found that 54% of physicians were experiencing burnout symptoms and prevalence of physician burnout was twice as high as in the general population. Other studies have associated burned-out physicians with higher rates of self-reported medical errors and poorer clinical outcomes.
The study published this week in Annals of Internal Medicine is one of the first attempts to estimate the cost of physician burnout to health systems, hospitals, and physician practices, the researchers wrote.
"Our study provides tools to evaluate the economic dimension of this problem. Together with previous evidence that burnout can be reduced effectively with moderate levels of investment, our results suggest that a strong financial basis exists for organizations to invest in remediating physician burnout."
The $4.6 billion national annual cost of physician burnout was calculated based on two elements:
1. Physician turnover: The researchers tried to account for two components of the cost associated with burned-out doctors leaving their jobs. The first component was the cost linked to physician replacement for search expenses, hiring, and new physician startup. The second cost was lost income from open physician positions.
2. Reduced clinical hours: To approximate the cost of physicians lowering their clinical hours, the net cost of turnover was adjusted by a fraction representing the average percentage difference in weekly work hours between physicians who were burned-out and physicians who were not burned out.
The researchers also estimated the annual cost of physician burnout at the organizational level. They found the costs linked to turnover and reduced clinical hours is about $7,600 per employed physician.
Burnout cost likely more than $4.6B
The $4.6 billion cost estimate almost certainly understates the economic burden of physician burnout, the researchers wrote. "Our analysis is conservative, omitting other burnout-related costs that are difficult to quantify."
The analysis does not account for several aspects of physician burnout that have financial consequences:
Physician burnout has been linked to reduced quality of care, lower patient satisfaction, and malpractice lawsuits
Some of the "friction costs" associated with replacing physicians were unaccounted such as the impact on other care team members
At the organizational level, the cost estimate for physician burnout does not account for patients who leave a practice after their burned-out doctor departs
The cost estimate does not include indirect revenue losses associated with a physician vacancy such as diagnostic tests and procedures
"Using data informed by the current state of research, our conservative analyses suggest that on a national scale, a substantial economic burden is associated with physician burnout in the United States," the researchers wrote.
To boost quality and reduce costs, an IHI initiative calls on clinical teams to focus on four evidence-based elements when caring for older adult patients.
An Institute for Healthcare Improvement (IHI) initiative to promote age-friendly clinical care for older adults is taking hold nationwide.
The number of Americans over age 65 is expected to double to nearly 100 million by 2060. With multiple chronic conditions and high costs of care at end of life, older adults have relatively higher healthcare costs compared to younger Americans. In 2010, citizens over age 65 were 13% of the population but accounted for 34% of healthcare spending.
IHI's Age-Friendly Health Systems initiative launched in early 2017. Now, 350 healthcare organizations including more than 125 health systems are implementing the effort in whole or in part.
Four-pronged intervention strategy
The main component of the IHI initiative is an evidence-based framework called the 4Ms:
What matters to the patient: With a potentially dramatic impact on medical decisions, determining what matters to patients may be the most momentous of the 4Ms, says Kedar Mate, chief innovation and education officer at Boston-based IHI. "Improving medical decision-making is a key element of attaining value. Of all the interventions, the first M—what matters—gets you to high value as defined by the patient. It gets you to services that offer value in the patient's eyes."
Medication: Managing medications is crucial for achieving therapeutic benefits and avoiding adverse drug reactions, which cause harm and costly complications. Annual costs in the United States associated with adverse drug reactions have been estimated at $30 billion, according to a December 2013 article in the Journal of Pharmacology & Pharmacotherapeutics.
Mentation: Addressing delirium in the inpatient setting generates significant mentation benefits, Mate says. "Delirium is extremely common among older adults in inpatient settings, and it is extremely costly both on the human cost side with complication rates and lengths of stay, and the financial side. Length of stay is often 20%–30% longer with delirium."
Mobility: Maintaining mobility also generates clinical and financial benefits, he says. "The data on functional impairment is stark. If you have a patient with one or two chronic conditions, then you add on functional impairment, the cost of care roughly doubles. Functional impairment is a big impediment in older adults' lives in achieving what matters to them, and it costs us a ton of money as a society."
In consultation with geriatricians and healthcare organization leaders, IHI selected the 4Ms after dissecting 17 evidence-based clinical practice models for older adults.
"To get to four things felt doable to folks. It felt conceivable for health systems to adopt, and achievable in a relatively short period of time for the average practitioner in the clinical service environment," Mate says.
Anne Arundel Medical Center benefits from 4M framework
At Anne Arundel Medical Center, asking older adult patients what matters to them has been a primary driver in adoption of the IHI initiative, says Barbara Jacobs, RN, chief nursing officer of the Annapolis, Maryland–based health system.
"We've changed our discharge plans and the way we interact with a patient and a family by asking that fairly simple question. We need to know what the patient wants in terms of the plan of care," she says.
Like most patients, many older adults want to go home after an inpatient stay, and Anne Arundel discharge teams have stepped up efforts to honor this desire, Jacobs says.
"If we don't ask patients where they want to be after discharge, we are not going to have a successful discharge. We have to work with patients if they say they want to go home. We can set up that support. It's a learning moment for us—listening to the patient."
Anne Arundel is pursuing all 4Ms, and a mobility intervention stands out, she says.
The main campus of the health system has an inpatient floor that specializes in care for older adults, the Acute Care for the Elderly (ACE) Unit.
At 11 a.m., medically cleared patients are encouraged to participate in "ACErcise," which features wheelchair-based exercises and walking. The age-friendly session has become a significant socialization event. "The patients enjoyed the togetherness, so the activity evolved into the opportunity to eat together. It has been very popular," Jacobs says.
The value of mobility is undeniable, she says. "If a patient stays moving, their chance of getting home is much better, which is where most people want to go."
Age-friendly care impact
Anne Arundel is implementing multiple age-friendly efforts simultaneously; so, it's difficult to gauge return on investment, but gains are expected, says Executive Vice President of Integrated Care Delivery and COO Maulik Joshi, DrPH.
"The age-friendly best practices are based on research and evidence that the interventions make a difference in outcomes. For us, we are strongly focused on quality and investing in quality. It can be hard to prove, but these best practices have been directly related to readmissions, patient satisfaction, length of stay, and other crucial outcomes," he says.
Anne Arundel is confident there will be clinical and financial gains from age-friendly efforts, Joshi says. "The evidence is incredibly profound. This is not weak evidence. We know mobility and medication management have a huge impact."
Jacobs says the value is apparent. "It's not like you are out on a limb with something that has barely been tested. It is palpable. You can see that this kind of care is better."
The early results at healthcare organizations participating in the IHI initiative are promising, Mate says.
"It didn't surprise us that the 4Ms improved the health of populations—they were derived from models that improved the health of seniors. And it didn't surprise us that patients were more satisfied when they were asked about what mattered to them and more satisfied when caregivers paid more attention to their mobility. What surprised us is that the 4Ms lowered costs significantly."
To help health systems, hospitals, and clinics track the financial impact of age-friendly efforts, the IHI initiative includes ROI calculators for the inpatient and outpatient settings.
In case studies conducted by IHI, two organizations reported significant ROI on their age-friendly activities, Mate says:
Ascension-affiliated St. Vincent Medical Group, Indianapolis: In an ambulatory setting where 4M care is being added to annual Medicare wellness visits, $600,000 of additional benefit was generated on a $3 million investment.
Hartford Healthcare-affiliated Hartford Hospital in Connecticut: The academic medical center implemented a delirium management program that generated a $3.6 million return on a $2.4 million investment in the program.
"If you want to figure out how you deliver higher-value care, then an age-friendly system is a good place to start," Mate says.
How healthcare organizations can implement the 4Ms
IHI published a list of steps for health systems, hospitals, and clinics to implement age-friendly care into their organizations:
Learn about age-friendly health systems
Inform IHI of your interest in participating
Identify an age-friendly champion
Send IHI a letter of commitment from a senior leader
Introduce clinical teams to the age-friendly framework
Describe how your healthcare organization will apply the 4Ms
Share your description of the 4Ms with IHI
Share the count of patients who are receiving age-friendly care with IHI for at least three months
An 11-member intervention team redesigns workflows, develops new EHR tools, and trains clinicians to use the EHR more efficiently.
An intense, two-week program to improve electronic health record systems at the clinic level improves clinician satisfaction with the EHR significantly, recent research shows.
EHR burden has been cited as a primary contributor to clinician burnout. Research indicates that nearly half of physicians are experiencing burnout symptoms, and a study published in September found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
In a study published this month in Mayo Clinic Proceedings, researchers show the two-week "Sprint" EHR intervention developed at Aurora, Colorado-based UCHealth increased clinician EHR satisfaction. On a net promoter scale ranging from -100 (worst) to +100 (best), clinician satisfaction with the EHR was -15 before the Sprint intervention and rose to +12 after the intervention.
The Sprint intervention is led by an 11-member team that helps clinic staff improve the EHR to make the system more efficient and user-friendly. The Sprint team includes one project manager, one physician informaticist, one nurse informaticist, four EHR analysts, and four EHR trainers.
Sprint intervention components
The Sprint intervention has three primary components: training clinicians to use the EHR more efficiently, redesigning a clinic's multidisciplinary workflow, and developing new specialty-specific EHR tools.
1. Training clinicians: In a Sprint intervention, clinicians participate in a two-hour kickoff meeting, three 1-to-1 training sessions, and a two-hour wrap-up session. In the 1-to-1 sessions, clinicians meet with either a trainer or the physician informaticist to learn specific skills or address frustrations with the EHR. The training content for Sprint features 10 sets of efficiency tips such as chart review efficiency, medical ordering efficiency, and medication management.
2. Workflow redesign: To examine multidisciplinary workflow and patient flow, Sprint team members meet individually or in small groups with a clinic's non-clinician staff. After assessing strengths and weaknesses, trainers teach EHR best practices to the clinic staff, and the clinic manager redesigns common workflows to promote standardization. For example, a UCHealth clinic developed a pre-visit online patient questionnaire for neurological disorders that is used at every visit.
3. Specialty-specific EHR tools: Clinic leaders review all new EHR tool requests. Examples of popular new EHR tools are synopsis reports, flow sheets, patient-entered questionnaires, and customized note templates. New tools that receive approval are listed in a chart under five headings: backlog, to do, in process, done, and parking lot, with the last designation for tools that cannot be addressed during the Sprint intervention. The chart is available to the clinic staff and updated daily.
Sprint team strengths and ROI
Researchers found the Sprint intervention team model has several strengths:
The physician informaticist plays a crucial role, translating clinician requests for EHR changes into technical solutions and training opportunities
The nurse informaticist targets staff and team workflows
The project manager gives the team a dedicated leader
Having the Sprint team onsite boosts clinic staff engagement in the intervention and allows team members to confer easily and make decisions quickly
The researchers estimate that the Sprint intervention generates a significant positive return on investment.
For one Sprint team, the total annual cost of the invention program is about $1.7 million:
The annual cost of funding one Sprint team, which can engage 500 clinicians, is estimated at $1.2 million.
The annual cost of lost clinician productivity during Sprint interventions is about $500,000.
The researchers estimated that one Sprint team can reduce the number of annual burnout-related clinician departures by 2.5 staff members, which can generate annual cost avoidance as high as $2.5 million.
Research indicates that nearly half of physicians nationwide are experiencing burnout symptoms, and a study published in October found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.
Since 2015, Providence St. Joseph's Own It program has been transforming how staff members interact with patients and each other.
"Number One, we focus on why people came into healthcare and help them reconnect with their purpose in healthcare. We talk and have training modules that are about compassion, empathy, accountability, and service cycle," says Kevin Manemann, executive vice president and chief executive of physician enterprise at the Renton, Washington-based health system.
The main component of the Own It program is a four-hour training session that emphasizes compassion and organizational values paired with communication standards, role playing, and storytelling.
About 35 people attend the training sessions, which group participants at tables of six to eight people. Facilitators lead the training sessions, with assistance from a peer facilitator seated at each table. "There's a leader at each table—someone who has been through the program and knows how to facilitate dialogue," Manemann says.
The emphasis on core healthcare values builds resistance to physician burnout, he says. "From a burnout standpoint, Own It reconnects people with why they came into healthcare in the first place. It also brings a reconnection with the organization and our purpose."
The training includes an introduction to "sacred encounters" among staff members and patients. Sacred encounters are caring and courteous conversations that establish connections between staff members and their patients and colleagues. "It's about connecting people with their daily interactions with each other," Manemann says.
As part of sustainment efforts for the Own It initiative, staff members share Own It Moments such as sacred encounters during routine employee huddles on inpatient floors and in other health system departments.
Own It by the numbers
So far, 12,000 Providence St. Joseph staff members have attended Own It training sessions and the initiative appears to be having a positive impact.
In staff surveys conducted immediately after Own It training sessions, 90% of session participants say the training better prepared them to improve the patient experience and interact with one another in a more positive way.
In Press Ganey scores, physician engagement rose from the 58th percentile in 2016 to the 71st percentile in 2017.
Physician engagement is currently trending above the 75th percentile.
Patient satisfaction scores have improved in three metrics: overall physician communication, overall caregiver helpfulness, and overall caregiver courtesy and respect.
"It’s really about behavior and attitude. The more that we understand how we treat each other, and the more that has an impact on our enjoyment in the work that we do, it impacts the patients' experience with us," Manemann says.
G.R.E.A.T. declarations and actions
Communication skills are an essential ingredient of Own It's G.R.E.A.T. principles:
Greet: Introducing yourself by name and role, greeting others in a manner appropriate to the situation, and using welcoming facial expressions and speech
Respect: Saying please, thank you, and you are welcome; facing the person you are speaking with for heart-to-heart conversation; respecting diversity, safety, and confidentiality; and working in an ethical manner
Engage: Providing opportunities for questions and engagement, listening with empathy, and validating needs
Assist: Explaining what you are doing and why you are doing it with good intent, working in partnership with patients, and conducting collaborative decision-making
Transition: Describing next steps and care coordination, escorting patients if necessary, and providing authentic departing remarks
Kenton Zehr wants DMC Heart Hospital to expand the for-profit health system's cardiovascular service line such as performing more open-heart surgeries.
An accomplished mechanic with an entrepreneurial spirit has his hands on the controls at Detroit Medical Center (DMC) Heart Hospital.
Kenton Zehr, MD, who earned his medical degree at Pennsylvania State University College of Medicine and completed a residency and fellowship in general surgery and cardiothoracic surgery at Johns Hopkins Hospital in Baltimore, was named executive director of DMC Heart Hospital in April.
The board-certified thoracic surgeon says a life-long interest in mechanics drew him to cardiac surgery as his field of interest.
"In sixth grade, we went to the grocery store to buy bottles and things, then I made a heart-lung machine out of bottles that pumped colored water with a syringe-type system. I won the science fair for that," Zehr told HealthLeaders.
"When I hit human anatomy at Penn State that became my favorite class with my mechanical background. My father and my brother and I built our house when I was a teenager. We pounded every nail. So, working in a mechanical healthcare subspecialty makes sense to me."
HealthLeaders recently spoke with Zehr about his vision for DMC Heart Hospital. Zehr wants DMC to perform more open-heart surgeries and expand the health system's cardiovascular service line.
Following is a lightly edited transcript of that conversation.
HL: Why do you find the mechanics of the heart and the vascular system appealing?
Zehr: First off, cardiac surgeons don't treat cancer, we treat something that is fixable. In large part, our patients do well; and once they are fixed, they are fixed with a durable result.
In some ways, it's like opening the hood of the car, fixing the car, and closing the hood. The cardiovascular system is very well circumscribed. You know your limitations—it's the pump and the vessels that come in and out of the pump.
HL: How has your medical background prepared you to lead DMC Heart Hospital?
Zehr: I've worked at several major institutions. I spent nine years training at Hopkins back in the day when we were on call every other night—before the resident work hours limited you to 80 hours a week. I did nine years working 100 to 120 hours per week. We were immersed in it very intensely.
After I finished my training at Hopkins, I went to the Mayo Clinic in Rochester, Minnesota. I spent eight years there. The mechanical portion of using the heart-lung machine started there as a tour de force.
I've worked at pioneering systems. The first successful pump support for heart surgery was done in Detroit in 1952. They made four of those machines. One is in the lobby here. One was given to the Smithsonian. I like to feel connected to the thread of history.
HL: How do you plan to strengthen the cardiovascular service line at DMC?
Zehr: For the past several years, the service line has been heavily oriented toward percutaneous interventions on coronary events, not so oriented to a balanced approach.
There has never been a study that has shown percutaneous interventions such as stenting are superior in terms of durability to open heart surgery. We need a balanced approach to cardiovascular care—more balanced than it has been here.
We need to expand into other areas like valvular work. We're not participating strongly in the surgical solutions for heart failure. We have durable pumps—ventricular assist devices—which are basically artificial hearts that are routinely used across the United States, but not in our program. These are the things I plan to bring to DMC.
HL: What are some of the key steps in that expansion effort?
Zehr: We'll start by expanding the surgical volume. I'm hiring another surgeon from Hopkins who will be starting in September and plan to hire another surgeon. So, I am expanding our surgical staff, and we will expand our internal staff at the Heart Hospital—we just hired two interventionalists for stents and percutaneous procedures.
We have hired an internationally known heart failure expert. With myself and the other surgeons we are recruiting, we will be able to put in artificial heart devices. Several years down the road, we hope to have a heart transplant program. Right now, some of those needs are being met by our competitors, which is fine, but it would be nice to offer that as part of being a comprehensive program.
We will have a full-on marketing strategy to market ourselves as available to our community.
HL: What is your vision for DMC Heart Hospital?
Zehr: I want to see us competitive with Beaumont, with Henry Ford, and with the University of Michigan. I would like to see somewhere between 500 to 1,000 open heart surgeries per year. We occupy a market in downtown Detroit that is not served by others in the area. It's a high-needs community, with high percentages of diabetics and high percentages of people with high blood pressure. The first system to be affected by those disease processes is the cardiovascular system.
One of the advantages we have at the Heart Hospital compared to other institutions is that we are in one building. We see patients in the same building. We drink coffee out of the same coffee pot. We have group meetings, where we have a team approach to discussing cardiac care, and we have cardiologists and cardiac surgeons sitting around the same table.
HL: You have a track record in medical entrepreneurism, including several mechanical device patents. Do you hope to involve DMC Heart Hospital in medical entrepreneurism?
Zehr: Historically in Detroit, there has been a lot of opportunity because we have the car companies here. The machine that did the world's first pump support for a heart operation in 1952 was called the Dodrill-General Motors Research pump. All of the engineers came out of General Motors. There are bioengineers who are still associated with those companies.
In Detroit, we have a history of being part of multi-institutional trials for devices like stents that open up clogged vessels and that will continue—one of our strengths is partnering with industrial companies.
The American College of Physicians is calling on policymakers to strengthen and expand the Patient Protection and Affordable Care Act.
The PPACA has achieved significant gains in access to healthcare, and policy makers should focus on nurturing and expanding the healthcare law, the American College of Physicians (ACP) says.
The healthcare law enacted by the Obama administration has notched several achievements, the ACP says in a recent article published by Annals of Internal Medicine. PPACA regulations such as barring coverage restrictions on pre-existing conditions have made health insurance more accessible. Premium tax credits and cost-sharing subsidies have made individual and family coverage more affordable. The essential health benefit package and preventive service coverage has made insurance more comprehensive. And Medicaid expansion has insured millions of previously uninsured adults.
The ACP, which represents internal medicine specialists and has more than 150,000 members worldwide, is making seven recommendations to improve the healthcare law:
1. Strengthen the PPACA: Efforts to undermine the PPACA such as decreased outreach and education funding should be reversed or eased. The PPACA should be redesigned to move closer to universal coverage. The current healthcare law falls short of universal coverage, with unaffordable premiums, coverage gaps, and weak insurer participation.
2. Individual insurance market affordability: Premium subsidies should be expanded and increased such as removing the 400% Federal Poverty Level cap for premium tax credits to boost enrollment and offset premium hikes. Incentivizing more healthy people to purchase insurance on the PPACA marketplace strengthens the individual insurance market.
3. Stabilize the marketplace: The federal government should take several steps to stabilize the PPACA marketplace, including adoption of a permanent reinsurance program and rollback of proposals to sell health plans that do not comply with PPACA regulations such as limited-duration plans. The reinsurance program provides financial protection to health plans with high-cost enrollees. Noncompliant health plans segment the risk pool and drive premiums for compliant marketplace plans higher.
4. Outreach, consumer assistance, and education funding: In 2017 and 2018, the federal government slashed funding for the PPACA's Navigator program and other efforts to provide education, outreach, and enrollment assistance. Federal, state and local agencies should fund initiatives to promote the PPACA's coverage options. These efforts should target people who are eligible for Medicaid or premium tax credits but are not enrolled in PPACA coverage.
5. Enrollment mechanisms: To increase patient participation in PPACA coverage, federal and state marketplace officials should strengthen enrollment mechanisms such as developing auto-enrollment programs, levying penalties for failure to enroll upon eligibility, and adopting an individual mandate.
6. Medicaid expansion: The expansion of Medicaid coverage to more adults in 36 states has increased access to care significantly, with more than 12 million newly eligible adults covered by Medicaid in September 2017. Medicaid should not be expanded with counterproductive conditions such as onerous work requirements that prompt patients to disenroll.
7. Public option: Congress should craft a public insurance plan to increase competition in the individual marketplace. For example, Sens. Tim Kaine (D-Virginia) and Michael Bennet (D-Colorado) have proposed "Medicare X," which would give PPACA marketplace enrollees a public insurance offering based on Medicare's provider network and reimbursement policies. Medicare X would have an expanded benefit package including services such as maternity and pediatric care.
PPACA by the numbers
The ACP says the health law has posted promising numbers:
With Medicaid expansion states leading the advance, the country's uninsured rate hit a historic low in 2016, dipping to 8.8%.
In 2017 and early 2018, the uninsured rate held steady at 8.8%.
With higher out-of-pocket costs, patients face significant financial side effects from their care.
With proactive communication and engagement, clinicians can ease the financial burden of their patients.
Out-of-pocket costs such as high-deductible health plans have expanded over the past decade. In 2018, 29% of patients with private insurance were enrolled in high-deductible health plans, up 25 percentage points from 2006. More than a quarter of Americans have trouble paying medical bills.
In this month's edition of Annals of Internal Medicine, researchers provide seven approaches to having effective cost-of-care conversations with patients:
1. Patient engagement: Most physicians take a passive approach to discussing patient finances. Months can be wasted before clinicians find out patients can't afford their medications. Patients should be screened for financial hardship.
2. Cost estimates: Clinicians make medical prognoses that allow patients to plan for their care, and they should make financial prognoses that help patients plan financially. Discussing costs early in care boosts awareness of available resources and increases patients' ability to plan for expensive treatments. Clinicians should consider financial burden as a side effect of medical treatment and try to prevent it.
3. Anticipate costs: Most patients are concerned about the indirect costs of their medical appointments such as lost income, transportation, and childcare. Through communication with patients, these costs should be anticipated.
4. Make exploring out-of-pocket costs routine: Hospitals and physician practices can give patients information about health insurance availability, local health-related resources, and tools for initiating cost-of-care conversations during clinic visits. Implementing a cost-conversation screening system should engage patients, ease shame patients feel about financial problems, and give patients options to speak with clinicians or ancillary staff.
5. Adjusting workflows: Clinicians should work cost-of-care conversations into their daily workflows. Effective strategies include assigning one staff member to serve as the out-of-pocket cost problem-solver to develop expertise and efficiency, using the electronic health record (EHR) to document patients' financial need, and mining the EHR for cost data and insurance coverage.
6. Ancillary staff play central role: Most practices involve ancillary staff—medical assistants, nurses, front desk staff, and financial counselors—in cost-of-care conversations. Ancillary staff generally have more flexibility in their workflows to accommodate financial conversations with patients, and their views on cost of care often align closely with patient views compared to clinician views.
7. Practice makes perfect: As clinicians conduct more cost-of-care conversations, the discussions become more effective and efficient. Clinicians who conduct cost-of-care conversations are more likely to consider cost in medical decisions.
Chronic conditions afflict more than 130 million Americans—more than 40% of the population. Costs for chronic illness and mental health account for about 90% of the country's $3.3 trillion annual healthcare expenditures.
Clinicians are not providing adequate lifestyle advice about chronic disease, the recent research indicates.
"Prevalence of lifestyle modification advised by healthcare providers is generally low among U.S. adults with chronic conditions, and worryingly low among those without chronic conditions, however overweight or obese. Prescribed lifestyle modification is a missing opportunity in implementing sustainable strategies to reduce chronic condition burden," the researchers wrote.
The study examined federal data collected from more 11,000 adults for weight status and five chronic conditions—high blood pressure, high blood cholesterol, osteoarthritis, coronary heart disease, and diabetes.
The study generated several key data points:
High blood pressure (32.7%) and cholesterol (29.3%) were the most common chronic conditions compared with osteoarthritis (7.4%), diabetes (5.7%), and coronary heart disease (3.7%).
Diabetes patients received considerably more frequent advice (56.5%) than patients with high blood pressure (31.4%) and cholesterol (27.0%).
A "remarkably low" number of overweight (21.4%) and obese (44.2%) adults free of chronic conditions reported receiving any lifestyle advice.
"Our analyses revealed that about 20% of overweight and about 40% of obese adults received any lifestyle modification advice when free of chronic disease, demonstrating that most healthcare providers are missing this crucial primary prevention opportunity recommended by numerous guidelines," the researchers wrote.
Lifestyle advice included in the study was increased physical activity, reduced dietary fat and calories, and weight control.
Chronic disease management
A co-author of the study told HealthLeaders earlier research indicated that physicians require more knowledge in lifestyle medicine and behavior modification.
"This would mean more emphasis on these issues during medical school but also during residency training, preferably across all medical specialties. This is very important given the high and still rising prevalence of overweight and obesity in the U.S. population," said Sinisa Stefanac, MSc, of the Institute for Outcomes Research at the Medical University of Vienna in Austria.
Clinicians need more time to dispense advice, he said.
"Physicians need more time per patient in order to discuss these issues and need to have structural support by hospital or health center management that allows them the extra time to work with their patients. These changes are more structural and would take more time and understanding from political stakeholders."
Encouraging physicians to follow evidence-based guidelines and best practices can drive improved patient outcomes.
The electronic health record can be more than a giant billing machine. A newly formed health system is using clinical software to manage order sets and tap current medical knowledge to promote evidence-based medicine.
LaGrangeville, New York–based Health Quest and Western Connecticut Health Network in Danbury, Connecticut, which merged as Nuvance Health in April, have been using clinical software to set alerts, to manage order sets called "power plans," and to give physicians access to the most recent guidelines, best practices, and journal articles.
Health Quest and Western Connecticut Health Network are not operating under the Nuvance Health brand yet.
"We're finding that our increased compliance scores with evidence-based practice are correlating with improved patient outcomes and financial outcomes, which is encouraging. It gives validity to the initiative," says Kelly Philiba, ND, physician informaticist at Health Quest.
Before an evidence-based alert was added to the EMR, compliance with VTE prophylaxis guidelines for heart failure patients was about 70%. After the alert was implemented, compliance increased to 92%.
"We're always attempting to perform at the top of the field, and we want to give our clinicians the resources they need to keep themselves well-apprised on the recommended best practices, emerging evidence, and guidelines," Philiba says.
Measuring adherence to evidence-based practice of medicine
Health Quest has more than 700 order sets, and recently reviewed all of them. "We went through every single one with our clinician experts and our software, and input evidence links and revamped any order sets that needed editing," she says.
Now, the health system tracks adherence to order set guidelines by individual physician and clinician cohorts such as cardiologists.
"We are asked to show whether cardiologists are adhering to evidence-based practice and who is not, who is using power plans and who is not, what is the length of stay for a provider who is using evidence-based practices and power plans and what is the length of stay for providers who are not," Philiba says.
Health Quest generates individual provider metrics, group-based metrics, adverse event metrics, and facility-based metrics on quality outcomes including length of stay, morbidity, mortality, and readmission.
Clinicians who do not follow order sets and fall short on clinical outcomes are held accountable for their performance through data presented to a hospital executive such as vice president of medical affairs or group lead, Philiba says. "Having the data and the best practices helps to facilitate the conversation regarding a physician's practice."
The emphasis on following a closely managed order set collection has encouraged physician engagement, she says. "Now that my clinicians have a better understanding of power plans and how they work, they feel more empowered to reach out to the IT department and ask about creating a power plan."
Managing medical knowledge
The pace of medical knowledge advancement has accelerated, with the doubling of knowledge estimated at 50 years in 1950 and projected at 73 days next year.
To keep pace, Health Quest is using software from Los Angeles–based Zynx Health to enter updated evidence-based information into the EHR workflows that physicians use daily. With the software, clinicians can click on links to access the latest guidelines, best practices, and peer-reviewed journal articles.
"The thing that I appreciate about the Zynx evidence links is that they are constantly updated when new articles or new guidelines are published. As a clinician, I find it difficult to know when new guidelines are published because they are on a haphazard schedule. You can't expect new guidelines every year—they come out when the evidence comes out," Philiba says.
The links also give clinicians crucial information at the point of care, she says. "Now that we have the evidence links at the point of care and they are constantly updated, guidance is delivered directly to the clinicians instead of making them search for information."
One of the goals of Health Quest's evidence-based medicine initiative is for the links to give physicians EHR-based decision support, Philiba says. The evidence links enable the review of evidence or guidelines with one click in the EHR. For example, cardiologists can get evidence-based information such as bleeding risk and oxygen utilization for heart failure patients.
"It makes information available in an easy and accessible way," she says.
Timely patient assessments and evaluation of symptoms are key care strategies to limit maternal mortality and morbidity.
Cardiovascular disease is a primary contributor to maternal mortality, particularly in the postpartum period.
Women face several cardiovascular disease risks during and after pregnancy, including heart rhythm abnormalities, heart valve conditions, congestive heart failure, and exacerbation of congenital heart defects. Recently released guidelines from the American College of Obstetricians and Gynecologists call for improved screening for cardiovascular disease during and after pregnancy as well as "pregnancy heart teams" for women at moderate to high risk for heart disease.
Jennifer Lewey, MD, is co-director of Penn Medicine's Pregnancy and Heart Disease Program, and director of the Penn Women's Cardiovascular Center in Philadelphia. Lewey earned her medical degree from Harvard Medical School and is board certified in cardiovascular disease and internal medicine.
The Penn Medicine cardiologist recently shared her approach to cardiovascular disease in pregnancy with HealthLeaders. A lightly edited version of that conversation follows.
HealthLeaders:Compare cardiovascular disease risk to other medical pregnancy risks.
Lewey: When looking at all deaths that occur during pregnancy, or in the year after delivery, one of the most common causes is cardiovascular, which includes deaths related to cardiomyopathies, congenital heart disease, valve disease, heart attacks, and stroke.
The risk varies according to the timing. We know that deaths that occur during pregnancy are more likely to be related to non-cardiovascular conditions. Deaths that occur on the day of delivery are due to obstetric causes. In the post-partum period, cardiovascular causes and cardiomyopathy in particular are much more common.
HL:When should pregnant women be assessed for cardiovascular disease?
Lewey: For assessment, there are three categories of women with cardiovascular disease.
There are women who have no cardiovascular disease who are at risk of worsening of their conditions during pregnancy given the hemodynamic changes that occur during pregnancy and delivery. These women may have congenital heart disease or acquire heart disease early in life, for example, valvular heart disease. For these women, they should be evaluated 6 to 12 weeks prior to pregnancy to evaluate their risk during pregnancy and to determine whether they need further testing to evaluate their risk.
Then there is a group of women who may have heart disease prior to pregnancy but were not diagnosed as such. A lot of these women have other risk factors for heart disease that could be diagnosed and optimized 6 to 12 months prior to getting pregnant. These are women who have obesity, severe uncontrolled hypertension, and severe diabetes.
The trickiest part are the women who don't have heart disease but develop it during pregnancy—we're not screening them before pregnancy because they don't have heart disease. This population highlights the importance of monitoring and evaluating new symptoms during pregnancy and the postpartum period.
HL:How do you coordinate care for pregnant women with cardiovascular disease?
Lewey: There needs to be communication between the primary care doctors and the cardiologists who see these women before they get pregnant, and the obstetricians and fetal medicine specialists who follow them during pregnancy.
I refer many of my patients for preconception counseling with an obstetrician prior to pregnancy—it's an opportunity for patients to learn more about their risks during pregnancy. It's also an opportunity for me to communicate with the obstetrician. The idea is we are following the patient together, before, during, and after pregnancy.
The biggest area for improvement is coordinating care after discharge, which is especially true for the women who are newly diagnosed with heart disease during pregnancy or the postpartum period.
HL:Should health systems and hospitals adopt heart care teams for pregnant women with cardiovascular disease?
Lewey: More and more large centers will be doing multidisciplinary heart care teams—it's something we certainly do at Penn. I serve as a point person for the obstetricians when questions arise. For our sickest patients, we discuss them at interdisciplinary meetings that occur at least once a month and more often if needed, so we can come up with a plan for monitoring during pregnancy and a delivery plan.
We're going to see more of these programs in response to the new guidelines and in response to the concerning rates of maternal mortality.
HL: What are the primary cardiovascular risks in the postpartum period?
Lewey: The leading cause of pregnancy-related death in the postpartum period is cardiomyopathy and the development of peripartum cardiomyopathy. Most women will present with this condition in the week after delivery. Oftentimes, it will develop after a woman has gone home from the hospital; however, they can present six months to a year after delivery.