University of Maryland Medical Center shares its recipe for critical care resuscitation unit success.
Critical care resuscitation units (CCRUs) can improve the transfer of critically ill patients from emergency departments to tertiary care hospitals, a recent research article indicates.
Critically ill patients are often transferred from a hospital when the facility lacks the capabilities at tertiary care centers. Transfers of trauma patients are well established, but transfers of critically ill, time-sensitive patients such as stroke patients who need clot retrieval can be impromptu and fragmented. Critically ill emergency department (ED) patients who do not receive timely treatment tend to have negative outcomes.
To rise to this challenge, University of Maryland Medical Center established a CCRU at its R Adams Cowley Shock Trauma Center. The recent research article, which was published in The Journal of Emergency Medicine, examined the impact of the CCRU in its first year—July 2013 to June 2014.
A co-author of the research who is the medical director of the CCRU, Daniel Haase, MD, says there are several differences between a CCRU and a traditional intensive care unit (ICU).
"The CCRU focuses on the acute resuscitation and time-sensitive care of critically ill patients. Our physicians are primarily emergency physicians, and all of them have specialized fellowship training in critical care. Our advanced practice providers and nursing staff are all specially trained and highly experienced," Haase recently told HealthLeaders.
The CCRU has capabilities that are not found in many ICUs, he said.
"Unlike most ICUs at tertiary care, academic hospitals, we are equipped to take care of nearly every kind of patient requiring one of the myriad of mechanical support devices, including extracorporeal membrane oxygenation for respiratory or cardiac failure, extraventricular drain for brain injury, resuscitative endovascular balloon occlusion of the aorta for massive hemorrhage, transesophageal echocardiography for advanced cardiac imaging, and hemodynamic monitoring."
The CCRU also has an elaborate process to help manage the transfer of ED patients, the research article says.
"The initial phone call from the ED provider is to the University of Maryland ExpressCare, which manages all transfer requests from another hospital to our academic hospital. University of Maryland Medical Center specialists immediately organize a conference call with the referring physician, the CCRU attending physician, and UMMC specialty consulting attending simultaneously on the phone call. This allows a single high-level discussion of the patient's clinical condition and appropriateness for transfer," the research article's co-authors wrote.
"The CCRU team then determines the appropriate mode of transport and, based on clinical information, anticipates patient needs, including imaging studies, medication, infusions, vascular access, and monitoring. The CCRU attending also directs medical care during transport. As a result, it took less time for ED-transferred patients with time-sensitive diseases to receive diagnostic studies or to go to the OR compared with ED patients who were admitted to traditional ICUs," the researchers wrote.
CCRU impact data
The research examined data from 1,565 critically ill patients—644 who were transferred to the CCRU and 574 in a 2011 control group who were transferred to ICUs and 347 in a 2013 control group. The research generated three key data points.
Transfers to the CCRU were faster than transfers to ICUs. The median time from a transfer request to arrival at the CCRU was 108 minutes, compared to 158 minutes for the 2011 control group and 185 minutes for the 2013 control group.
After arrival at the CCRU or ICUs, CCRU patients had faster times to undergo surgical interventions in an operating room. The median time for CCRU patients to get into an OR was 220 minutes, compared to 429 minutes for the 2011 control group and 356 minutes for the 2013 control group.
CCRU patients also had lower mortality compared to the ICU patients, with an odds ratio of 0.64.
"This study demonstrated that the CCRU expedited transfer of patients from referring EDs and provided earlier interventions. Patients admitted to the CCRU were associated with lower mortality likelihood compared with patients admitted to other traditional ICUs at our academic quaternary center," the research co-authors wrote.
Keys to CCRU success
The CCRU model at University of Maryland Medical Center will not fit every tertiary care facility, Haase said.
"We were created to focus on the transfer and resuscitation of critically ill patients from outside hospitals because we were seeing delays in transfer and lost admissions for patients that needed tertiary care quickly. Other 'ED-ICU' models exist to focus on boarding issues in the emergency department, while still others focus on prevention of ICU admission of emergency department patients," he said.
Several factors have contributed to the effectiveness of the University of Maryland Medical Center CCRU, Haase said.
"Our creation and success have been predicated on support from hospital administration and supporting specialty services—particularly surgical services and other critical care units—that recognized the need for and supported the idea of the CCRU. We depend on collaboration with our specialty services for training of our physicians, advanced practice providers, and nursing staff as well as the care of our patients. Success of a CCRU is dependent on far more than just the skilled providers that staff the CCRU," he said.
Rapid sepsis testing benefits patients, lowers cost of care, and boosts antibiotic stewardship.
Rapid sepsis testing at Allegheny Health Network has boosted care quality with improved clinical outcomes and reduced costs.
Sepsis is the body's extreme reaction to an infection, which can result in life-threatening symptoms such as multiple organ failure. Annually, more than 1.7 million people get sepsis in the United States, with about 270,000 fatalities, according to Centers for Disease Control and Prevention statistics. One-third of patient deaths in hospitals involve sepsis, the CDC says.
Time to effective treatment is a critical factor for patients infected with sepsis bacteria, says Thomas Walsh, MD, medical director of the Antimicrobial Stewardship Program at Pittsburgh-based AHN. "Every hour delay in antibiotic administration is associated with decreased survival."
For the past eight months, AHN has been using the AcceleratePheno test system to analyze bloodstream infections and determine the best antibiotic therapy for sepsis patients.
Before adopting the relatively new technology, Walsh says it could take AHN two to five days to detect sepsis and match the strain of sepsis bacteria to a narrow-spectrum antibiotic. Now, that process has been shortened to seven hours.
In addition to cutting time to treatment, which improves clinical outcomes, reducing the use of broad-spectrum antibiotics has significant benefits, he says. "We can avoid the downstream effects of unnecessarily broad antibiotic use such as propagating antimicrobial resistance and higher rates of Clostridium difficile."
Antimicrobial resistance to antibiotics is one of the most daunting public health problems of this generation, the CDC says.
Generating positive results
For sepsis patients who were not treated in an ICU, AHN has posted several clinical gains, Walsh says.
"We dropped the time that we were able to identify bacteria from 39 hours to 90 minutes. We were able to decrease the time to knowing which antibiotics would be optimal from 46 hours to 7 hours," he says.
Walsh continues, "For patients who were initially on an inadequate antibiotic, we were able to reduce the time to get them on effective antibiotics from 51 hours to 11 hours. We reduced our length of stay from 8 days to 5.5 days. Our total duration for antibiotics went from 14 days to about 9.5 days."
Similar results have been achieved for sepsis patients treated in an ICU, he says. "For patients who were critically ill who were on inadequate antibiotics initially, we dropped the time to effective antibiotics from 43 hours to 12 hours. That led to a two-day drop in length of stay for those patients. For duration of antibiotics use in the ICU, we went from 15 days to 10 days."
The Accelerate Pheno testing has reduced cost of care, Walsh says. "For these kinds of rapid tests, to run one of the tests is usually between $150 and $200. The cost of being in the hospital is usually between $600 and $1,000 per day. If a patient is in an intensive care unit, the cost is usually between $1,000 and $2,000 per day. So, if you can use this new technology and get patients home two days quicker, you are saving about $1,000–$2,000 per day."
The rapid testing also has reduced medication costs, he says. "We are using less broad-spectrum antibiotics, which tend to be more expensive than narrow-spectrum antibiotics."
Incorporating rapid testing into the sepsis care pathway
The rapid testing technology must be combined with efficient workflows, Walsh says. "For us, the critical part was tying this testing to our antimicrobial stewardship team, which is a team of infectious disease doctors who help our bedside physicians use the appropriate antibiotics to maximize our clinical benefit while minimizing the collateral damage of broad-spectrum antibiotic use."
He says there are three primary steps in the care pathway associated with the rapid testing:
Once a blood culture flags positive for possible sepsis bacteria, microbiology technicians start the Accelerate Pheno testing and call nurses on the floor to alert them that bacteria is growing in the patient's blood and test results will be available within seven hours. The technicians also page the antimicrobial stewardship team, so they are aware as well.
The patient is given a broad-spectrum antibiotic as soon as possible.
When the testing results are available, the technicians call the nurses on the floor, who relay the message to the patient's attending physician that sepsis bacteria have been matched to effective antibiotics. The stewardship team is also alerted, and an infectious disease clinician and a pharmacist review the test results and the patient's medical record. Then the stewardship team members call the patient's care team to make recommendations for antibiotic administration.
"The antimicrobial stewardship team plays a key role. It acts as an intermediary between the technology being performed in the lab and how we act on that information at the bedside," Walsh says.
Yale New Haven Hospital has developed a two-step assessment process for all clinicians who are at least 70 years old and seeking reappointment to the medical staff.
Like the general population, the proportion of the country's physician workforce entering retirement age is growing. In 2019, the American Association of Medical Colleges reported that nearly half of physicians were either at retirement age or approaching retirement age in the next decade: 15% of physicians were more than 65 years old and 27% of physicians were between the age of 55 and 64.
In an article published recently by the Journal of the American Medical Association, doctors from Yale New Haven Hospital and Yale Medical School describe how the New Haven, Connecticut-based hospital is rising to the aging clinician challenge. "The two most important steps in this assessment process are the selection of a neuropsychologist and the selection of the members of the review committee," the article co-authors wrote.
1. Evaluation of cognitive function
For clinicians at least 70 years old, the first step in determining reappointment status is a screening with multiple tests to assess cognitive ability, the JAMA article says. A neuropsychologist administers 16 tests:
Rudimentary information processing (two tests)
Visual scanning and psychomotor efficiency (two tests)
Processing speed and accuracy under decision pressure (one test)
Executive functioning (three tests) such as the ability modify behavior when circumstances change
The time to complete the tests ranges from 50 minutes to 90 minutes.
"A cognitive screening battery of tests was developed and designed to balance brevity with broad coverage of abilities relevant to clinical practice. The instrument was constructed to account for the cognitive decline and neurodegeneration commonly associated with aging," the journal article co-authors wrote.
2. Review committee process
The next step in determining reappointment status is an assessment performed by the hospital's Medical Staff Review Committee (MSRC), the journal article says. The MSRC has four members: the previous and current chief medical officers of the hospital, a faculty geriatrician, and the neuropsychologist who performed testing on the reappointment candidates.
The MSRC reviews the test results and makes recommendations to the hospital's medical staff credentialing panel. Rather than making pass/fail determinations, the MSRC makes a range of decisions based mainly on the cognitive functioning level of reappointment candidates, the journal article says.
Clinicians who post test scores within normal limits are recommended for the hospital's regular credentialing process. These clinicians are subjected to rescreening and recredentialing in two-year intervals.
Clinicians with test scores marginally below normal limits or with weakness but no deficits in one or two abilities are recommended for credentialing. These clinicians are subjected to rescreening and recredentialing in one-year intervals.
Clinicians with some weaknesses that could compromise the safe practice of medicine are requested to have a comprehensive neuropsychological exam.
Clinicians who demonstrate significant deficits in the screening tests are either asked to have the comprehensive exam or undergo evaluation for their ability to practice medicine. If these further reviews show inadequate cognitive abilities to practice medicine, the clinician meets with the CMO and possibly another MSRC member to weigh options including a restricted form of proctored practice and retirement.
Reappointment data
The neuropsychological assessment was conducted for 141 Yale New Haven Hospital clinicians from October 2016 to January 2019, the journal article says. The mean age was 74.3 and the oldest clinician tested was 92.
Most of the reappointment candidates were physicians (125). The other candidates were five advanced practice registered nurses, four dentists, three psychologists, two podiatrists, one physician associate, and one midwife.
The disposition of the MSRC reviews included the following:
Eighty-one reappointment candidates (57.4%) posted screening test scores within normal limits, were recommended for the regular recredentialing process, and were set for rescreening at two-year intervals.
Thirty-four candidates (24.1%) posted test scores marginally below normal limits or with weakness but no deficits in one or two abilities. These clinicians were recommended for credentialing and set for rescreening at one-year intervals.
The testing of 18 clinicians (12.7%) showed inadequate cognitive abilities to practice medicine independently. These clinicians decided to either practice in a proctored environment or stopped practicing medicine.
An editorial accompanying the JAMA article calls for a balanced approach in the assessment of aging clinicians' fitness to practice medicine. "It is imperative that medicine forge a thoughtful path forward—patients deserve nothing less. Nuanced, supportive, evidence-based programs can help ensure that patients are protected from late-career physicians who become affected by cognitive decline, and also that they may continue to benefit from physicians with successful cognitive aging and their unique breadth of experience and wisdom."
Although it has limits, open communication can decrease the emotional and behavioral impacts of medical errors.
Open communication with patients after medical errors decreases emotional impacts and diminishes patient avoidance of doctors and organizations involved in errors, new research indicates.
Earlier research found that about one-quarter of Massachusetts adults had been personally involved in a medical error incident in the previous five years. Errors have been linked to emotional, financial, physical, and socio-behavioral effects such as decreased trust and willingness to seek medical services.
The new research, which was published by BMJ Quality and Safety, produced several significant findings, the study's co-authors wrote. "Our findings highlight substantial persisting emotional harm, healthcare avoidance, and loss of trust in healthcare among 253 patients and family members who self-reported an experience with medical error up to 6 years ago."
Research results
The study features survey and interview data collected from 253 Massachusetts adults who had experienced a medical error personally or through a family member. Open communication was defined with six elements, including acknowledgment of the error, whether the error was discussed openly and truthfully, and whether the error was discussed in terms that were easily understood.
The research generated several key data points.
41% of the subjects reported the medical error occurred in a hospital inpatient setting
27% of the subjects reported the medical error occurred in an ambulatory care setting or doctor's office
A significant proportion of subjects reported physical impacts of medical errors persisted for years. For subjects who reported experiencing a medical error in the prior year, 42% said there were ongoing physical impacts such as loss of function. For subjects who reported experiencing a medical error in the prior 3-6 years, 27% said there were ongoing physical impacts.
Emotional impact was also persistent for years. For subjects who reported experiencing a medical error in the prior 3-6 years, 51% said they had at least one emotional impact from the error. Emotional impacts in the research included anxiety, anger, depression, feelings of abandonment or betrayal by the doctor, and sadness.
The impact of medical errors on healthcare avoidance persisted for years. For subjects who reported experiencing a medical error in the prior year, 45% said they had avoided medical care. For subjects who reported experiencing a medical error in the prior 3-6 years, 37% said they had avoided medical care.
The impact of medical errors on erosion of trust in healthcare also persisted for years. For subjects who reported experiencing a medical error in the prior year, two-thirds said they had lost trust in healthcare. For subjects who reported experiencing a medical error in the prior 3-6 years, 67% said they had lost trust in healthcare.
There was significant variation in subjects receiving the six elements of open communication examined in the study. The most common form of open communication was an offer to ask questions about the medical error, at 46% of subjects. The least common form of open communication was acknowledgment that an adverse event was an error, at 29% of subjects.
Open communication lowered most emotional impacts of medical errors. For subjects who received no open communication, 33% to 52% reported persistent abandonment, anger, depression and sadness. For subjects who reported at least five of the six kinds of open communication, persistence of abandonment, anger, depression and sadness was less than 10%.
For subjects who received no open communication, 77% to 80% said they had avoided doctors and healthcare facilities involved in a medical error. For subjects who reported at least five of the six kinds of open communication, 30% or less avoided doctors and healthcare facilities involved in a medical error.
Open communication has limits, the researchers wrote. "Open communication is not a panacea. Our findings suggest that it does not protect against persistent anxiety, avoiding medical care in general, or loss of trust in healthcare. All three outcomes reflect a common factor—lost faith in the efficacy and safety of medical care."
Boosting open communication
The study suggests a possible solution to improve communication about medical errors and decrease the negative effects, the researchers wrote. "Communication and resolution programs (CRPs), not yet widely implemented, could increase open communication through structured disclosure practices, reducing some of the negative impact of medical error on patients and families."
CRPs have several primary elements, they wrote.
"These programs facilitate transparent conversations about disclosures and apology, and [they] provide compensation for patient injuries when appropriate. In addition, CRPs may need to adopt a comprehensive communication approach that acknowledges the error, explains what happened and why, provides an apology, … and explains how recurrences will be prevented."
A full understanding of the causes of the pay gap between male and female physicians remains elusive.
New research shows the gender pay gap for physicians has persisted into recent years, and the study casts doubt on whether female physician preferences on work-life balance play a significant role in the pay gap.
American medicine was a male dominated field through most of the 20th century. Researchers have found a persistent and widespread gender pay gap among physicians, including a Journal of Hospital Medicinearticle published in 2015 that showed female hospitalists earned $14,500 less than their male counterparts.
The new research, which was published recently in Health Affairs, focuses on physician starting compensation because the approach excludes many variables, the researchers wrote. "Information about new physicians accepting their first non-training position is valuable, as it minimizes unobserved differences in productivity and work experience that may confound analyses of a wider range of physician seniority."
Research data
The study examines 1999-2017 survey data from New York State, featuring survey responses from 9,000 men and 7,000 women. To gauge the impact of more female physicians making work-life balance a higher priority than male physicians, the study examines the survey data from 2014 to 2017, which features responses from 1,800 men and nearly 1,700 women. New York trains more resident physicians than any other state.
Starting compensation was defined as a combination of starting salary and any expected starting pay bonus. Measures of work-life balance were predictable nature of the workday, length of workday, frequency of overnight call duty, and frequency of weekend duty.
The research generated several key data points.
From 1999 to 2017, mean starting compensation was $235,044 for men and $198,426 for women.
Compared to men, women were more likely to rate control over all four measures of work-life balance as "very important." The difference ranged from 9 percentage points to 12 percentage points.
When work-life balance and relationship and family factors were added to the New York survey in 2014, "salary differences changed only negligibly (less than $1,000)," the researchers wrote.
Compared to men, women worked in primary care fields more often and surgical specialties less often.
Choice of specialty played a major role in salary differences from 1999 to 2017, the researchers wrote. "Specialty consistently explained 40% to 55% of the total starting salary differences, with a mean share over the entire period of 46%."
Other significant factors in determining salary differences were all in single-digit percentages. After choice of specialty, time spent in patient care was the second most significant factor, explaining 7% of the starting salary difference from 1999 to 2017.
Interpreting the data
The study indicates that work-life balance preferences have little impact on the gender pay gap between male and female physicians, the researchers wrote.
"Approximately 60 percent of the unadjusted gap in starting salary could be explained by observable characteristics—primarily specialty and hours spent in patient care. However, our analysis showed that physician-stated preferences for controlling work-life balance, including having predictable hours, the length of the workday, the frequency of being on call overnight, and the frequency of weekend duty, had virtually no effect on the starting salary differential between men and women."
To address the gender pay gap, the researchers call for more transparency in physician compensation.
"For example, if greater on-call responsibilities are associated with higher pay, making that expectation transparent and quantifiable is essential for the functioning of physician labor markets. Additionally, residency programs can play an important role in both setting expectations for graduating residents and disseminating information to aid and educate them about salary negotiations. If pay differences are the result of conscious choices, let them at least be well-informed choices," they wrote.
The CDC awarded a $1.8 million contract to Intermountain and the University of Utah to improve antibiotic stewardship at urgent care centers.
With funding from a federal contract, Salt Lake City–based Intermountain Healthcare is developing a four-part set of best practices for antibiotic stewardship in its urgent care clinics.
Urgent care centers are a growing segment of the healthcare sector, with the Urgent Care Association recently pegging the number of clinics nationwide at more than 9,000. In 2018, a Centers for Disease Control and Prevention-led research team published a study on antibiotic-inappropriate respiratory diagnoses at emergency departments, medical offices, retail clinics, and urgent care centers. The researchers found inappropriate antibiotics prescribing was highest at urgent care centers.
In October 2018, the CDC awarded a first-of-its-kind $1.8 million contract to Intermountain and the University of Utah designed to improve antibiotic stewardship at urgent care centers. A top goal is to develop a model for antibiotic stewardship at urgent care centers that other organizations and clinics can adopt across the country.
"Previous studies were conducted in one or two urgent care clinics—this is the first large-scale initiative with the CDC Core Elements for antibiotic stewardship in an urgent care network," says Edward Stenehjem, MD, MSc, medical director of antimicrobial stewardship at Intermountain.
Two factors were pivotal in the CDC accepting Intermountain's bid for the contract, he says. "One, we are a fully integrated health system, so all 39 urgent care clinics are on the same electronic health record, which allows us to capture data. Second, Intermountain is focused on what we call One Intermountain. So, if you present to a rural clinic or an urban clinic, you can get the same standard of care. We have a dedicated urgent care service line that can prioritize initiatives and make antibiotic stewardship a focus across our urgent care clinics."
In addition to following the CDC's request to incorporate the agency's core elements for outpatient antibiotic stewardship, Intermountain reports updates to the CDC every three months. The $1.8 million awarded in the contract is being used primarily to support project management, support the initiative's media and communications team, and support salaries for investigators and an urgent care physician champion.
University of Utah researchers are playing active roles in the initiative. For example, Adam Hersh, MD, PhD, is a pediatric infectious disease physician at the university who serves as the co-principal investigator on the contract with Stenehjem.
4-part antibiotic stewardship initiative
Intermountain has developed four interventions to improve antibiotics prescribing at all of the health system's urgent care clinics, which include Intermountain's urgent care telemedicine platform, Connect Care. The focus of the effort is on treatment of respiratory conditions.
1. Educating clinicians and patients. Intermountain is teaching antibiotics prescribing best practices to physicians, advanced practice practitioners, and patients.
"We are educating patients about when an antibiotic is needed, about delayed prescription, and about symptomatic therapy they can do for their conditions that are not antibiotics. For delayed prescription, a clinician may give patients an antibiotic prescription, but they are asked to wait three to five days to see whether they are getting any better. If patients are getting better, they don't take the medication," Stenehjem says.
2. Electronic health record (EHR) modifications. "We have made some modifications to our EHR to ensure that doing the right thing is also the easiest thing. We have made modifications to streamline the workflow and be able to nudge our providers to do the best thing for the patient," he says.
For example, when an antibiotic is necessary, the EHR helps make sure the antibiotic that is given is the right medication, in the right dose, and in the right duration, Stenehjem says. Order sentences were added to the EHR to help achieve all three prescribing goals.
3. Real-time antibiotic prescribing data. All urgent care clinicians are provided with fully transparent antibiotic prescribing data. "They can log on and look at a dashboard to see how they compare to their peers in their clinic and peers in other clinics across the state of Utah. It allows them to see whether they are a high prescriber compared to their peers or whether they are doing a good job. It also allows them to know areas where they can improve," Stenehjem says.
4. Media campaigns. Intermountain urgent care centers have in-clinic antibiotic stewardship signage in waiting rooms and exam rooms. "In addition, we are using traditional media and social media to try to reach patients and engage them, so when they see one of our physicians or advanced practice providers, the clinician is not the first to tell them about not needing an antibiotic," he says.
Early results
Since launching the four-part initiative in July 2019, Intermountain has achieved significant results at its urgent care clinics, Stenehjem says. Respiratory antibiotic prescribing has been reduced by nearly 30%, and the health system estimates 10,000 antibiotic prescriptions have been avoided.
"That's a lot of antibiotics not going into our communities," he says.
The main metric for the initiative is antibiotic prescribing in respiratory patient encounters—any encounter that includes a respiratory condition whether it is pneumonia, sinusitis, bronchitis, or any other respiratory condition. Intermountain is looking at the percentage of those encounters that involve the prescribing of an antibiotic.
The health system purposely decided not to base data collection on ICD-10 codes, Stenehjem says. "We wanted to keep our primary metric broad because we know that there is incredible variation in the way clinicians code encounters, especially for respiratory encounters."
Studying respiratory condition prescribing is an ideal way to gauge antibiotic stewardship in the urgent care setting, he says. "Urgent care sees a relatively homogenous patient population—the severely ill patients go to emergency departments and urgent care sees lower acuity patients who are often presenting with coughs, colds, and flus. So, we can use a respiratory prescribing measure and look at variation across the health system's urgent care clinics."
Urgent concern
Improving antibiotics prescribing at urgent care clinics is a major front in the battle against antimicrobial resistance, Stenehjem says. "Urgent care clinics are increasing, and we don't have any oversight in terms of antibiotic prescribing in many of those centers. Most clinics are privately owned, and there are not strong incentives for privately owned clinics to prescribe antibiotics well."
The financial incentives at urgent care centers run counter to good antibiotic stewardship, he says. "Think about a private urgent care, where providers make money by fee for service. If a patient comes in and the clinician gives an antibiotic, they can bill at a higher level, which means higher reimbursement. If they give an antibiotic, the visit is often shorter, which means you can see more patients and bill more."
Last year, the Urgent Care Association (UCA) started an initiative to strengthen incentives for antibiotic stewardship at the country's urgent care centers. The Warrenville, Illinois–based trade association and the UCA-affiliated College of Urgent Care Medicine launched their Antibiotic Stewardship Commendation program, which recognizes urgent care organizations that follow best practices for antibiotics prescribing.
Patient experience at urgent care centers is also problematic for antibiotic stewardship, Stenehjem says. "There is a perception that when you give an antibiotic, patients are happier. So, you get a higher patient satisfaction score and better reviews on Google and Yelp. We are going to have to engage payers and others to incentivize antibiotic stewardship in the urgent care setting."
CVS Health and its corporate partner Aetna have launched initiatives to take on some of the most daunting challenges in healthcare.
CVS Health has published a report on six top 2020 healthcare trends and how the pharmacy giant is helping to address them.
Pharmacies are well-positioned to rise to healthcare challenges. For example, through retail clinics and screening programs, pharmacies can make a significant contribution to healthcare access in underserved communities.
1. Digital revolution in healthcare takes hold
Healthcare organizations have embraced data-driven medicine such as the National Institutes of Health All of Us program, which is gathering health-related data on more than 1 million Americans.
Managing a wealth of healthcare data will be a major challenge this year and for years to come.
"No one company will invent all of the breakthrough technologies. Part of our role at CVS Health, given the breadth of our involvement in various areas of healthcare, will be to stitch the information from all of these sources into experiences that are truly meaningful and impactful," Firdaus Bhathena, chief digital officer at CVS Health, says in the report.
For example, CVS Health is harnessing consumer data from several sources within the company, including health insurance, pharmacies, and retail clinics. CVS Health and healthcare insurer Aetna merged in 2018.
"One application has been to use machine learning to calculate the 'next best action' for a healthcare consumer—crunching all of this data and advising when it might be good to get an examination or take a new tactic in managing a chronic condition," the report says.
2. On cusp of advances in kidney care
Chronic kidney disease (CKD) is one of the most challenging health conditions in the country. The Centers for Disease Control and Prevention says that about one in seven adult Americans have some form of CKD.
To help address CKD, CVS Health launched CVS Kidney Care in 2018. Primary elements of the program include CKD identification, patient engagement, and patient education to slow disease progression.
"In 2019, CVS Kidney Care began applying information already available through CVS Health and Aetna to identify people who may not yet know they have kidney disease. Predictive algorithms sort through pharmacy and medical claims, lab data, and demographics to identify individuals at the highest risk for kidney failure. A similar strategy identifies patients who already have a CKD diagnosis, but may be progressing quickly to kidney failure," the report says.
3. Countering epidemic of loneliness
Loneliness is impacting a wide range of Americans. A recent AARP survey found one out of three adults 45 years and older considers themselves as lonely. Last year, CVS Health's Path to Better Health Study showed significant levels of loneliness among millennials, with 48% saying they had no desire to be social outside their homes.
"A lack of connection can have a corrosive effect on health. Loneliness and social isolation are risk factors for depression, impaired cognitive performance, progressive dementia, compromised immune systems, cardiovascular disease and hypertension," the report says.
Aetna has implemented a Social Isolation Index to gauge Medicare patients' risk for social isolation. "The Index, which is based on claims data and multidimensional information related to social determinants of health, helps to identify high-risk Medicare beneficiaries. They will get proactive outreach from specially trained consultants within Aetna's Resources for Living program," the report says.
In 2019, CVS Health, the CVS Health Foundation, and the Aetna Foundation launched Building Healthier Communities, which includes efforts to address loneliness. "It works with local partners at the neighborhood level to promote, among other goals, affordable transportation and new walkable destinations—both keys to a connected community, especially for seniors with limited mobility," the report says.
4. Closing community care gaps and tackling social determinants of health
The most affluent 1% of Americans live on average more than 10 years longer than the least affluent 1%, according to Massachusetts Institute of Technology research.
"Many families in this country are still under- or uninsured and struggle to find the care they need. Without regular access to care, the likelihood of chronic conditions and complications from those conditions increases," Eileen Boone, CVS Health senior vice president of corporate social responsibility and philanthropy, says in the report.
"Recognizing that eight out of 10 Americans live within 10 miles of a CVS Pharmacy location, CVS Health operates Project Health, an annual campaign offering free screenings that can reach deep into underserved communities. … Since it began 13 years ago, Project Health has delivered more than $127 million in free health care services to 1.6 million Americans," the report says.
5. Boosting drug cost transparency
The rising prices of prescription drugs is one of the hottest flashpoints in healthcare. CVS Health is advocating for patients to know more about their out-of-pockets expenses when physicians prescribe new medications.
CVS Caremark, the pharmacy benefit management subsidiary of CVS Health, has developed Real-Time Benefits program to provide more transparency about drug costs.
"These tools can be accessed online, by mobile app, at the pharmacy counter or, most critically, at the time of prescribing. In fact, the program is accessible via the electronic health records for physicians of CVS Caremark members, allowing a physician to check within seconds if the drug they are prescribing is covered for their patient. The database also identifies up to five lower-cost, clinically appropriate alternatives or therapeutically equivalent generics," the report says.
6. Monitoring the self-care market
Americans are spending more than ever on self-care such as fitness and nutrition, and dietary supplements are now used by about three-quarters of Americans, the report says.
CVS Health is helping consumers gauge the safety and effectiveness of dietary supplements. "In 2019, CVS Pharmacy rolled out its Tested to Be Trusted program, a first-in-the-industry initiative that requires supplements sold by the company in stores and online—some 1,400 products—to undergo third-party testing, either with U.S. Pharmacopeia, National Safety Foundation or another independent third-party testing company approved by CVS," The report says.
Healthcare organization leaders can pursue clinician-focused strategies to help achieve successful M&A transactions.
A significant proportion of clinicians have a skeptical view of healthcare organization merger and acquisition (M&A) deals, a survey report published recently by LocumTenens.com says.
Hospitals have been involved in a wave of M&A transactions over the past two decades, with studies documenting a spike in deals since 2010. Several other studies have shown that hospital service pricing increases after M&A transactions. A research article published earlier this month found hospital M&A deals do not improve care quality.
The LocumTenens.com survey report, which was published as part of the staffing agency's 2019 Physician and Advanced Practice Salary Report, is based on data collected from more than 3,500 physicians and advanced practice practitioners nationwide. The survey report includes several key data points.
48% of the clinicians surveyed said they did not feel valued by the new organization after an M&A transaction
39% of survey respondents said it took more than a year to integrate the organizations involved in an M&A deal
39% of respondents did not think leaders placed adequate value on shared culture
Only 20% of respondents said their organization became more efficient after an M&A deal
43% of respondents did not think the cost of care for patients decreased
35% of respondents did not think quality of care improved
Clinician participation in M&A deals
Chris Franklin, president of LocumTenens.com, which is a subsidiary of Alpharetta, Georgia-based Jackson Healthcare, recently shared three clinician-focused strategies to achieve effective M&A deals.
1. Valuing medical staff after an M&A deal: The most meaningful action healthcare organization administrators can take to ensure medical staff feel valued after a merger or acquisition is to take a step back and listen, Franklin said.
"Encourage a culture where staff don't feel afraid to voice their opinions, concerns, and fears, and be open to their ideas. The employees are the ones who are most affected by policies and procedures day in and day out. They are knowledgeable and can provide healthcare organizations with a unique perspective and unique solutions to issues likely to arise during consolidation."
2. Promoting a shared culture: An organization's culture is defined by how it lives and models its values and beliefs, he said.
"A first step in a newly consolidated organization promoting a shared culture is reaching common ground on how values and beliefs contribute to achieving mission and vision. Be sure to actively involve medical staff in these conversations rather than disclosing details once they've concluded, and make sure that what emerges from those conversations is woven into every aspect of the organization's behaviors."
3. Amplify clinician voices throughout the M&A process: One of the best ways to amplify clinician voices during a consolidation is to regularly administer brief and anonymous surveys to medical staff, Franklin said.
"If the surveys are anonymous, clinicians are more likely to provide honest feedback. This is also another way to help them feel valued. It's not enough to simply conduct the surveys, though. Administration needs to acknowledge the collective feedback they receive and demonstrate how they are thoughtfully considering solutions and making progress toward resolving any issues that the surveys highlight."
Hospitals can promote good nutrition and healthy lifestyles through many programs, including plant-based menus and educational efforts.
There are a growing number of successful nutrition and lifestyle initiatives at health systems and hospitals across the country, a recent journal article shows.
Largely due to poor dietary habits and sedentary lifestyle, the number of overweight Americans has reached pandemic proportions. More than two-thirds of Americans are overweight or obese, according to the National Health and Nutrition Examination Survey. Dietary risks are now a top cause of premature death.
The recent journal article, which was published in The American Journal of Medicine, says hospitals are well-positioned to have a positive impact on patient weight. "Acute care settings present an opportunity to improve nutrition and lifestyle of patients, especially because patients may be highly motivated to embrace these tools as part of the healing process," the co-authors wrote.
Boosting hospital nutrition
There are several examples of initiatives designed to improve the hospital food environment for inpatients, visitors, and employees, according to the journal article.
Partnership for a Healthier America is a public-private program developed by former first lady Michelle Obama. "It encourages hospitals to offer lower-calorie meals, eliminate deep-fried products, increase fruit and vegetable offerings, promote healthful beverages, and keep unhealthy snack foods away from cash registers," the co-authors wrote.
The American Medical Association has urged hospitals to implement three measures to improve hospital food: offering a range of healthy food such as plant-based meals and meals that are low in fat and added sugar; dropping processed meats from meals; and providing healthy drinks.
At least five hospitals and health systems offer 100% plant-based meals to patients on a separate menu, give educational materials to inpatients on how diet impacts chronic disease, and include their plant-based menu in admission orders to require physicians to have diet-related conversations with inpatients: Tampa, Florida-based James A. Haley Veterans' Hospital; New York-based Lenox Hill Hospital; Bronx, New York-based Montefiore Health System; Denver, Colorado-based National Jewish Health/St. Joseph Hospital; and Gainesville, Florida-based UF Health Shands Hospital.
Outpatient initiatives
There also are several examples in the journal article of health systems that have nutrition and lifestyle programs for outpatients.
New York-based NYC Health + Hospitals/Bellevue has implemented a pilot program that promotes plant-based nutrition and lifestyle changes to lower cardiometabolic risk. The program features a team with physicians, a dietitian, and a health coach.
UF Health in Gainesville assesses diet and lifestyle in an outpatient prevention cardiology program, which includes hour-long meetings with a preventative cardiologist. Patients also meet with physician educators to promote plant-based meals and create an eating plan and grocery list.
Since 2017, Manhattan, New York-based Northwell Health has launched three nutrition initiatives for outpatient settings: offering fresh products such as antibiotic-free chicken; reducing and eventually eliminating sugar-sweetened drinks in areas such as cafeterias and coffee shops; and eliminating fryers and pre-fried food.
Beginning in 2003, Oakland, California-based Kaiser Permanente developed a network of more than 50 hospital- and clinic-related farmers markets.
The Cardiology Division at Montefiore Health System has a plant-based prevention clinic that includes free Saturday morning sessions for patients with a physician and a registered dietitian to learn about plant-based nutrition.
Implementing nutrition initiatives
The lead author of the journal article told HealthLeaders there are key commonalities in hospital nutrition programs.
"All of the initiatives focus on adding more plants into the hospital foods, eliminating refined and simple sugars and processed foods, and offering more fiber-rich foods. We have a common focus, and everyone realizes that hospital food programs need improvement," said Monica Aggarwal, MD, an associate professor in the Division of Cardiology at the University of Florida in Gainesville, and director of integrative cardiology and prevention at UF Health Shands Hospital.
UF Health Shands Hospital has transitioned to healthy food and beverages without having a negative impact on patient satisfaction, she said.
"Patients are understanding the common goals. We have a lot of supportive education to explain why we want people to eat more plants. On our regular menu, we also have a lot of plant-based options, so that those who may be intimidated by the idea of plants can see it is an option. That has really helped—people often prefer plants and don't realize it."
Becoming more customer-friendly for patients was the primary reason IU Health launched its online ratings and reviews initiative, executive director of digital marketing and experience says.
Indianapolis-based IU Health has launched and implemented an extensive effort to post physician and clinic-level star ratings and reviews online.
After University of Utah Health pioneered online physician reviews in 2012, a small but growing number of health systems have followed in its footsteps. For health systems that have implemented posting online ratings and reviews, the initiatives are viewed as an essential element of transparency and patient experience.
Becoming more customer-friendly for patients was the primary reason IU Health launched its online ratings and reviews initiative in 2018, says Jeremy Rogers, the health system's executive director of digital marketing and experience.
"We heard from our patients through studies and surveys that they wanted to have this type of information when they were making critical decisions about who their next physician or provider would be. We all know in our modern lives that we use ratings and reviews for almost every decision we make—whether it's our next vacation or purchasing a new car. One of the first things we do is go online and look for reviews from other customers," he says.
The IU Health initiative has achieved significant results since its launch a year-and- a-half ago:
The health system is publishing ratings and reviews for more than 1,500 clinicians
About 150,000 reviews have been posted online
The volume of reviews is growing by about 7,500 reviews per month
The average provider star rating is between 4.6 and 4.7 out of 5 stars
More than 500 IU Health locations are getting star ratings. "These locations are at the clinic level, so a hospital could have dozens of locations with star ratings," Rogers says.
How online ratings and reviews are generated at IU Health
Star ratings and online reviews are drawn from a patient experience survey developed at IU Health three years ago.
For every patient inpatient and outpatient encounter, within 48 hours patients receive an email or a text message asking them to respond to the survey. The survey has a half-dozen questions such as likelihood to recommend a clinician to friends and family, whether the clinician spent enough time with the patient, and whether the clinician made the experience easy for the patient.
"We get a strong response rate to our surveys—about 20% to 25% of patients respond. On an annualized basis, we are processing about half a million survey responses," Rogers says.
In addition to generating star ratings for physicians and advanced practice practitioners, the data is used internally for score cards that go out to administrators and individual clinicians to show the experience they are providing to patients.
Online reviews are more difficult to administer.
"Every month, we load the raw data from the third-party administrator of our experience surveys. We then have processes such as scrubbing out protected health information and scrubbing out profanity and incoherent language. These processes are all done using machine learning and artificial intelligence techniques. We have published about 150,000 patient reviews over the past year and a half. Once we've done the scrubbing, we then publish the reviews automatically," he says.
IU Health publishes both positive and negative reviews, and the health system rarely blocks publication of a review, Rogers says. "Our intent is to never edit a comment. We want to have the patient's review in their own words."
There is also a governance model to manage reviews when clinicians raise concerns about patient comments. A common example that requires governance is when a clinician questions whether a patient review should be directed to another provider because the patient has commented on the wrong clinician, he says.
"We have patients who have multiple IU Health physicians and they can have multiple appointments in a week. Occasionally, these patients may respond to the wrong survey for an encounter. In these cases, we have a governance process [in which] our team digs into the electronic medical record to verify the data based on the encounter ID of the survey."
Other clinician concerns are less clear cut, such as when a provider thinks that a review is unjust or does not reflect a patient encounter accurately. In those cases, the chief medical officer for the physician group in question conducts research to help determine whether a review should be removed.
"We're not trying to be punitive to our providers or trying to foster a culture where they feel disrespected, but we must be transparent. So, we are balancing both transparency for our patients and fairness for our physicians," Rogers says.
Impact of online reviews
IU Health has made several changes based on comments in online reviews, he says. "Part of our overall effort with online reviews is to empower our providers and other staff to drive change at the local level. For example, based on the real-time feedback from patients, our team members and providers have leveraged reviews from the patients to improve the performance of registration staff or add valet parking to their location."
Wait times are a common topic in negative reviews, which have prompted the health system to improve access at some clinics, Rogers says. "We use the data from the reviews to analyze how we are scheduling the providers, and, in some cases, how we are recruiting providers. If we see areas where we don't have sufficient access, we make changes to address that issue."
At IU Health, online ratings and reviews have become a key ingredient for patient engagement, he says.
"When you talk about consumers in healthcare, it is no longer optional for patients to have choice and options in their care. For us, we are moving beyond just physician ratings and reviews. We publish ratings for locations such as urgent care clinics. We are publishing ratings and reviews for advance practice providers. Patients expect this level of transparency and empowerment."
