The primary goal of the project is to keep most geriatric patients at rural hospitals through telemedicine rather than transferring them to Dartmouth-Hitchcock Medical Center.
Telemedicine is the cornerstone of a Dartmouth-Hitchcock Medical Center geriatric emergency department (GED) initiative with four rural hospitals.
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.
In a partnership with West Health, Lebanon, New Hampshire–based Dartmouth-Hitchcock Medical Center (DHMC) has launched a three-year effort to build a "hub-and-spoke" model GED. Work to establish the hub at the medical center began in fall 2019 and is set to finish at the end of this year. Four rural hospitals will join in the effort as spoke facilities during year two and year three of the initiative.
"Most of the other accredited GEDs nationally are in more urban settings than ours. Related to that, we will be the first GED that uses telemedicine to extend central resources to rural spoke sites," says Scott Rodi, MD, chief and regional director of emergency medicine at DHMC.
The GED initiative is expected to be a threefold win. Older adult patients will benefit by receiving high-quality emergency department services close to home, the four rural hospitals will benefit from having fewer patients transferred to DHMC, and the medical center will benefit from being able to keep more beds open for high-acuity patients who generate higher reimbursement rates.
"The idea is to keep geriatric patients near home in their regional hospitals and to keep the most complicated cases coming to Dartmouth-Hitchcock rather than patients who are frail with simple medical problems and needing a lot of social support. If we can do that, we will provide better care and increase capacity at Dartmouth-Hitchcock for the complicated patients who need tertiary care and generate increased reimbursement," says Daniel Stadler, MD, director of geriatrics at DHMC.
How the rural GED will work
The GED initiative has five primary building blocks, Rodi and Stadler say.
1. Hub: The first step in the initiative is creating a GED at the medical center's emergency department.
Rodi says the organization is creating an area in the existing emergency department that will be generally dedicated to the geriatric population. Modifications to the space include larger clock faces, non-skid surfaces, and telephones that have a large keyboard. Telemedicine equipment will likely be cart-based.
"The project is much more about people and process than it is about bricks and mortar," Rodi says.
2. Staffing: Staffing the GED will include using new or "repurposed" personnel, Rodi says. Stadler will serve as a co-director of the GED with an ER physician, a new emergency department nurse will develop care protocols and implement screening tools, and new care management staff members will help establish community connections and bring local resources to bear for the geriatric population.
Rodi and Stadler are also creating a pool of geriatricians who will be on call for the GED at the medical center and via telemedicine when the spoke sites are activated. "We will have access 24/7 to a geriatrician who is part of this project," Rodi says.
3. Screening: At the triage level, screening tools are an essential process component of the GED project, Rodi says. "When a patient who is over 65 years old presents, there will be screening for dementia, fall risk, and other factors that will trigger additional actions such as reviewing the medication list or bringing home-care resources to bear depending on the screening tool that has been activated."
4. Accreditation: The GED at the medical center hit its first milestone in January, when the first geriatric patients received care at the GED. The next milestone for the hub site is gaining Level 1 GED accreditation status. "It's analogous to trauma certification. You have Level 1 trauma centers and now there are going to be Level 1 GEDs," Rodi says.
The accrediting organization is the American College of Emergency Physicians, and the spoke hospitals will be required to attain Level 2 or Level 3 GED accreditation.
5. Spokes: Criteria for selection as a spoke hospital features operating in a rural market, Rodi says. "In our area, many of the hospitals are considered critical access hospitals. Their financial viability is only possible because they get some preferential federal pricing for their services. Critical access hospitals are generally rural, with limited access to tertiary care. Almost certainly, our four spoke sites will be critical access hospitals."
In addition to geriatrician consults 24/7, the spoke hospitals will receive a range of services from the medical center's GED, Stadler says. Care managers will be well-versed in the community resources available near DMHC and the spoke hospitals.
"As another example, if a spoke hospital felt they could keep a patient if only they could get an endocrine consult or a cardiology consult, we are hopeful that we would be able to leverage telehealth to bring specialty consults to that hospital," Stadler says.
Modes of telemedicine communication will be telephone calls and video links, he says. "Whether we are on-site or not, we can pull in the son who lives in California, the daughter who lives in Chicago, and a member of the primary care team down the road all using telehealth. They can all engage in a meeting—we call it Brady Bunch technology because of all the faces on the screen. We're training care managers to facilitate those conversations."
Monitoring progress
The initiative is set to receive $4.5 million in funding over the first three years, with West Health contributing $3 million and Dartmouth-Hitchcock Health contributing $1.5 million.
"West Health is paying more in the beginning and Dartmouth-Hitchcock will be taking on more over time. The thought is that once the three-year period is over, Dartmouth-Hitchcock will fund the GED going forward," Stadler says.
Project managers will be monitoring several metrics, he says.
Patient transfer rates from spoke hospitals
The time that geriatric patients spend in emergency departments. "We know the longer geriatric patients spend in an emergency department the higher the risk of delirium, falls, and decompensation," Stadler says.
Goals of care such as determining whether patient care is in concordance with advance directives
Percentage of patients screened
Percentage of patients referred to community resources
Emergency department throughput for geriatric patients, which will help to determine whether low-acuity patients are being admitted for inpatient care at DHMC
"There is good data showing that when frail elders are cared for in quieter settings with their family around, they have better outcomes and spend less time in the hospital. When they come to busy tertiary academic centers far from home and far from familiar surroundings, they have a much higher tendency to get delirious and they generally have long hospital stays," Stadler says.
Yale New Haven Hospital's Late Career Practitioner Policy violates two anti-discrimination laws, federal lawsuit contends.
Yale New Haven Hospital's Late Career Practitioner Policy, which features an assessment of whether clinicians 70 and older are fit to practice medicine independently, has been challenged in federal court.
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.
The Late Career Practitioner Policy at Yale New Haven Hospital (YNHH) requires clinicians who are at least 70 years old and seeking reappointment to the medical staff to undergo vision and neuropsychological assessments. The evaluation of cognitive functioning includes a battery of 16 tests. The hospital's Medical Staff Review Committee supervises the process of determining whether impaired clinicians can practice medicine independently or should retire.
Clinicians under age 70 are not subject to the evaluation.
Last month, the federal Equal Employment Opportunity Commission (EEOC) filed a lawsuit in the U.S. District Court for the District of Connecticut challenging the Late Career Practitioner Policy. The lawsuit claims the hospital's policy violates the Age Discrimination in Employment Act and the Americans with Disabilities Act.
"While Yale New Haven Hospital may claim its policy is well-intentioned, it violates anti-discrimination laws. There are many other non-discriminatory methods already in place to ensure the competence of all of its physicians and other healthcare providers, regardless of age," Jeffrey Burstein, regional attorney for the EEOC's New York District Office, said in a prepared statement.
The EEOC's New York District Office oversees Connecticut, Maine, Massachusetts, New Hampshire, New York, Northern New Jersey, Rhode Island, and Vermont.
A YNHH spokesman told HealthLeaders the hospital is confident that the policy will withstand the court challenge.
"Yale New Haven Hospital's Late Career Practitioner Policy is designed to protect our patients from potential harm while including safeguards to ensure that our physicians are treated fairly. The policy is modeled on similar standards in other industries and we are confident that no discrimination has occurred and will vigorously defend ourselves in this matter," YNHH spokesman Mark D'Antonio said.
A tentative shift from fee-for-service to value-based payment models has constrained primary care initiatives under the Affordable Care Act, new research suggests.
In its first decade, the Affordable Care Act (ACA) sparked significant innovations to boost primary care but new payment models lacked sufficient incentives to drive change, new research suggests.
President Barack Obama signed the ACA into law on March 23, 2010. One of the top goals of the healthcare reform law is to improve primary care. A body of research indicates that robust primary care capabilities are linked to lower healthcare spending, better clinical outcomes, and lower mortality rates for several conditions.
The new research, which was published today by Health Affairs, examines the impact of primary care reform initiatives launched under the ACA through the Center for Medicare & Medicaid Innovation (CMMI). The initiatives generated mixed results, the study co-authors wrote.
"Considerable progress has been made in understanding how to implement and support different approaches to improving primary care delivery in that decade, though evaluations showed little progress in spending or quality outcomes. This may be because none of the models was able to test substantial increases in primary care payment or strong incentives for other providers to coordinate with primary care to reduce costs and improve quality."
Research data
The Health Affairs study includes data showing the largely limited impact of seven CMMI primary care reform initiatives on healthcare spending, utilization, and quality for Medicare fee-for-service beneficiaries.
1. Comprehensive Primary Care (CPC)
Spending: No effect
Hospitalizations: Reduced by 2%
Quality: No significant effect
2. Comprehensive Primary Care Plus (CPC+)
Spending: Increased by 2% to 3% in first year
Hospitalizations: No effect
Quality: Small quality-of-care measure improvements
3. Federally Qualified Health Center Advanced Primary Care Practice Demonstration
Spending: Small increases
Hospitalizations: Small increases
Quality: Mixed patient experience impacts
4. Independence at Home Demonstration
Spending: No effect
Hospitalizations: No effect
Quality: Reduced preventable hospitalizations by 6.7%, but there was no effect on hospital readmissions
5. Health Care Innovation Awards: Primary Care Redesign programs
Spending: One awardee (hospital) achieved a 31% reduction in Medicare spending
Hospitalizations: Two awardees reduced combined hospitalizations and emergency department visits by 6% and 15%
Quality: Awardees improved quality-of-care measures by 2% to 10%
6. Multi-Payer Advanced Primary Care Practice Demonstration
Spending: No states achieved savings and two states increased spending
Hospitalizations: Decreased in one state but increased in two states
Quality: Three states improved process-of-care measures, but three states had unfavorable results in process-of-care measures
7. State Innovation Models initiative, round one
Spending: Increased in one of three states by 12.3%
Hospitalizations: Inpatient admission rates were reduced by 34.6% in one state but increased by 15.5% in another state
Quality: Two states achieved small improvements in quality-of-care measures
"Model results show how hard it is for primary care delivery—in the context of modestly reformed payment that still rests firmly on a fee-for-service chassis—to improve cost and quality outcomes," the study co-authors wrote.
ACA primary care model keys to success
The lead author of the study, who has experience as an evaluator of the CPC and CPC+ initiatives, told HealthLeaders that primary care practices can have their greatest effect on overall healthcare spending by reducing hospitalizations.
"Many of the models encouraged practices to work with hospitals to alert the practice when a patient was admitted or discharged from the hospital or the emergency room, so they could work with patients to prevent future admissions when clinically appropriate," said Deborah Peikes, PhD, MPA, a senior fellow at Princeton, New Jersey-based Mathematica.
She said there are three other main ways primary care practices could reduce hospitalizations through the CMMI initiatives or other programs.
First, primary care practices in the CMMI models were encouraged to enhance care management for patients with complex needs, including teaching patients self-care for chronic conditions. "The goal of enhanced care management and self-care is to improve patients' quality of life and to prevent patients' conditions from worsening, thereby avoiding preventable hospitalizations," Peikes said.
Second, some CMMI models also attempt to improve the coordination of care with specialists, she said.
Third, Peikes said data feedback to help clinicians understand which patients and diagnoses are driving costs can also be helpful.
She also provided advice for primary care practices seeking to make gains through CMMI initiatives.
Practices should be prepared to make substantial changes in how care is delivered, Peikes said. "To succeed in such efforts, it is important to build buy-in among the practitioners and staff at the practice. A healthy learning culture where everyone has a voice and feels empowered to try new things and see what worked well and what did not will help practices redesign multi-step work processes and avoid team burnout."
Patients are an important piece of the puzzle, she said. "Primary care practices that engage their patients, encourage them to set goals and take better care of themselves, and solicit their feedback on how to improve their experience are more likely to be successful. Promising approaches include shifting from dictating recommendations to exploring the patient's readiness to change and using motivational interviewing."
Primary care practices should consider the impact of participating in a CMMI model carefully, Peikes said. "Practices should make sure they understand the incentives baked into the new payment approaches tested in the ACA models, which patients are covered, and the standards that need to be met to earn any bonuses or shared savings. They should weigh the benefits versus costs of model participation and investment in care delivery changes, such as new staff, technology, and time spent on different aspects of care."
At Bascom Palmer Eye Institute, the annual cost savings from switching to alcohol-based scrubbing is estimated at $281,000 per operating room.
Switching from water-based surgical scrubbing to an alcohol-based method generates substantial cost savings and environmental benefits, new research shows.
Preoperative hand scrubbing has been an established practice since the 1800s. The safety and efficacy of alcohol-based scrubbing is well-established, including an endorsement published in 2014 by the American Hospital Association, the Infectious Diseases Society of America, The Joint Commission, and the Society for Health and Epidemiology of America.
The new research, which was published today by JAMA Ophthalmology, examines the potential for cost savings from alcohol-based scrubbing at the University of Miami Miller School of Medicine's Bascom Palmer Eye Institute (BPEI).
"Waterless hand antisepsis is now well established as equal to or superior to traditional running-water scrubs in safety and efficacy. Our study suggests that the actual cost saving in water alone is eclipsed by savings in supplies as well as staff and facilities resources," the research co-authors wrote.
Research data
The JAMA Ophthalmology study, which was conducted in 2019, developed several key data points.
Eliminating water-based scrubbing would result in saving $277 in water and sewer cost per operating room per year.
For supply costs, savings from switching to alcohol-based surgical scrubbing range from $548 to $1,360 per operating room per year.
When calculating personnel costs associated with standard 5-minute and 6-minute scrubbing with soap and water, alcohol-based scrubbing would save between $280,000 and $348,000 per operating room per year. The World Health Organization's recommendation for waterless scrubbing is 40-70 seconds.
At BPEI, which has 10 ORs, the annual savings from lower personnel costs associated with alcohol-based scrubbing would be $2.8 million to $3.4 million.
If every surgical procedure at BPEI was performed with water-based scrubbing, about 163,000 gallons of water would be consumed annually.
From 2014 to 2018, BPEI performed an average of nearly 13,000 surgical procedures annually, with an average of three scrubbed staff members in the OR per procedure.
"A conversion from traditional water-based preoperative hand antisepsis to waterless, alcohol-based techniques has the potential to save a modern U.S. healthcare institution $281,323 per OR per year with a surgical volume similar to that of BPEI. Although there are environmental imperatives for saving water, by far the largest component of actual cost savings is attributable to the lower costs of supplies and the savings in chargeable OR time associated with waterless scrub techniques," the study co-authors wrote.
Environmental impact
Alcohol-based scrubbing contributes to water conservation, the co-authors wrote. "Access to clean water is a large obstacle to improving health outcomes in impoverished regions. Conserving water in the OR will help to alleviate the burden of healthcare on public water stores."
Waterless scrubbing also helps protect the environment, they wrote.
"Antibacterial agents used in hand soaps immediately enter the sewer system and pass through a sewage treatment plant to enter rivers and coastal waters. In doing so, they create a toxic environment for aquatic life, which is of growing concern worldwide. Alcohol-based scrubs, on the other hand, do not enter the ecosystem, except to the extent that residues are later washed off the skin during casual handwashing, bathing, or swimming."
Operating room black boxes collect video and audio of the OR staff as well as images of the surgical field.
Black boxes not only help ensure airliner safety, but they are now used to ensure the quality and safety in Northwell Health operating rooms.
In February 2019, the Manhattan-based health system became the first in the nation to deploy OR Black Box, technology developed at Surgical Safety Technologies in Toronto, Canada. At Northwell, OR Black Box has been used to examine adverse events in granular detail, to assess teaching in ORs, and to look for improvement opportunities.
Northwell is piloting the black box technology with laparoscopic urologic and colon surgical teams at Long Island Jewish Medical Center, says Mark Jarrett, MD, MBA, senior vice president, chief quality officer, and deputy chief medical officer at the health system. "It takes several inputs from the room—the physiology, audio from microphones, video of the staff, and the digital image from the scope to make certain that the gradings of the surgical technique and the teaching going on are analyzed."
OR Black Box is designed to record laparoscopic procedures, which is why urologic and colon procedures were chosen to pilot the technology, he says. "We wanted laparoscopic surgery because it depends on the digital feed from the camera of the actual surgery."
Northwell also picked urologic and colon surgical teams to be the first ORs with the black box technology because there were eager physician champions willing to pioneer the initiative, Jarrett says. "It required a physician champion with a team in the OR that would feel comfortable doing this."
The OR Black Box computer packages the scope video with video and audio collected from the OR staff as well as physiology data collected from the patient such as heart rate, pulse, blood pressure, and oxygen level. Then all the time-synched data is sent electronically to Surgical Safety Technologies for analysis.
"It pays for all of us to do the analysis centrally—it leads to more reliability and validity. By doing the analysis centrally, we can also share information between hospitals. For example, if Northwell does 150 urology cases and five other medical centers do 150 urology cases each, we can have 900 cases analyzed. That will give us better information in terms of things that happen frequently and infrequently. Maybe there is a near miss that happens once every 300 cases," Jarrett says.
The cost of the black box equipment is $100,000 per OR.
How Northwell uses black box technology in operating rooms
At Northwell, all black box data collected in an OR is de-identified, he says.
"It's the team approach that we look at. Everything is de-identified. The cameras blur out the faces of the OR team members. The purpose is to look for system issues—not individual people issues. That was important because one of the fears of people was having Big Brother watching over them. We are not looking to get anyone in trouble. What we are looking for is system issues that we can correct to protect the patients. It's about taking a proactive approach based on the data."
De-identifying the data also protects patient privacy, Jarrett says.
Taking a team approach for analysis of OR Black Box data is a key element of capitalizing on the new technology for OR performance improvement, he says.
"Outcomes are not totally dependent on the surgeon. They are also dependent on the interplay between all the nurses in the room, the anesthesiologist, the problems that occur no matter how good the surgeon is, and how those problems are addressed. All those things can be looked at because the technology uses digital algorithms much like a black box in a plane."
Northwell is also generating surgical technique and teaching gains from the black box technology, Jarrett says.
"When we do the analysis of the video for technique, we can give scores for it and we can show what happened. We can use this information at conferences to show how a surgeon approached a problem and achieved a great outcome. So, you can use this information for teaching. For residents who rotate into a service for four months, you can see whether there is improvement in performance or not to assess the quality of the teaching program."
And the black box technology is well-suited to analyzing adverse events, he says.
"Adverse outcomes can occur even when nobody does anything wrong—it can be the anatomy of the patient. However, when we analyze the surgery, we can ask whether there was any way to anticipate the anatomy was different than expected and how the situation was addressed. Was it addressed in a timely fashion? Did the surgeon communicate that there was a problem and what was needed to address it? Was all the right equipment in the room?"
Jarrett says "it's too early in the game" to measure the impact of OR Black Box at Northwell, but the pilot program is focusing on an area for improvement—distractions. "There are a lot of distractions in the OR. Not all of them are bad, but there are more distractions than we realized, which is one of the reasons we are studying their impact."
A major distraction identified in analyzing the black box data is people leaving and entering the OR, he says.
"Some people go out of the room for breaks, some people go out of the room to get special equipment, but the question is do we need to have that happening all the time? We may want to limit people going in and out of the OR, and the black box technology can tell us whether that kind of a rule makes a difference. We want to base decisions about our protocols on real data rather than assumptions."
Adapting to black box technology
The OR teams that have worked with OR Black Box have acclimated to the technology, Jarrett says. "Now that we have been doing this for a year, the first team performs like it doesn't even know the black box is there. They turn it on at the beginning of a case, turn it off at the end of a case, and work as if it wasn't even there. They get used to it."
Northwell is considering whether to install the black box technology at more hospitals in the health system, and several other U.S. health systems are contracting for OR Black Box with Surgical Safety Technologies this year, he says.
CareMore Health's care management program in Tennessee has multidisciplinary care teams with community health workers, primary care providers, and social workers.
A care management program in Tennessee for high-need, high-cost Medicaid patients reduces healthcare service spending and healthcare utilization, research published this month indicates.
"Superutilizer" patients account for a disproportionate share of healthcare spending in the United States, with earlier research finding that 5% of the country's population accounts for 50% of annual healthcare expenditures. A study published last month by New England Journal of Medicine stirred controversy about care management programs for superutilizer patients—finding that the Camden Coalition of Healthcare Providers "hotspotting" program did not reduce hospital readmissions.
The research published this month, which appears in American Journal of Managed Care, features a care management program for Medicaid patients conducted by CareMore Health in Memphis, Tennessee. The lead author of the CareMore research told HealthLeaders that the NEJM study is a reminder that there is no silver bullet for hotspotting, but he said care management for complex patients should continue.
"The results from our evaluation of CareMore’s complex care management program suggest that carefully designed and targeted programs can improve care and reduce spending for high-need, high-cost patients. Hopefully, this results in a more optimistic view on the potential of hotspotting, and spurs continued work to develop care models that better serve our most complex patients," said Brian Powers, MD, MBA, director of population health strategy and analytics at CareMore.
CareMore research data
The CareMore care management program was staffed with a multidisciplinary team including a community health worker, a social worker, and a primary care provider.
The community health worker conducted patient accompaniment, activation, engagement, and outreach. The social worker conducted counseling and brief interventions for patients with behavioral health needs and coordinated referrals to social service agencies and other medical providers. The PCP conducted comprehensive care for acute and chronic conditions as well as coordination with specialists and inpatient clinicians.
The CareMore research examined data collected from nearly 200 Medicaid patients, with 71 assigned to the care management program and 127 assigned to usual care over a year-long period. The research includes several key data points:
Compared to patients receiving usual care, care management program patients had significantly lower total medical expenditures ($7,732 lower per member per year)
Care management program patients had 3.46 fewer inpatient bed days per member per year
Care management program patients had 1.35 fewer specialist visits per member per year
"A complex care management program reduced spending and inpatient utilization among high-need, high-cost Medicaid patients. Patients randomized to complex care management had [total medical expenditures] that were 37% lower than those randomized to usual care, an absolute reduction of $7,732 per patient per year. This spending reduction appeared to be driven primarily by decreases in inpatient utilization—bed days were reduced by 59% and admissions by 44%," Powers and his co-authors wrote.
Keys to care management success
Powers told HealthLeaders that CareMore's hotspotting program has four essential elements.
Target the right patients: CareMore's care management program used predictive models, claims data, clinical criteria, and clinician judgment to identify "rising risk" populations and those most likely to benefit from complex care management, rather than focusing on historical "superutilizers" whose care needs and spending often regress to the mean.
Incorporate non-traditional healthcare staff such as community health workers: CareMore's hotspotting program underscored the important role that community-based, non-medical team members play in engaging patients, building trust, and better understanding and managing the non-medical drivers of poor outcomes. For example, the community health worker served as an engagement specialist, creating a safe and welcoming environment for patients and utilizing their training to increase patient motivation and activation. The community health worker also functioned as the engaged family member that many patients lacked.
Integrate within the clinical team: The care management program was built into an existing medical home model. This removed barriers for collaboration and coordination between the community health worker, social worker, and primary care physician. It also allowed the care team to simultaneously address the medical and non-medical drivers of poor outcomes, rather than approaching each in a siloed fashion.
Focus on the most impactable drivers of poor outcomes: The hotspotting program tailored complex care management to the needs of individual patients rather than using a one-size-fits-all approach. For each patient, the care team identified and prioritized patients' unique drivers of poor health and high costs, with a focus on the drivers that mattered most to the patient and those that could be addressed over the course of weeks and months. This was essential for improving efficacy and efficiency.
A new study finds that female and minority medical students face significantly higher rates of mistreatment compared to male and white students.
Women, racial and ethnic minorities, and sexual minorities bear a disproportionate share of medical student mistreatment, new research shows.
In medical school, mistreatment of students includes a range of actions such as assault, discrimination, sexual harassment, and verbal abuse. Mistreatment has been linked to several negative consequences, including alcohol abuse, burnout, depression, and medical student attrition.
The new research, published today in JAMA Internal Medicine, suggests that mistreatment of women, racial and ethnic minorities, and sexual minorities in medical school impacts not only the quality of education but also efforts to boost diversity among physicians. "This differential burden of mistreatment may have substantial implications for the medical school learning environment and the diversity of the physician workforce," the research co-authors wrote.
The research is based on data collected from the 2016 and 2017 Association of American Medical Colleges Graduation Questionnaire. The AAMC Graduation Questionnaire is administered annually to all 140 accredited allopathic medical schools in the country.
The researchers analyzed 27,500 graduation questionnaires, which represents 72.1% of medical school graduates in 2016 and 2017. More than one-third of survey respondents reported experiencing at least one type of mistreatment. The most common form of mistreatment was public humiliation, which was reported by 21.1% of survey respondents.
Student mistreatment data
The JAMA Internal Medicine study generated several key data points.
1. Mistreatment by sex:
More female students reported at least one episode of mistreatment compared to male students (40.9% vs. 25.2%)
More female students reported public humiliation compared to male students (22.9% vs. 19.5%)
More female students reported unwanted sexual advances compared to male students (6.8% vs. 1.3%)
More female students reported a higher rate of gender-based discrimination compared to male students (28.2% vs. 9.4%), including being denied training opportunities and receiving lower evaluations
2. Mistreatment by race or ethnicity:
Among white students, 24.0% reported experiencing mistreatment. Reported rates of mistreatment were higher for Asian (31.9%), underrepresented minority (38.0%), and multiracial (32.9%) students.
Among white students, 3.8% reported discrimination based on race or ethnicity. Reported discrimination rates were higher for Asian (15.7%), underrepresented minority (23.3%), and multiracial (11.8%) students.
Among white students, 0.7% reported receiving low evaluations because of race or ethnicity. Reported rates of low evaluations because of race or ethnicity were higher for Asians (5.0%), underrepresented minorities (9.6%), and multiracial (3.4%) students.
3. Mistreatment by sexual orientation:
Nearly twice as many lesbian, gay, or bi-sexual (LGB) students reported an episode of mistreatment compared to heterosexual students (43.5% vs. 23.6%)
More LGB students reported being publicly humiliated than heterosexual students (27.1% vs. 20.7%)
More LGB students reported being subjected to unwanted sexual advances than heterosexual students (7.7% vs. 3.7%)
More LGB students reported discrimination based on sexual orientation than heterosexual students (23.1% vs. 1.0%)
More LGB students reported receiving lower evaluations based on sexual orientation than heterosexual students (4.0% vs. 0.3%)
Data interpretations and implications
The study's data reveals trends in the mistreatment of medical school students, the co-authors wrote. "The major findings of our national study include not only a high prevalence of medical student mistreatment but also differences in the prevalence of mistreatment by student sex, race/ethnicity, and sexual orientation," they wrote.
The data also demonstrate that several inappropriate behaviors are common in medical school, the co-authors wrote.
"These reported behaviors include, but are not limited to, unwanted sexual advances (6.8% of female students and 7.7% of LGB students), lower evaluations secondary to bias and discrimination (6.8% of female students and 9.6% of underrepresented minority students), and being subjected to sexist or bigoted comments (24.3% of female students, 18.9% of underrepresented minority students, and 21.8% of LGB students)."
The data indicate several disturbing implications, they wrote.
"The differential treatment reported by medical students in this study suggests a noninclusive learning environment, which could have profound implications for the well-being and academic success of students. … Another concerning negative experience reported by students was missed opportunities or lower grades because of discrimination. These experiences may have incremental consequences as trainees advance through their medical careers."
Medical schools can take actions to combat mistreatment of students, the co-authors wrote. "Potential interventions include implicit bias and bystander intervention training, better protections for individuals who have been subjected to and report instances of bias and discrimination, and greater transparency in policies for reporting and remediating instances of bias and discrimination."
New research findings are a step forward in understanding the harms and benefits of screening for dementia in the primary care setting.
Screening for Alzheimer disease and related dementias (ADRDs) in the primary care setting does not harm patients as measured by prevalence of depression and anxiety, recent research shows.
Primary care clinicians provide the most care to older adults, and at least half of primary care patients afflicted with ADRDs are never diagnosed with the conditions. For patients who do receive an ADRD diagnosis, the determination is often made two to five years after the onset of symptoms, which limits the benefits of early detection such as reducing family burden.
The recent research, which was published in the Journal of the American Geriatrics Society, examined data collected from 4,005 primary care patients over age 65. Half of the patients were screened for ADRDs and the other half served as a "no screen" control group.
"This is the first randomized controlled trial to evaluate the benefits and harms of population screening for ADRD among asymptomatic patients attending primary care. Our trial demonstrated no harm from screening, as measured by depressive and anxiety symptoms," the research co-authors wrote.
Research data
To assess harm to patients, prevalence of depression was measured with the Patient Health Questionnaire-9 (PHQ-9) and prevalence of anxiety was measured with the Generalized Anxiety Disorder seven-item scale (GAD-7). Assessment of benefits to patients included data collected for health-related quality of life (HRQOL).
The assessments generated several key data points:
At baseline for the ADRD screened group and the control group, the scores for the PHQ-9 and GAD-7 assessments were similar.
At one month, six months, and 12 months for the ADRD screened group and the control group, the mean scores for the PHQ-9 and GAD-7 assessments remained similar.
At baseline for the ADRD screened group and the control group, the mean HRQOL score was similar.
At 12 months for the ADRD screened group and the control group, the mean HRQOL score remained similar.
"We were unable to detect a difference in HRQOL for screening for ADRD among older adults. We found no harm from screening measured by symptoms of depression or anxiety," the researchers wrote.
Interpreting the data
The research is a significant contribution to the debate over whether ADRD screening should be standard practice in the primary care setting, the lead author of the study told HealthLeaders.
"The results from this study are some of the first to show that screening for dementia does not increase harm for patients, as measured by an increase in depression or anxiety. They get us a step closer to determining if screening for dementia should be part of routine care for older adults," said Nicole Fowler, PhD, an assistant professor of medicine at Indiana University School of Medicine in Indianapolis, and a research scientist at the Regenstrief Institute in Indianapolis.
Fowler said her research team is examining whether other harms may be linked to ADRD screening in the primary care setting. "For example, how does early detection of dementia via screening impact the older adults' family members who might be in a position to be a caregiver?"
More research is also required to determine the benefits of ADRD screening, she said. "This study measured benefits of screening using measures of health-related quality of life, healthcare utilization, and creation of new advance care plans. We did not find benefits among these measures. But the caveat is that only 66% of the people who screened positive sought follow-up testing to determine if they had ADRD, and if so, received collaborative care."
Future research on the benefits of ADRD screening need to account for essential actions after screening, Fowler said. "To truly determine benefit of screening, we need to ensure that screening is coupled with appropriate diagnostic follow-up and care for the patients and family."
A recent New England Journal of Medicine study is "not an indictment against all care management and care coordination programs," Camden Coalition's CEO says.
Despite the recent publication of a research article that generated disappointing results about its care management program for "superutilizer" patients, the Camden Coalition of Healthcare Providers is continuing its commitment to serve a complex patient population.
The Camden Coalition's "hotspotting" program targets complex patients with comorbidities and social needs. These kinds of superutilizer patients account for a disproportionate share of healthcare spending in the United States, with earlier research finding that 5% of the country's population accounts for 50% of annual healthcare expenditures. Programs such as the Camden Coalition's care management initiative are designed to help reduce these healthcare costs.
The recent research, which was published in the New England Journal of Medicine, assessed the hospital readmissions impact of the Camden Coalition's hotspotting program from 2014 to 2017.
The randomized, controlled trial featured 800 patients split evenly between participants in the Camden Coalition's care management intervention and a control group receiving usual care. The study found that the 180-day readmission rate for the intervention group was 62.3% compared to a 61.7% rate for the control group.
The Camden Coalition's care management intervention focuses on the 90-day period after hospital discharge. The program is staffed by a multidisciplinary team that includes community health workers, health coaches, registered nurses, and social workers. The team conducts several interventions such as connecting patients with social services, medication management, self-care coaching, and coordinating follow-up care.
Camden Coalition of Healthcare Providers CEO Kathleen Noonan, JD, recently spoke with HealthLeaders about the Camden, New Jersey–based organization's perspectives on the NEJM study. The following is a lightly edited transcript of that conversation.
HealthLeaders: What is your reaction to the NEJM study's finding that your hotspotting program had no effect on hospital readmissions?
Noonan: It's clear to us that there is still a lot to learn in this area. We don't think that there is a clear-cut solution for how to reduce utilization and costs for this very complex population. And because our healthcare and social service systems are siloed—and accessing services from either is complicated and difficult—we found that accessing the services that our population needed was difficult even with a skilled team.
We were dealing with issues of poverty, racism, and disinvestment that were front-and-center for our patients. Sometimes, these issues were even more front-and-center than the health issue that brought them into the hospital. So, the healthcare intervention that was trying to connect patients to social services within a 90-day time period was not sufficient.
You have to remember that this study was done between 2014 and 2017. If you did an Internet search of the phrase social determinants of health during that period, you would see it far less often than you would see it in the past couple of years. The changes that have occurred since 2017 have built up the ecosystem that is trying to connect health and social services.
HL: What lessons have you learned from the NEJM study?
Noonan: Our main lessons are that extreme hospital and emergency room over-utilization is driven by the patient's complexity and the inability of any one system to manage that complexity. What we are doing now is working with others across the country who are also trying to build new care models that can respond to the needs of complex patients.
We also are trying to figure out how to catch patients earlier. There is a lot of terrific work being done in predictive modeling and how to find complex patients earlier.
While we didn't reduce readmissions in the study, we did see an increase in SNAP participation in the intervention group, which is a promising outcome since food insecurity is a key social determinant—something we see in Camden over and over again. Many of our local hospital partners are responding to this need, with the development of food pantries, food prescriptions that are connecting patients to nutritionists, and other supports.
HL: Is Camden Coalition going to re-evaluate its hotspotting program?
Noonan: Before, during, and after the study, we have been learning about the patients and adjusting the hotspotting model. The authors of the study recognized that they knew that the Camden Coalition was going to modify certain parts of the intervention, so the examination of the intervention looked at the average effect of the program.
One thing we did two years into the study was to create a housing program called Housing First. We knew that it is difficult for us to help a patient when there is homelessness or severe housing instability. That's one change we made.
Another change we made that we were not able to get off the ground during the study period was the creation of a medical-legal partnership. For many of our patients, we found they faced difficulties because of civil cases or barriers to benefits that we needed legal help to resolve. We are now partnered with Rutgers Law School, and we have two lawyers who work with the care team. This has helped us to quickly deal with legal issues that our care team did not have the expertise to address.
We have also worked locally to support the development of medication-assisted treatment. We've worked at the state level with partners to waive prior authorization for medication-assisted treatment.
We are trying to look at the whole system around these patients and to work at the levels of care intervention, healthcare providers, and policy to make changes that can respond to some of the barriers identified during the study.
HL: How much more work do you have to do to perfect a care management model for complex patients?
Noonan: Now that the study's data has been published, we are continuing to analyze the data in partnership with the Abdul Latif Jameel Poverty Action Lab at MIT and Rutgers University, so we can understand more about sub-populations and promising trends. We are going to use that analysis to guide us through the demographics—and the health and social history—of this population to target patients better.
There was a broad population that was included in the study, from 18 to 80 years old. So, we are trying to understand different trends for different parts of the population.
HL: What advice can you offer to other healthcare providers that have launched hotspotting programs?
Noonan: The study's results make a significant contribution to the field. But it is important to consider what the results do not say. The results are not an indictment against all care management and care coordination programs.
Other studies have shown positive results, but the populations for those studies were older and predominantly Medicare populations. The NEJM study noted that our patients had much higher levels of complexity at baseline. We don't want other healthcare providers to think that the core elements of care management have been proven ineffective. That's not the case.
Angela Shippy shares her perspectives on quality improvement and C-suite leadership skills.
Angela Shippy, MD, is eager to apply her clinical and administrative experience in an expanded role at Memorial Hermann health system.
For the past five years, Shippy has served at the chief quality officer at the Houston-based health system. She has been promoted to senior vice president, chief medical officer, and chief quality officer.
Prior to joining Memorial Hermann, she was HCA Healthcare's Gulf Coast Division chief medical officer. Before working at HCA, Shippy was vice president of medical affairs at St. Luke's Episcopal Hospital, an affiliate of Houston-based Texas Medical Center, where she also practiced as a hospitalist.
Shippy recently shared her perspectives on the CMO and chief quality officer roles with HealthLeaders. The following is a lightly edited transcript of that conversation.
HealthLeaders: How will your experience as chief quality officer help you in your new role as CMO?
Shippy: There are a couple of different ways. First, as a chief quality officer you interact with everyone, you collaborate on projects, and you help to prioritize. We have strategic initiatives that are ongoing, so it helps me to continue to make connections on those initiatives.
Second, quality is involved in everything we do—particularly providing care to patients. The same could be said of the chief medical officer role. There are opportunities to be involved in multiple different aspects of the clinical care that we deliver.
HL: Give one or two examples of quality initiatives that you led as chief quality officer.
Shippy: Over the past six years, one of the key changes at Memorial Hermann from a quality standpoint is we went from an emphasis on process measures to outcome measures. Early on in value-based purchasing, the emphasis was on whether you were doing particular interventions. For example, you could check the box for heart failure if you gave an ACE inhibitor or did an echocardiogram.
Where we have been evolving over the past six years is to actual outcomes. So, if you are doing all of the processes properly, you should see outcomes such as decreased readmissions or decreased mortality. We have been working toward hardwiring processes, so we know the outcomes are good for patients and patients are able to take care of themselves outside of our acute interventions.
We also have been working outside of clinical areas to make sure that we have quality improvement methodology for operational areas. We have been identifying waste, we have been standardizing processes, and we have been sustaining changes once we have made them. We have been taking principles we use in clinical areas and helping operational colleagues and departments use those principles for their improvement.
HL: What aspects of your career best prepared you to work in C-suite roles?
Shippy: As a resident, I used to moonlight in the emergency department quite a bit. One of the hardest things to do there is to call one of your colleagues to admit a patient. So, very early on, I learned to completely assess a patient, to conduct all the testing that was needed, and to be able to succinctly present that patient to colleagues so they could understand the necessity to admit the patient. That teaches you how to put information together and put it in a format that other people can understand.
As a practicing hospitalist, I had the opportunity to interact with every member of the medical staff and every specialty. When you are taking care of patients who come through the ED, some are very ill, and you have to tap into your colleagues at all times of the day. So, you understand how the hospital works at 8 a.m., 8 p.m., and 2 a.m. You learn about the staff outside of the clinical staff that you have to deal with to make sure the patients get the care that they need. Having those interactions gives you a unique perspective on how to activate people and get things done.
HL: What are the essential leadership skills to be a successful CMO?
Shippy: To be a successful CMO, you have to understand that clinical skills and that background initially led you on the journey to get to the C-suite; but, ultimately, you need to have the ability to lead, collaborate, and inspire across multiple disciplines and across the entire organization.
In healthcare, you also must understand that caring for the patient is a team sport and the same can be said for administrative roles. You are never doing the work alone—it is a group of people coming together to provide the best outcomes or the best results.
The opportunity to be a chief medical officer is truly an honor for anyone who started their career as a practicing physician. It is an opportunity to take your clinical skills and combine them with what your organization wants to do from an operational standpoint to deliver the best possible care for patients.
