An intellectual giant played a large role in shaping the career of Neel Shah, MD, MPP.
Shah is making his mark in Boston, where he is an obstetrician-gynecologist at Beth Israel Deaconess Medical Center, an assistant professor at Harvard Medical School, director of the Delivery Decisions Initiative at Ariadne Labs, and board chair of Costs of Care. He is a self-described health systems scientist—a calling that started when he studied neuroscience at Brown University in Rhode Island.
"My interest in neuroscience came from following a person. When I was in college, there was a professor named Leon Cooper who was my advisor. He won the Nobel Prize in Physics in 1972 for the theory of superconductivity at a relatively young age, then [he] moved on. He decided he was going to study the brain, and he came up with a bunch of theories about the brain that revolutionized the field," Shah says.
"Professor Cooper was an audacious thinker. For every young person, there is someone who believes a better world is possible, and he was that person for me. He was a mentor who taught me to think about systems because the brain is a complex system."
Healthcare reform advocate
Shah cofounded Costs of Care—a nongovernmental organization dedicated to providing better healthcare at lower cost—a decade ago.
"When we started, Costs of Care was focused on transparency. Abraham Verghese has a wonderful quote: 'If you are ordering off a menu with no prices, it's easy to get the filet mignon every time.' We wanted to put prices on the healthcare menu because there were brand-new clinicians clicking on a mouse who were spending tens of thousands of dollars without even knowing it," he says.
"Now, we have moved beyond transparency, which is important, but there are multiple failures at the point of care that are preventing people from accessing affordable, safe, dignified care. We can't tell people what services cost. We often don't tell patients whether a service is worthwhile to begin with. Then, when services are worthwhile and expensive, we are not deploying all of the resources to make sure that patients can comply with our recommendations."
Pursuing innovation
At Ariadne Labs—a joint healthcare innovation center of the Harvard T.H. Chan School of Public Health and Brigham and Women's Hospital, Shah has played a leadership role in the Team Birth Project. The initiative seeks to revolutionize the relationship between pregnant women, their families, and their healthcare teams to boost childbirth outcomes.
"The Team Birth Project is a large-scale experiment across the country that is trying to get clinicians and families on the same page to achieve more appropriate, safer, and more affordable care," he says.
Shah says even though he has always been "a little bit of a generalist," he gravitated toward the field of OB-GYN. He says that as he's spent more time in the field, it's become more personal for him. "I have a family of my own, and one of the things I have realized is that the period when you are growing your family from pregnancy to parenting an infant is a universal period of vulnerability. There are a lot of opportunities to make our systems of support and care better."
Perspectives on healthcare
Following are highlights from a conversation between Shah and HealthLeaders where he shares his perspectives on obstetrics-gynecology, value-based care, medical entrepreneurship, and health systems science.
"In childbirth, the main way we think about quality is the absence of injury. The absence of injury is good, but most women have goals beyond escaping unscathed from the process. Survival is the floor of what they are expecting and what they deserve. If we are going to design a better system, we should be aiming for the ceiling, but we haven't figured out what that looks like."
"Nobody goes to medical school thinking about GDP, but Americans have the least affordable healthcare compared to a half century ago. So, for the longest time of taking care of people, the ethic in U.S. medicine has been thoroughness rather than appropriateness. Thoroughness is a good goal, but appropriateness is a better goal."
"In the quest for thoroughness, 50 years ago there were only a handful of causes of chest pain; now, there are thousands. You literally cannot test for all of them—it's not efficient, it costs people a lot of money, and it can even be harmful to over-test. So, that's why appropriateness is important. We must find out how to deliver healthcare affordably for every American."
"The best models are the ones that put a contingency on payment over and above having simply provided a service. Any of those models are better than testing for something, drawing blood, or poking you with a sharp object, then billing for it irrespective of the outcome. That clearly is a crazy system. There is no other sector of the economy or other industry where that would be OK. There's no other area that tolerates the kind of paternalism or opacity that behavior requires."
"The mission of Ariadne Labs is trying to figure out how we can drive improvements at scale in healthcare. It's kind of the opposite of Costs of Care in some ways. Costs of Care is focused on catalytic, breakthrough innovations. Ariadne Labs is based on the recognition that the dominant cause of suffering in the world is not necessarily lack of knowledge—it's lack of execution. It's about fixing execution failures in a way that works in multiple settings across the world."
"It's 100% entrepreneurship in my mind because there's a vision, a commitment to realize that vision, and there's an ROI that is not necessarily cold, hard cash. It's more about making an impact. It's the same mindset and the same process as entrepreneurship. The things I invent are not widgets or artificial intelligence—the Team Birth Project has a totally analog whiteboard as a key tool. You write with a dry-erase marker, but it is fundamentally changing the way people experience care."
Pictured above: Neel Shah, MD, MPP, is an obstetrician-gynecologist at Beth Israel Deaconess Medical Center; assistant professor at Harvard Medical School; director of delivery decisions initiative at Ariadne Labs; and board chair of Costs of Care. (Photo credit: Jason Grow/Getty Images.)
Since 1997, CVS Health and its subsidiary Aetna have invested more than $1 billion in affordable housing and other social needs.
Woonsocket, Rhode Island-based CVS Health invested $67 million in affordable housing last year and plans to invest $75 million in affordable housing this year, the company announced today.
Housing is considered as one of the leading social determinants of health (SDOH), along with other social needs such as transportation and food security. By making direct investments in initiatives designed to address SDOH and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.
Last year, CVS Health supported affordable housing projects in 24 cities in California, Georgia, Hawaii, New Hampshire, Oregon and Texas, creating more than 2,200 affordable homes often with support services, the company reported. This year, CVS Health's plans to invest in affordable housing include $25 million in Ohio.
"Providing affordable housing options to people who are facing significant challenges can be their first step on a path to better health. However, we understand that more support is often needed—that is why we work with community organizations to provide access to services such as independent living skills, cooking and nutrition, financial literacy, health information classes, resident outreach and engagement, client-centered treatment plans, and social support," Karen Lynch, executive vice president of CVS Health and president of the company's Aetna Business Unit, said in a prepared statement.
CVS Health and healthcare insurer Aetna merged in 2018. Since 1997, CVS Health and Aetna have invested more than $1 billion in affordable housing and other social needs. The two-decade effort has supported the construction or renovation of more than 93,000 affordable rental units, the company reported.
Affordable housing investments in The Golden State
California has been a primary focus of CVS Health's and Aetna's affordable housing efforts, Kristen Miranda, California market president for Aetna, said in a prepared statement.
"We have made more than $160 million of affordable housing investments in California over the past 20 years, including nearly $50 million in the past two years alone. These investments are helping to address the unique needs of residents in California, helping to improve health at both the individual and community level," Miranda said.
The investments in California affordable housing include four recent projects, the company reported:
This month, CVS Health is working in partnership with CREA LLC to close an $8.1 million deal to finance development of 85 affordable housing units. The project is in collaboration with East LA Community Corporation and New Directions for Veterans.
On Feb. 14, there will be a grand opening of Sequoia Commons in Goshen, California. The 66-unit low-income community received funding from CVS Health, the California Department of Housing and Community Development, the Federal Home Loan Bank of San Francisco, Red Stone Equity Partners and Pacific Western Bank.
In December 2019, CVS closed on a $25 million commitment to an investment fund that will build or rehabilitate more than 500 affordable housing units in five California cities.
In November 2019, there was a grand opening of Bishop Street Studios in San Luis Obispo, California. The 33 permanent supportive housing units were established through the renovation of an abandoned orphanage and were funded by CVS Health, the Transitions-Mental Health Association, and the Housing Authority of San Luis Obispo. The affordable housing units are for individuals with mental health issues.
Cancer Treatment Centers of America CEO Pat Basu discusses three oncology care challenges and three challenges facing the healthcare sector.
The CEO of Boca Raton, Florida-based Cancer Treatment Centers of America (CTCA) recently talked with HealthLeaders about major challenges facing oncology care and the healthcare sector in 2020.
Pat Basu, MD, MBA, worked in several healthcare roles before taking on the top leadership position at CTCA last year.
The University of Chicago Pritzker School of Medicine graduate has worked as a physician at Stanford University Medical Center, as senior vice president at Optum, as a White House healthcare fellow, and as president, chief operating officer, and chief medical officer at vRad, a provider of radiology services. Basu is also one of the founders of telehealth pioneer Doctor On Demand.
He told HealthLeaders there are three primary challenges facing oncology care this year as well as three major challenges facing the healthcare sector this year and into the new decade. The following is a lightly edited transcript of Basu's comments.
Oncology care challenges
1. Access and affordability: This is simultaneously an environment where we have made exceptional strides in turning cancer into a chronic disease and adding years to life. At the same time, we still struggle with access and affordability.
On the affordability front, the cost of the therapies including the drugs and immunotherapy has implications for access. With such a prevalent and horrible disease as cancer, ideally you would want treatment to be 100% accessible.
2. Geographic barriers: In our case, we get a lot of patients who come from all over the country and all over the world. We get many patients who come to us after they have tried treatment at their local hospital. It's a major journey for these patients to travel.
By offering telehealth and partnering with local providers, we are trying to bridge this gap. But just because you have wonderful new therapies and protocols at facilities like ours, it doesn't mean that everyone can overcome the geographical barriers to access them.
3. Time: There might be a clinical trial that is in its infancy but it's so close to unlocking an important scientific discovery that I would wish that I could get it to patients today instead of a year from now.
Time is also a factor in catching disease early and preventing disease. Just like with cardiac care and diabetes, there are lots of things that can prevent cancer—upto 50% of cancer is preventable. Through prevention and very early detection and diagnosis, we can stop cancers at the cellular level before they progress to more complex diseases.
Healthcare sector challenges
1. Building a better American healthcare system: We need a healthcare system that is dramatically improved in quality, dramatically improved in access, and dramatically improved in affordability and sustainability for patients, doctors, employers, and the country as a whole. Quality, access, and cost are major challenges that are going to require transformative change.
For example, in the quality bucket, studies have shown that about 25% of hospital admissions have some sort of safety error or harm caused to the patient during their episode of care. That's totally unacceptable and can no longer be tolerated.
With access, one in four Americans will defer care because of cost reasons. One in three Americans will not take prescription drugs because of cost. One of the major causes of personal bankruptcy is healthcare. We have a highly inefficient system. Out of the $3.5 trillion that we spend on healthcare in this country, which is close to 19% of our gross domestic product, about $700 billion to $900 billion is wasteful care.
2. Siloed healthcare: It is so frustrating to me as a doctor and as someone who leads a large national care organization that we have siloes in healthcare. There are siloes down to the patient level, where there is limited compatibility of electronic medical records and limited portability of patient examinations.
We are also still struggling to establish robust partnerships. One of the things we are trying to do at CTCA is to determine how we partner with other providers and how we partner with payers, employers, pharmaceutical companies, and other members of the healthcare ecosystem. We want to lock hands together with partners to solve big problems. All of us take pride in how good we are and what we do, but we can do so much more if we partner with others.
3. Prevention and diagnosis: Often, the treatment side gets the most attention—more dollars and more resources. Treatment is very important, but we need to pay as much attention to devoting dollars and resources to prevention and diagnosis.
Although most cases of novel coronavirus have been reported in China, cases have been reported in 26 countries, including the United States.
An article published this week by the Journal of the American Medical Association provides clinical insights about the new coronavirus outbreak that started in China.
The Centers for Disease Control and Prevention (CDC) calls the new coronavirus 2019 novel coronavirus (2019-nCoV). Cases of 2019-nCoV mainly have been reported in China, where the epidemic began in the city of Wuhan in Hubei Province but cases have been reported in 26 countries, including 11 cases in the United States, the JAMA article says.
As of Feb. 4, more than 20,000 cases of infections had been reported, with 98.9% of the cases in China, and the virus had been tied to more than 400 deaths, the JAMA article says. A CDC webpage has updated information about the spread of 2019-nCoV and the response to the epidemic.
The JAMA article features several key points of information for clinicians:
Five cities with high volumes of travel from China have had the most cases of 2019-nCoV outside of the epicenter in China: Bangkok, Hong Kong, Singapore, Taipei, and Tokyo.
The first case of 2019-nCoV in Wuhan is believed to have spread from an animal to a human. There have been two other zoonotic coronavirus outbreaks in the past two decades: severe acute respiratory syndrome {SARS) and Middle East respiratory syndrome (MERS). Early data suggests that 2019-nCoV has greater infectivity and lower mortality than SARS and MERS.
One study reported the incubation period for 2019-nCoV is 5.2 days, but it could be as long as 14 days. It is possible that the virus can be transmitted when an infected person is asymptomatic, but it is likely that most transmission occurs when an infected person is symptomatic.
A study of 99 coronavirus patients in Wuhan found that most symptomatic people presented with fever and dry cough, with shortness of breath experienced by nearly a third of patients. Other symptoms included headache, sore throat and diarrhea. The study found the average age of patients was 55.5 years old.
There have been few cases reported in children.
Most cases appear to be mild. Patients who have required hospital admission have had pneumonia, and about a third of hospitalized patients have developed acute respiratory distress syndrome and have been admitted to an intensive care unit.
Clinicians should obtain a travel history when patients have fever and respiratory symptoms, especially a dry cough. If these patients have a history of travel to Hubei Province in the prior 14 days, they should be considered a person under investigation (PUI).
If a PUI presents, clinicians should report the case as soon as possible to their healthcare facility's infection prevention staff and to local or state health departments. Currently, the CDC is conducting all diagnostic testing for 2019-nCoV. Clinicians should test PUIs for other respiratory pathogens, and they should consider prescribing oseltamivir until influenza testing is completed.
If there is a high level of suspicion that a PUI has 2019-nCoV, the patient should don a face mask immediately and caregivers should wear N95 respirators.
There is no vaccine for 2019-nCoV and no medications have been proven effective against the virus. Care has been mainly supportive. The antiviral remdesivir was prescribed for the first U.S. coronavirus patient.
Public health measures that were effective in the SARS epidemic may be effective in the prevention of spreading 2019-nCoV: handwashing, respiratory etiquette such as covering the mouth when coughing, and staying home when sick.
A state-funded organization in New York builds partnerships between healthcare providers and social care providers.
A New York–based organization is pioneering a novel approach to help healthcare providers address social determinants of health.
Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. Through finding ways to address SDOH, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.
Troy, New York–based Alliance for Better Health is pursuing a new model to address SDOH. The state-funded organization is acting as a convener—playing the role of intermediary between healthcare providers, payers, and community-based organizations (CBOs). If the new model spreads nationwide, it would provide an alternative SDOH approach for healthcare providers, which have been either making direct investments in social needs services or establishing direct partnerships with CBOs.
"We are in the early stage of this model nationally. What has been great for us is that the health plans have agreed that there is value in addressing social determinants of health—they are just waiting to see how much value there is before they devote more resources," says Jacob Reider, MD, CEO of Alliance for Better Health.
How the convener SDOH model works
In Alliance for Better Health's convener model, healthcare providers do not make direct investments in social needs services or forge direct partnerships with CBOs, Reider says. A key element of Alliance for Better Health's model is a subsidiary of the organization, an independent practice association called Healthy Alliance IPA that has the regulatory authority to execute contracts with managed care plans on behalf of healthcare providers.
"The IPA is the solution. Our IPA, which has funding through the New York State Delivery System Reform Incentive Payment program, is focusing on the social needs and the medical providers are not part of that picture. Doctors are not the answer to address social determinants of health—the social network is the answer," he says.
Alliance for Better Health and Healthy Alliance IPA build partnerships between healthcare providers and social care providers, Reider says. "We are brokering these partnerships, helping with the referrals for social needs network activities, and building trust from end to end."
For healthcare providers, working with Alliance for Better Health to address SDOH has several advantages, including creation of an infrastructure for social need services ensuring that referrals to CBOs are timely and effective.
Over the past 18 months, Alliance for Better Health and its IPA have focused on the Capital District of the State of New York. There have been two important steps to convening partnerships between healthcare providers and social care providers, he says.
1. Social care network: "The first thing you need to have is willing participants to provide services in communities. In our community, we started with food, housing, and transportation, which is not everything but it's a good start," Reider says.
He says the social care network is an indispensable building block, making a reference to a 1989 film. "It's like the Field of Dreams concept. We need to build these networks, and then the social determinants screening will happen, and the referrals will occur."
2. Technical infrastructure: Alliance for Better Health has developed an IT platform to manage referrals from healthcare providers to social care providers, Reider says.
"You need an information technology infrastructure, so that when you refer patients into a social needs network you don't have to know exactly where the patient needs to go. You just need to know the services that are necessary."
In addition to the platform, Reider says Alliance for Better Health also has a referral center. "The referral center takes the referrals for services, then our referral coordinators take those referral requests and get them to the facilities that can meet those requests."
He continues, "What happens with the information technology platform is it holds everyone accountable and it allows us to watch the referral workflow so that we know if people fall through the cracks."
The IT platform facilitates referrals, Reider says, adding that for the referral center to work efficiently, social care organizations and medical providers must be able to receive and send electronic referrals, otherwise the participants cannot "properly engage."
Role of payers and generating ROI
Payers play an essential role in Alliance for Better Health's convener model, he says.
"In general, healthcare providers don't bill a payer for a referral. The social care providers such as food pantries, homeless shelters, and transportation providers should bill the health plan. The reason they should bill payers is their services reduce the total cost of care—they diminish the likelihood that patients end up in a hospital or get readmitted to a hospital," Reider says.
Healthy Alliance IPA manages the billing process, he says. "The way we have found for social care providers to bill a payer is through an aggregator—we call it a trusted broker. To play this role, we created the independent practice association. The IPA aggregates the services of the social care providers and bills payers for those activities."
Healthy Alliance IPA has established contracts with three payers, including Schenectady, New York-based MVP Health Care. "Alliance for Better Health is sharing the cost with the health plans. Our goal over time is for them to own all of the costs because there is return on investment," Reider says.
Alliance for Better Health only has preliminary data indicating that its SDOH program is lowering total cost of care, but transportation has been shown to have an ROI impact, he says.
"Medicaid pays for transportation to and from medical appointments, but it doesn't pay for things like trips to a pharmacy or social services, which we do pay for. We have found a positive correlation between reduced emergency department visits and free rides to Narcotics Anonymous. That speaks to the value of NA—in the context of the opioid epidemic, it is important," Reider says.
The new research, which was published this week by Annals of Internal Medicine, focuses on commercial payer data collected from 2008 to 2016. The data is from one commercial payer with patient members in every state and the District of Columbia. About 20 million patients were enrolled in the payer's health plans for each year of the study period.
Primary care visit data
The primary metric in the study is primary care provider (PCP) visit rates per 100 member years. The researchers examined claims data from 142 million primary care visits.
The research generated several key data points.
Visits to PCPs fell 24.2% from 2008 to 2016.
The decline in PCP visits during the study period was greatest among young adults (27.6% drop), patients with no chronic conditions (26.4% drop), and patients who lived in the lowest-income areas (31.4% drop).
The percentage of adults aged 18 to 64 who did not have a PCP visit on an annual basis increased from 38.1% to 46.4% during the study period.
Young adults (aged 18 to 34) were most likely to not have a PCP visit on an annual basis, with 48.2% having no PCP visits in 2008 and 56.7% having no PCP visits in 2016.
Older adults (aged 55 to 64) were least likely to not have a PCP visit on an annual basis but also had fewer visits over time, with 26.6% having no PCP visits in 2008 and 33.9% having no PCP visits in 2016.
PCP visits for medical problems fell 30.5% during the study period.
PCP visits for preventative care increased by 40.6% during the study period.
PCP visits for low-acuity conditions fell by 47.7% during the study period.
Visits to alternative care settings, particularly urgent care clinics, increased by 46.9% during the study period.
Patients faced higher costs for PCP visits during the study period. The out-of-pocket cost for PCP visits for medical problems increased 31.5%. The percentage of visits subject to a deductible increased from 9.2% in 2008 to 25.2% in 2016.
Interpreting the data
Three factors are likely driving the changes in primary care utilization, the researchers wrote.
1. Need for in-person PCP visits has decreased: "Declines were larger for younger, healthier adults, who may have fewer routine care needs and be increasingly comfortable with online self-care or a secure message with their clinician when acute needs arise. In kind, visit rates decreased sharply for low-acuity conditions, such as conjunctivitis, that might be addressed more easily by calling a nurse or searching the Internet," the researchers wrote.
2. Financial barriers: "In our data, we found that a growing proportion of primary care visits were subject to a deductible while out-of-pocket costs per visit increased. The decline in PCP visits was largest in low-income communities, consistent with prior work showing that lower-income adults are particularly sensitive to increases in out-of-pocket costs.
3. Replacing PCP visits: "Specialist visit rates remained steady. … Visits to alternative venues, such as urgent care clinics, retail clinics, emergency departments, and telemedicine, increased by 9 visits per 100 member-years, offsetting about one quarter of the PCP visit decline (35 visits per 100 member-years). The convenience of these alternatives may be particularly attractive compared with the often inefficient or inflexible scheduling practices in traditional primary care settings," the researchers wrote.
A community health worker program focused on addressing social determinants of health can generate a significant return on investment for Medicaid payers, new research indicates.
Medicaid accounts for about one-sixth of annual healthcare spending. There are inefficiencies in this spending because it is directed mainly to treat patients as illnesses occur rather than addressing underlying factors such as social determinants of health, which include nutrition, housing, and transportation.
The new research, which was published today by Health Affairs, examines data related to the Individualized Management for Patient-Centered Targets (IMPaCT) program at a Pennsylvania-based health system. In the IMPaCT program, community health workers provide tailored social support to patients in low-income neighborhoods.
"We have described a community health worker model that achieves a favorable return on investment for Medicaid payers by effectively responding to the social determinants of health," the research article's co-authors wrote.
Research data
The researchers conducted a randomized control trial with 302 patients—150 assigned to the IMPaCT intervention group and 152 assigned to a control group. The primary analysis compared the costs of hospital inpatient admissions and outpatient visits with expenses associated with the IMPaCT program.
The research generated several key data points:
The annual expenses associated with a six-member team of community health workers including salary, infrastructure, and supervisory costs were $567,950.
The patients in the control group had 98 hospital admissions during the study's one-year follow-up period compared to 68 admissions for patients who received IMPaCT services, amounting to a 30% reduction in admissions.
For Medicaid payers, the average facility and professional fees cost of an admission was nearly $16,500.
The total annual cost of care (inpatient admissions and outpatient visits) for the IMPaCT patients was $2,450,881, compared to $3,852,189 for the control group, amounting to a 38% cost reduction.
A team of community health workers saved Medicaid $1,401,307 on an annual basis. When this figure was divided by the expenses of a six-member team of community health workers ($567,950), annual ROI was $2.47 for every dollar invested.
"Within a single fiscal year, the standardized, evidence-based, Individualized Management for Patient-Centered Targets community health worker program yielded an annual return of $2.47 for every dollar invested, from the perspective of a Medicaid payer," the research article's co-authors wrote.
How the IMPaCT program works
The IMPaCT program studied at the Pennsylvania-based health system has several primary elements.
The IMPaCT intervention features community health workers conducting interviews of patients to help determine their social needs such as housing instability and food insecurity
The interviews helped form individualized action plans for the patients. "For example, one patient told her community health worker that she ate unhealthy food to cope with family stress, and she wanted to find a more healthy, creative outlet. The community health worker helped her enroll in a pottery class at a local senior center," the researchers wrote.
The community health workers conducted weekly support groups to build social networks for patients
Community health workers functioned closely with primary care practices, with workspace in the practices and access to the electronic health record
IMPaCT is highly structured, including recommended caseloads, training courses, and quality control
During the study period, the community health workers were full-time employees of the health system
Managers are assigned to each six-member community health worker team
Community health workers are centralized and can be deployed to specific primary care practices or hospitals. "This centralization allows for economies of scale: Practices that can support only one or two community health workers benefit from a robust infrastructure," the researchers wrote.
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."
