Research shows higher mortality for children brought to ERs that can't provide pediatric services.
Critically ill children brought to hospital emergency departments that aren't prepared to care for pediatric emergencies face more than three times the odds of dying compared to children brought to hospitals well-equipped to care for them.
It's a problem that will not be solved simply by dumping lots of money into hospitals to upgrade their pediatric emergencies services, says study senior author Jeremy Kahn, MD, because it costs too much money.
"The vast majority of hospitals in the United States care for very small volumes of children, and when you have those low numbers, it's very hard to be ready for anything that can come your way," Kahn says.
"It's not so different from a Caribbean nation being prepared for a snowstorm. It might happen, but it's going to be incredibly unusual. So, the resource investment required to prepare for every eventuality for every pediatric emergency is ultimately enormous," he says. "There are reasonable questions about whether that's a value-based strategy."
Kahn spoke with HealthLeaders about shortcomings in the nation's pediatric emergency medicine network and offered suggestions for how that network might be improved. The following is a lightly edited transcript.
HL: What are the different needs of pediatric and adult ERs?
Kahn: The key difference obviously are the diseases themselves. The things that a child is going to present with will be vastly different than the things that an adult will present with. Even with the same symptoms, chest pain for example, is a very common presenting symptom in an adult and it has a very serious differential diagnosis, things like heart attacks, obviously, are very concerning. But in a child chest pain has just a very different set of considerations.
There are some things that are very specific to pediatric emergencies, like weight-based dosing. In the adult emergency world, it's very often one-size-fits-all. But for children, dosage will vary dramatically in their size. And then they use very specific equipment as well.
HL: Why aren't all hospital ERs "pediatric ready"?
Kahn: The vast majority of hospitals in the United States care for very small volumes of children, and when you have those low numbers, it's very hard to be ready for anything that can come your way. It's not so different from a Caribbean nation being prepared for a snowstorm. It might happen, but it's going to be incredibly unusual. So, the resource investment required to prepare for every eventuality for every pediatric emergency is enormous.
HL: In what ways are ERs unready for pediatrics?
Kahn: The most common reasons for having low readiness scores was not a lack of ability to do things such as weight-based dosing, or lacking all the equipment, because almost all emergency departments have pediatric-sized equipment. The problem was not having a pediatric-focused quality improvement officer, not having all the policies and procedures in place. Unfortunately, what we found in our study is that those things translate into patient outcomes.
We knew going into our study that there was wide variation in the amount of readiness among hospitals across the country. But now we have empirical data to show that low readiness scores do translate into poor outcomes for at least the sickest patients.
HL: Are you able to estimate how much improving ED pediatric readiness would cost?
Kahn: I don't know the answer to that, but I think that's the issue. It's just not a value-based strategy to have every hospital in the United States become maximally pediatric ready because, again, there are some hospitals that will just see very low numbers of children.
The key is to take a multipronged approach that customizes for a region or a state. In some areas where there are no specialized children's hospitals, it may behoove that area for every hospital to be ready to care for children. But in other areas, maybe there are alternative strategies, such as regionalization, where the sickest children are triaged in the pre-hospital setting to go right to the one or two hospitals in the region that are most ready to care for pediatric emergencies.
Telemedicine is another exciting potential strategy to extend the benefits of pediatric readiness to more hospitals using remote audio-visual equipment. So those are alternative strategies.
HL: What are some of the key commonalities for pediatric readiness in the high-scoring, pediatric and adult hospitals?
Kahn: One is volume. We found that obviously having a high volume of children makes you more likely to be pediatric ready. But the highest determinant was having a dedicated physician and nurse who oversee pediatric-focused quality improvement in the hospital.
HL: How difficult would it be for a hospital to do a pediatric readiness assessment?
Kahn: If there's any lesson from our study, it's that hospitals should know what their capabilities are for caring for critically ill children. Those readiness assessments should already be a routine part of that hospital's policies and procedures.
The question then becomes, how do they respond if they perceive that there are gaps in their readiness? That has to be a very customized approach. There's not going to be a one-size-fits-all approach.
This is not the responsibility of individual clinicians to fix. This is a systemwide issue, and hospitals and regions within states should get together to strategize about the best ways to deliver emergency care for children.
HL: What would you like to see done with your study findings?
Kahn: We should not respond to these data with a shrug. We need to do something to increase pediatric readiness among our nation's hospitals. What we do will be determined by specific hospitals, and specific regions. Different approaches are going to work in different ways in different areas.
The only mistake would be to do nothing.
Editor's note: This story was updated on September 5, 2019.
Penn Medicine researchers believe their findings show that administering AVP to trauma patients with severe bleeding could become standard practice in trauma care.
Dosing gunshot victims and other hemorrhaging trauma patients with the hormone arginine vasopressin cut the need for stabilizing blood products in half, clinical trials at Penn Medicine show.
The study, published in JAMA Surgery, treated 100 hemorrhagic shock patients with a low-dose AVP at the Penn Medicine trauma center between 2013 and 2017. The protein is produced in the hypothalamus, stored in the pituitary gland, and constricts blood vessels when it is secreted into the bloodstream when blood pressure is too low.
All but seven of the patients were males who were victims of gunshot or knife wounds. The researchers randomized 49 of the patients to receive AVP in an initial moderate dose plus a slow infusion—during the first 48 hours of care—and the other 51 to receive the placebo equivalent.
The researchers found that the patients treated with AVP for 48 hours ended up receiving an average of 1.4 liters of blood products – less than half the 2.9 liters that was the average amount given to patients treated with the placebo.
The AVP group also had a markedly lower rate (11% vs. 34%) of deep-vein thrombosis. Rates of complications within 30 days for the AVP and placebo groups were otherwise similar (55% vs. 64%), and the numbers of deaths in that period were the same (six in each group), the study said.
While the AVP group had shorter average stays in the hospital, the relatively small number of patients in the study meant that these length-of-stay differences were not statistically significant.
There are more than 100,00 firearm-related injuries resulting in more than 36,000 deaths annually in the United States. The Penn Medicine researchers believe their findings show that administering AVP to trauma patients with severe bleeding could become standard practice in trauma care, reducing the use of blood products and their adverse side effects.
"Unintentional traumatic injuries are the leading cause of death in the United States for people younger than 45, and the injuries often involve severe blood loss," said Carrie A. Sims, MD, an associate professor of Surgery and Laboratory Director of the Penn Acute Research Collaboration, in comments accompanying the study.
"We can replace a patient's lost blood with blood products such as packed red blood cells, fresh frozen plasma, and platelets, but use of these options can lead to serious complications and they may not fully replace key molecules in blood that are needed to support blood pressure and the normal function of vital organs," Sims said. "The results of this trial suggest a promising way to reduce the amount of blood needed to save the lives of patients with life-threatening injuries."
(Support for the study was provided by the National Trauma Institute and the U.S. Department of the Army.)
The financially troubled 496-bed teaching hospital in Philadelphia shutters on September 6.
The Federation of State Medical Boards FSMB will make the records available to physicians after the records have been collected and catalogued.
The Federation of State Medical Boards will take custody of physician training records at Philadelphia's Hahnemann University Hospital before the financially troubled 496-bed teaching hospital shutters on September 6.
"Effective August 26, the FSMB has become the central repository and primary source for all graduate medical education records of residents and fellows who completed training at HUH after 1990," FSMB said in a media release. "In some cases, earlier records may also be available."
FSMB said it will make the records available to physicians after the records have been collected and catalogued, and will be accessible through the federations Closed GME Prorgrams service.
Current or former residents and fellows who need instructions on how to obtain their training records should send a request with current contact information to hahnemann@fsmb.org.
The transfer of medical training records to the FSMB is a standard practice when residency program close. FSMB will permanently store the records and will become the primary source for information about residents who trained at the hospital for future uses, such as state medical licensure applications and hospital/health care privileges, FSMB said.
Hahnemann University Hospital, which had served the city for more than 170 years, declared bankruptcy in June, citing "financial difficulties," and discharged its last patient in late July. A group of six Philadelphia-area health systems won the Aug. 8 at auction for $55 million, topping bids by Tower Health and KPC, which operates seven hospitals in Southern California.
The Philadelphia Inquirerreported earlier this month that California-based KPC Global, which lost in the Aug. 8 auction, would up its bid to $60 million if bidding were reopened.
The breach in the hospital's Neurology Department did not include Social Security numbers, or insurance or financial information.
Nearly 10,000 people are being notified by Massachusetts General Hospital that an unauthorized third-party had access to their personal information.
The breach affecting as many as 9,900 people occurred between June 10 and June 16 at the renown Boston-based hospital's Department of Neurology, and was traced to two computer applications used its research programs, MGH said in a media release. The breach was discovered on June 24.
"The research data did not include any study participant's Social Security number, insurance information, or any financial information," MGH said. "The research data did not include any study participant's address, phone number, or other contact information. The incident did not involve MGH's medical records systems."
However, the breached data "may have included a participant's first and last name, certain demographic information (such as marital status, sex, race, ethnicity), date of birth, dates of study visits and tests, medical record number, type of study and research study identification numbers, diagnosis and medical history, biomarkers and genetic information, types of assessments and results, and other research information," MGH said.
Some of the breached data was "many years ago," MGH said, and for deceased research participants, included date of death, and a summary autopsy results.
MGH hired a third-party forensic investigator to review the breach, and the hospital contacted federal law enforcement as a precaution.
At this point, the hospital said no action is needed on the part of the research participants because the breach did not involve Social Security numbers, insurance or financial information.
(People who have any questions or would like additional information can call (866) 904-6219, Monday-Friday (9:00 am – 9:00 pm Eastern) or Saturday-Sunday (11:00 am – 8:00 pm Eastern).
Weight loss of at least 20 pounds was also associated with a 72% reduction in the odds of being discharged from the hospital to a facility.
Morbidly obese patients who lose 20 pounds before knee replacement surgery cut their hospital stays by about one day, and were 76% less likely to have an extended hospital stay of four days or longer, new research shows.
Writing in The Journal of Bone & Joint Surgery, researchers at Dartmouth-Hitchcock Medical Center said shorter hospital stays were not associated with morbidly obese patients who lost between five and 10 pounds before the surgical procedure.
"Losing at least 20 pounds was associated with lower absolute length of stay, lower odds of extended length of stay, and lower odds of being discharged to a facility," lead researcher David S. Jevsevar, MD, MBA, and colleagues wrote.
The study reviewed data on 203 morbidly obese patients who underwent total knee arthroplasty between 2011 and 2016 at one hospital. These patients accounted for 13.5% of the 1,500 patients who had knee replacement in that span.
In the months before surgery, 41% of patients lost at least five pounds, 29% lost at least 10 pounds, and 14% lost at least 20 pounds.
The researchers found that patients who lost at least 20 pounds spent about one fewer day in the hospital and were 76% less likely to have an extended hospital stay of four days or longer. Weight loss of at least 20 pounds was also associated with a 72% reduction in the odds of being discharged from the hospital to a facility.
However, no noticeable improvements in outcomes were noted for patients who lost between five and 10 pounds, and the study found that length of hospital stay and operative time were "significantly increased" for patients who added weight before surgery.
In addition, no association was found between preoperative weight loss and change in operative time or with postoperative health improvements and functions.
Jevsevar said larger studies will be needed to prove that preoperative weight loss can improve outcomes after total knee replacement. However, he said the Dartmouth-Hitchcock study suggests that "providers may want to focus on larger, specific amounts of weight loss in morbidly obese patients preparing for total knee arthroplasty."
A retroactive study found no differences in urinary complications between patients who used a Foley catheter and patients who did not.
Hip and knee replacement surgery can be performed safely without relying on a commonly used Foley urinary catheter, according to a new study in The Journal of Arthroplasty.
Researchers at Henry Ford Hospital in Detroit conducted a retrospective study of 335 patients and found no increased risk for post-surgery complications among those patients who were not catheterized.
"Until now, we didn’t have the research to show that we could perform the surgery without a Foley catheter," study senior author Michael Charters, MD, a Henry Ford joint replacement surgeon, said in remarks accompanying the study.
"All of our patients are now undergoing surgery without the catheter," Charters said. "It's a huge benefit for patients because it improves their mobility immediately after surgery. They can get up and walk around without being impeded by catheter tubes."
Before the study, Henry Ford clinicians commonly inserted a catheter into the patients' bladders in the operating room before surgery and removed the next day.
The researchers compared complications risks between patients with and without a catheter under epidural anesthesia between 2016 and 2018. Of the 335 patients, whose average age was 65, 103 used a catheter and 232 did not. Data was collected from patients' hospital admission and for the next 90 days.
Researchers found no differences in urinary complications, urinary retention, urinary incontinence or urinary tract infection between the two groups, Charters says.
Policymakers are sifting through more than 800 public comments on proposed changes to the Hospital Compare methodology.
The Centers for Medicare & Medicaid Services said Monday it will update its controversial Overall Hospital Quality Star Ratings in 2021.
Until then, CMS said it will "refresh" the Star Ratings, which appear on the Hospital Comparewebsite, in early 2020 using the existing methodology while a new methodology is being finalized for 2021.
Although the methodology had typically been updated every six months, the ratings have been updated only once since 2017 amid long-running complaints over their accuracy.
CMS said in a media release that "only a few comments recommended removing or suspending the Overall Star Ratings from Hospital Compare until changes are made."
"The comments are largely consistent with previous stakeholder feedback, with the most common concerns about the Overall Star Ratings being that CMS should improve its usefulness for consumer decision-making and hospital improvement," CMS said.
Since the five-star ratings inception in 2016, hospital stakeholders have repeatedly called on CMS to delay, revise or eliminate them until policymakers could address hospitals' concerns about the accuracy and correct use of the data.
CMS provided no details on what the changes to the star rating could encompass for 2021. However, the agency acknowledged that stakeholders have continued to raise concerns that the ratings are too complex, or oversimplified, imprecise, and provided without proper context for "more direct 'apples-to-apples' comparisons."
The American Hospital Association has a long history of criticizing the methodology, calling it confusing, complex, inaccurate and basically useless for most consumers.
AHA Senior Vice President of Policy Ashley Thompson said Monday the association was "disappointed that CMS intends to continue using a hospital star ratings approach plagued by longstanding concerns about its accuracy and meaningfulness."
"While we appreciate that CMS is working on potential improvements to the rating methodology, we strongly believe CMS should not refresh the ratings until those improvements have been vetted and are ready for implementation," Thompson said.
"Republishing the flawed ratings in 2020 will not advance the goal of providing the public with accurate, purposeful information about quality."
Bruce Siegel, MD, MPH, president and CEO of America's Essential Hospitals, said the safety net hospitals' association appreciates CMS' "efforts to engage stakeholders" in the rulemaking process.
"However, in the meantime, the agency's plan to refresh data using a methodology that is under review for its shortcomings is misleading to patients," Siegel said.
"The star ratings continue to reflect a flawed methodology rather than actual hospital performance and improvement. In particular, these ratings fail to account for social risk factors beyond a hospital’s control that affect performance."
Siegel said safety net hospitals support providing patients with "relevant information."
"But the current star ratings are not the way to do this. We urge the agency to suspend the ratings until methodology updates are complete," he said.
CMS said it is planning additional public outreach to shape potential changes to the Overall Star Ratings methodology, including a public listening session in Baltimore on September 19 that will include a call-in option.
Atlantic Health System President and CEO Brian Gragnolati says he believes healthcare that is delivered as a 'team sport' works best when the focus is on access, insurance, affordability, and proactive, preventive care.
"From day one," Brian Gragnolati, president and CEO of Morristown, New Jersey–based Atlantic Health System, says without hesitation, when the veteran healthcare executive is asked when he became a true believer in the gospel of value-based care.
A long-held belief in healthcare delivered as a "team sport" that works best when the focus is on access, insurance, affordability, and proactive, preventive care started when Gragnolati was an undergraduate at the University of Connecticut in the late 1970s.
At UConn, Gragnolati got an introduction to the clinical side of healthcare by working as an emergency medical technician to help pay his tuition.
"It was that experience of taking care of patients that convinced me that healthcare would be a great way to continue the work that I was doing as an EMT," Gragnolati recalls. "But I also recognize that I did not necessarily have what was needed to be a physician."
Fortunately for Gragnolati, UConn offered a healthcare systems engineering program and that's where he found his niche.
"In retrospect, that program was way ahead of its time," Gragnolati recalls. "It was interdisciplinary, so I took classes in the School of Public Health, the School of Allied Health, the School of Business, and the School of Engineering."
"We had interdisciplinary projects that we worked on and, lo and behold, that set up the work that I do here, even today, trying to bring different groups together to work on complex problems," he says.
"That's really what started my career. I came to realize that healthcare is a team sport, and how you finance healthcare is also a team sport, and we've got to do a better job playing like teammates on that."
The other big influence in Gragnolati's life was his father, who served as a Connecticut state legislator, and who taught his son the importance of cooperation, building consensus, being practical, and believing in the process.
"Getting involved on the advocacy and policy side was another way that I could approach healthcare and use a skill set that I understood," says Gragnolati, who is also the 2019 chairman of the board of trustees at the American Hospital Association.
"Consequently, I've always been pragmatic about how is healthcare going to continue to be funded, and I have always had an eye on affordability and how we make sure that whatever we're doing is going to be able to be continued," he says. "Throughout my career, I realized that unless you had access to insurance, you were going to struggle to get healthcare. As I continued my work in various capacities, I kept seeing that becoming a roadblock."
In mid-2015 Gragnolati took the CEO job at Atlantic Health System after serving for several years as a senior vice president at Johns Hopkins Medicine.
Following are highlights from a recent conversation between Gragnolati and HealthLeaders.
"What I saw here when I was looking at this role was an organization that was of sufficient size that could make the kinds of investments needed to be made in data systems, in the talent that we were able to bring in, in the technology."
"Specifically, I really liked what was being done here with the accountable care organizations and how they were developed, and I liked that they were beginning to move the commercial payment systems and data into an ACO infrastructure."
"[Atlantic Health System in mid-2018 began a partnership with urgent care provider MedExpress, owed by Optum, a subsidiary of UnitedHealth Group, co-operating 11 joint clinics in northern New Jersey] and is another example of how you partner with somebody differently. Historically, they haven't done these types of relationships where we actually own part of that organization."
"The reason we did it is because there are a lot of urgent care centers in this region. The easy thing for us to do would be to just put another one up and put our brand on it, but then all four corners of an intersection would have an urgent care center on it and continue to confuse the heck out of the patient-consumers about where they were going to receive high-quality accessible care."
"We found a great partner in MedExpress, and we've been able to co-brand to take advantage of how the community feels about the care that they receive at Atlantic Health."
"One thing that I've learned through this process is, in addition to being available and convenient and affordable, through the myriad of choices that patients have, they're also looking for urgent care centers that they can have confidence in. Our participation did bring that. When you talk to the folks on the ground, the leadership in each of the centers, they would agree with that."
"Probably the most important thing that I've learned is that continuity of care is very important. What's critically important is that we can get reliable information moved across from MedExpress and to MedExpress for our patients in a way that reduces unnecessary testing and makes sure that the providers have access to information that can help the patient when they're there."
"That's a really important piece because we have a system in this country of fragmented care. Our example of our relationship with MedExpress moves that in another direction."
Starting with the 2020 enrollment period, Health Exchange plans in every state will be graded on a five-star quality rating.
Health plans offered on the Health Insurance Exchanges will be required in the 2020 enrollment period to post their grades on a five-star Quality Rating System, under a mandated announced Thursday by the Centers for Medicare & Medicaid Services.
"Knowledge is power, and for the first time, consumers will have access to meaningful, simple-to-use information to compare the quality, along with the price, of health plans on Exchange websites, including HealthCare.gov," CMS Administrator Seema Verma said in amedia release.
"This addresses our strongly held commitment to equip consumers with the tools they need to find the best choice possible. Increasing transparency and competition drive better quality and cost, with consumers benefitting the most, " Verma said.
The overall star rating is based on three categories: Medical Care, Member Experience and Plan Administration. The ratings will address factors including how enrollees rate the doctors and the care they receive in the plan's network, how well the network providers coordinate care with enrollees and doctors, administrative competence, customer service, and access to personal health information.
CMS operated a pilot five-star ratings on HealthCare.gov in Virginia and Wisconsin during the 2017 and 2018 enrollment periods. The pilot was expanded to Michigan, Montana, and New Hampshire during the 2019 enrollment period.
The ratings system has the blessing of America's Health Insurance Plans, which said in a statement that "the nationwide expansion of the health quality measures is a positive step to help consumers review and select a plan that fits their needs for the year."
The Blue Cross Blue Shield Association said its member companies would "continue to work with CMS on ensuring that the information is displayed in a manner that is meaningful for patients when making selections during Open Enrollment this fall."
CMS is posting star ratings and quality measure level data from the 2019 Plan Year in a Public Use File. The star ratings data for the 2020 Plan Year will be released closer to open enrollment, which runs from Nov. 1, to Dec. 15, 2019.
Population growth and gains in employer-sponsored coverage did not overcome drops in Medicaid, CHIP and ACA marketplace coverage.
Even with a strong economy and robust job market, 700,000 people lost health insurance between 2016 and 2017, an Urban Institute study shows.
The uninsured rate national increased from 10% in 2016 to 10.2% in 2017, the first increase since 2013 and the advent of the Affordable Care Act. Under the ACA, the uninsured rate fell every year between 2013 and 2016 and 18.5 million people gained coverage, according to the study, which was commissioned by the Robert Wood Johnson Foundation.
The report found that population growth and increases in employer-sponsored insurance mitigated, but did not overcome, reductions in Medicaid and CHIP and ACA marketplace coverage.
"An additional 2.3 million people had ESI in 2017, but 1.9 million fewer people had coverage through Medicaid, CHIP, or the ACA marketplaces," the report said.
The uninsured rate in Medicaid expansion states held at 7.6%, but grew from 13.7% to 14.3% in non-expansion states, which also lost marketplace coverage at twice the rate of expansion states.
The coverage losses were felt across all age groups and incomes, although non-Hispanic white and black nonelderly people, those with at least some college education, and people living in the South and Midwest saw disproportionate coverage losses.
Earlier this week, the Centers for Medicare & Medicaid Services reported that enrollment in the individual health insurance market continued to decline last year, especially among those who pay full price for their coverage.
After average monthly enrollment in the individual market rose 7% from 2015 to 2016, it fell 10% in 2017 and another 7% in 2018, according to the CMS report.
Unsubsidized beneficiaries accounted for 85% of the enrollment decline in 2017 and all of the enrollment decline in 2018, which was offset by a small increase in subsidized enrollment, the report states.
While some states saw unsubsidized enrollment drop by less than 1%, others saw more dramatic changes, including six states where unsubsidized enrollment declined by more than 70% between 2016 and 2018, according to the report. Nationwide, unsubsidized enrollment dropped by 40%, or 2.5 million people, during that period, CMS said.
