Laura Joszt, MA

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Use of big data is allowing researchers to better understand a nurse’s risks for a near miss (NM) based on workload variables. A NM is an event that could have caused harm for the patient but ultimately did not, either because it was caught or simply through chance. NMs are similar to medication errors.

“NMs also occur as the result of the same systemic, organizational, and personal problems that cause errors, but occur more frequently, with estimates of NMs occurring 300 times more frequently than full-fledged errors,” the researchers wrote.

They conducted a literature review on past studies to understand the factors that increase medication administration errors and NMs. There were six workload factors commonly found across in-patient clinical hospital settings:

A the medical-surgical unit of a private, medium-sized hospital participated in the study. The nursing staff was observed across shifts and times throughout the day. Data on gender, employment status, and each of the six workload factors was pulled from electronic health records, call lights, and bar-code medication administration (BCMA) systems. The data was collected over a 60-day period.

Over the study period, data was collected on the workload of 23 nurses caring for 389 patients. There were 11,595 tasks were assigned and 26,150 medications ordered. However, the study only included oral medications, which dropped the number of medications to 18,104. Tasks that could be completed by nurse assistants were also removed, dropping the number of tasks reviewed 6,605.

The data was reviewed for two-hour time periods since medications were typically not ordered more frequently than that. The majority of the nurses were female (87%) and they accounted for 88% of the two-hour blocks worked and 86% of the blocks with NMs. The three male nurses accounted for 12% of the blocks worked and 14% of the blocks with NMs.

The authors noted that while such gender disparity is common in the nursing workforce, there was no significant association between gender and NMs, nor was there a significant association between the full-time nurses (3 males and 15 females) and part-time nurses (5 females).

In total, there were 1,174 NMs associated with the oral medications flagged by the BCMA database. The majority (91%) of the NMs were of scanning the wrong dose-time-medication and the remaining NMs were flagged as the wrong patient.

Over the 60 days, the majority (78%) of two-hour time periods “were devoid of any NM,” the authors noted. Of the periods with at least 1 NM, 60% had only one NM, 27% had two NMs, 6% had three NMs, and 7% had four or more NMs.

Regarding the 6 workload factors, the researchers found considerable variation among the two-hour blocks. There was no significant correlation among the independent variables. A comparison of the workload factors among the nurses showed significant differences for each factor “indicating considerable variation in factors recorded from nurse to nurse.”

According to the researchers, the findings suggest the risk for an NM is impacted by a combination of variables, which means systemic and organizational changes that impact only a few factors would have only a moderate impact in reducing NMs. Instead, interventions to reduce NMs must be customized to each nurse’s risk profile.

They added that data on nurse workloads is already being gathered at hospitals and can be used to identify the risk for NMs.

“It is time that researchers and managers harness this vast amount of data and use it to improve the quality of care nurses are providing,” the authors concluded. “This can be done successfully if the data that are currently fragmented and locked away inside different clinical systems can be brought together and used to improve patient care.”

Articles

Interventions to address and prevent near miss events must be customized to a nurse's individual risk profile.

Big Data Can Identify Risks for Near Misses Among Nurses

During the first four months of the COVID-19 pandemic, in-person ambulatory visits decreased while Americans gained wide access to telehealth services. A 

 documents shifts in telehealth use and ambulatory care from March to June 2020 and could have implications for the future of virtual care.

Prior to the onset of the pandemic telehealth services were not commonly used, but research has indicated that usage skyrocketed from less than 1% of visits to as much as 80% in areas with a high prevalence of COVID-19 cases. The use of telehealth as a way to deliver care at a social distance was made possible because “policy makers, payers, and practitioners eliminated almost all financial, regulatory, and technical barriers that hampered past telehealth expansion,” explained the authors.

They used data from the Blue Health Intelligence data repository, which includes complete claims files for commercial health plan members. The study compared March to June 2019 and 2020 and only analyzed ambulatory encounters with a telehealth-eligible service. They did not include inpatient and emergency department services.

The study cohort included 36,568,010 individuals with a mean age of 36 years. For this group, in-person ambulatory visits decreased by 37% between 2019 and 2020. Only 0.3% of ambulatory visits in 2019 were billed using telehealth designations, which increased sharply to 23.6% in 2020.

Patients who were between the ages of 18 and 49 and who had two or more chronic conditions used more telehealth in 2020, and states that were COVID-19 hot spots during the four months studied had higher rates of virtual care (36.0% vs 21.6%), as did urban locales compared with rural locales (24.2% vs 14.2%), and the most socially advantaged neighborhoods compared with the least (27.4% vs 19.9%).

Ambulatory visit rates were approximately 30% higher for patients who were placed in the COVID-19–related subgroup based on whether they had a diagnosis code associated with the disease, exposure to it, screening, or testing, but their telehealth use was only slightly higher (25.0% vs 23.5%).

The per member rate for behavioral visits stayed constant year over year, as did the encounter rate for addressing diabetes, hypertension, cancer, and well-child care. However, telehealth use for acute conditions was only 14.1% compared with 21.5% for chronic conditions.

“The use of telehealth for new patients and for new problems in 2020 was lower than overall rates,” the authors noted.

While total medical costs decreased from $358.32 per member per month (PMPM) to $306.04 PMPM (or approximately 15%) between 2019 and 2020, expenditures for patients with 1 or more ambulatory contacted increased slightly ($632.48 PMPM in 2019 vs $653.78 PMPM in 2020). The patients in the COVID-19–related subgroup had medical costs that were three times higher than patients in the non-COVID-19 subgroup.

The authors noted that a limitation of the study is that it was limited to the first four months of the pandemic and that further analysis is warranted “as virtual care becomes more established, as COVID-19 prevalence increases, and as coverage policies may change.” In addition, the study did not include the uninsured or patients covered by Medicare or Medicaid.

“Although some of the associations we uncovered may be unique to the COVID-19 environment, arguably the insights we gained will be relevant to the future trajectory of telehealth no matter what direction it takes,” the authors concluded.

A study documented shifts in telehealth use and ambulatory care during the first four months of the COVID-19 pandemic, from March to June 2020.

Patterns of Virtual Care and In-Person Ambulatory Contacts During the Onset of the Pandemic

Altarum, a nonprofit healthcare research and consulting institute, has released an outline for a new value-based insurance design model that it will test at pilot sites across the country. The plan is meant to address the needs of those who use the healthcare system the most, often as a result of chronic conditions.

Altarum created the Medical Episode Spending Allowance (MESA) plan with support from the Robert Wood Johnson Foundation. The model is well-suited to those with diseases and ongoing conditions that require recurring clinical visits. In comparison, the use of high-deductible health plans with health savings accounts has helped lower the cost of care, but can hurt patients with chronic conditions who need more care.

MESA is based on a reference pricing model, which sets a price for services and anything above that price is paid for by the consumer. According to Altarum, the model encourages consumers to seek out high-value care and providers. Members in a MESA plan only pay out of pocket when their cost of care exceeds the allowance for an episode of care, and when they use network providers in risk-based models of care, they could potentially have no out-of-pocket costs.

“Employers and consumers are looking for alternatives to increasingly unaffordable health coverage, and finding a solution that works is essential,” François de Brantes, vice president and director of Altarum’s Center for Payment Innovation, 

. “That’s what our MESA Blueprint is all about. By turning the high deductible health plan on its head, the MESA plan significantly reduces the potential for people with on-going illnesses from foregoing needed care.”

Through MESA, consumers will also have access to tools to help them make financially savvy choices with tools to research procedures, identify providers in their area, and view cost and quality ratings for providers. MESA also identifies Potentially Avoidable Complications, which are a significant driver of cost and a reliable indicator of quality, 

“Strategies that reduce the patients’ out-of-pocket cost burden for clinically indicated services provided by high performing clinicians are necessary and important strategies to achieve the Triple Aim,” said A. Mark Fendrick, MD, director of the University of Michigan Center for Value-Based Insurance Design.

MESA will be tested at select pilot sites throughout the United States, although none have been chosen yet. Sites that are interested in becoming pilots should have current engagement in and familiarity with alternative payment models, according to Altarum.

“MESA provides a comprehensive plan that marries payment reform with benefits reform, provider engagement with consumer engagement, and physician accountability for costs of care with patient accountability for managing their health and costs of care,” said Emmy Ganos, program officer at the Robert Wood Johnson Foundation. “Many of the concepts aren’t new—they are tried and tested&mdash;but their combination is, quite simply, a better solution.”

A version of this story originally appears in the 

The plans could be of benefit to those with chronic conditions that require recurring clinical visits.

Laura Joszt, MA

Articles

Big Data Can Identify Risks for Near Misses Among Nurses

Patterns of Virtual Care and In-Person Ambulatory Contacts During the Onset of the Pandemic

Altarum to Pilot Value-Based Plans for Those Who Need the Most Healthcare