Samantha DiGrande

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Despite the massive undertaking, both financially and structurally, that the US federal government took on to digitize the healthcare system by creating and nationally adopting electronic health records (EHRs), the promise of EHRs to significantly improve quality has remained tenuous.

One mechanism by which EHRs were expected to improve quality in particular was the implementation of computerized provider order entry (CPOE), coupled with clinical decision support (CDS) tools. CPOE enables healthcare providers to write orders for patients electronically, as opposed to verbal or written communication. CDS coupled with CPOE then uses EHR data specific to the patient as well as medication reference databases to supplement clinician decision-making and prevent potential adverse drug events, such as ordering a drug a patient may be allergic to or a drug with a potential contraindication.

While CDS tools intervene at the point of care, performance outcomes have been mixed and a significant amount of customization happens at the organization level which results in differences even within hospitals using the same technology.

A potential policy mechanism to incentivize quality improvement is public reporting of performance. However, recent evidence has cast doubt on whether national programs are useful tools in identifying high quality and it remains unclear if public reporting is an effective way to encourage improvement.

In order to determine whether publicly reported feedback was associated with hospital improvement in an evaluation of medication-related CDS safety performance, 

 authors conducted a nonrandomized controlled trial that included U.S. hospitals that participated in the CPOE Evaluation Tool in the Leapfrog Hospital Survey. This tool is a is a national quality reporting program that evaluates safety and performance of CDS using simulated orders and patients from 2017 to 2018.

A total of 1183 hospitals were included in the study with a mean CPOE score of 59.3% (16.3%) at baseline. Hospitals receiving negative feedback improved 8.44 percentage points more in the subsequent year compared with hospitals that received positive feedback on the same evaluation. This change was driven by differences in improvement in basic CDS capabilities rather than advanced CDS.

Overall, the authors found that publicly reported feedback was associated with quality improvement, which suggests that targeted measurement and reporting of process quality may be an effective policy that encourages improvement in specific areas.

Articles

Hospitals receiving publicly reported negative feedback improved their electronic health record medication safety.

Public Quality Reporting Associated With Quality Improvement in Hospitals 

Hospitals need to develop better ways to identify and treat patients with alcohol and substance abuse disorders as they represent an increasing percentage of emergency department (ED) visits and hospitalizations in the United States, according to a recent study by researchers at the University of California, San Francisco.

Researchers analyzed data from the National Hospital Ambulatory Medical Care Survey, which is an annual survey administered by the National Center for Health Statistics. Based on patient medical charts, alcohol use disorder and other substance use disorders were identified.

The study, which looked at ED visits from 2014 to 2018, found that adults with alcohol and substance use disorders were visiting the ED at an increased rate of 30%. Additionally, hospitalizations among patients with those disorders increased by 57%.

In fact, during the study period, one out of 11 visits and one out of nine hospitalizations each year was an individual with an alcohol or other substance use disorder.

“These statistics are comparable to common conditions like heart failure, but hospitals and EDs are rarely as equipped to treat addiction as they are to treat cardiovascular diseases,” said Leslie Suen, MD, MAS, of the UCSF Department of Medicine and lead author of the study in a 

The study also found that patients with alcohol and other substance use disorders that presented to the ED were more likely to have Medicaid health insurance, have depression, be experiencing homelessness, have received mental health treatment, and present with injury and trauma.

“Illness and death from complications of alcohol and other substance use are increasing nationally,” said Suen. “Hospitals are one place where we can begin to reverse that trend, but we must be prepared to identify and treat these patients while they are in the hospital and continue following and treating them after they are discharged, as well.”

Of note, these estimates are higher or similar than previous national estimates using claims data. This underscores the importance of identifying additional opportunities to address alcohol and other substance use disorder in acute care settings, especially in tandem with other medical concerns but particularly among visits also presenting with injury, trauma, or coexisting depression.

The number of patients presenting in the emergency department (ED) with alcohol and substance use disorders is on the rise, but hospitals are not equipped to treat addiction.

Hospitals Are Ill-Equipped to Handle an Increase in Patients With Addiction in EDs

COVID-19 vaccines have been free and available to American adults in all states since April 2021. Despite this, as of early September 2021, 25% of adults over the age of 18 in the US remain unvaccinated. This has led to an increase in new cases, hospitalizations and deaths, according to a 

 from Peterson-KFF Health System Tracker.

This surge, which is largely preventable because the vaccines have been proven to be highly effective at preventing severe disease, hospitalization and death from COVID-19, is adding billions of dollars in preventable costs to the nation’s healthcare system.

According to the report, the average hospitalization cost of treating a patient with COVID is around $20,000. According to data from HHS and CDC, there were 32,000 preventable COVID hospitalizations in June, 68,000 in July, and an additional 187,000 in August for a total of 287,000.

Given this, new estimates of the preventable costs of treating unvaccinated patients in hospital total nearly $3.7 billion as of August, almost twice the estimates for June and July combined. From June to August, the total preventable cost reached nearly $5.7 billion.

Of note, the report points out, the monetary cost of treated unvaccinated people for COVID-19 falls not only on the patient but on society at large, including taxpayer-funded public programs and private insurance premiums paid by workers, businesses and individual purchasers.

In an analysis of privately insured patients who were hospitalized with pneumonia, the typical out-of-pocket payment was $1,300. This is, of course, relative to each individual’s insurance plan and would also depend on how COVID-19 hospitalization costs are billed. While this amount is significant for most patients to pay, it is far less than the amount covered by public and private insurance.

The report goes on to note that the Affordable Care Act and other laws prohibit insurers from charging unvaccinated people higher premiums. However, through wellness programs, employers have the ability to impose higher costs. Private insurers have begun reinstating cost-sharing for COVID-19 hospitalizations. The federal government requires insurers to cover the cost of COVID-19 tests without cost sharing for individualized diagnosis purposes, but insurers are not required to cover the cost of COVID-19 testing for employment purposes.

Unvaccinated workers may be required to get COVID-19 tests regularly to return to work physically, and insurers have the ability to, and may shift some or all costs for those tests to the workers. However, adults can largely avoid these out-of-pocket costs and severe illness by getting the free vaccine.

An increase in new COVID-19 cases and hospitalizations among unvaccinated individuals cost nearly $3.7 billion August, according to report from the Peterson-KFF Health System Tracker.

Hospitalizations for Unvaccinated Patients With COVID-19 Cost Billions

As the pandemic continues on, there are many concerns about the nursing workforce that have surfaced. In order to dig deeper into some of the most prominent concerns, namely staffing, the UCSF Health Workforce Research Center on Long-Term Care conducted two surveys in California to assess the current and future supply and demand of registered nurses (RNs). Their findings were published in a recent 

According to the authors, California is poised to face a significant shortfall of RNs over the course of the next five years. This is primarily due to long-term trends that have worsened due to the COVID-19 pandemic. Current estimates place the shortage at around 40,567 full-time equivalent RNs, a 13.6% gap, anticipated to continue until 2026, according to a preliminary analysis from the 2020 Survey of California Registered Nurses and final data from the 2019-20 Annual RN Schools Survey.

California has more than 350,000 RNs employed in hospitals, clinics and other facilities, in addition to more than 450,000 licensed nurses. In fact, California nurses make up approximately 12% of all nurses employed nationwide. Among employed RNs in California, it is estimated that 30% are over the age of 55 years.

“The pandemic is accelerating a broad trend that has been building for some time. To address this, employers need to retain older RNs, while developing career paths for new graduates," said Joanne Spetz, PhD, co-author of the report and director of the UCSF Philip R. Lee Institute for Health Policy Studies, in a 

. "They also need to rapidly develop and implement strategies to mitigate the potential harm of nurse shortages over the next five years."

Underscoring Spetz’ recommendations are further findings from the study: Many older RNs in California have left the field and a large number plan on retiring or quitting within the next two years, while unemployment among younger RNs has increased. Specifically, in 2020, 26% of RNs between the ages of 55 and 64 reported that they plan to leave the field in the next two years, a significant increase from 12% reporting the same in 2018.

Concurrently, employers have been hesitant to hire less experienced RNs presumably because of the challenge in onboarding them amidst a pandemic. Despite this, there is record-breaking interest in the nursing profession. According to Spetz, RN education enrollments are projected to surpass pre-pandemic levels during the 2022-23 academic year.

She summarized the challenge ahead as this: “Can you address older RNs’ burnout and keep them in the workplace part-time to help onboard the new grads?”

California is poised to face a significant shortfall of registered nurses over the course of the next five years, according to 2 surveys.

Samantha DiGrande

Articles

Public Quality Reporting Associated With Quality Improvement in Hospitals

Hospitals Are Ill-Equipped to Handle an Increase in Patients With Addiction in EDs

Hospitalizations for Unvaccinated Patients With COVID-19 Cost Billions

Shortage of California Nurses Projected to Last Until 2026