Samara Rosenfeld

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On this week's episode of Data Book, Chief Healthcare Executive spoke with Steve Wigginton, CEO of Icario, platform that promotes health action to connect everyone to better health. We discussed how value-based care and artificial intelligence are helping health systems and health plans to provide more personalized care and to address social determinants of health.

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Steve Wigginton, CEO of Icario, discussed how value-based care and artificial intelligence are helping health systems and health plans to provide more personalized care and to address social determinants of health.

Podcast: Joining Technology and Value-Based Care to Provide More Personal Care

Opportunities exist to improve the selection of transfer destinations for patients with emergency general surgery conditions.

The findings of the recent study suggested optimizing transfer destination in the interhospital transfer network may improve such outcomes.

Cindy Y. Teng, M.D., and a team of Pittsburgh-based investigators examined whether patients with emergency surgery conditions were consistently directed to hospitals with more resources and better outcomes. The team analyzed interhospital transfers among adults with emergency general surgery conditions from January 1 to December 31, 2016. They used all-payer claims data from the 2016 Healthcare Cost and Utilization Project state inpatient and emergency department databases in eight states.

More than 700 hospitals were included in the study. Eligible participants were at least 18 years old and had an acute care hospital encounter with a diagnosis of an emergency general surgery condition.

The primary outcome was hospital-level centrality ratio — the normalized number of incoming transfers divided by the number of outgoing transfers. If the ratio was higher, it meant there were more incoming transfers per outgoing transfer. The team hypothesized higher hospitality centrality ratio was associated with more resources, higher volume, and better outcomes.

There were more than 80,000 patients analyzed, of whom, the median age was 63 years old, 52.1% were male, and 78.8% were White. The median number of outgoing transfers per hospital was 106, while incoming transfers was 36.

As the investigators hypothesized, a higher log-transformed centrality was associated with more resources like higher ICU capacity and higher emergency general surgery volume. But such a ratio was not linked with better outcomes, such as lower in-hospital mortality and lower failure to rescue — the occurrence of a complication followed by in-hospital death for emergency general surgery episodes that involved an operation or procedure.

Hospitals with a higher ICU capacity, higher volume, and higher-quality trauma care were associated with better emergency general surgery outcomes.

The findings emphasized the need for further research into the appropriate selection of transfer destinations as a strategy to improve emergency general surgery outcomes.

“Our results raise questions about whether [emergency general surgery] transfers are consistently directed to appropriate hospitals for further care and new concerns regarding how we determine appropriate hospitals in the absence of standardized guidelines,” Teng and the team wrote.

Assessment of Hospital Characteristics and Interhospital Transfer Patterns of Adults With Emergency General Surgery Conditions

Articles

Larger hospitals are associated with more resources for emergency general surgery patients.

Improvements Needed for Selection of Transfer Destinations for Emergency General Surgery

Hispanic and low-income communities have the largest percentage increase in telehealth use in response to the COVID-19 pandemic.

Findings of the study suggested virtual care can potentially mitigate the impact of the pandemic on healthcare use in vulnerable populations.

Due to the COVID-19 pandemic, there were dramatic decreases in outpatient healthcare visits and increases in telehealth visits. Still, healthcare workers and investigators were unsure of whether the changes in healthcare access were different based on patient demographics and socioeconomic status.

Lei Qian, Ph.D., and a team of investigators from Kaiser Permanente Southern California assessed the impact of the pandemic on in-person outpatient and telehealth visits by demographic characteristics and household income in a diverse population. The study cohort comprised patients of all ages who were members from January 5, 2020, to October 31, 2020 and the same period in 2019.

The investigators identified outpatient and telehealth visits using the electronic health record (EHR) data and claims data. Outpatient visits included all in-person outpatient visits and telehealth visits included telephone appointment visits and video visits conducted synchronously using real-time telephone or live video-audio interactions.

Of the more than 4.5 million members enrolled in January 2020, 15% were at least 65 years old, 51.5% were female, 39.4% were Hispanic, and 7.7% lived in census tract areas with a median household income less than $40,000.

After the start of the pandemic, outpatient visit rates had a steep drop-off across all sub-groups. Lowest levels of outpatient visits were in early April 2020, then gradually increased but still remained lower than before the pandemic. Patients at least 65 years old had the smallest decrease in outpatient visits with 6.25 visits per person-year during the later pandemic period versus 8.92 visits per person-year during the pre-pandemic period in 2020. Those aged 6-17 years old had the largest decrease, with 1.92 visits per person-year during the later pre-pandemic period versus 3.86 visits per person-year during the pre-pandemic period in 2020. Outpatient visit decreases did not differ statistically by sex, race/ethnicity, and household income groups.

In all sub-groups except patients aged 6-17 years old, telehealth visits increased after the start of the COVID-19 pandemic and then slowly decreased. For those aged 6-17 years old, telehealth visit rates remained stable after initial increase during the pandemic.

Telehealth visits increased the most for children aged 0-5 years old (475.5%; 95% CI, 446.2-506.4) and the least among adults at least 65 years old (236.6%; 95% CI, 228.8-244.5). Such visits increased significantly more among males (293.9%; 95% CI, 283.4-304.7) than females (260%; 95% CI, 252.6-267.6). What’s more, Hispanic patients had the largest increase in telehealth visits (295.5%; 95% CI, 275.5-316.5), and visits for patients in the low-income group increased the most (313.5%; 95% CI, 294.8-333.1).

The use of telehealth and virtual care among these sub-groups reduced exposure to COVID-19, reinforced social distancing, increased the number of patients who could be treated, and may have mitigated the impact of COVID-19 in vulnerable populations.

“Furthermore, the use of virtual care might be a promising way to reduce healthcare disparities even after the COVID-19 pandemic ends,” Qian and the team concluded.

Disparities in Outpatient and Telehealth Visits During the COVID-19 Pandemic in a Large Integrated Health Care Organization: Retrospective Cohort Study

Virtual care can reduce healthcare disparities even after the pandemic ends.

Telehealth Increased Healthcare Access for Hispanic, Low-Income Populations During COVID-19

Exposure to COVID-19-positive household members is a risk factor associated with infection among vaccinated healthcare workers.

The findings of the recent study suggested reconsideration of quarantining vaccinated people who have had significant exposure to household members who tested positive for the virus.

While mass vaccination of Israeli adults who received the BNT162b2 vaccine (Pfizer-BioNTech) is associated with a significantly lower rate of SARS-CoV-2, there are still cases of infection among fully vaccinated adults. And after the vaccination rollout, the CDC eliminated the need for quarantine after exposure.

Yonatan Oster, M.D., and a team of Israel-based investigators studied the association between exposure characteristics and infection risk among vaccinated and non-vaccinated healthcare workers in Israel. To do this, they conducted a case-control study between January and March 2021 at the Hadassah-Hebrew University Medical Center. Hospital executives executed the vaccination program and within two months, it achieved almost complete vaccination coverage and a significant decrease in the number of infected healthcare workers.

The investigators compared all vaccinated healthcare workers who tested positive at least two weeks after getting the second dose. Workers were placed into two control groups — all non-vaccinated workers who had positive test results during the same period and a sample of vaccinated workers who were tested but had negative results. The team collected data including demographic characteristics, symptoms, characteristics of exposure, and disease course.

There were 5,312 vaccinated healthcare workers and 690 non-vaccinated healthcare workers at the end of the study period. Of those vaccinated, .5% had positive test results for COVID-19 and 10% of non-vaccinated healthcare workers had positive test results for the virus.

Among the positive groups, symptoms were the common cause for testing (62% in the non-vaccinated-positive group and 63% in the vaccinate-positive group), but not in the vaccinated-negative group (22%).

Being exposed to a positive household member was significantly more common for healthcare workers in the vaccinated-positive group (56%) compared to the non-vaccinated-positive group (38%) and the vaccinated-negative group (9%). When it came to the odds ratio of exposure to positive household members, vaccinated-positive healthcare workers had an OR of 2.03 compared to non-vaccinated-positive healthcare workers and an OR of 12.5 compared with vaccinated-negative healthcare workers.

Association Between Exposure Characteristics and the Risk for COVID-19 Infection Among Health Care Workers With and Without BN-T162b2 Vaccination

Vaccinated people should quarantine if they are exposed to household members who tested positive for COVID-19.

Exposure to COVID-Positive Household Members a Big Risk Factor for Vaccinated Healthcare Workers

A partnership between Ochsner Health and Bold aims to leverage digital health to reduce falls and improve health outcomes in older adults.

The platform is one of five interventions in Ochsner’s Connected Stability pilot fall prevention and monitoring programs to help Medicare Advantage members at the highest risk for falls.

Bold’s evidence-based fitness programs keep older adults active to prevent such falls. In fact, findings of a clinical study conducted by Bold demonstrated up to a 60% reduction in annualized fall rate in members enrolled in the program. The digital health program features strength, balance, and mobility exercises, along with education and community support.

According to the CDC, one in three adults over the age of 65 years old fall each year. And the falls come with a high cost — nearly $50 billion annually on non-fatal fall injuries and $754 million is spent on fatal falls. In 2018 alone, Medicare paid $29 billion for treatment and care of non-fatal falls.

“Falls is one of the leading problems facing healthcare today in terms of both cost and mortality,” Richard Milani, M.D., medical director for iO and chief clinical transformation officer for Ochsner Health, said in 

. “Bold’s balance training program was a natural fit as one of multiple interventions in our comprehensive fall prevention and monitoring program as we work to prevent future falls.”

To use Bold, members complete an online assessment about their current health and fitness levels. With the data, the platform designs a personalized program specific to the member’s abilities. The program offers options that are easy to follow and accessible at home. While participating in the program, members can have supportive and motivational check-ins. What’s more, they can join virtual live classes and other community events to encourage social connections.

The partnership is not the first time Ochsner Health used health tech and digital platforms to help its patients.

Through Connected Maternity Online Monitoring, expecting mothers can manage their pregnancy at home without scheduling an appointment. Patients can digitally send weights and blood pressure readings to their medical team.

Ochsner Health was also among the first hospitals to integrate with Apple HealthKit via Epic. And a few years ago, the hospital launched the O Bar, an in-person center for learning about health and wellness apps. The hospital recommends hundreds of apps that range from nutrition tracking, to fitness, to managing chronic conditions. A majority of the apps help patients track their vital signs and integrate with Apple HealthKit.

The new partnership between Ochsner Health and Bold firmly reiterates digital health platforms can improve patient outcomes from outside the traditional four walls of care.

The partnership highlights the importance of leveraging digital health to improve patient outcomes. 

Ochsner Health, Bold Partner to Use Digital Health to Decrease Falls

Use of a mobile app significantly decreases the rate of medication errors and time to drug delivery for emergency drug preparation in a prehospital setting.

Findings of the recent study suggest such apps have the potential to improve medication safety and change practices in pediatric emergency medicine.

Johan N. Siebert, M.D., and a team of Switzerland-based investigators assessed the efficacy of an evidence-based mobile app in reducing the occurrence of medication errors compared with conventional preparation methods during simulated pediatric out-of-hospital cardiac arrest scenarios. The nationwide, open-label, multicenter, randomized clinical trial took place at 14 emergency medical services centers in Switzerland.

Two methods were evaluated to guide the preparation of emergency drugs for IV administration at pediatric doses. Those included in the study were randomly assigned to prepare the drugs with support of the app (intervention group) or by conventional methods (control group).

Participants were registered advanced paramedics who worked in EMS and had a three-year formal educational program in Switzerland. Paramedics were trained in advanced life support procedures.

Those randomized to the intervention group needed to: (1) complete a survey collecting data about their demographic characteristics, healthcare training, and simulation and computer experience; (2) attend a five-minute training session on how to use the app; and (3) attend a presentation of the simulation manikin characteristics. Paramedics participated in a simulated cardiopulmonary resuscitation scenario on a high-fidelity manikin. The scenario was filmed to be analyzed to verify whether any errors were made.

In the scenario, participants were asked to sequentially prepare and inject four different drugs of varying degrees of preparation difficulty with the support of the mobile app designed to assist with drug preparation. Those in the control group followed conventional pediatric drug preparation methods.

The team’s primary outcome was medication error, defined as failure in drug preparation if at least one error was committed — a deviation in drug dose higher than 10% from the correct weight dose, inability to calculate drug dose without guidance from the paramedic investigator leading the resuscitation room, or a deviation of higher than 10% of the final administered concentration of sodium bicarbonate from the prescribed 4.2% concentration.

There were 150 advanced paramedics randomized to the two study groups — 74 to the mobile app group and 76 to the conventional group.

Overall, 600 drug doses were delivered. More than 62% of doses given using the conventional method and 5.7% of those delivered using the mobile app were associated with medication errors. A majority of errors were due to a dose deviation higher than 10% of the prescribed dose (56.6% using the conventional method and 5.4% using the mobile app). The risk of incorrect preparation of the four drugs was decreased by 66.5% using the mobile app.

All participants in the control group committed at least one preparation error during the scenario, while 18.9% of the intervention group had at least one error. The proportion of those committing several preparation errors was substantially lower with the app (4.1%) than with the conventional method (85.5%).

Use of the mobile app resulted in significantly shorter times for drug preparation and delivery. Such was observed for three of the drugs. The time to drug preparation decreased by 40 seconds and the time to drug delivery decreased by 47 seconds. The decreases represented an overall saving in time of 20% compared with the conventional method.

The study findings emphasized the efficacy and positive outcomes related to medical mobile apps to improve medication safety and change prehospital clinical practice in pediatric emergency medicine.

Effect of a Mobile App on Prehospital Medication Errors During Simulated Pediatric Resuscitation

A mobile health app provides a safer and more timely drug delivery system.

Mobile App Substantially Decreases Medication Errors, Delivery Time

Findings of a new report highlight 40% of hospitals accelerated hiring to meet the increased demand in medical services following COVID-19 lockdowns.

 revealed 36% of hospitals surveyed plan for normal hiring and 24% are being cautious by delaying or issuing a hiring freeze.

The survey findings strongly differentiate from 2020 when hospitals took measures to cut costs during the onset of the COVID-19 pandemic lockdowns. Last year, 54% of hospitals had furloughs, 45% laid off workers, 15% suspended 401(k) or 403(b) retirement plan contributions, and 10% announced voluntary separation programs.

“The top priority in 2020 was to mitigate rising costs for the employer — understandably, given the financial shock that health systems were reeling from,” Sheena Singh, senior vice president of Aon’s national healthcare industry practice, said in a press release. “Now, the pandemic has exacerbated a labor shortage that could impact patient care delivery, delay attainment of organizational objectives, and accelerate burnout among clinical staff.”

A majority of health system employers (77%) expressed concerns with employee burnout and workforce resiliency, while 76% were concerned with employee work/life balance. Additional concerns included financial stress for employees (75%) and benefits to support diversity, equity, and inclusion (73%).

The report demonstrated average health benefit expenses per hospital employee per year may grow 2.7% from nearly $14.5k to more than $15k. This is due to hospitals ramping up to accommodate deferred medical services.

When it comes to healthcare costs, 77% of hospitals plan on paying at least 76% for their employees. And 23% offer a no-cost health plan. Most health systems surveyed (85%) provide a discount to employees through a plan design to access their own facilities and providers.

As far as benefits are concerned, 94% of hospitals offer tuition reimbursement programs and 69% offer flexible work options. Many hospitals (66%) offer cash-out vacation policies and 45% offer adoption benefits. Other employee rewards include on-site daycare, student loan repayment plans, back-up childcare, and back-up elder care.

“Attracting and retaining talent remains a top priority and health systems have prioritized benefits as a mechanism to reward their workforce,” Singh said. “This is a trend that will continue with a shortage of qualified health professionals and rising demand for healthcare services, as these organizations seek to build a resilient workforce in the wake of the COVID-19 pandemic.”

Survey results came from benefit plans for more than 2.4 million health system employees from more than 1,150 hospitals across the U.S.

Tides are changing a year and a half after the COVID-19 onset, as health systems accelerate hiring.

Hospitals Focused on Hiring, Benefits Following COVID-19 Onset

There has been increases in the proportions of women faculty across clinical academic departments over the past three decades.

Further, racial and ethnic diversity among faculty increased, but at a lower rate.

Alexander Yoo, M.D., and a team of investigators evaluated the distribution of women and underrepresented groups in medicine (American Indian or Alaskan Native, Black, Latino or Hispanic, and Native Hawaiian or other Pacific Islander) among U.S. medical school faculty for 16 clinical academic medical departments. To gather the information, the team used the Association of American Medical Colleges Faculty Roster from 1990-2019. Specialties included ranged from anesthesiology, to dermatology, to radiology, to neurology, and many more.

Models were used to estimate the mean change per year in percentages of women and underrepresented groups in medicine. Data included department, time, and a department-by-time interaction. The investigative team collected demographics like race and ethnicity of U.S. resident physicians from 2012-2013 from the Accreditation Council of Graduate Medical Education.

Of the faculty entries reviewed from 1990-2019, 34.6% were women and 71.9% were for White physicians. In five of the clinical academic departments, proportions of women faculty increased, with women making up more than 50% of faculty members.

As of 2019, specialties with more women faculty did not necessarily have high representation compared with residents. The specialty with the highest proportion of women faculty, obstetrics and gynecology, had the third lowest representation ration (.81). And while orthopedic surgery had the lowest overall proportion of women faculty, it had the highest representation ratio (1.48).

When it came to underrepresented groups in medicine, most specialties had representation ratios of less than one, with an overall representation ratio of .76.

The investigators noted the increase in faculty diversity may be due to improvements in diversity among medical students and residents. Still, underrepresented groups in medicine faculty are still underrepresented compared with the resident pipelines for a majority of specialties. Most departments have only a fraction of the available underrepresented groups in medicine resident pipeline. There were also differences in representation ratios across departments for women.

Yoo and the team suggested additional investigation is needed to understand barriers and factors associated with women and underrepresented groups in medicine trainees from pursuing academic careers.

Representation of Women and Underrepresented Groups in US Academic Medicine by Specialty

The increase in a more diverse faculty starts with a more diverse group of medical students and residents.

Increases in Women, Underrepresented Groups in Clinical Academic Departments

Communication interventions at hospital discharge are significantly associated with fewer readmissions, higher treatment adherence, and higher patient satisfaction.

The findings of the new study suggested healthcare systems implement such communication strategies at discharge to facilitate the transition of care.

Although healthcare practitioners explain critical information to patients at the time of discharge, patient may not understand or remember the information provided, which may result in confusion, misinterpretation, and mismanagement of treatment regimen. Christoph Becker, M.D., and a team of investigators conducted a systematic review and meta-analysis on the association of communication interventions at discharge with readmission rates and other patient-relevant outcomes. Randomized controlled trials were included if the effect of any communication intervention assessed readmission, medical adherence, mortality, satisfaction, medical knowledge, or reattendance to the emergency department. Eligible studies if the intervention was performed shortly before or at hospital discharge, if they had a randomized clinical design, and included medical patients.

The investigative team searched PubMed, Embase, CINAHL, and PsycInfo. Two investigators screened titles and abstracts. They independently extracted data of the studies, then assessed the included randomized controlled trials for methodological quality using the Cochrane Risk of Bias Tool.

The primary endpoint was readmission to the hospital. Additional endpoints included adherence to treatment regimen, satisfaction, mortality, and knowledge of medication or diagnoses assessed 30 days after hospital discharge.

Overall, 60 studies were eligible for inclusion and 19 trials were included in quantitative analysis. Of the 60 studies, 32% reported data about readmission within 30 days after discharge. Among them, 58% had low risk of bias, 32% had high risk, and 11% had unclear risk. The results demonstrated a significant association between communication interventions and fewer readmissions to the hospital (RR, .69; 95% CI, .56-.84).

A subgroup analysis was performed to stratify the type of intervention, age, primary disease, use of handouts, study quality, setting of the study, sex, and location of the study. The team reported a significant difference regarding the main disease of patients with trials including those with respiratory conditions (RR, .32; 95% CI, .18-.57) and patients with other illnesses (RR, .78; 95% CI, .64-.96). Trials with cardiac conditions demonstrated no significant difference (RR, .62; 95% CI, .38-1.02). Further, trials with <50% of patients being women, compared to those with >50% women patients, had better outcomes in hospital admission (RR, .55; 95% CI, .39-.77 vs .82; 95% CI, .64-1.06).

Becker and the team reported that, along with lower readmission rates, there was higher adherence to treatment regimen and higher patient satisfaction for those who had a communication intervention.

The results of the review suggested communication interventions at discharge could help to increase patient knowledge regarding disease, its therapy, and further therapeutic regimen.

Interventions to Improve Communication at Hospital Discharge and Rates of Readmission

The results demonstrate such intervention can increase patient knowledge about their disease, treatment, and regimen.

Communication Interventions at Discharge Reduce Hospital Readmission

Telehealth models are associated with positive outcomes for both patients and healthcare professionals, especially in rural communities across the U.S.

Findings of a new study suggested such models were feasible and could be effective.

In rural populations, there are gaps in design and effectiveness of technology for treating diseases and addressing social determinants of health. So, Michael Butzner, Dr.P.H., and a colleague evaluated literature on current applications, therapeutic areas, and outcomes of telehealth interventions in such communities in the U.S.

To conduct the narrative review, the team searched PubMed MEDLINE from January 2017 to December 2020. They searched terms including “telehealth,” “telemedicine,” “rural,” and “outcomes.” Randomized controlled trials, mixed methods studies, qualitative studies, post hoc analyses, and prospective and retrospective cohort studies were included.

Overall, 15 studies reported telehealth intervention outcomes and were reviewed by the investigators. The areas examined were mental health (n=3), HIV (n=2), reproductive care/women’s health (n=3), osteoporosis (n=1), orthopedics (n=1), acute ischemic stroke (n=1), cancer (n=1), substance use disorder (n=1), ophthalmology (n=1), and emergency medicine (n=1). Study outcomes focused on feasibility and acceptability of telehealth, diagnostic and treatment validation of telehealth, patient satisfaction and self-confidence, education and training, and telehealth design features (prevalence and access, type of service, and therapeutic area).

Among the studies that analyzed telehealth interventions in patients, the findings demonstrated internet, electronic adherence monitors, and telelactation were feasible and accepted in rural, underserved populations, and improved access to care. Additional studies highlighted advantages of telemedicine visits, including decreased indirect and direct costs, lower travel costs and travel times, similar patient satisfaction compared to onsite visits, and patient satisfaction among telelactation users.

What’s more, healthcare providers and patients considered the technology convenient and efficient. Use of telehealth resulted in lower onset healthcare resource utilization, improved physician recruitment and retention, improved access to care, and increased education and training of patients and healthcare providers.

Still, several disadvantages to telehealth were reported. Disadvantages included having visits with unknown providers and technological issues like loss of connectivity and limited Wi-Fi access in rural areas.

“The findings support the existing literature on the need to increase and validate telehealth interventions and further update and implement policies to increase access and provide high-quality telehealth programs,” Butzner and his colleague concluded.

Telehealth Interventions and Outcomes Across Rural Communities in the United States: Narrative Review

Rural populations have the opportunity to leverage telemedicine to improve health outcomes.