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Distressed Community Index Data Supplements MVC Equity Work

Distressed Community Index Data Supplements MVC Equity Work

Emphasizing health equity in Michigan is a key strategic initiative for the Michigan Value Collaborative. MVC kicked off this strategic initiative at its October 2021 semi-annual meeting with the theme of “The Social Risk and Health Equity Dilemma.” Since then, MVC has expanded its access to data sets related to health equity, developed hospital health equity reports, and regularly convened stakeholders from around the state via a health equity workgroup series that launched in January 2022. MVC is eager to find new and exciting ways to utilize data and collaborate with members on health equity topics in Michigan.

One of the more recent enhancements to MVC’s capacity was the addition of more granular data on social determinants of health. MVC secured access to Distressed Community Index (DCI) data, a tool for measuring the comparative economic well-being of US communities. DCI data was first integrated into MVC reporting in August with the distribution of a new push report on emergency department and post-acute care use. It was also incorporated in MVC’s newest physician organization report on chronic obstructive pulmonary disease, which was distributed to PO members last month.

The DCI data are developed by the Economic Innovation Group and derived from the US Census Bureau’s Business Patterns and American Community Survey Five-Year Estimates (2016-2020). The DCI is a composite measure of ZIP-code level socioeconomic distress comprised of seven key indicators, including education, housing, unemployment, poverty, income, employment changes, and business (see Figure 1).

Figure 1.

The resulting DCI composite measure assigns individual five-digit ZIP codes a number from 0 to 100 with 0 representing the least distressed communities and 100 representing the most distressed communities. The DCI is then grouped into five ordered categories for ease of comparison: distressed, at risk, mid-tier, comfortable, and prosperous. The data include details on 874 ZIP codes in Michigan that have at least 500 residents, of which 192 (22%) are prosperous communities and 120 (14%) are distressed communities. The map below (see Figure 2) highlights the distribution of community-level distress categories across the state of Michigan, with the blue areas representing more prosperous communities and the red areas representing more distressed communities.

Figure 2.

The data also reveal staggering racial/ethnic disparities in Michigan. As seen in Figure 3 below, Black/African American Michiganders are far more likely to live in distressed communities relative to non-Hispanic whites. This information is further evidence of the need for broad efforts to reduce disparities according to race/ethnicity and local community distress.

Figure 3.

Incorporating the DCI into MVC data analytics will offer new opportunities to better understand health equity challenges in Michigan. The MVC Coordinating Center looks forward to using these data in collaboration with its members and is eager to discuss how best to leverage such data sets to identify inequity in Michigan healthcare. Please contact MVC to learn more or request custom analytics.

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First Annual MiCR Meeting Draws Cardiac Rehab Stakeholders

First Annual MiCR Meeting Draws Cardiac Rehab Stakeholders

Since its inception earlier this year, the Michigan Cardiac Rehabilitation Network (MiCR) has sought to equitably increase cardiac rehabilitation (CR) participation for all eligible individuals in Michigan. A key step in this process has been to assemble an engaged group of stakeholders that share this vision from around the state, which culminated in the first MiCR Annual Meeting on October 7, co-hosted by MVC and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). Over 40 attendees representing institutions throughout Michigan came to Ann Arbor to present and discuss ongoing challenges facing CR utilization, and to brainstorm solutions that could be implemented across the state.

The first session of the meeting discussed strategies to cultivate buy-in from clinicians and administrators to support CR for their patients and health systems. Dr. Frank Smith, MD, from Trinity St. Joseph Mercy Ann Arbor discussed the importance of identifying and educating the key administrators and clinicians within the organization and developing a rigorous financial plan for a growing CR program. Jacqueline Harris, BS, CCEP, from McLaren Northern Michigan discussed how she developed small, laminated cards that mapped out the process to get eligible patients to CR, which she distributed to clinical teams within her institution. Rob Snyder, EP, MSA, from McLaren Greater Lansing emphasized the importance of continual monitoring and engagement with clinical and administrative leadership to ensure CR program growth.

Following the presentations, small group discussions among attendees identified other challenges related to achieving buy-in from clinicians and administrators. The referral phase was a consistent source of frustration for many attendees, including delays in referral from qualifying events, inefficient referral processes that require physician action, and limited staffing to close the gap from referral to enrollment. The session panelists noted that implementing automatic referrals and recruiting a physician champion can help facilitate referrals among colleagues with lower referral rates.

The second session of the day focused on navigating challenges with insurance coverage for CR programs. Robert Berry, MS, ACSM-CEP, FAACVPR, from Henry Ford Health discussed strategies to minimize insurance delays in starting CR. It is critical to know the regulations and policies that guide CR so that staff can work within them to reduce delays to enrollment. Like the prior session, implementing automatic discharge order sets that include CR for eligible patients can minimize delay, but more work may be needed within an institution to work through pre-authorizations that often accompany CR use. Dedicated liaisons can be a critical resource for addressing insurance issues and securing enrollment during the hospital stay. Jacqueline Evans of Covenant HealthCare reiterated the importance of understanding the regulations and policies of major insurers and developing tools to educate colleagues and patients. Being the local expert can ensure the financial health of the CR program and minimize the insurance burden for patients.

The day's final session featured discussions about how to better engage patients and providers in CR. Greg Merritt of Patient is Partner discussed his experience with CR—having survived a cardiac event and benefitted from participating in CR—and how patients could be involved to improve the CR experience. Integrating former graduates of CR programs into the orientation process may help alleviate fear and concerns facing new attendees. He also challenged the group to think about how CR could be reshaped to reflect the patient population or foster better adherence through engaging with community partners such as dog shelters or social groups. Patients are often an untapped resource and can help innovate CR to improve participation.

The Healthy Behavior Optimization for Michigan (HBOM) collaborative closed out the day with a brainstorming session on how attendees might innovate the current CR system to create better experiences and outcomes for all patients. Attendees raised challenges that face vulnerable populations, such as access to nutritional foods and health literacy. Solutions to these issues could include standardized and accessible resources for patient education and opportunities to provide nutritional support to patients such as grocery delivery services. Developing peer support systems and community-building among CR graduates may also facilitate a better introduction to new patients and improve long-term adherence to behavior changes developed during the program.

Several next steps were identified at the conclusion of the meeting. First, the MVC and BMC2 collaboratives will continue to work towards broader dissemination of CR reports to relevant stakeholders in Michigan. MVC’s latest CR reports were distributed to MVC and BMC2 members this week. In these reports, members can see how their CR utilization rates compared to their peers throughout Michigan within 90 days of discharge following transcatheter aortic valve replacement (TAVR), surgical aortic valve replacement (SAVR), coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), acute myocardial infarction (AMI), and congestive heart failure (CHF). The reports also included figures for the mean number of days to a patient’s first CR visit and the mean number of CR visits within 90 days. Since these reports were the first version released following the May announcement of new collaborative-wide CR goals, the reports also include figures detailing a hospital’s rates relative to those goals (see Figure 1). The first goal is to reach 40% CR utilization for TAVR, SAVR, CABG, PCI, and AMI patients. Currently across the collaborative, 30% of patients utilize CR following one of these “main five” procedures. The second statewide goal is a collaborative-wide utilization rate of 10% for CHF patients since only about 3% of CHF patients currently utilize the program.

Figure 1.

In addition to report dissemination, several other next steps were identified at the conclusion of the recent MiCR meeting. A second next step was to collate resources that have been developed by individual institutions for broader dissemination. In addition, continued collaboration between the MiCR and HBOM teams will seek to develop solutions that address key behavioral factors and barriers to CR. Lastly, the MiCR team will continue to develop relationships and provide content that works towards its mission of improving CR participation for all eligible individuals in Michigan. If you are interested in collaborating with the MiCR team, please reach out to MVC or BMC2.

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MVC Efforts to Improve Cardiac Rehab Enrollment in Michigan

MVC Efforts to Improve Cardiac Rehab Enrollment in Michigan

Cardiac rehabilitation (CR) is designed to improve cardiovascular function and mitigate risk factors for future cardiovascular events through monitored exercise, patient education, lifestyle modifications, smoking cessation, and social support (1). For over a decade, CR has been a Class I indication in clinical guidelines for patients who have had a heart attack, chronic stable angina, chronic heart failure, or have undergone a percutaneous coronary intervention (PCI), surgical (SAVR) or transcatheter aortic valve replacement (TAVR), or coronary artery bypass grafting (CABG). The evidence supporting CR as a high-value therapy for patients is clear: better long-term survival, fewer secondary cardiovascular events, fewer readmissions, improved quality of life, and lower healthcare utilization (2–6). 

Unfortunately, only a fraction of Michigan residents eligible for CR attend a single session following hospitalization for a qualifying condition, with rates as high as 59% for patients undergoing CABG and as low as 4% for patients with congestive heart failure (CHF) (see Figure 1). These data highlight that we as a state are well short of the national goal set by the Million Hearts Initiative of 70% enrollment for all eligible patients. Data from Michigan also suggests wide variation in CR enrollment across hospitals that are not fully explained by differences in patient case-mix (7).

Figure 1. Collaborative-wide CR enrollment rates for qualifying conditions (01/2017-12/2019)

Since 2019 the MVC Coordinating Center sought to equitably increase participation in CR for all eligible individuals in Michigan in partnership with the Blue Cross Blue Shield Cardiovascular Consortium (BMC2) and the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC). In an effort to drive improvement in this area across the collaborative’s membership, MVC developed a number of resources and strategies. For example, the MVC Coordinating Center built hospital-level reports that provide members with information on CR enrollment across eligible conditions benchmarked against all MVC hospitals. This week the newest iteration of this CR report was distributed to members. The previous version of the report was sent in March 2021 with a reporting period of 1/1/17 – 12/31/19. The latest version shifted that reporting period by six months (7/1/17 – 6/30/20), included Medicaid episodes for the first time, expanded the time horizon from 90 days to one year, and added information on CHF and acute myocardial infarction (AMI) episodes. 

With the addition of CHF and AMI (both “high-volume” MVC conditions), the number of hospitals eligible to receive a CR report doubled from 47 to 95, so many MVC hospitals received this report for the first time this month. The most significant methodological change compared to the previous report was the expansion of the episode window from 90 days to 365 days (one year). Previous reports undercounted the number of CR visits by using the standard MVC episode length of 90 days when a full CR program consists of 36 sessions, which are often not feasible to complete in 90 days. Therefore, it was important to expand the time horizon to achieve a fuller count. The report instead looked one full year beyond the index event (either PCI, TAVR, SAVR, CABG, CHF, or AMI) to calculate CR utilization rates and number of visits.

The MVC team also convened a multidisciplinary stakeholder group of CR practitioners, physicians, and CQI leaders to foster discussion around barriers and facilitators to CR enrollment. Many of the recent changes to the CR reports were a direct result of suggestions from this stakeholder group. Quarterly seminars have also provided opportunities for local facilities to share ongoing quality improvement activities and to learn from national leaders about innovations in the delivery and quality of CR.

More recently, the MVC team conducted virtual site visits with several CR facilities around the state to learn about their programs, the successes and challenges they have encountered, and ways to improve collaboration in Michigan around CR enrollment. Common themes emerged as barriers to CR enrollment, including lack of patient or physician engagement, geographical and/or technological gaps in care between the hospital and CR facility, and insurance coverage and reimbursement. Through collaborative learning and dissemination of best practices, the MVC Coordinating Center believes that its members can begin to address many of these challenges moving forward. 

These efforts are all the more important as CR facilities begin to recover from the effects of the COVID-19 pandemic. Many facilities had to reduce capacity and staff as a result of the pandemic, and the number of CR visits declined significantly compared to pre-pandemic months (see Figure 2). While many CR facilities are back to operating at full capacity, continued efforts will be needed to return CR enrollment to pre-pandemic levels. Some sites in Michigan have adopted virtual, home-based, or hybrid versions of CR to continue providing care to patients throughout the pandemic, and its place as a substitute for facility-based CR will require continued exploration that can be supported through collaborative efforts.

Figure 2. Changes in CR enrollment from 2019 to 2020 over time and by qualifying condition

While many challenges remain to achieve the national goal of 70% enrollment in CR for eligible individuals, the MVC Coordinating Center is optimistic that its current and planned efforts will provide opportunities for Michigan to lead the way. If you are interested in joining our efforts to equitably increase CR enrollment for eligible patients in Michigan, please reach out for more information at michiganvaluecollaborative@gmail.com.

References

  1. Rubin R. Although Cardiac Rehab Saves Lives, Few Eligible Patients Take Part. JAMA [Internet]. 2019 Jul 17; Available from: http://dx.doi.org/10.1001/jama.2019.8604 PMID: 31314061
  2. Heran BS, Chen JM, Ebrahim S, Moxham T, Oldridge N, Rees K, Thompson DR, Taylor RS. Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev. 2011 Jul 6;(7):CD001800. PMCID: PMC4229995
  3. Taylor RS, Long L, Mordi IR, Madsen MT, Davies EJ, Dalal H, Rees K, Singh SJ, Gluud C, Zwisler A-D. Exercise-Based Rehabilitation for Heart Failure: Cochrane Systematic Review, Meta-Analysis, and Trial Sequential Analysis. JACC Heart Fail. 2019 Aug;7(8):691–705. PMID: 31302050
  4. Taylor RS, Brown A, Ebrahim S, Jolliffe J, Noorani H, Rees K, Skidmore B, Stone JA, Thompson DR, Oldridge N. Exercise-based rehabilitation for patients with coronary heart disease: systematic review and meta-analysis of randomized controlled trials. Am J Med. 2004 May 15;116(10):682–692. PMID: 15121495
  5. Anderson L, Thompson DR, Oldridge N, Zwisler A, Rees K, Martin N, Taylor RS. Exercise‐based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev [Internet]. John Wiley & Sons, Ltd; 2016 [cited 2021 Jan 25];(1). Available from: https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001800.pub3/abstract
  6. Rejeski WJ, Foy CG, Brawley LR, Brubaker PH, Focht BC, Norris JL 3rd, Smith ML. Older adults in cardiac rehabilitation: a new strategy for enhancing physical function. Med Sci Sports Exerc. 2002 Nov;34(11):1705–1713. PMID: 12439072
  7. Thompson MP, Yaser JM, Hou H, Syrjamaki JD, DeLucia A 3rd, Likosky DS, Keteyian SJ, Prager RL, Gurm HS, Sukul D. Determinants of Hospital Variation in Cardiac Rehabilitation Enrollment During Coronary Artery Disease Episodes of Care. Circ Cardiovasc Qual Outcomes. American Heart Association; 2021 Feb;14(2):e007144. PMID: 33541107