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MEDIC Helps EDs in Michigan Improve Care for Adults, Children

MEDIC Helps EDs in Michigan Improve Care for Adults, Children

Serving a spectrum of functions, emergency departments (EDs) provide essential care and services, operating in the critical space between outpatient and inpatient care. EDs also serve as a safety net within the US healthcare landscape by performing necessary clinical services for populations who may not otherwise have access. Patients visiting the ED may undergo a wide range of rapid diagnostic and treatment options, ranging from unscheduled procedures, laboratory testing, utilization of basic and advanced imaging studies, and admission of patients to the hospital. Despite the ED’s critical role and services, there are few coordinated, scalable efforts to improve care quality in the ED. These realities within emergency medicine made it a prime opportunity for quality improvement (Kocher et al., 2019), which was the impetus for adding an emergency medicine-focused Collaborative Quality Initiative (CQI) to the Blue Cross Blue Shield of Michigan (BCBSM) Value Partnerships portfolio.

The Michigan Emergency Department Improvement Collaborative (MEDIC) was founded in 2015 to address the critical gap in coordinated quality improvement in the ED, including intervention design through implementation and evaluation, at scale, across health systems. Michigan Value Collaborative (MVC) members recently heard about MEDIC and its work as part of the launch of MVC’s new ED-based episodes and reporting; MEDIC and MVC collaborated on the development of this new episode of care data structure.

MEDIC’s quality improvement efforts to date have included initiatives such as improved appropriateness of head CT imaging utilization for children and adults with minor head injuries, greater CT diagnostic yield for adults with suspected pulmonary embolism, decreased use of chest x-rays in children with respiratory illness (i.e., asthma, croup, bronchiolitis), higher rates of ED discharge for children with asthma and adults with low-risk chest pain, and increased distribution of take-home naloxone to patients with opioid use disorder (OUD) or who experience opioid overdose or withdrawal.

MEDIC Success Stories

Since 2017, MEDIC participating sites have significantly improved collaborative-wide performance on all MEDIC quality measures. By reducing unnecessary imaging utilization and decreasing unwarranted hospitalization rates from the ED, MEDIC positively impacted the emergency care experience for thousands of patients in Michigan who received more evidence-based care and fewer low-value services. These improvements also contributed to an estimated total reduction in the ED cost burden in the millions of dollars (Figure 1).

Figure 1.

Zach Sawaya, MD, an emergency physician at MyMichigan Medical Center, reflected positively on the benefits of partnering with MEDIC on specific quality improvement initiatives. "MEDIC has pushed our group to be more cognizant of our imaging use, in particular in the pediatric population,” he said. “We've seen significant improvements in our rates of pediatric head CTs and chest X-rays that have been driven by MEDIC-provided data and decision-making resources.  In particular, we've seen wait times on pediatric head injuries go down as parents have been very open to discussion of PECARN rules and foregoing head imaging.”

The fact that MEDIC’s efforts support patients of all ages within its participating sites is unique; MEDIC is one of only a few CQIs with initiatives focused on pediatric patients. The MEDIC 2023 pay-for-performance incentive program, for example, focused on performance improvement on its pediatric-specific metrics. A key goal of this work was to ensure that children receiving emergency care in community hospital EDs received the same high-quality evidence-based care delivered in a pediatric emergency center. Since there are only three Michigan pediatric centers—all members of MEDIC—most children receive emergency care in community hospital EDs, and MEDIC observed disparities in the quality of emergency care delivered to children treated in community EDs. Children seen in community EDs were less likely to receive evidence-based care, as measured by our quality initiatives, than those seen in pediatric centers. In an emergency, patients can’t often choose which ED to go to, rather they need to go to the closest option. Over time and with participation in MEDIC, the data indicate MEDIC community hospitals improved their collective performance on MEDIC pediatric measures to be nearly on par with that of pediatric specialty hospitals.

The COVID-19 pandemic and its resulting impact on EDs also put MEDIC in a unique position. Within days of the pandemic being declared in the US, the MEDIC team pivoted from its standard work to support the COVID-19 response by leveraging its collaborative-wide learning network to support frontline efforts. MEDIC rapidly assembled a platform for informal and formal discussion between member EDs, which manifested as a series of virtual town halls and Grand Rounds focused on information exchanges among colleagues to rapidly innovate and meet challenges as the situation evolved.

This series began with lessons learned from the experience of its southeast Michigan EDs where the pandemic first unfolded in Michigan. This allowed sites in other areas of Michigan to understand what they would likely experience in the coming weeks or months, giving them valuable preparation time. Over several weeks, these well-attended sessions focused on the following topics: conservation of PPE, management of COVID-19 respiratory failure, special considerations for the pediatric population, and supporting the wellness of the ED workforce.

MEDIC – ED Partnerships

EDs partner with MEDIC in two primary ways: data collection and collaborative engagement in quality improvement. To participate in MEDIC, a partner ED must establish a flow of electronic health data for all ED visits to the MEDIC data registry as well as provide additional abstracted data, facilitated by a data abstractor hired with support from BCBSM. This then allows MEDIC to provide detailed evaluation and performance reporting on all measured quality initiatives, which in turn helps facilitate and inform site quality improvement interventions. MEDIC provides member hospitals with a level of insight into their ED practice patterns that would not be possible without participating in the collaborative.

In addition to being able to understand their data, participating in MEDIC allows hospitals to learn from one another, which significantly shortens the learning curve for improvement. Each site’s emergency medicine physician champion and abstractor(s) lead local intervention design and implementation, participate in MEDIC tri-annual collaborative-wide meetings, and share experiences and lessons learned with collaborative peers. MEDIC provides quality improvement evidence, guidelines, standardized performance measurement, data visualization, evaluation, and support for local intervention efforts.

MEDIC currently partners with hospital EDs across the state. Any sites not currently partnered with MEDIC are encouraged to visit their recruitment page for more information on becoming a member and contacting the team.

As MVC continues to build its offerings for members, the coordinating center is cognizant that hospitals and providers partner with multiple CQIs. MVC posts regular blogs about some of its peer CQIs to showcase their activities and highlight collaborations with MVC. Please reach out to the MVC Coordinating Center with questions.

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MVC Honors Mental Health Awareness Month with Workgroup

MVC Honors Mental Health Awareness Month with Workgroup

Mental illness and related conditions such as depression are increasingly prevalent and costly. More than 50% of patients will be diagnosed with mental illness or disorder at some point in their lifetime, according to a World Health Organization research survey, and one in four adolescents will experience depression by the age of 18, contributing to an estimated $406 billion in medical treatment costs in a single year in the U.S. To bring attention and awareness to this issue, the month of May is celebrated nationally as Mental Health Awareness Month. It represents an important opportunity for healthcare providers and hospitals to evaluate the ways in which they currently support patients experiencing mental health/substance use disorder (MH/SUD) conditions.

To help facilitate this conversation, the Michigan Value Collaborative hosted a workgroup yesterday focused on increasing access to high-quality mental health for patients and increasing support for providers. MVC’s guest speakers hail from the Michigan Collaborative Care Implementation Support Team (MCCIST), including Gregory Dalack, MD, MCCIST Co-Lead and Daniel E. Offutt III Professor and Chair of the Michigan Medicine Department of Psychiatry, and Karla Metzger, LMSW, MCCIST Program Manager.

The presenters highlighted the psychiatric Collaborative Care Model (CoCM), an evidence-based integrated behavioral health model that is primary care based and highly cost-effective. Research evidence suggests that up to $6 are saved in long-term healthcare costs for every dollar spent on collaborative care. The presentation included research evidence of the benefits of CoCM, an introduction to its components, tips for implementation and common challenges, and several success stories from both patients and providers.

The Collaborative Care Model

Those unable to attend Thursday's MVC workgroup can access the full recording on MVC’s YouTube channel. Additionally, the American Psychiatric Association (APA) and Academy of Psychosomatic Medicine (APM) jointly developed a report on the CoCM that reviews current evidence, essential elements of implementation, and recommendations for better meeting the health needs of people with mental health conditions, which is available here.

The American Hospital Association has also compiled a variety of resources on its Mental Health Awareness Month webpage related to mental health information, suicide prevention, opioid stewardship, downloadable posters to help employees adopt respectful language, case studies, and other tools and resources.

For those working in the behavioral and mental health space, there is also a recently formed Collaborative Quality Initiative (CQI) focused on mental health. Established in 2022, the Michigan Mental Innovation Network and Clinical Design (MI Mind) CQI is a statewide partnership with providers and provider organizations that works to prevent suicide and improve outcomes by reducing suicide attempts and deaths. MI Mind offers access to and engagement in evidence-based services for providers with a focus on suicide prevention, with plans to expand into other behavioral health domains, such as depression, anxiety, and substance use disorders. For a closer look at MI Mind, read MVC’s blog about their formation and check out the MI Mind website.

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MVC Evaluates Impact of MOQC Antiemetic Initiative on Healthcare Utilization During Chemotherapy

MVC Evaluates Impact of MOQC Antiemetic Initiative on Healthcare Utilization During Chemotherapy

Chemotherapy-Induced Nausea and Vomiting (CINV) is among the most feared side effects of chemotherapy among cancer patients. It impairs the patient's quality of life and also adds to the morbidity and cost of therapy. That is why the Michigan Oncology Quality Consortium (MOQC)—a physician-led, voluntary collaborative of medical and gynecologic oncologists who work to improve the quality and value of cancer care in Michigan—initiated its Antiemetic Initiative. Through this initiative, MOQC supports participating oncology practices in aligning with current guidelines for use of prophylactic antiemetics, including olanzapine, in patients receiving chemotherapy. The Michigan Value Collaborative (MVC) recently partnered with MOQC to evaluate the impact of this initiative and estimated a cost savings of $334,095 across the course of chemotherapy from the increased use of olanzapine and decreased inpatient admissions in this cohort of patients.

Olanzapine is underused in patients receiving high-emetic-risk chemotherapy, despite evidence of efficacy and good patient tolerance (Navari et al., 2016). Olanzapine is a long-used medication (originally in higher doses for the treatment of psychosis) that is highly effective at decreasing nausea and vomiting. Uptake of olanzapine has been low, however, in part due to oncologists' lack of familiarity with the medication, lack of awareness or agreement with the guidelines, and lack of olanzapine inclusion on prepopulated order sets. The current labeling of olanzapine as an antipsychotic poses an additional barrier since this labeling generates additional concerns about stigma and side effects among patients. A benefit to this medication, in addition to its effect on nausea and vomiting, is its low cost compared with other medicines used to prevent the side effects of chemotherapy; the cost for each pill is about 25 cents.

Practices participating in MOQC’s Antiemetic Initiative receive performance data and baseline assessments in the area of CINV guideline adherence, support in identifying gaps in care and quality improvement measures, and resources for provider and patient education. To help evaluate the impact of this work on guideline-concordant olanzapine use, MOQC first reached out to MVC in 2022 to leverage its robust claims-based data. MOQC hypothesized that patients treated in medical oncology practices with low rates of olanzapine prescribing would have higher rates of healthcare utilization, including hospitalizations, emergency department (ED) visits, and unplanned outpatient visits between treatment cycles. The goal of this analysis was to estimate the initiative's overall impact on healthcare utilization for breast cancer patients undergoing chemotherapy as well as any related cost savings that improved the value of care delivery.

Methodology

The cohort for this analysis was comprised of female patients with a 90-day claims-based MVC episode of care for lumpectomy or mastectomy in 2016-2021 who received combination chemotherapy with doxorubicin and cyclophosphamide as either neoadjuvant or adjuvant chemotherapy. The cohort included patients covered by Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial, BCBSM PPO Medicare Advantage (MA), Blue Care Network (BCN) HMO Commercial, BCN HMO MA, and Medicare Fee-For-Service. The resulting MVC analysis included episodes for 1,891 patients who had a breast cancer resection, received both chemotherapy drugs on the same day, and were attributed to a MOQC provider/practice. Patients were attributed to 45 of MOQC's participating practices.

Practice-level olanzapine data collected by MOQC was then used to assess whether each patient's first chemotherapy receipt was during a time when their attributed practice had high or low prescribing rates of olanzapine. The threshold for high versus low prescribing at a particular practice was set at a 25% prescribing rate. Once a practice reached 25% prescribing rates of olanzapine in MOQC's data, that practice was considered to have "high" olanzapine prescribing rates in all subsequent months for this analysis. Using that distinction of whether the practice was a high or low prescriber during the course of the patient's chemotherapy regimen, MVC compared post-chemotherapy healthcare utilization among patients treated by high- versus low-prescriber practices. Sub-analyses further restricted the cohort to patients attributed to a practice that ever became categorized as having high olanzapine prescribing rates. When limiting the analysis to practices that became high prescribers at any point, the cohort was narrowed down to patients attributed to 15 MOQC practices.

Limitations

The nature of claims data limited MVC's ability to identify patients attributed to participating oncologists at MOQC practices; the requirement of each patient in the cohort having a MOQC provider NPI on one of their claims reduced the analytic cohort to a smaller size than what would be seen in clinical data. Another limitation is that the findings may include period effects not controlled for in this analysis. Practice behavior and availability of inpatient beds may have differed between when a practice was a low olanzapine prescriber compared to when they began prescribing olanzapine at a higher rate. Finally, payment calculations included in this analysis are limited to dollars saved among the attributed claims-based population and, therefore, do not reflect savings that may be attributed to olanzapine use among the broader population of interest.

Impact & Next Steps

A key finding in the analysis included a significant difference in healthcare utilization across the course of chemotherapy among patients treated by high olanzapine prescribing MOQC practices compared to when they had low olanzapine utilization. Among the patients with cancer who received their first cycle of chemotherapy when their provider's practice had a high prescribing rate (≥25%), 10% were hospitalized (Figure 1). This inpatient admission rate was significantly lower than for those patients undergoing chemotherapy regimens at practices with low olanzapine prescribing rates, 15% of whom were hospitalized (p=0.02). This finding was based on a subset of patients attributed to practices who eventually became high olanzapine prescribers during the study period (922 patients at 15 practices).

Figure 1. Rates of Inpatient Admission Across Patients' Course of Chemotherapy, by Practice's Utilization Rate of Antiemetics at the Start of Chemotherapy (N=922)

This analysis further discovered a significant difference in the percentage of patients who had either an ED visit or inpatient admission. Of the patients receiving chemotherapy at MOQC practices, fewer patients at high-prescribing practices had either an ED visit or inpatient admission (19%) across the course of their treatment compared to patients receiving care at low-prescribing practices (26%).

MVC estimated a cost savings of $334,095 across the course of chemotherapy from the increased use of olanzapine and decreased inpatient admissions in this cohort of patients. Dollars saved were calculated by taking the number of patients whose chemotherapy began when their practice was a high prescriber (525), multiplied by the difference in the percentage of patients with an inpatient admission across the course of chemotherapy attributed to practice antiemetic prescribing rate (5.3%), multiplied by the average price-standardized payment for an inpatient admission during a 90-day episode of care among breast cancer resection episodes for the included payers ($12,007).

This analysis demonstrated further evidence that the use of prophylactic olanzapine is an effective strategy for managing CINV-related ED visits or hospitalizations. It furthermore identified tangible CQI impact in the form of patients who underwent breast cancer treatment being less likely to visit the ED or be hospitalized over the course of their chemotherapy regimen, as well as in the form of dollars saved on facility inpatient costs across the course of chemotherapy. Ongoing work will continue to support practices to make changes in the use of olanzapine, not only in patients receiving combination therapy with doxorubicin and cyclophosphamide but also in other high-emetic-risk regimens.

MVC’s expertise and data frequently result in partner projects like this; MVC completed a number of CQI impact assessments last year, as well as several more so far in 2023. MVC also participates in collaborative activities with peer CQIs through new condition and report development, data analysis and metric consultation, and data matching exercises that pair clinical and claims-based data. To request a copy of any of MVC’s completed CQI impact assessments, please contact the MVC Coordinating Center.

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MVC, MBSC Estimate Significant Diabetes Medication Savings Following Bariatric Surgery

MVC, MBSC Estimate Significant Diabetes Medication Savings Following Bariatric Surgery

Diabetes is commonly cited as the most expensive chronic disease in the U.S., accounting for over $37 billion in 2017. As many as 1 in 10 Americans have been diagnosed, 90-95% of whom have Type 2 diabetes. Management of Type 2 diabetes involves healthy eating, physical activity, and often taking medication prescribed by a doctor, such as insulin, other injectable medications, or oral diabetes medicines to help manage blood sugar. It is both clinically and economically significant, then, that the Michigan Value Collaborative (MVC) was recently part of an analysis that estimated over $76.5 million in insurance savings on prescription diabetes medications after patients underwent metabolic surgery.

MVC identified these savings in partnership with the Michigan Bariatric Surgery Collaborative (MBSC) last year and published their findings in a co-authored research letter in JAMA Surgery. This work was featured recently by the medical news site Medpage Today.

The partner project was initiated by MBSC in 2022 to help assess the impact of bariatric surgery on prescription fills for diabetes medications across the state of Michigan, driven largely by existing evidence in the literature that bariatric surgery resolved or improved Type 2 diabetes symptoms in a large proportion of patients (Varban et al., 2022). MBSC is a regional group of hospitals and surgeons that aim to innovate the science and practice of metabolic and bariatric surgery through comprehensive, lifelong, patient-centered obesity care.

Using its rich administrative claims data sources, the MVC team first analyzed pre-surgery and post-surgery receipt of diabetes medications, which was then used to estimate a high-level snapshot of the overall impact across Michigan. MVC's analysis included estimated cost savings to health insurance providers that could be attributed to a decrease in post-surgery diabetes medication prescription fills.

The analysis used bariatric surgery episodes for Roux-en-Y Gastric Bypass (RYGB) and sleeve gastrectomy hospitalizations. It was limited to bariatric surgery patients with a diagnosis of Type 2 diabetes who filled an outpatient diabetes medication prescription prior to their discharge. The analysis focused on episodes with index admissions between 2015 and 2021 for Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial and BCBSM Medicare Advantage plans for individuals who were continuously enrolled in a prescription sub-plan. This amounted to 760 patients with Type 2 diabetes undergoing gastric bypass (22%) or sleeve gastrectomy (78%) between 2015 to 2021.

In the 120 days prior to surgery, MVC found that 88% of patients filled an outpatient oral diabetes medication prescription, 30% filled an insulin prescription, and 21% filled a GLP-1 receptor agonist prescription. From the 120 days pre-surgery to the 120 days post-surgery, there was a significant decrease in fills for any diabetes medication (p<.001). The most frequent change in medications between pre- and post-surgery was from oral diabetes medication to no diabetes medication. In the 1 to 120 days following surgery, half (50%) of patients filled no diabetes medication prescriptions, and in the 121 to 240 days following surgery, most patients (63%) filled no diabetes medication prescriptions (see Figure 1).

Figure 1.

This amounted to an average decrease in diabetes prescription payments made by the insurance provider of approximately $4,133 per patient in the first year following surgery. Given that 34% of bariatric surgery patients have diabetes and 54,454 bariatric surgeries were performed in Michigan between 2015 and 2021, MVC estimated that insurance providers in Michigan saved $76.5 million on diabetes medications in the 360 days following bariatric surgeries in 2015-2021. In addition, data suggest that savings would continue to increase in future years due to long-term diabetes remission and cost benefits from optimized diabetes management. These results provide evidence of significant statewide clinical outcome improvement and cost savings for Type 2 diabetes following bariatric surgery.

These findings and their implications were also highlighted recently during an MVC workgroup featuring Dr. Oliver Varban of MBSC as the guest speaker. See below for a complete recording of his insightful presentation about bariatric surgery, its impact on chronic disease management, and more.

MVC’s expertise and data frequently result in partner projects like this; MVC completed three other CQI impact assessments last year (Figure 2). These projects are an example of MVC’s interest in CQI collaboration, which is also demonstrated through new condition and report development, data analysis and metric consultation, and data matching exercises that pair clinical and claims-based data.

Figure 2.

To request a copy of any of MVC’s completed impact assessments from 2022 or prior, please contact the MVC Coordinating Center.

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HMS CQI Receives Endorsements from National Quality Forum

HMS CQI Receives Endorsements from National Quality Forum

Michigan healthcare systems and professionals have the unique opportunity to leverage a portfolio of Collaborative Quality Initiatives (CQIs), all working diligently to support collaboration and data sharing. Together with their partners, these CQIs improve the quality and value of healthcare in Michigan and beyond. One such CQI achieved a momentous distinction in January 2023 when the National Quality Forum (NQF) recognized the Michigan Hospital Medicine Safety Consortium (HMS) with two prestigious endorsements for measures that can reduce unnecessary antibiotic use.

“We are incredibly proud of the work our collaborative has accomplished to date,” said Dr. Scott Flanders, MD, HMS Program Director. “Having two of our quality measures validated by the National Quality Forum reinforces the value of our work in Michigan and across the nation.”

The focus of these measures relates to two common and costly hospital incidents: inappropriate diagnosis of community-acquired pneumonia (CAP) in hospitalized medical patients, and inappropriate diagnosis of urinary tract infection (UTI) in hospitalized medical patients. HMS’s work in this space began in 2017 when the Joint Commission launched required standards for hospital antimicrobial stewardship. The HMS team, led by infectious disease physician Dr. Tejal Gandhi, partnered with experts from the Centers for Disease Control and Prevention (CDC) to develop and validate related quality measures across a diverse set of hospitals. The primary aim of this work was to prevent the use of unnecessary antibiotics, which can lead to adverse events, antibiotic resistance, and delays in diagnosing underlying conditions. Since antimicrobial use is broad within the hospital setting, HMS first narrowed its scope to CAP and UTIs, which accounted for up to 50% of antibiotic use in general hospitalized patients. The HMS team collected hospital data on the appropriate duration of treatment for patients with uncomplicated CAP as well as testing and treatment of asymptomatic patients with a UTI. The CDC already uses HMS collaborative-wide improvement rates to set national targets.

In the early years of the Blue Cross Blue Shield of Michigan (BCBSM) Value Partnership program, several CQIs were actively partnering with hospitals on various aspects and types of surgery. However, this failed to account for the care of hospitalized medical patients, who are at risk for adverse events and account for over 50% of healthcare costs. In response, HMS was established with the aim to help Michigan hospitals improve patient safety and care quality for hospitalized medical patients (i.e., general medicine, emergency medicine, infectious diseases, pharmacy, vascular access, etc.). HMS supports hospitals via rigorous data collection and analysis, as well as collaboration on best practice implementation.

Since its formation, the HMS team has achieved many substantial successes throughout its tenure. Long before its antibiotic stewardship initiative, HMS had significant success working on venous thromboembolism (VTE). The collaborative helped hospitals make significant gains by increasing rates of VTE risk assessment, increasing pharmacologic prophylaxis in at-risk patients, and increasing the use of mechanical prophylaxis in patients with contraindications for pharmaceutical prophylaxis. The HMS VTE initiative has since been retired, though resources are still available here.

In 2014, HMS pivoted into other areas of patient safety when members voted to focus on the appropriate use of peripherally inserted central catheters (PICC) and measuring complication rates associated with these devices, led by hospitalist Dr. Vineet Chopra. At the time, the use of these devices was growing and there were few evidence-based best practices to support indications for use and management of complications. Together with national experts and collaborative members, HMS developed guidelines for the use of devices in different scenarios, a resource known as the Michigan Appropriate Guide to Intravenous Catheters (MAGIC) that was published in the Annals of Internal Medicine. This toolkit is used across the world to determine appropriate catheter device use and is offered in conjunction with other PICC quality improvement resources on the HMS website here.

In conjunction with its PICC initiative, HMS later adopted a focus on the appropriate use and complication rates for midlines. While doing quality work related to PICCs, a number of HMS member hospitals noticed significant use of midlines at their hospitals. HMS leveraged its unique ability to collect data on midline use across its membership to understand complication rates, which resulted in the development of the HMS Midline Toolkit available here.

More recently in 2021, HMS launched a new sepsis initiative at 12 volunteer pilot sites, collecting data to assess the care of patients diagnosed with sepsis, led by intensivist Dr. Hallie Prescott. The initiative was introduced to the remaining HMS-member hospitals in January 2023. The sepsis initiative focuses on the care of sepsis patients during the entire continuum of care, including on admission/early diagnosis, inpatient hospitalization, discharge, and 90 days post-hospitalization.

The Michigan Value Collaborative (MVC) and HMS teams have partnered several times over the years, especially on recent sepsis-related initiatives. Developed in partnership with HMS, MVC developed and shared a sepsis report with MVC and HMS member hospitals in 2021 and 2022, providing insights on measures such as 90-day price-standardized total episode payments, inpatient length of stay, ICU/CCU utilization, 90-day post-acute care utilization, and 90-day readmission rates. Both CQIs hoped to facilitate cross-collaboration between clinical and quality personnel on the identification of patterns, opportunities, and strategies related to care for sepsis patients. MVC and HMS have also partnered on various matching exercises designed to bring MVC’s robust administrative claims data together with HMS’s clinically rich abstracted data to further inform quality improvement efforts.

Projects focused on such a large, diverse patient population inherently come with complex challenges. One challenge is the need for HMS to engage all areas of the hospital, generating buy-in among those individuals treating hospitalized medical patients. At the outset, HMS primarily engaged with member hospitals and hospitalists. However, over the last several years the collaborative has increasingly engaged muti-disciplinary stakeholders, such as infectious disease physicians, critical care physicians, emergency medicine, infection preventionists, pharmacists, vascular access experts, interventional radiologists, nursing, and hospital leadership.

As evidenced by its recent endorsement and focus areas to date, the work of the HMS team impacts the majority of patients treated at Michigan hospitals and beyond. With a focus on improving care for hospitalized patients, there are also many other possible focus areas for quality improvement on the horizon. For more information on HMS, visit their website.

As MVC continues to build its offerings for members, the MVC Coordinating Center is cognizant that hospitals and providers partner with multiple CQIs. Throughout 2023, MVC will post quarterly blogs about some of its peer CQIs to showcase their activities and highlight collaborations with MVC. Please reach out to the MVC Coordinating Center with questions.

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Healthy Weight Awareness Month Inspires Workgroup Collaboration

Healthy Weight Awareness Month Inspires Workgroup Collaboration

This January, healthcare organizations and advocacy groups across the country are promoting Healthy Weight Awareness Month, as well as innovations in weight loss procedures. In alignment with this national conversation, MVC recently hosted its first workgroup of 2023 with a guest presentation by Oliver Varban, MD, FACS, FASMBS, Associate Director at the Michigan Bariatric Surgery Collaborative (MBSC), about obesity in Michigan, the main challenges of treatment, and how MBSC uses data to improve surgical management outcomes. The aim of such workgroups is to impart relevant data, best practices, and success stories for the benefit of MVC members and partners working in that clinical area.

According to data from CDC, the prevalence of obesity increased from 30% to 42% over the past 20 years, with 41% of Americans currently considered clinically obese. Excess body weight is associated with many different conditions and comorbidities (e.g., certain types of cancer, heart disease, diabetes, and stroke) and is a risk factor for increased severity and fatality of various conditions, such as those who experienced more severe illness from COVID-19 infection. Clinical management interventions range from screening and lifestyle changes to medication and surgery.

Identification and treatment of obesity often begins by measuring a patient’s body mass index (BMI), an estimate of body fat based on height and weight. The CDC uses BMI to measure obesity, but this measure falls short in several ways. For one, the accuracy of the measurement is lower among men, the elderly, and those in the intermediate BMI ranges. In addition, racial groups experience differing levels of disease for a given BMI. On its own BMI is not an accurate predictor of health. There are also a number of complex connections to social determinants of health since patients residing in environments with more limited access to healthy food and physical activity often have higher BMIs.

MBSC has been working to support quality improvement in healthy weight management since 2005 and aims to innovate the science and practice of metabolic and bariatric surgery through comprehensive, lifelong, patient-centered obesity care. MBSC utilizes its extensive clinical registry data to generate tools that support clinicians and patients in decision-making, including several patient- and provider-facing tools that outline a patient’s likely risks, benefits, and costs for various treatment pathways.

Given obesity’s prevalence and association with other chronic conditions, improved outcomes for patients managing obesity have far-reaching implications. Therefore, MVC and MBSC partnered last year to measure the value of bariatric surgery in treating diabetes, one of the most common and costly chronic conditions. According to the American Diabetes Association, $1 in $7 healthcare dollars are spent treating diabetes and its complications, and patients diagnosed with diabetes face 2.3 times the average person's healthcare costs. The analysis performed by MVC and MBSC was largely driven by existing evidence in the literature that bariatric surgery resolved or improved Type 2 diabetes symptoms in a large proportion of patients (Varban et al., 2022). Using its rich administrative claims data sources, MVC helped analyze pre-surgery and post-surgery receipt of diabetes medications, which was used to estimate the overall impact across Michigan and its estimated cost savings due to a decrease in post-surgery diabetes medication prescription fills.

The most impressive finding of the analysis was a significant decrease in the percentage of bariatric surgery patients who filled any diabetes prescription post-surgery (Figure 1), with over 50% of patients who previously used diabetes prescriptions taking no medications within 120 days post-surgery. This amounted to an annual cost savings of about $4,133 per patient. Five years post-surgery, the continued estimated cost savings from reduced reliance on prescriptions ($20,665) surpassed the average price-standardized total episode cost of bariatric surgery ($14,832). These results provide evidence of statewide clinical outcome improvement and cost savings for Type 2 diabetes following bariatric surgery. A summary of this return-on-investment analysis was developed and publicized by MBSC and MVC in August 2022.

Figure 1.

This analysis was also evidence of the opportunities for cross-collaboration and information sharing in obesity care—between primary care providers, chronic disease management care teams, and bariatric surgeons; between collaborative quality initiatives with varying clinical, value-based, and socioeconomic focuses; and between providers, their patient, and their patient’s families. Obesity is a clinical diagnosis with extensive social complexities and implications for one’s physical and mental health. Improving support and care for those in seek of treatment requires intentional, innovative collaboration.

The complete recording of Dr. Varban’s recent MVC Health in Action workgroup presentation and the discussion that followed are available on MVC’s YouTube channel. Those with questions about any of the above-mentioned materials or analyses are welcome to contact the MVC Coordinating Center at Michigan-Value-Collaborative@med.umich.edu. MVC’s next workgroup takes place on Tues., Jan. 24, from 11 a.m. - 12 p.m., featuring a guest presentation by Karla Stoermer Grossman, MSA, BSN, RN, AE-C, Clinical Site Coordinator at the Inspiring Health Advances in Lung Care (INHALE) Collaborative Quality Initiative. Register to join us and hear about INHALE’s approach to improving outcomes for patients with asthma and chronic obstructive pulmonary disease.

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MVC Q4 Newsletter Highlights EOY Success Stories

MVC Q4 Newsletter Highlights EOY Success Stories

The Michigan Value Collaborative's quarterly newsletter provides in-depth synopses of MVC events, updates, and spotlights on members and partners. The final newsletter of 2022 was released this week (Figure 1), summarizing the activities and accomplishments that took place in Q4 of this year. First and foremost, the Coordinating Center thanked its members for their partnership in what turned out to be a very active year and highlighted new additions to the collaborative, including new hospital member Bronson Lakeview Paw Paw and new MVC Site Engagement Coordinator Kristy Degener.

Figure 1. Page 1 of MVC December Newsletter for Q4 of 2022

This edition included a full synopsis of MVC's 2022 Fall Semi-Annual Meeting, outlining the unblinded data session and the topics covered by the many talented and inspiring guest speakers. It also called attention to important updates that will impact Program Years 2024-2025 of the MVC Component of the BCBSM Pay-for-Performance (P4P) Program, outlining some aspects of the program structure that are changing and some that are staying the same as previous program cycles. Finally, the December newsletter highlighted the large portfolio of work that was taken on by MVC staff in partnership with its peer Collaborative Quality Initiatives (CQIs), highlighting in particular four completed return-on-investment analyses and several spotlights on the MVC blog.

The publication of MVC's final newsletter in Q4 coincides with MVC's submission of its end-of-year progress report to funder BCBSM. In developing this impressive summary document, MVC developed an infographic that highlights key statistics and accomplishments from the past six months (Figure 2). MVC plans to distribute a public version of this summary report, MVC's Annual Report, in January 2023. In the meantime, read the full MVC Q4 December Newsletter here.

Figure 2. Summary Infographic of MVC Activity, 7/1/22-12/31/22

The MVC Coordinating Center looks forward to continuing its work in 2023 and wishes everyone a happy holiday season and new year!

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New MI Mind CQI Connects Body and Mind to Health in Michigan

New MI Mind CQI Connects Body and Mind to Health in Michigan

Suicide is a leading cause of death in the United States. It claimed nearly 46,000 lives in 2020—a rate 30% higher than two decades ago. More recent data has even shown an increase in the rate of suicide after two years of declining rates. In the state of Michigan, the suicide mortality rate was 14 per 100,000 people.

There are significant opportunities for suicide prevention in primary care and other healthcare settings. Research suggests that patients seek care from primary care physicians within 30 days of establishing a suicide plan or attempting suicide. Furthermore, for every suicide death, there are four hospitalizations and eight emergency department visits (Figure 1).

Figure 1.

In response to this significant health need in Michigan, Blue Cross Blue Shield of Michigan partnered with Henry Ford Health to launch a new Collaborative Quality Initiative (CQI) called the Michigan Mental Innovation Network and Program Design (MI Mind). The MI Mind Coordinating Center team brings providers, health systems, and suicide prevention experts together to reach shared goals of improving suicide prevention, care, and access to key behavioral health services in Michigan. Its mission is to engage psychiatrists, psychologists, and primary care physicians in the use of care pathways to reduce suicides in Michigan significantly.

The core program is a collaboration with provider organizations that aims to determine and implement system-specific suicide prevention elements and use data to implement rapid cycle quality improvement processes. MI Mind hopes to assess what levels and characterizations of risk are most urgent and can be addressed by clinicians to inform recommendations for suicide prevention and quality improvement. The MI Mind program will help facilitate enhanced collaboration and referrals among behavioral health and primary care clinicians and promote purposeful screening for suicidal risk. The MI Mind team aims to train clinical staff using the well-established Zero Suicide protocol and anticipates the program will improve patient support, enable more effective and efficient healthcare, and reduce suicide rates.

The MI Mind collaborative is co-led by Program Director Brian Ahmedani, PhD, LCSW, who is internationally recognized for his work in suicide prevention and the Director for the Center for Health Policy and Health Services Research at Henry Ford Health; and Program Director Cathrine Frank, MD, a practicing and board certified psychiatrist widely regarded as the original clinical architect of the Zero Suicide program and Chair of the Department of Psychiatry and Behavioral Health Services at Henry Ford Health.

For more information on MI Mind, visit their website, where a variety of easy-to-use, organized tools and materials or available for the benefit of primary care providers, behavioral health professionals, patients, and their loved ones. Providers may also contact the MI Mind Coordinating Center at MiMIND@hfhs.org. In addition, the 988 Suicide and Crisis Lifeline (previously the Suicide Prevention Lifeline) is available to provide equitable and accessible suicide prevention support across the United States.

As the Michigan Value Collaborative (MVC) continues to build its offerings for members, the Coordinating Center is mindful that many other CQIs also partner with hospitals and providers throughout Michigan. MVC posts recurring feature blogs about some of its peer CQIs to showcase their activities and highlight collaborations with MVC. Please reach out to the MVC Coordinating Center with any suggestions or questions.

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HBOM Resources Help CQIs, Providers Reduce Smoking

HBOM Resources Help CQIs, Providers Reduce Smoking

Today, the leading preventable cause of death, disease, and disability in the United States is tobacco use. National studies show that 70% of smokers want to quit, but in Michigan only about 15% receive treatment. This critical gap is the current focus of one of the newest population health Collaborative Quality Initiatives (CQIs) in the Blue Cross Blue Shield of Michigan (BCBSM) Value Partnerships portfolio. The Healthy Behavior Optimization for Michigan (HBOM) CQI aims to ensure that all smokers who are interested in quitting receive the support and resources they need to be successful.

HBOM’s mission is to make “the healthy choice the easy choice,” which is accomplished in this case by providing tobacco cessation support throughout the state of Michigan through value-based reimbursement (VBR). In 2022, nine CQIs committed to working with HBOM to provide targeted, just-in-time tobacco cessation support to seize on their “teachable moment.” This approach draws on evidence-based behavior change strategies that leverage unique shifts in patient motivation around major health events, when they may find new motivation to commit to positive health behaviors like smoking cessation.

HBOM works with hospitals, clinics, and care teams across the state of Michigan through its partner CQIs to promote healthy behaviors among patients. They also provide partner CQIs and their respective members with the infrastructure and metrics to measure the impact of these changes. Although HBOM is primarily concerned with three health behaviors (smoking cessation, healthy eating, and physical activity), smoking cessation is their current focal point.

HBOM’s smoking cessation tools and resources are available in both paper and electronic formats to ensure equitable access, and are being shared widely at the patient, physician, and organization levels. Clinicians can share these materials with patients to increase access, awareness, and utilization of smoking cessation opportunities. One example includes a “Tap for Support” near-field communication (NFC) badge (see Figure 1) that clinicians and healthcare staff can wear for patients to scan with their phone, providing them with instantaneous online smoking cessation tools and resources.

Figure 1.

Another example is the Tobacco Cessation Box that HBOM tailored to meet the needs of those wishing to quit smoking. In addition to the badges, it includes HBOM’s Quit Smoking Resource Guide Tear Off Pad (see Figure 2), which providers can use as a discussion tool for Nicotine Replacement Therapy options. The box also includes a reference guide containing a high-level overview of tobacco cessation prescription medication options and HBOM’s VBR toolkit.

Figure 2.

When CQIs and their members wish to learn more or provide support beyond the resources mentioned above, they can connect with HBOM to discuss state-wide smoking cessation metrics, best practices, challenges, and collaboration opportunities. The HBOM collaborative meets regularly with participants and partnering CQIs to address challenges and improve population health. The team is also closely connected with the Michigan Tobacco Quitline and resource recommendations delivered by text message for anyone who wishes to quit smoking.

The MVC and HBOM teams have discussed plans to include HBOM resources in future relevant MVC report communications, such as those chronic conditions that are related to tobacco use. In the meantime, hospitals and physicians can request their own tobacco cessation boxes (see Figure 3).

Figure 3.

For more information on HBOM, visit their website.

As the Michigan Value Collaborative (MVC) continues to build its offerings for members, the Coordinating Center is cognizant that many other CQIs also partner with hospitals and providers throughout Michigan. Throughout 2022, MVC will post a series of blogs about some of its peer CQIs to showcase their activities and highlight collaborations with MVC. Please reach out to the MVC Coordinating Center with any suggestions or questions.

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New Collaborative MIBAC Seeks to Address Back Pain

New Collaborative MIBAC Seeks to Address Back Pain

Lower back pain is a common—and challenging—realm of healthcare that is the leading cause of disability globally. As many as 80-95% of patients presenting to primary care providers with this condition have no identifiable origin for their pain. The absence of a specific etiology is exacerbated by challenges related to treatment; although there are many treatment options, not all are evidence-based and there is rarely a simple, easy fix. In addition, most primary care physicians do not like managing back pain and feel they have not been adequately trained in musculoskeletal medicine.

With the above considerations in mind, researchers argue that greater attention is urgently needed in response to the rising burden and impact of this condition. Low back pain was, therefore, an ideal area of focus for the Blue Cross Blue Shield of Michigan’s Collaborative Quality Initiatives (CQI) portfolio. The Michigan Back Collaborative (MIBAC) was rolled out in 2021 and is based at Henry Ford Hospital. This new statewide quality improvement initiative focuses on better care for low back pain to address issues such as rising costs, rising disability, and patient and provider dissatisfaction (see Figure 1).

Figure 1

MVC Coordinating Center staff had the pleasure of meeting with the MIBAC team recently to learn more about the program, its focus, and goals. MIBAC has two components: training and quality analysis (see Figure 2). Training is the focus of the first year of commitment to the collaborative, with progression to quality analysis in years two or three. These components are all voluntary and participation in one is not contingent on completion of another.

Figure 2

MIBAC membership currently includes clinicians such as primary care physicians and chiropractors, as these are typically the “first-contact” clinicians for low back pain. As the program expands, there is a plan for additional provider types (including physical therapists and emergency room physicians) to become involved as members of the collaborative, and the MIBAC Coordinating Center is working to recruit more physician organizations as well as independent chiropractic practitioners from across the state of Michigan.

MIBAC’s evidenced-based training is available to all its providers and was delivered to more than 800 primary care and chiropractic practitioners in 2021. The curriculum was developed by Spine Care Partners and delivers information on a biopsychosocial model of spine care management. Education is provided on guidelines for referrals, imaging, and pain medication, with an emphasis on solutions and techniques that cultivate inter-professional and doctor-client partnerships. Training sessions are offered virtually and in-person and provide continuing educational credit.

MIBAC is also planning to provide data for clinicians to support more effective care patterns, better outcomes for patients, and greater satisfaction for clinicians and patients. The MIBAC database will integrate patient-reported outcomes (PROs) along with clinical and demographic data. The hope and goal of the MIBAC registry is to identify variations in practice and key quality metrics whilst building clinical and administrative “best-practices” in spine care. In order to establish a data cohort, MIBAC will focus on a six-month review and a six-month follow-up as their defining period. MIBAC plans to cultivate collaboration and networking between participating members at meetings, site visits, webinars, and other strategies.

To date, the MVC team has supported the MIBAC Coordinating Center to assess the utilization of appropriate imaging by providers to inform the development of the collaborative's VBR program. Moving forward, the MVC team will continue to work closely with MIBAC to explore other avenues to help achieve the collaborative's aim of achieving better care for low back pain for Michigan residents.

For more information on MIBAC, visit their website at https://mibac.org/.

As the Michigan Value Collaborative (MVC) continues to build its offerings for members, the Coordinating Center is cognizant that many other CQIs also partner with hospitals and providers throughout Michigan. Throughout 2022, MVC will post a series of blogs about some of its peer CQIs to showcase their activities and highlight collaborations with MVC. Please reach out to the MVC Coordinating Center with any suggestions or questions.