The Michigan Value Collaborative wishes you a happy Thanksgiving holiday. Thank you to all Michigan hospitals and physician organizations for working tirelessly every day to improve healthcare quality across Michigan. We are grateful for your partnership and your efforts on behalf of Michigan patients.
The Michigan Value Collaborative (MVC) held its second semi-annual meeting of 2022 last Friday, marking MVC’s first in-person collaborative-wide meeting since 2019. A total of 90 leaders registered for the meeting, representing 25 different hospitals, seven physician organizations (POs), and five stakeholder organizations from across the state of Michigan. This meeting’s theme of “Prescribing Health in Michigan” showcased strategies to drive evidence-based medication utilization and support patient access to medications through the implementation and evaluation of quality improvement projects.
MVC Director Hari Nathan, MD, kicked off Friday’s meeting with an update from the MVC Coordinating Center. He welcomed one new collaborative member, Bronson Lakeview (Paw Paw), as well as MVC’s newest team members, Associate Program Manager Erin Conklin and Statistician Lead Usha Nuliyula. Dr. Nathan also highlighted the successes delivered by the Coordinating Center since May’s Semi-Annual Meeting. For instance, MVC launched its Qualified Entity registry pages to provide authorized users with more granular data than is available in the Medicare FFS reports, incorporated Distressed Community Index data into push reports as part of MVC’s commitment to emphasizing equity in healthcare, and distributed three new push reports (chronic obstructive pulmonary disease for POs, emergency department and post-acute care utilization for acute and critical access hospitals, and a hysterectomy report for hospital members).
Dr. Nathan also provided an update on the MVC Component of the Blue Cross Blue Shield of Michigan (BCBSM) Pay-for-Performance (P4P) Program, noting that final scorecards for Program Year 2022 will be distributed in quarter one of 2023. Attendees also learned about P4P changes coming with Program Years 2024 and 2025 (see Figure 1).
Based on member feedback, MVC will be rolling out an updated methodology to improve the actionability of the program. Along with the existing 30-day episode of care component, MVC is introducing new value metrics and engagement metrics for PYs 2024 and 2025. The value metrics will incentivize evidence-based and actionable high-quality services, such as increasing cardiac rehabilitation utilization after percutaneous coronary intervention (PCI), increasing follow-up rates after hospitalizations for pneumonia, or decreasing preoperative testing prior to low-risk procedures. The engagement metric will award points to hospitals for attending and contributing to MVC engagement activities, such as attending both semi-annual meetings or presenting at a workgroup. Stay tuned for additional details on PYs 2024 and 2025; informational webinars on the program changes are coming soon.
Showcasing MVC’s new pharmacy claims data from BCBSM and Blue Care Network was a focal point for the meeting. MVC Senior Analyst Monica Yost led attendees through an overview of MVC’s current pharmacy claims data along with an unblinded data session focused on opioid overprescribing after joint surgery (see Figure 2 for a blinded version of utilization across the collaborative). Leveraging opioid prescribing recommendations from the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI), the data session allowed hospitals and POs to see their opioid prescribing rates in the 30 days following hip and knee replacements compared to their peers. Hospitals and POs performing well were invited to offer insights as to how this was achieved and what mechanisms other members could adopt to improve performance levels.
With the scene set, MVC welcomed keynote speaker Lindsey Kelley, Associate Chief of Pharmacy at Michigan Medicine. Dr. Kelley provided attendees with an overview of the challenges patients face accessing high-cost, complex medications as well as opportunities to improve access and patient experience through integrated health system specialty pharmacy. Walking through Michigan Medicine’s model, Dr. Kelley noted that simplifying the workflow for specialty pharmacies reduces strain on clinic staff (i.e., physicians, nurses, medical assistants) and eliminates the instances of prescriptions being sent that cannot be filled, thereby reducing gaps in therapy starts. Sharing the model’s evaluation strategy, Dr. Kelley highlighted the project’s collaboration with MVC, which led to a larger proportion of all target specialty medication prescription fill data being tracked and extended the evaluation’s reach.
Following Dr. Kelley’s presentation, Troy Shirley, PharmD, MBA, System Director of Pharmacy for Bronson Healthcare, presented Bronson’s efforts to improve health equity through pharmacy-supported discharge initiatives. One initiative focused on medication reconciliation at discharge, which leveraged unit-based pharmacists to complete medication reconciliation for patients hospitalized with chronic obstructive pulmonary disease, pneumonia, heart failure, and acute myocardial infarction. Additionally, Bronson’s “Meds to Beds” program engaged a multi-disciplinary team that included a retail pharmacist, pharmacy, technician, unit nurse, and care manager to hand-deliver patients’ medications at the bedside and provide medication counseling prior to discharge.
Next on the agenda was a presentation from Tiffany Jenkins, PharmD, BCACP, Director of Population Health Pharmacy at Trinity Health Alliance of Michigan, who shared insights about population health pharmacy initiatives within a physician organization, including a diabetes medication management initiative focused on evidence-based diabetes management to improve quality of care, reduce inappropriate use of pharmaceuticals, and lower cost of care; a pharmacy tech-led medication adherence monitoring strategy to engage patients, providers, and care teams in appropriate medication use; an obesity medication management initiative focused on evidence-based utilization of chronic weight management medications to lower cost of care; and a comprehensive medication management project that leverages pharmacist-care team collaboration to support medication management.
Closing out the morning session, Mark Bicket, MD, PhD, Co-Director of the Opioid Prescribing Engagement Network (OPEN) and Assistant Professor with the Division of Pain Research, Department of Anesthesiology at the University of Michigan, presented information on shifts to prescribing recommendations after surgery to decrease opioid use, techniques to promote the adherence of non-opioid medications and non-pharmacological approaches to pain management, and strategies to maximize safe storage and disposal of controlled substances.
In the afternoon following a networking lunch, the presenters participated in a panel discussion moderated by MVC Co-Director Michael Thompson, PhD, MPH. The group discussed strategies to change provider behavior and navigate the challenges of pharmacy-related improvement initiatives. The meeting concluded with a summary of the day and upcoming MVC activities, led by MVC Associate Program Manager Erin Conklin. The slides from Friday’s meeting have been posted to the MVC website. If you have questions about any of the topics discussed at the fall 2022 semi-annual meeting or are interested in finding out more, please reach out to the Coordinating Center at Michigan-Value-Collaborative@med.umich.edu. MVC’s next semi-annual meeting will be in person on Friday, May 19, 2023, at the Vistatech Center in Livonia.
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.
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.
As the conclusion of National Healthcare Quality Week approaches, MVC is proud to honor healthcare quality professionals for their unique contributions toward service delivery and improvements in healthcare facilities. Thus far in 2022, much was achieved by MVC staff, members, and partners. Collectively, these teams work to improve outcomes for patients in a way that doesn’t add to the burden of healthcare costs. This week is an opportunity to celebrate those achievements and express gratitude to the dedicated professionals whose hard work made them possible.
MVC strives to help its members better understand their performance using robust multi-payer data, customized analytics, and at-the-elbow support. MVC has been active in each of these areas (summarized in Figure 1) thanks to MVC’s dedicated Coordinating Center staff. Of note is the fact that MVC distributed 16 push reports to 100+ hospitals and 40 physician organizations (POs) so far this year, and prepared 19 custom analytic reports in response to specific member requests. These data help identify areas of opportunity and trends over time that—in conjunction with other internal and external data sets—inform quality improvement initiatives underway at hospitals and POs across the state.
MVC previously published a detailed mid-year summary of its activities from January to June of 2022, which is available here. Since then, MVC distributed five additional push reports, three of which were new to the collaborative in recent months:
- Hospital hysterectomy report – new push report!
- Preoperative testing report refresh
- Emergency department and post-acute care report – new push report!
- MVC Pay-for-Performance (P4P) Program Year 2022 mid-year scorecards
- Chronic obstructive pulmonary disease report for POs – new push report!
MVC’s P4P Program mid-year scorecards also highlighted the extraordinary work taking place at hospitals across Michigan. The MVC Component of the BCBSM P4P Program evaluates each participating hospital’s risk-adjusted, price-standardized episode payments for two selected conditions by measuring improvement over time and achievement relative to their peers. At the conclusion of Program Year 2021, hospitals in the collaborative contributed to an overall price-standardized decrease in payments from 2018 to 2020 for the selected P4P conditions of $7.7 million.
The average points scored for the recent mid-year scorecards was 5.9/10 before including the survey bonus points—0.9 points higher than the average points scored at the conclusion of Program Year 2021. These points reflect tangible improvements to service delivery and patient outcomes, such as reduced readmissions or shifting post-acute care in skilled nursing facilities (SNF) to home health following joint replacement surgery.
To help facilitate practice sharing among members, MVC workgroups have continued to be a valuable activity, with 28 virtual workgroups completed as of this week. Workgroup topics offered in 2022 include chronic disease management, diabetes, health equity, health in action (ad hoc topics), joint replacement, and sepsis. Quality improvement is a team effort, so MVC is extraordinarily grateful to the long list of members and partners who shared their expertise and time by presenting. Thank you to the following organizations for presenting to the collaborative at an MVC workgroup thus far in 2022:
- Area Agency on Aging
- Ascension Genesys
- Beaumont Dearborn
- Bronson Healthcare
- Henry Ford Health
- Michigan Social Health Interventions to Eliminate Disparities (MSHIELD)
- Munson Healthcare
- Olympia Medical, LLC
- Sparrow Health System
- Spectrum Health
- Spectrum Health Medical Group
- Trinity Health Muskegon
- Washtenaw County Health Department
As hospitals and POs press ahead to improve the quality of care delivered in 2022, MVC is eager to support your important work. If you have a follow-up question about a report, please contact MVC to discuss a custom analysis. If you have benefitted from or are looking for guidance on a quality initiative, please reach out so MVC can connect you with members undertaking similar initiatives. MVC thanks you for your tireless work, and looks forward to a continued partnership in 2023.
October brings celebrations of Fall – with pumpkins, trips to the orchard for apple picking, and Halloween - and also Healthcare Quality Week (October 16 – 22), a time for healthcare teams to highlight their efforts to improve the quality of care for patients and families.
Over the years, various improvement methodologies have been applied in healthcare settings to advance the quality of care, reduce costs, and improve patient outcomes. Here is a look at some of the models and how they could bring value to your organization.
Six Sigma uses statistics and data analysis to reduce errors and improve processes. Originally developed in the 1980s, Six Sigma has grown over the years into an industry standard, with training and certification programs too. The Six Sigma methodology leverages the DMAIC (Define, Measure, Analyze, Improve, Control) approach (Figure 1). Following the five steps of DMAIC provides teams with a framework for identifying, addressing, and improving processes.
Figure 1: The Six Sigma DMAIC
Lean, a methodology borrowed from the automobile industry, optimizes an organization’s people, resources, and effort to create value for customers (Figure 2). Lean’s focus is on sustaining improved levels of quality, safety, satisfaction, and morale through a consistent management system. With a goal to promote, evaluate, and implement ongoing process improvements, Lean uses Value Stream Mapping (VSM) to create a visual map of each step in a workflow, allowing teams to identify opportunities for efficiency.
Figure 2: Lean Process Improvement
Additionally, Lean encourages teams to focus on continuous improvement through the Plan Do Check Act (PDCA) model, an interactive form of problem-solving used to improve processes and implement change. In a PDCA cycle, teams work through four key steps: 1) identify the problem and create a solution plan (Plan), 2) implement a small-scale test (Do), 3) review the test performance (Check), and 4) decide to adjust or implement the test on a larger scale or adjust (Act/Adjust).
Figure 3: PDCA Cycle
Total Quality Management (TQM) is a management approach for long-term success through customer satisfaction. Originally used by the Naval Air System Command, TQM is based on the principles of behavioral sciences; qualitative and quantitative analysis; economic theories, and process analysis. Using the TQM methodology allows organizations to be customer-focused, with all employees participating and engaging in continual improvement. By utilizing strategy, data, and effective communication, TQM becomes integrated into the organizational culture and activities (Figure 4).
Figure 4: Total Quality Management
With a goal to optimize activities that generate value and reduce waste, the Kaizen approach is based on the belief that continuous, incremental improvement adds up to substantial change over time (Figure 5).
Figure 5: Kaizen (Continuous Improvement) Principles
The MVC Coordinating Center supports hospital and physician organization members across the state in identifying opportunities for improvement and facilitating a collaborative learning environment for members to exchange best practices. If you are interested in discussing improvement opportunities for your site, please contact the MVC Coordinating Center at email@example.com.
The MVC Coordinating Center recently released the full agenda for its forthcoming Fall 2022 Semi-Annual Meeting, which takes place in Lansing at the Radisson Hotel on Friday, October 28, 2022, from 9 a.m. to 2:30 p.m. MVC holds collaborative-wide meetings twice each year to bring together quality leaders and clinicians from across the state. This meeting’s theme of “Prescribing Health in Michigan” will support attendees in learning strategies to drive evidence-based medication utilization and support patient access to medications through the implementation and evaluation of quality improvement projects.
Speakers at semi-annual events are often members who share their successes, challenges, barriers, and solutions in pursuing a higher value and quality of care. The speakers this fall represent a variety of stakeholder groups, including member hospitals and physician organizations (POs), pharmacy experts, pain management experts, and of course MVC Coordinating Center leadership.
The keynote presentation will be given by Dr. Lindsey Kelley, Associate Chief of Pharmacy at Michigan Medicine. She also serves as Program Director for the PGY1 Community Pharmacy Residency and adjunct faculty at the University of Michigan College of Pharmacy. Dr. Kelley earned her Doctor of Pharmacy degree from the University of Arizona in Tucson. She completed a pharmacy practice residency at Abbott Northwestern Hospital in Minneapolis, MN, and received her MS from the University of Minnesota College of Pharmacy while completing a two-year Health-System Pharmacy Administration and Leadership residency at the University of Minnesota Health. Dr. Kelley has been an active member of national pharmacy associations, state affiliates, and advisory councils. She was also honored with the ASHP New Practitioners Forum Distinguished Service Award in 2010 and recognized as a fellow in 2019. Her presentation will focus on improving patient care through better access to high-cost and complex medications.
MVC members will also hear presentations from their peer hospitals and POs about pharmacy initiatives implemented at other sites. Dr. Troy Shirley, System Director of Pharmacy at Bronson Healthcare, will present on improving health equity through pharmacy-based initiatives. Dr. Tiffany Jenkins, Director of Population Health Pharmacy at Trinity Health Alliance of Michigan, will present on population health pharmacy initiatives within a PO.
The Opioid Prescribing Engagement Network (OPEN) will touch on pain management best practices and resources. They are represented by Dr. Mark Bicket, Co-Director of OPEN and Assistant Professor in the Division of Pain Research in the Department of Anesthesiology at the University of Michigan. His presentation will focus on improving medication adherence for surgical pain management.
Attendees can also expect to hear from MVC Coordinating Center leadership and staff about the MVC Component of the BCBSM Pay-for-Performance (P4P) Program, unblinded data on prescribing practices across the collaborative, new conditions and data sources that are available to members on the registry and in push reports, MVC’s new Qualified Entity status and resulting patient-level Medicare data, and updates about other upcoming MVC events. The guest presentations will be followed by a panel discussion about medication adherence facilitated by MVC leadership.
At the conclusion of the meeting, attendees will have learned approaches to improving medication access and utilization, patient experience, treatment adherence, care transitions, post-discharge support, patient education, reduced readmissions, and health equity. The full agenda can be accessed online here.
These presentations would be informative and applicable for any of the following stakeholders who are invited to attend:
- MVC hospital site coordinators
- MVC PO site coordinators
- Quality leadership
- Nurse practitioners
- Community-based organizations or social workers
- CQI staff
CME CREDITS AVAILABLE
The University of Michigan Medical School is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The University of Michigan Medical School designates this live activity for a maximum of 4.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Those interested in attending this informative and collaborative meeting should register here. The MVC Coordinating Center looks forward to a fantastic meeting. See you there!
Hari Nathan, MD, PhD; Deborah Evans, RN; Erin Conklin, MPA; Chelsea Pizzo, MPH; Chelsea Andrews, MPH
Michigan Value Collaborative data and efforts were on display this week as Coordinating Center staff attended the Learning Health System (LHS) Collaboratory Seminar Series Poster Session on Thursday and the Michigan Bariatric Surgery Collaborative (MBSC) / Blue Cross Blue Shield of Michigan 2022 Obesity Management Summit on Friday. At each event, MVC was able to highlight some of its recent work.
At the LHS Collaboratory poster session, MVC presented on behalf of the Michigan Cardiac Rehabilitation Network (MiCR), a partnership recently established by MVC and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) with the aim to equitably increase cardiac rehabilitation participation for all eligible individuals in Michigan. Cardiac rehabilitation is highly beneficial to patients and cost-saving for the healthcare system, yet it is significantly underutilized in Michigan with only about 30% of eligible patients enrolling following a cardiac procedure. Using claims data, MVC can assess whether and when someone enrolls, and how long they keep going. There is wide variability in enrollment between MVC’s member hospitals as well as across cardiac conditions. The focus of the poster (see Figure 1) was a recent publication co-authored by MVC and BMC2 staff, which evaluated the feasibility of a statewide collaboration to improve cardiac rehabilitation participation. The poster summarized the key services provided by the MiCR collaboration and some of the lessons learned thus far about barriers to and facilitators of improvement. It also promoted the new statewide goal of 40% cardiac rehabilitation participation by 2024 for all eligible conditions - a goal set by MVC and BMC2. More details on this statewide goal and MiCR’s activities are summarized here.
For Friday’s Obesity Summit, several MVC products were on display, including two recent analyses performed in partnership with MBSC. The two CQIs recently collaborated on a statewide improvement assessment about the impact of bariatric surgery on prescription fills for diabetes medications. Much of the evidence in the literature suggests that bariatric surgery may resolve or improve Type 2 diabetes symptoms in a large proportion of patients. MVC used its claims data to compare pre- and post-surgery receipt of diabetes medications, as well as the estimated cost savings to health insurance providers that could be attributed to a decrease in post-surgery diabetes medication prescription fills. There was a significant decrease in prescription fills for any diabetes medication (p<.001) from the 120 days pre-surgery to the 120 days post-surgery (see Figure 2).
Furthermore, insurance providers in Michigan saved an estimated $76.5 million on diabetes medications in the 360 days following bariatric surgeries in 2015-2021, based on the average decrease in diabetes prescription payments per patient, the number of bariatric surgeries performed in that timeframe, and the proportion of bariatric surgery patients who have diabetes. These results provided evidence of statewide clinical outcome improvement and cost savings for Type 2 diabetes patients following bariatric surgery. The full summary of this analysis is available here.
MVC partnered with MBSC on a similar analysis of opioid medication use that was also highlighted at the 2022 Obesity Summit. MBSC has been working to reduce opioid utilization and prescribing following bariatric surgeries across Michigan for the past five years. Some of their strategies include an opioid value-based metric and a voluntary enhanced recovery initiative that incorporates evidence-based guidelines for pre-, peri-, post-operative, and post-discharge care of bariatric surgery patients. This includes a recommendation of prescribing no more than 75 morphine milligram equivalents (MME) of oral opiate following surgery - a recommendation consistent with surgery-specific guidelines set by the Michigan Opioid Prescribing Engagement Network (OPEN).
In evaluating the impact of MBSC’s opioid reduction work, analysts identified that the average amount of opioids received in 30-day post-surgery outpatient prescriptions decreased from 297.0 MME in 2015 to 65.4 MME in 2021. The percentage of patients receiving more than the recommended threshold of 75 MME decreased from 75.8% to 17.9% of bariatric surgery patients. Furthermore, hospitals that participated in MBSC’s enhanced recovery initiative saw the rate of patients receiving opioid amounts above 75 MME decrease more sharply than the rate at other hospitals (p=0.02) (see Figure 3). Given these findings, MVC estimated that MBSC’s efforts resulted in $12.5 million in cost savings because of reduced opioid prescribing after bariatric surgery. The full summary of this analysis is available here.
MVC will continue to leverage its robust claims data to further the goals of fellow Collaborative Quality Initiatives as well as MVC member hospitals and physician organizations. To stay informed about newly released analyses, resources, or projects, follow MVC Coordinating Center updates on Twitter or LinkedIn. To learn more about these projects or MVC’s reporting capabilities, contact the Coordinating Center at firstname.lastname@example.org.
Throughout the month of September, providers and advocacy groups are calling attention to the prevalence and signs of sepsis, the body’s life-threatening response to infection. It is the leading cause of death in U.S. hospitals, taking the life of a patient every two minutes and affecting an estimated 49 million people every year worldwide. Despite this, at least one in every three adults has never heard of sepsis. That is why in 2011 the Sepsis Alliance officially designated September as Sepsis Awareness Month.
To support its member hospitals in improving their outcomes related to sepsis, MVC collaborated with the Michigan Hospital Medicine Safety Consortium (HMS) in 2019 to develop a sepsis episode definition for its registry. MVC then began distributing sepsis push reports in 2020 with regular refreshes each year. Hospitals received their latest sepsis reports in April, which showcased wide variation across the Collaborative for measures such as total episode payments and 90-day readmission rates (see Figure 1). In addition, hospitals received details on their inpatient mortality and discharge to hospice rates compared to their geographic region and the Collaborative as a whole (see Figure 2). More information about this report was detailed in a previous MVC blog post.
MVC also began hosting a sepsis workgroup in June 2019 to help facilitate idea and practice sharing among Collaborative members. MVC has continued to host sepsis workgroups since then, with the most recent workgroup taking place last week on September 8. That workgroup honored Sepsis Awareness Month with a member panel featuring guest speakers from several health systems in Michigan. Attendees learned about current sepsis initiatives underway at hospitals throughout the state as well as insights on the impact of COVID-19, sepsis screening, sepsis bundle compliance, transitions of care, and other related topics. Those unable to attend can view the complete recording of this panel and discussion here.
One area of focus for this year’s Sepsis Awareness Month is a Sepsis Alliance tool to help providers remember the signs and symptoms. Their acronym approach asks providers to remember, “It’s about T-I-M-E,” with the word “time” representing temperature, infection, mental decline, and extremely ill (see Figure 3).
This resource and many others have been created, collated, and packaged by the Sepsis Alliance in their yearly Sepsis Awareness Month Toolkit. Hospitals and providers are encouraged to utilize these resources to help educate their staff and patients. The hope is that through public education we can raise awareness of the signs and symptoms of sepsis so people in our communities know when to seek emergency care. Together, we can help save lives and limbs from sepsis. Learn more at sepsisawarenessmonth.org. To contact the MVC Coordinating Center about your sepsis reports, future workgroup speakers, or other questions, please email email@example.com.
After declaring the nation’s first-ever blood crisis in early 2022 and the worst shortage in over a decade, the American Red Cross and other blood donation organizations continue to plea for blood donors. In Michigan, blood donations fell with the start of COVID-19 and continue to lag pre-pandemic levels.
Based on data from the Red Cross, someone in the United States needs blood or platelets every two seconds, resulting in approximately 29,000 units of red blood cells, 5,000 units of platelets, and 6,500 units of plasma required daily. And, while an estimated 6.8 million people in the U.S., or 3% of eligible individuals, donate blood each year, more donors are always needed!
According to the Association for the Advancement of Blood and Biotherapies, donating blood is a safe, simple, and rewarding experience that usually only takes 45-60 minutes. During a typical whole blood donation, approximately 0.5 liters of blood is collected. For donations of other blood products, such as platelet or plasma, the amount collected is based on the donor’s height, weight, and platelet count.
Along with helping others in need, blood donation also has some surprising health benefits, including:
- A free mini health screening: before donating, potential blood donors receive a brief physical exam that includes taking blood pressure, body temperature, and pulse to ensure they are fit for donation.
- A healthier heart and vascular system: in hypertensive individuals, regular blood donation has been linked to lower blood pressure and may lower the risk for heart attacks.
- A happier, longer life: people usually donate because it feels good to help others and altruism has been linked to positive health outcomes, including a lower risk for depression and greater longevity.
Alternatively, to help protect the limited supply of blood, reduce costs associated with the collection and administration of blood products, and reduce patient complications of allergic, febrile, and hemolytic reactions, restrictive transfusion practice or conservative blood use can be considered. This practice, recommended by the National Institute for Health and Care Excellence and the Choosing Wisely campaigns, uses the two major clinical decision points of hemoglobin concentration when transfusion should be considered and the number of units being transfused.
Whilst evidence suggests there is no increase in morbidity or mortality by following restrictive transfusion practices, outcomes related to the quality of life, symptoms of anemia, and length of hospital stay are not as well studied.
Some examples of multimodal interventions to reduce unnecessary blood transfusions include the START (Screening by Technologists and Auditing to Reduce Transfusions) study which produced guideline development, education for clinicians, prospective order screening, and immediate feedback to physicians for potentially inappropriate orders, and monthly feedback to the clinical teams on appropriateness. Secondly, an Australian system-wide initiative focusing on education, practice audits, and feedback for individuals and a policy promoting single-unit red blood cell transfusions showed success. Other blood management approaches including anemia prevention, iron supplementation for iron deficiency, and a reduction in blood loss during procedures are other methods that can be used.
To implement strategies for reducing the unnecessary use of transfusions, individuals should assess their own practice against evidence-based standards. Additionally creating a multidisciplinary team to discuss and set guidelines and protocols based on evidence, auditing practices against identified evidence-based standards and tailoring interventions to the institutional setting and context can help with the implementation of restrictive transfusion practices.
Until we can find an alternative source or increase supply, we will continue to need people to step up and donate.
If you plan to donate blood, a few helpful tips can make for a better experience:
- Drink plenty of water. Staying hydrated makes it easier to find your veins and prevents you from becoming light-headed after donating
- Eat well beforehand and be sure to eat snacks offered to you.
- Get a good night’s sleep and, if you are planning to exercise, do so before donating, not after.
- Take iron tablets. The American Red Cross recommends individuals who donate blood frequently take an iron supplement or a multivitamin with iron.
Typically, donors are eligible to donate blood every 56 days or up to six times per year. To find a blood donation site near you, visit the American Red Cross or your local donation center. Every drop helps!
As August is National Breastfeeding Month, many healthcare professionals and hospitals across the country are joining in to promote its benefits. Currently, the American Academy of Pediatrics (AAP) recommends exclusive breastfeeding of infants for the first six months of life and then alongside solids as long as mutually desired by mother and child for two years and beyond. This updated recommendation – the AAP previously recommended breastfeeding through age one and beyond – acknowledges its continued benefits for mother and child.
Many experts suggest that it is an investment in the health of current and future patients, not just a lifestyle choice. In updating its guidance, the AAP clarifies that breastfeeding beyond one year and up to two years has significant benefits to the mother in particular; lower rates of diabetes, high blood pressure, and breast and ovarian cancers are associated with long-term breastfeeding. In breastfeeding infants, some studies indicate there are fewer respiratory and gastrointestinal infections, incidents of severe respiratory disease or sudden infant death syndrome (SIDS), development of chronic illnesses, doctor visits, hospitalizations, and prescriptions. The Centers for Disease Control and Prevention (CDC) estimates that an additional $3+ billion in medical costs per year can be attributed to low breastfeeding rates.
Breastfeeding is a personal choice – not everyone wants to or even can breastfeed their baby. For those who choose to, however, being successful is linked to the presence of interventions and support along the way. Evidence-based practices at the hospital level are a critical component for establishing breastfeeding.
The Agency for Healthcare Research and Quality (AHRQ) cited a systematic review of 38 randomized controlled trials that found short- and long-term increases in breastfeeding as a result of direct assistance and education across a variety of providers and settings in conjunction with structured training for health professionals. The AHRQ and the AAP also both cite increases in breastfeeding initiation and duration as a result of the Baby-Friendly Hospital Initiative, which gives a special designation to facilities that successfully complete an assessment and implement the World Health Organization’s 10 Steps to Successful Breastfeeding.
Some of the evidence-based practices linked to higher breastfeeding rates include individualized support in the first few hours and days following birth, rooming-in, and education and support. Additionally, the CDC’s 2018 national survey of Maternity Practices in Infant Nutrition and Care (mPINC) identified institutional management as an area with the widest range of scores across all states, with 45 being the lowest state score and 95 the highest state score (see Figure 1). As this category is defined by activities such as nurse training and clinical competency, record keeping, and policy setting, it is clear that some important breastfeeding initiatives extend beyond the maternity ward.
Figure 1. National score and state score ranges for mPINC subdomains in 2018
According to the AAP, there are also significant opportunities for more equitable gains in breastfeeding outcomes. The United States continues to see evidence of disparities in success rates – none of the Healthy People 2020 objectives for breastfeeding were met for non-Hispanic black mothers and infants. The rates for any breastfeeding are approximately 10% lower in non-Hispanic black mothers compared to the average for all races/ethnicities (see Figure 2). Similarly, there are disparities in mothers who are younger than 20, low income, or less educated. Hospitals interested in health equity initiatives likely have an opportunity in the realm of breastfeeding support that accounts for socioeconomic and cultural differences.
Figure 2. Rates of any breastfeeding in U.S. by race/ethnicity
A summary of recommendations, provider implementation tools, and other resources are summarized for healthcare providers in the AHRQ breastfeeding provider fact sheet. In addition, MVC would like to spotlight those members with ongoing or completed improvement efforts around breastfeeding. If your site has achieved the Baby-Friendly Hospital designation or has tools for addressing patient disparities in breastfeeding, please consider sharing your story with the Coordinating Center for the benefit of the larger collaborative.