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MVC Showcases Recent Work at Obesity Summit, Poster Session

MVC Showcases Recent Work at Obesity Summit, Poster Session

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.

Figure 1.

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).

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.

Figure 3.

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 michiganvaluecollaborative@gmail.com.

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MVC and Members Promote Sepsis Awareness Month

MVC and Members Promote Sepsis Awareness Month

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.

Figure 1.

Figure 2.

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).

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 michiganvaluecollaborative@gmail.com.

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Roll Up Your Sleeve to Save a Life

Roll Up Your Sleeve to Save a Life

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!

Figure 1.

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.

Figure 2.

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.

Figure 3.

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!

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Breastfeeding Awareness Month: The Value of Hospital Initiatives

Breastfeeding Awareness Month: The Value of Hospital Initiatives

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.

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MVC Draws Attention to Cardiac Rehab in Promotional Week

MVC Draws Attention to Cardiac Rehab in Promotional Week

Every February while the nation honors American Heart Month, a subset of heart health advocates spend one week paying tribute to the lifesaving value of cardiac rehabilitation. Last week the Michigan Value Collaborative (MVC) Coordinating Center joined in on Cardiac Rehabilitation Week by helping to increase awareness and promote MVC’s efforts to improve utilization. Over the course of the week, MVC distributed press releases, published a daily cadence of social media content on Twitter and LinkedIn, and launched a video about the importance of cardiac rehab – all in service of inspiring collaboration in this area.

Cardiac rehabilitation (CR) has a Class IA indication for recent cardiac-related events or procedures, meaning there is high-quality evidence that it is beneficial to patients. In fact, individuals who complete the full program of 36 sessions have a 25% lower risk of death and a 30% lower risk of heart attack than those who attend only one session. It also reduces hospital readmissions and saves thousands of dollars per patient per year of life saved. Nevertheless, CR is widely underutilized, with national utilization rates of only 25-50%. It is for this reason that MVC wishes to equitably increase CR participation for all eligible individuals in Michigan. Throughout CR week, therefore, MVC endeavored to define the value of CR, what it entails, and how the actions of MVC members impact CR participation.

MVC’s role in the CR space is two-fold. One is the preparation of reports using its unique multi-payer data sources, and the second is providing opportunities for MVC members to collaborate. The reports that MVC prepares for members analyze claims data with time-specific hospital-level information on CR enrollment and completed visits within one year of discharge. This allows hospitals to benchmark their performance against peers and identify areas for improvement. There’s a huge amount of variation in CR rates across many dimensions – hospitals, qualifying events, and payers. For example, the hospital with the highest rate of CR after coronary artery bypass graft surgery (CABG) succeeds at sending 75% of their CABG patients to CR, while another only sends 28% of their CABG patients. This variation shows that it is possible to reach high CR rates, and hospitals can learn from each other to make systemic improvements that get more patients into this life-changing (and cost-saving) program.

To support collaboration among its member base of 100 hospitals and 40 physician organizations, MVC hosted a special, one-time workgroup on CR last week as part of its newly launched “Health in Action” workgroup series. This series is meant to drive discussion and collaboration on special topics that rotate throughout the year. Last week’s session featured the expertise of two special voices in the world of CR: Steven Keteyian, Ph.D., Director of Cardiac Rehabilitation/Preventive Cardiology at Henry Ford Medical Group, and Greg Merritt, Ph.D., patient advocate and founder of Patient is Partner. The workgroup was well attended with over 100 guests, who benefitted from informative and inspiring presentations from both speakers.

Dr. Keteyian presented updates on the clinical effectiveness of CR as well as some of the key barriers facing the field. There is high-quality evidence that CR is beneficial to patients on a variety of physiological measures, including improved exercise tolerance, decreased risk of future hospitalization, and decreased cardiovascular mortality. He also reiterated the value of cardiac rehab relative to other recommended cardiac interventions, with CR demonstrating more lives saved per 1000 patients than ACE inhibitors, statins, and other common medications (see Figure 1).

Figure 1. Calculating the Value of Cardiac Rehab

The current quality measures for CR suggest a patient’s time to enrollment should occur within 21 days of discharge, and that the patient should attend at least 36 sessions to receive the greatest benefit. The current goal for CR participation set by the Million Hearts initiative is 70%. However, Dr. Keteyian found that of the CR-eligible beneficiaries, only 28.6% participated and only 27.6% of those participants completed all 36 sessions. This represents a significant utilization gap. While discussing related challenges, Dr. Keteyian suggested that hospitals implement EMR-driven automatic referrals, overt provider endorsements, and an inpatient liaison to bridge the gap between referral and enrollment. He also recommended the use of hybrid CR programs that leverage telehealth to offer remote options.

Dr. Merritt’s presentation included his own personal story of surviving a cardiac event and his ensuing participation in a CR program. Following his experience, he became a “patient questionologist” dedicated to finding opportunities for patient and provider collaboration. His story ultimately led to the founding of an organization called Patient is Partner, which is dedicated to the principles of patient-partnered care. Inspired by the writings of behavioral scientists as well as Why We Revolt by Victor Montori, Dr. Merritt outlined a vision for healthcare innovation that invites patients and their unique perspectives to help solve healthcare’s greatest challenges. He encouraged attendees to join the movement and invite more patient voices to contribute to their respective committees and teams.

At the conclusion of the week, the MVC team had helped its audiences connect to educational materials, data, specialists, former patients, and successful peers in this space. The Coordinating Center is eager to continue this momentum from CR Week in pursuit of a variety of goals for 2022 and beyond. If your hospital or physician organization is interested in improving CR utilization rates, you can learn more about how MVC supports members to increase CR enrollment or reach out directly at michiganvaluecollaborative@gmail.com. You can also view a recording of the full CR workgroup here.

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Happy Thanksgiving!

Happy Thanksgiving!

The Michigan Value Collaborative wishes you a happy Thanksgiving holiday. Thank you to our partners and members for working tirelessly every day to improve healthcare quality across Michigan.

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Healthcare Leaders Issue Support for Climate Change Mitigation

Healthcare Leaders Issue Support for Climate Change Mitigation

The past year forced healthcare to grapple with never-before-seen challenges. In response, facilities and clinicians found ways to think creatively, adapt, and find common ground with peers to best steward the health and safety of our communities. But the pandemic isn’t the only challenge requiring that kind of response. The healthcare industry is placing greater emphasis than ever before on the issue of climate change amidst the news and commitments coming out of the 2021 United Nations Climate Change Conference, also known as COP26.

The greater emphasis following this year’s conference is perhaps related to an increased overall focus on direct impacts to public health as well as the looming presence of a global pandemic that nearly all countries have struggled to manage. Countries like Britain are looking to reduce emissions by piloting a first-of-its-kind zero-emissions ambulance, citing that air pollution contributes to one out of every 20 deaths in the United Kingdom. The new vehicle was parked and promoted at the events in Glasgow. It is also notable that the healthcare industry has been increasingly concerned with variability in health outcomes due to social determinants of health; the impacts to human health by climate change and environmental pollution are also felt disproportionately by vulnerable communities.

The COP26 commitments included one from the U.S. Biden Administration to halve the United States’ greenhouse gas emissions by 2030. According to Health Care Without Harm (HCWH), an international nongovernmental organization concerned with mitigating healthcare’s impact on environmental health, “the U.S. health sector is responsible for 8.5% of U.S. greenhouse gas emissions and 27% of the global health care emissions… Addressing the climate crisis as a core driver of disease must be central to the health sectors’ mission today and in the future. As a fundamental sector in our society, and the only sector with healing as its mission, it makes sense for health care to lead the way to kick our addiction to fossil fuels, improve public health, and save billions of dollars in health costs in the process.”

They posited that healthcare has a unique relationship with climate change because of healthcare's role in bearing the financial costs and human health burden (see Figure 1 from the Centers for Disease Control and Prevention) from “increased disease spread and more frequent extreme weather events.”

Figure 1.

This belief is shared by at least 45 million healthcare workers (which represents 75% of the health professionals in the world) associated with letters urging immediate action on climate change. There are already leaders in these efforts throughout the U.S. The Healthcare Climate Council created a playbook (see Figure 2) for operationalizing climate solutions in areas such as energy, food, leadership, operating rooms, purchasing, infrastructure, transportation, and waste.

Figure 2.

The playbook contains success stories of facilities that have made meaningful changes, such as one about the Cleveland Clinic saving more than $4 million in 2019 by reducing air changes per hour during non-surgical periods as part of their Operating Room Setback Plan. They save 25 million kWh/year in energy use and $2.5 million annually. Similarly, Ascension deployed a data dashboard to report facility operations (energy, water, temperature, humidity, and air changes) on a real-time basis, and they implemented a pulse oximeter collection project that resulted in 664,000 medical devices collected and 66.4 tons of landfill waste avoided. They reported that this effort required collaboration between green teams, the purchasing department, environmental services, clinicians, facility managers, and the medical device reprocessing vendor.

Quality improvement efforts in healthcare have always been multifaceted, seeking to systematically reduce variation and improve outcomes by standardizing processes and structures. Quality professionals look at technology, personnel, culture, physical capital, leadership, training, operations, and procedures, among other areas. This means that healthcare’s quality improvement teams are uniquely positioned to support their leadership in identifying and implementing climate solutions. These changes that help mitigate climate impacts also often lead to more efficient, sustainable care delivery.

There are a number of professional organizations ready to assist and offer guidelines for practice improvement, including Health Care Without Harm, its sister organization Practice Greenhealth, the Alliance of Nurses for Healthy Environments, the American Society of Anesthesiologists, the Association of American PeriOperative Registered Nurses, and the American Academy of Family Physicians, among others.

Much like with the COVID-19 pandemic, the actions and decisions of one facility, community, or country ultimately have an impact on everyone else, which means a culture of collaboration is a prerequisite for the successful integration of climate change mitigation in healthcare. If your hospital or physician organization has achieved value or outcome improvements that relate to environmental health or sustainability, the MVC Coordinating Center can help share your story. Please contact the MVC team at michiganvaluecollaborative@gmail.com.

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Staffing Shortage Challenges Hospitals Across Michigan

Staffing Shortage Challenges Hospitals Across Michigan

The past 18 months of the pandemic forced healthcare to be creative and responsive to the needs of the moment, and in that time the MVC Coordinating Center heard from members about how they are working to maintain a high quality of care. The challenges and pivots shared by members vary significantly because facilities were impacted at different points in time and with varying levels of severity. However, one challenge echoes loudly and consistently for hospitals big, small, urban, or rural: the staffing shortage. This problem isn’t specific to Michigan. Across the United States, hospitals don’t have enough staff to keep up with their normal standards of care, with many having to turn away patients and ration care.

Health professionals are the lifeblood of healthcare delivery, so attaining or maintaining a high quality of care is only achievable with appropriate staffing levels. The Institute of Medicine framework defines quality care with six aims: that it be safe, effective, patient-centered, timely, efficient, and equitable. Some of those aims have been directly exacerbated by the pandemic—such as health equity or safety—while many have been at least indirectly impeded by the strains on frontline workers.

An article published by the Detroit Free Press this month titled, “Michigan hospital staffing shortage nears crisis point as COVID-19 patients rise,” paints the current situation as dire. The article quotes Brian Peters, the CEO of the Michigan Health & Hospital Association, as saying, “I have never heard a consistent theme from across our entire membership like I have on this staffing issue." He adds that the shortage affects multiple sectors of the workforce, such as nurses, physicians, housekeeping, technicians, and food service personnel. These new staffing issues occur within an industry that was already concerned about an expected shortage of primary care physicians (PCPs). The Association of American Medical Colleges (AAMC) published data that predicts an estimated shortage of between 21,400 and 55,200 PCPs by 2033 (see Figure 1), in part due to a population that continues to grow and age.

Figure 1.

Some hospitals suggest burnout as the main culprit for the current staffing shortages. A literature review on the effect of burnout on quality of care defines burnout as a state of fatigue and frustration manifested as physical and emotional exhaustion characterized by dissatisfaction and stress, with symptoms such as, “physical fatigue, cognitive weariness, and emotional exhaustion.” Anyone in that condition cannot perform at their best. So as quality teams try to find treatment efficiencies for conditions such as chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), the elephant in the room is that they may not be able to provide treatment if nurses, technicians, and physicians aren’t adequately staffed.

The industry is expecting the shortages to increase slightly in the coming weeks as vaccination mandate deadlines approach. Currently, those health systems requiring COVID-19 vaccination include Henry Ford, Michigan Medicine, Beaumont Health, Trinity Health, Spectrum Health, OSF HealthCare, Ascension Health, and Bronson Healthcare, along with Veterans Health Administration facilities.

A variety of strategies are being proposed to lessen the burden felt by the shortage. Since it takes time to recruit new people into medical fields, these approaches generally fall into one of two categories: 1) retain current staff, and 2) deploy current staff as efficiently as possible.

The approaches that hospitals have mentioned for retaining staff are short-term in nature, ranging from approval of overtime and bonuses to instituting new staff well-being programs and sharing mental health resources. Efficient staffing is a more complex approach, but long-term with the potential to reduce the expected burden from future PCP shortages. The Harvard Business Review published an article that outlines strategies for efficient staffing in response to the PCP shortage, which could be repurposed and applied to other healthcare workforces. Among their suggestions, they highlight Advisory Board research that proposes the threefold answer is, “better use of PCPs targeted at specific populations, greater use of non-physician labor where appropriate, and much broader deployment of technology to increase access to primary care.” These suggestions align with several other priorities often voiced to the MVC Coordinating Center by members, including equitable access to care, expanded telehealth offerings, and improved care coordination utilizing nurse practitioners and physician assistants.

The work ahead will be challenging, as it often is in healthcare. Hospitals will continue to shoulder a shared burden in the months ahead. MVC encourages all members and partners to share resources that may help a peer institution improve the quality of care for Michigan residents. Please continue to bring these ideas to future workgroups and networking events, and contact the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.

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Growth On the Horizon for Robotic Process Automation in Healthcare

Growth On the Horizon for Robotic Process Automation in Healthcare

Hospital quality improvement teams have an increasingly difficult task ahead. Their efforts to improve quality of care across a wide range of medical services must be balanced with the need to expand their facility’s capacity, ensure proper handling of sensitive data, adhere to strict procedures, cut costs, and adapt to the limitations of a pandemic. This work poses challenges both organizational and operational. Even though patient care is the primary focus for hospital staff, they must maintain a constant stream of paperwork and other administrative tasks such as data entry, scheduling appointments, billing, and managing claims paperwork. Robotic process automation (RPA) presents an opportunity to decrease these administrative costs and streamline some operations.

RPA is defined as software that can automate repeatable, rule-based processes. RPA interacts with the assigned applications in the same way that a human does, logging into a given system and following a defined set of keystrokes and rules. It is not the same as artificial intelligence (AI)—there is no decision-making capacity. RPA can only offload manual, high-volume computer processes. The primary benefit of RPA, therefore, is its ability to free up time for humans to complete more complex tasks, such as interfacing with patients or interpreting data.

RPA is a burgeoning field recommended by consulting groups such as Deloitte, McKinsey, and Bain & Company. Although RPA hasn’t had sufficient time to make its way into academic literature, it is spreading quickly in all types of industries. For example, according to Deloitte’s Global RPA Survey, more than half of their 400 respondents from multiple industries were already pursuing automation with as many as 72% looking to add RPA in the next two years.

“RPA exceeds adopters’ expectations not only when it comes to the rapid rate of ROI increase, but also when it comes to facilitating compliance (92%), improved quality and accuracy (90%), or improved productivity (86%),” the report read. The report also suggests that the benefits of utilizing RPA may include cost reductions, boosts to productivity, more stable workflows, and fewer human errors, among others (see Figure 1).

Figure 1.

Source: Summit Healthcare

Healthcare as an industry has the potential to significantly benefit from offloading administrative tasks to bots. According to McKinsey, the healthcare sector has the potential to automate around 36% of tasks. They suggest that the greatest potential for healthcare payers is in areas such as claims processing, customer service, and billing activities (see Figure 2).

Figure 2.

Hospitals and health systems have pursued RPA in these areas as well and found success. One example written about in Forbes recently described the efforts of Baylor Scott & White Health (BSWHealth), an academic medical system with 52 different hospitals and the largest not-for-profit provider in Texas. BSWHealth uses RPA to automate “claim statusing” in its insurance collections department. The bot helps to check the status of outstanding insurance claims that, previously, a human employee would have to do by logging into multiple payer websites or placing phone calls. The RPA bot uses screen-scraping technology that mimics keystrokes the employee would enter to obtain claim statuses from payers. As a result, an abundance of claims—those that are accepted and scheduled to be paid—never clutter the employee’s desk. Instead, the employee only sees those that are denied and require human attention, resulting in outstanding claims being addressed faster. BSWHealth is pursuing a variety of RPA projects like this one across all of its revenue cycle departments. They reduced their total FTEs by over 20% while simultaneously reducing payer denials by 20%.

Success stories like this one are particularly exciting for hospitals struggling to manage their case load amidst the pandemic. Daily operations and procedures have been severely impacted financially and operationally by coronavirus. A recent survey conducted by the World Health Organization identified that almost half of the countries surveyed (49%) reported strains on their ability to treat diabetes, with 42% reporting the same for cancer and 31% struggling to properly manage cardiovascular emergencies. As a result, companies are pursuing automation opportunities more than ever before (see Figure 3), with Bain & Company reporting as many as 81% of hospitals pursuing RPA initiatives.

Figure 3.

Still, according to a 2019 white paper by The Economist, “extensive” use of automation is only used by half of healthcare organizations, and healthcare in general is among the most resistant to adopting it. Some healthcare organizations remain cautious for a variety of reasons, including concerns about initial investments, maintenance costs, and the possibility of failure. The same white paper also proposes that data privacy and security concerns might be a significant hinderance to RPA efforts, as well as a deficit in the skill sets needed to develop the bots.

Plus, any discussion of RPA sometimes begets fears about job replacement. In some scenarios, health systems have seen an overall decrease in FTEs after putting RPA initiatives in place. However, the overall goal is usually to reallocate effort toward more high-level, cognitive projects in a way that increases productivity without replacing people. If an administrative task requires no higher-level thinking, then giving it to an RPA bot will free up time for clinical staff to attend to patient care rather than paperwork. In fact, according to Harvard Business Review, most new adopters of RPA have promised their employees that it won’t result in layoffs.

Despite hesitations, health systems are likely to test out RPA projects in the coming years in response to the current state of affairs. Hospitals have been forced over the past year to find efficiencies where they can. RPA bots appear to have the potential for a variety of benefits, not the least of which is flexibility to redeploy personnel to areas in need of increased staffing. As RPA begins to make its way into the literature, it will be important to consider research findings about best practices going forward.

It will also be helpful going forward to share lessons learned with peer institutions. One of the goals of the MVC Coordinating Center is to support collaboration and idea sharing across its membership. If any member is implementing RPA projects and would be interested in sharing their experience with others, please contact the MVC Coordinating Center team at michiganvaluecollaborative@gmail.com.

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Identifying and Solving Potentially Preventable Hospitalizations

Identifying and Solving Potentially Preventable Hospitalizations

As hospitals continue to work on reducing readmissions, another area of focus to reduce costs is through preventing potentially preventable hospitalizations, especially in chronic conditions. Potentially preventable hospitalizations, known as PPHs, are unplanned hospitalizations that have the potential to be avoided if timely and appropriate outpatient care had been received. However, in order to reduce these admissions, there has to be a means of identification. A number of methods have been reviewed to try and develop a way to identify those patients at risk of having a PPH.

In Australia, a Preventability Assessment Tool (PAT) was developed to attempt to identify patients at high risk of PPH The use of the tool compared to a similar assessment performed by an expert panel was assessed to learn if the tool identified appropriate patients. The  findings were recently published in a journal article. The expert panel consisted of a hospital physician, a primary care physician (or general practitioner (GP)), and a community nurse with expertise in the chronic conditions. The publication identified that the carefully constructed and developed PAT, when compared to the assessment of the expert panel, did not effectively identify those at risk of a PPH.

Another method to potentially identify these types of admissions is a hospital outreach program, also implemented in Australia. In the program, the patient record is flagged for areas of concern such as general health, medication, and wellness. Red flags are specific to disease or symptoms that have the potential for hospitalization. Trained telehealth guides reach out on a frequent basis (greater than weekly), while patients and caregivers can call in to the program at any time. Analysis of the flags being triggered through these phone calls may alert personnel to a deterioration in patient health, concerns about medications or a lack of support, and allow for outpatient care to be provided in a timely manner to avoid a hospitalization.

A study within the United States compared deep learning against a logistical regression model to identify prediction models for preventable hospitalizations, emergency department visits, and costs in heart failure patients. The study found that deep learning approaches identified these preventable areas more accurately than the traditional methods, indicating that outcomes are contributed to by clinical, demographic, and socioeconomic factors. The study found the main predictors for preventable hospitalizations in heart failure patients were diuretic usage, orthopedic surgery, and age (see Figure 1).

Figure 1.

Research suggests that although hospitals can work to identify who is at risk for a preventable hospitalization or preventable emergency department visit, a more preferable method of reducing these is improving not only quality of care but also access to care within the primary sector of the community. By reducing barriers to healthcare and improving local community services, population health outcomes can potentially be enhanced which, in turn, may lead to a reduction in potentially preventable hospitalizations.

The Michigan Value Collaborative is interested in hearing how your facility is working towards identifying potentially preventable hospitalizations and ED utilization. Please contact us at michiganvaluecollaboarative@gmail.com.