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MVC Efforts to Improve Cardiac Rehab Enrollment in Michigan

MVC Efforts to Improve Cardiac Rehab Enrollment in Michigan

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

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

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

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

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

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

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

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

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

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

References

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

MVC Releases New Physician Organization Joint Report

Taking care of patients is the most important responsibility of the healthcare industry. To achieve optimal care, providers require robust and valuable resources that support their efforts. At MVC’s inception in 2013, the primary focus was the development of hospital-based metrics to improve patient outcomes, reduce healthcare costs, and encourage hospitals to collaborate in best practice sharing. MVC has since expanded its focus outside the hospital walls, recruiting all 40 physician organizations (POs) to participate as MVC members and collaborate to improve the health of Michigan through sustainable, high-value healthcare.

In April of 2021, MVC released its first PO population-level report containing data on health care utilization, allowing POs to benchmark themselves against all MVC PO members. To ensure the continued provision of the highest quality information, MVC engages regularly with PO members to solicit feedback on MVC outputs and to understand their priorities. For example, feedback from MVC’s first PO-specific report resulted in the MVC Coordinating Center updating its patient attribution process to align with that of its Blue Cross Blue Shield of Michigan (BCBSM) partners and their Physician Group Incentive Program (PGIP). As a result, MVC members are attributed to their respective POs with Blue Cross attribution methodology. The MVC Coordinating Center continues to leverage input from these stakeholders to drive the formation of PO-specific reports (see Figure 1).

Figure 1.

A new PO report released this week focuses on episode-based metrics related to joint replacement surgery. This report utilizes updated methodologies and is comprised of administrative claims from attributed members spanning 1/1/19 – 12/31/20 for BCBSM PPO Commercial and BCBSM Medicare Advantage. Reports were prepared for all POs that participate in MVC and had at least 11 joint replacement surgeries per year in 2019 and 2020, respectively. The selection of metrics contained in this report is a result of feedback from PO members and BCBSM.

The new PO Joint Replacement Report includes:

  • Top five facilities where attributed patients had a joint replacement surgery
  • Percent of joint replacement surgeries performed in an inpatient setting by six-month interval
  • Percent of joint replacement surgeries performed in the inpatient setting
  • Utilization rate after a joint replacement surgery in the inpatient/outpatient setting for the following:
    • Home health care
    • Skilled nursing facility (SNF)
    • Emergency department (ED)

The MVC Coordinating Center is stratifying metrics by employed vs. independent PO using BCBSM’s Summer 2021 PGIP physician list. Therefore, POs with greater than 50% of their aligned providers employed by a health system are considered employed, and those with fewer than 50% are considered independent.

The report indicates a downward trend over time in the percent of surgeries performed in the inpatient setting (see Figure 2). This is a positive finding given the push for joint replacements to occur in the outpatient setting; however, it is unclear whether COVID-19 was a factor in this decrease given that the reporting period includes 2020.

Figure 2.

In addition, POs generally have low rates of skilled nursing facility (SNF) utilization (see Figure 3) and relatively higher rates of home health (see Figure 4) utilization. This finding is also encouraging since SNFs are expensive.

Figure 3.

Figure 4.

The metrics with the greatest variation among the different POs are home health rates as well as the overall percentage of joint replacement surgeries performed in the inpatient setting (see Figure 5).

Figure 5.

By understanding the needs of MVC PO members regarding present and future patient care improvement activities, MVC will be better able to improve its future PO reports. If you are interested in sharing feedback about these new PO reports, have any specific PO analytic requests, are undergoing new PO improvement initiatives, and/or would like more information about the Michigan Value Collaborative, please reach out to the Coordinating Center at michiganvaluecollaborative@gmail.com.

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MVC Component of the BCBSM P4P Program Year 2021 Update

MVC Component of the BCBSM P4P Program Year 2021 Update

The COVID-19 pandemic impacted hospitals throughout the state in 2020 and the MVC Coordinating Center deemed it necessary to evaluate the effect of COVID-19 on the MVC Component of the Blue Cross Blue Shield of Michigan (BCBSM) Pay-for-Performance (P4P) program. The goal was to determine if adjustments needed to be made to maintain fairness across the collaborative for index admissions in the calendar year of 2020, which will be used to score the 2021 program year.

The MVC Coordinating Center found that 223 of the 25,627 (0.9%) episodes included in the P4P conditions from the first half of 2020 had a code for confirmed COVID-19 infection in the index event or other inpatient settings. Pneumonia and congestive heart failure (CHF) were the most common conditions to have a COVID-19 diagnosis.

The MVC Component of the BCBSM P4P program rewards hospitals for either making improvements over their baseline episode payment or for being less expensive than peer hospitals. The MVC Coordinating Center has also found that episodes of COVID-19 patients are generally more expensive than typical episodes. Additionally, COVID-19 was not present in the baseline year of 2018 that hospitals will be evaluated against and hospitals were impacted differently.

Therefore, with approval from BCBSM, the MVC Coordinating Center will remove any 2020 episode with a COVID-19 diagnosis on an inpatient facility claim during the 30-day episode if the COVID-19 ICD code is one of the first three diagnosis codes on the claim. Please contact the MVC Coordinating Center with any questions at michiganvaluecollaborative@gmail.com.

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Fall Semi-Annual Meeting Agenda Highlights Health Equity Topics

Fall Semi-Annual Meeting Agenda Highlights Health Equity Topics

The MVC Coordinating Center recently released the full agenda for its forthcoming fall Semi-Annual Meeting on Friday, October 22, 2021, from 10:00-11:30 am. The MVC Coordinating Center holds collaborative-wide meetings twice each year to bring together quality leaders and clinicians from across the state. This year’s theme of “the social risk and health equity dilemma” is reflective of a growing priority within the healthcare system generally, as well as newer activities within the MVC Coordinating Center.

Speakers at semi-annual events are often members who share their stories of success, challenges, barriers, and solutions in pursuing a higher value and quality of care. The speakers outlined on October’s agenda showcase the breadth and depth of knowledge that exists within the collaborative in the health equity space. They also represent a variety of stakeholder groups, including hospitals, physician organizations (POs), Collaborative Quality Improvement (CQIs) programs, and of course MVC Coordinating Center leadership.

The first guest speaker will be Carol Gray, Program Manager of the new Michigan Social Health Interventions to Eliminate Disparities (MSHIELD) CQI. She leads the overall management, performance, and coordination of the MSHIELD program and Coordinating Center team. She has extensive experience managing public health research teams, communicating across and coordinating with multiple partnerships, and linking and engaging with community-based organizations in Detroit and academic faculty at the University of Michigan. Her presentation on, “Aligning Partnerships to Achieve Health Equity,” will speak to that expertise.

The meeting also features the expertise of Dr. Nicole J. Franklin, Assistant Medical Director at the McLaren Bariatric and Metabolic Institute. She provides psychological support to bariatric patients before and after weight loss surgery. In addition, Dr. Franklin is the chair of the Diversity and Inclusion Committee at McLaren Flint and has co-facilitated the Diversity Committee within all three local hospitals’ psychology training programs for the last 10 years. She is an Air Force veteran and a graduate of Wright State University’s School of Professional Psychology. Referencing her work within the greater Flint community, her session will address, “The Health Gap: An Exploration of how one hospital is working to bridge the gaps between health care and social care.”

Another perspective will be brought by Leah Corneail, Director of Utilization and Population Health at the Integrated Healthcare Association (IHA). In this role, she is responsible for leading utilization and cost improvement efforts, ensuring success in risk-based contracts and CMS demonstration programs, and collaborating with community partners to improve population health. Corneail has several years of experience in population health and health policy. Prior to joining IHA, she served as a Senior Project Manager in the Michigan Medicine Population Health Office, where she managed Michigan Medicine’s portfolio of value-based payment models and partnered with operations to implement care transformation initiatives. Leah received her Master of Public Health degree from The George Washington University’s Milken Institute School of Public Health. She will speak to, “IHA Efforts to Screen and Address Patient Social Influencers of Health (SIOH).”

Also representing the approach of a PO will be Melissa Gary, Community Liaison with the Great Lakes Physician Organization (GLPO). In this role, Melissa is responsible for bridging the gap between healthcare providers of GLPO and the local community agencies to better align the mission of GLPO. Utilizing her several years of experience in healthcare and nonprofit organizations, she has built the GLPO social determinants of health process. She is a passionate community servant with the ability to motivate and inspire individuals to identify their own potential and shares in the passion to serve others. Melissa is a graduate from Ferris State University where she studied nuclear medicine and healthcare administration. She has minors in science, biology, pre-pharmacy and paralegal.

Attendees can also expect to hear from MVC Coordinating Center leadership and staff about MVC’s Medicaid data, the MVC Component of the Blue Cross Blue Shield of Michigan (BCBSM) Pay-for-Performance (P4P) Program, and general program updates.

These presentations could be informative and useful for any of the following stakeholders who are welcome to attend:

  • MVC Hospital Site Coordinators and Champions
  • MVC Physician Organization Site Coordinators
  • Quality Leadership
  • Clinicians
  • Managers and front-line staff in the following clinical areas:
    • Population health
    • Chronic disease management
    • Post-acute care
    • Value-based care
    • Care coordination
    • Discharge planning
    • Social work
    • Others whose work addresses health equity or social risk factors

In addition, hospitals that have attended both of MVC's 2021 Semi-Annual Events (May 2021 and October 2021) will be eligible for one additional bonus point toward Program Year 2021 of the MVC Component of the BCBSM P4P Program.

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!

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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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Approach to quality improvement unique for rural hospitals

Approach to quality improvement unique for rural hospitals

Quality improvement is a key effort for healthcare systems and a driving force behind the work of the Michigan Value Collaborative. It is also an increasingly complex task with significant implications. Not surprisingly, quality improvement is not a one-size-fits-all approach, with the challenges impacting hospitals varying significantly by factors such as size and location. This variability showcases the importance of sharing tailored resources among Collaborative members.

Critical-access hospitals (CAHs) are the newest type of members to join the Collaborative. They play an important role in the healthcare system by caring for rural patients who might not otherwise have access to inpatient services. Defined as hospitals maintaining no more than 25 acute care beds and located more than 35 miles from the nearest hospital, they are unique in their populations, services, and structure. The majority of their patients would have to drive 30 minutes or more for an alternative hospital, and many communities have no alternative. Their offerings and size are reflective of the communities they serve, with services such as emergency care, inpatient care, laboratory testing, rehabilitation, long-term care, maternity care, home health care, and even primary care. As a result, their capacities, priorities, and challenges differ from those of their larger colleagues, as do their quality improvement efforts.

For example, a 2015 report from the National Quality Forum titled, “Performance Measurement for Rural Low-Volume Providers,” highlights several challenges to quality improvement in rural areas including fewer providers, lack of information technology, and fewer people to share the workload. Furthermore, rural hospitals often don't meet patient volume thresholds that are required for meaningful comparative analyses. It is critical, therefore, that CAH facilities are connected to resources tailored to their circumstances. One such resource is the 2021 Small Rural Hospital Blueprint for Performance Excellence and Value, produced by the National Rural Health Resource Center.

The purpose of this Blueprint is to aid rural hospital leaders in taking a comprehensive systems approach to quality improvement using factors and strategies relevant to small rural hospitals. Guided by the components of the Baldrige Framework that first took hold in healthcare over 20 years ago, the Blueprint outlines typical challenges, factors for success, and relevant resources for seven key inter-linked focus areas (see Figure 1): leadership; strategic planning; patients, partners, and communities; measurement, feedback, and knowledge management; workforce and culture; operations and processes; and impact and outcomes.

Figure 1.

The Blueprint also incorporates specific comments and feedback shared during the Small Rural Hospital Performance Excellence Summit that was held in the spring of 2021. For instance, within the section on leadership, the Blueprint suggests that educating and engaging the CAH’s board members on healthcare trends and issues is a critical factor of success, in large part because board members in rural areas often do not have a healthcare background. A quote from the Summit on this issue reads, “changes in healthcare are complicated, particularly for those that don’t spend all day every day focused on it.” The Blueprint then recommends resources listed in its appendix that are specifically designed for engaging CAH board members. In addition, a full companion resource focused on related strategies and resources for state flex programs is also available.

CAHs are an important piece of the healthcare puzzle and, like their larger colleagues, they stand to benefit significantly from quality improvement efforts. In fact, an October 2019 CMS fact sheet, “CMS Hospital Value-Based Purchasing Program Results for Fiscal Year 2020,” looked at adjustments made for Medicare payments to hospitals based on their performance on a set of quality measures. Compared to urban hospitals, rural and smaller hospitals generally performed better in both efficiency and cost reduction, among other areas.

The MVC Coordinating Center established regions within its membership in order to help hospitals network and share practices with their peers. Many of the CAH members within the Collaborative operate in region 1 in the northern parts of the state, and a regional networking event was held for region 1 earlier this week. The Coordinating Center is proud of its diverse membership and continues to encourage facilities and POs to leverage the knowledge of peers who operate in a similar capacity so that, together, members can improve the value of healthcare for Michigan patients. If your facility or PO is utilizing a resource that would benefit the work of a peer institution, please contact the Coordinating Center at michiganvaluecollaborative@gmail.com so it may be shared with the Collaborative.

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Patient-Reported Outcomes Improve Quality, Equity of Care

Patient-Reported Outcomes Improve Quality, Equity of Care

For several years, patient-reported outcomes (PROs) have been a topic of interest, in part due to increased utilization of electronic data and the integration of delivery systems. PROs are defined by the Food and Drug Administration (FDA) and National Quality Forum as "any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else." In short, PRO tools ask patients questions to measure how they feel and what they are experiencing. With patient-reported outcome measures (PROMs), patients provide information about their health, quality of life, and functional status, either in absolute terms (e.g., pain severity rating) or in response to treatment changes (e.g., new nausea onset). The goal of gathering this information from the patient’s perspective without any interpretation from a healthcare provider is to improve both the quality of care being delivered and health outcomes.

The use of PROs has a variety of potential benefits. They can elicit enhanced patient engagement, be used to clarify the patient’s priorities and thus improve shared decision-making between patients and providers, and can bring to light any benefits or harms of interventions. The potential impact of PROs, therefore, is substantial because involving patients in their healthcare is linked to a myriad of positive patient outcomes. For example, based on a review of studies investigating patient participation, some of the benefits to patients include:

  • increased satisfaction and trust,
  • empowerment,
  • greater self-efficacy to manage health,
  • higher quality of life,
  • better understanding of condition and personal requirements,
  • improved adherence to medical treatment plans,
  • improved communication about symptoms with positive and lasting effects on health.

Ever increasing in its availability, the use of PROs is included in clinical investigations, healthcare practice, healthcare management, and various regulatory or reimbursement areas. As the patient continues to become more central to healthcare, they are in the best position to determine if their healthcare objectives have been achieved. PROMs are not the same as measures reported by patients on their experience of the healthcare system, such as being treated with dignity or waiting too long; however, patient-reported outcome-based performance measures (PRO-PMs) are beginning to find their way into healthcare and may integrate such measures. To help understand the relationship between PROs, PROMs, and PRO-PMs, see Figure 1, which was designed by the Centers for Medicare and Medicaid Services (CMS) in their supplemental guide on PROMs.

Figure 1.

To gather PROs, the tools and instruments known as PROMs must measure criteria that are identifiable, valid, and reliable. Most often these are general or disease-specific self-completed questionnaires, scales, or single-item measures that provide a score for any of the following:

  • functional status,
  • health related quality of life,
  • symptom and/or symptom burden,
  • personal experience of care,
  • health-related behaviors.

Generic PROMs often delve into areas covered by a variety of different conditions, allowing for comparisons across multiple medical conditions. These PROMs help with evaluation and implementation of care provision methodology and equality of service delivery. Some may even provide a cost-effectiveness component. Disease-specific PROMs identify the impact of definitive symptoms on the condition. PROMs can be used as either the primary or secondary outcome measure of a study or trial, and most studies use a combination of disease-specific and generic PROMs.

Measurement tools integrate other existing data (biological, genetic, clinical, and physical) to assess how a patient is functioning regarding their overall health, quality of life, mental well-being, or satisfaction with a healthcare process. Using all these data sources provides a more complete picture of the patient’s health journey and allows for patients and their providers to share decision-making and define individualized care. They also provide a unique opportunity to identify inequalities in healthcare access and treatment.

When utilizing PROMs, practitioners must plan for how the information will be collected and utilized. PROMs can be collected in a variety of ways, including face-to-face interviews, online or paper questionnaires, telephone interviews, or diaries. When deciding which PROMs to utilize, it is important to consider the preferences of patients, providers, and any other involved decision-makers. It is also essential to consider the cognitive, physical, demographic, and socioeconomic barriers that may exist for the patient to ensure they have adequate accommodations to participate. The length, schedule, and timeframe of assessments should also be appropriately assessed, along with any permissions needed to use the information. Lastly, the PROMs should be easy to score and interpret, actionable, and able to facilitate clinical decisions.

The use of PROs is here to stay. The hope is that improvements in interoperability, data governance, security, privacy, and ethics will allow greater integration of PROs. In turn, PROs will allow patient preferences, needs, and health outcomes to further drive value-based healthcare.

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Joint, CHF Top Members’ Selections for MVC P4P Program

Joint, CHF Top Members’ Selections for MVC P4P Program

The MVC Coordinating Center recently distributed condition selection reports for Program Years 2022 and 2023 of the MVC Component of the Blue Cross Blue Shield of Michigan (BCBSM) Pay-for-Performance (P4P) Program. The reports were provided in conjunction with details pertaining to the condition selection process, as well as changes to the scoring methodology, cohort assignments, and bonus points available. More details about those changes was published in a previous MVC Coordinating Center blog.

Eligible members were tasked with reviewing these reports and returning their condition selection form at the end of August. Each participating hospital selected two of the seven available conditions for PY22 and PY23: spine surgery, joint replacement, chronic obstructive pulmonary disease (COPD), coronary artery bypass grafting (CABG), congestive heart failure (CHF), colectomy (non-cancer), and pneumonia. The condition that was selected by the most participants was joint replacement with 41 hospitals selecting it, followed closely by CHF with 40 selections. COPD was selected by 32 hospitals. See Figure 1 for a depiction of the total selections for each condition.

Figure 1.

Although the two conditions selected most frequently were consistent across a variety of hospitals, the overall selections varied somewhat from region to region and by hospital size or type. For instance, hospitals with fewer than 100 beds were much more likely to select pneumonia as one of their two conditions than peers with more than 100 hospital beds (see Figure 2).

Figure 2.

Conversely, larger hospitals that perform more complex procedures made up the totality of selections for spinal surgery, colectomy, and CABG. Still, joint replacement and CHF were the most commonly selected conditions among all hospital sizes.

Similarly, CHF and joint replacement were popular among all hospitals regardless of location type, such as urban or rural (see Figure 3), or location within the state (see Figure 4), with the exception of Region 4 hospitals selecting COPD more frequently than joint replacement.

Figure 3.

Figure 4.

With the majority of hospitals focusing on both joint replacement and CHF, the MVC Coordinating Center hopes that continued participation at the joint and CHF workgroups will result in meaningful collaboration among members. MVC will also continue to offer events for virtual networking with facilities and physician organizations (POs) within a member’s geographic region (see Figure 5). These regional networking events provide additional opportunities to connect and share knowledge with peers who may share your hospital’s priorities. For instance, the next Coffee, Chat, and Collaborate virtual networking event takes place among hospitals and POs in Region 1 on Monday, September 13, at noon. Members from Region 1 interested in attending can register here.

Figure 5.

P4P cohorts were reassigned for PY22 and PY23. These changes were also detailed in the new technical document, and the new cohort assignments were published on the MVC website. The cohorts were not intended to group hospitals that are exactly alike; rather, they created a reasonably comparable grouping from which MVC can complete statistical analyses.

This program began in 2018, when BCBSM allocated 10% of its P4P program to an episode of care spending metric based on MVC data. This metric measures hospital performance using price-standardized, risk-adjusted 30-day episode payments for BCBSM Preferred Provider Organization (PPO), Medicare Fee-for-Service (FFS), BCBSM Medicare Advantage, Blue Care Network (BCN) Health Maintenance Organization (HMO), and BCN Medicare Advantage.

If you would like to receive notices about the MVC workgroups or have questions about any aspect of the MVC Component of the BCBSM P4P Program, please contact the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.

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MVC Coordinating Center Launches Health Equity Report

MVC Coordinating Center Launches Health Equity Report

As hospitals begin to identify lessons learned since the start of the pandemic, providers are keenly aware of the prevalence and exacerbation of existing health inequities. Despite the fact that many providers are increasingly interested in addressing the social determinants of health (SDOH) and equitable access to care, communities of color and other minorities that are statistically more impacted by SDOH and socioeconomic status (SES) have endured even wider gaps in health outcomes and care this past year. For many hospitals and physician organizations, the way forward requires the application of a health equity or social risk lens across the board, so that basic healthcare and quality improvement decision-making can be maximized for all patient populations, not just those with fewer social risk factors. The MVC Coordinating Center is, therefore, proud to have released its first MVC Health Equity Report to its membership on Wednesday morning.

MVC began developing metrics for its membership in this area over the past year so providers might better understand where inequities are materializing within the four walls of their hospitals and beyond. One popular method for identifying low-SES patients is by determining where someone lives and applying population-level metrics to the individual. Examples of this would be using the Area Deprivation Index (ADI) or Social Vulnerability Index (SVI). Both indexes are based on census tract data and provide SES characteristics about a population within a specific geographic location (i.e., a census tract), including risk factors such as poverty, education level, transportation access, and housing security. However, in developing the MVC Health Equity Report, the MVC Coordinating Center elected to utilize a patient-level metric of SES that is compatible with MVC claims data. As a result, the report identifies low-SES patients using dual-eligibility status.

Dual-eligible beneficiaries are patients that are eligible for both Medicare and Medicaid. In the MVC Health Equity Report, dual eligibility is defined as having been eligible for both Medicare and Medicaid at any point during the year of the index admission and is limited to patients that were at least 65 years old at the time of admission. Medicaid eligibility is a good indicator of SES when using claims data since it is income-based, and studies have shown that there is a strong association between low-income status and adverse health outcomes. Dual eligibility allows MVC analysts to identify Medicaid-eligible patients within its more extensive Medicare data set for analyses. Medicare data on the MVC registry currently includes claims data from 1/1/2015 through 9/30/2020. The resulting reports prepared for members focuses on episodes occurring between 2017 and 2020, or between 2017 and 2019 if the circumstances of 2020 resulted in unusual case counts by facility.

In developing this report, there was a conscious decision to exclude any sort of comparison group alongside each individual hospital's metrics. This is because the socioeconomic factors of a hospital’s patient population cannot be changed, and there is great diversity between hospitals throughout the state and within geographic regions. For those reasons, benchmarking was not the intention of this report. However, it is important to note that across the state, the data analyzed by the MVC Coordinating Center consistently indicates that dual-eligible patients have poorer outcomes than their non-dual-eligible counterparts, including longer lengths of stay, higher readmission rates, higher post-discharge emergency department utilization, lower rates of office visits post-discharge, higher rates of post-discharge outpatient procedures, and higher utilization of skilled nursing facilities. Blinded sample graphs for length of stay (Figure 1) and readmission rates (Figure 2) were created using data from three distinct, large hospitals in order to showcase some of these differences.

Figure 1.

Figure 2.

Members receiving reports will see a variety of graphs depicting, for example, total episode payment trends, 30-day readmission rate trends, and post-acute care utilization. Also provided is a table outlining a hospital or region’s highest volume of conditions within its dual-eligible population (see Figure 3 for a blinded sample). The purpose of this table is to help members better understand the proportion of dual-eligible patients at their hospital and the prevalence of various conditions within that population. It will also help members to better understand their report overall by identifying the conditions and procedures driving the various metrics included within it.

Figure 3.

MVC is eager to do more in this space in the months ahead. With the recently added Michigan Medicaid data on the MVC registry, the Coordinating Center has a new opportunity to more closely examine the types of disparities that are prevalent in healthcare. Additionally, with the addition of 13 rural or critical access hospitals to the collaborative in the past 12 months, the Coordinating Center aims to expand its metrics outside of the episode structure to examine population health metrics. This will allow for better understanding about healthcare delivery and how outcomes differ in rural regions compared to urban.

The MVC Coordinating Center wants to hear feedback from its members. With the addition of Medicaid data, we are working hard to develop more metrics and reports that focus on health equity. If you have any questions, comments, or suggestions, please contact the MVC Coordinating Center at michiganvaluecollabortative@gmail.com.

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Predictive Analytics Assist with Chronic Disease Prevention

Predictive Analytics Assist with Chronic Disease Prevention

The healthcare system has an immense wealth of information at its digital fingertips. Big data is constantly expanding from sources such as digitized patient records, patient wearables, medical apps, genome datasets, monitoring devices, and more. A critical challenge facing hospitals and health systems today is in effectively identifying strategies and personnel to utilize big data in a way that influences clinical care. Those that succeed in this task will find themselves in a much better position to advance care and improve patient outcomes.

One developing strategy to convert big data sets into improved patient outcomes is the use of predictive analytics, an approach that differs from what many hospital quality improvement departments are currently utilizing. For example, the Michigan Value Collaborative (MVC) Coordinating Center has been helping hospitals identify opportunities for quality improvement since 2013 by aggregating and analyzing payor claims data and presenting the results on the registry and in analytics reports. The goal of these efforts is to help hospitals compare utilization against peers and draw important insights across a range of medical and surgical procedures. This retrospective approach helps MVC members to learn from their past performance in order to pursue meaningful, observable improvements within their buildings. It is one piece of the big data puzzle. Predictive analytics, on the other hand, allows clinicians to utilize big data before their patient experiences significant healthcare services or treatments. As its name denotes, this approach identifies prevention opportunities before the incidence of disease by predicting a patient’s risk. This is especially important for diseases that require early detection for optimal treatment and survival.

Unlike Robotic Process Automation (RPA), which is also on the rise in health systems across the country, predictive analytics is performed by Artificial Intelligence (AI). This means that computer systems will perform tasks typically requiring human intelligence, including analyses and decision-making. In some ways, this strategy mimics what physicians have long been doing at a patient’s bedside: collecting a patient’s medical history and risk factors in order to tailor their treatment and advice. This process is essential in evaluating a patient’s risk of developing chronic diseases, which often run in their family or are more likely due to socioeconomic factors. An article from the University of Illinois Chicago posits that predictive analytics represent a significant potential for cost savings if they help clinicians and their patients prevent the onset of chronic diseases, one of healthcare’s costliest areas.

“On a population-wide level, predictive analytics can help greatly cut costs by predicting which patients are at higher risk for disease and arrange early intervention, before problems develop,” the article stated. “This involves aggregating data that are related to a variety of factors. These include medical history, demographic or socioeconomic profile, and comorbidities.”

The Centers for Disease Control and Prevention (CDC) states that, “90% of the nation’s $3.8 trillion in annual health care expenditures are for people with chronic and mental health conditions.” So the potential cost savings from reducing chronic disease treatment are significant.

Using predictive analytics in a clinical setting can leverage both patient records and socioeconomic factors. Medical records will often include family history of chronic diseases such as cancer, diabetes, and heart disease, which would make a patient more likely to develop the condition themselves. In addition to family history, a patient’s socioeconomic factors (e.g., education, employment, and environment) and lifestyle choices are significant predictors of chronic disease. A study in the American Journal of Preventive Medicine outlines how researchers used predictive analytics to screen for cardiovascular disease risk from social determinants of health, and ultimately guide clinician treatment options. The researchers also suggest that large databases about social determinants of health variables, especially environmental ones, are not as readily available as they should be, and are an important area of opportunity for future data collection efforts.

A similar application of this technology was used in a study published by Cancer Immunology Research to predict lung cancer immunotherapy success. In the study, researchers used an AI algorithm to identify changes in patterns from CT scans that were previously not detected by clinicians, which ultimately predicted how well a patient would respond to immunotherapy. This suggests that predictive analytics can help improve the accuracy of diagnoses and treatment.

Of course, the applications for predictive analytics extend beyond chronic disease prevention and treatment. In the past year, researchers have also used predictive analytics to forecast outcomes for patients positive for COVID-19. In The American Journal of Emergency Department Medicine, a published study validated a tool that helps physicians predict adverse events among patients presenting with suspected COVID-19. The study suggests that the algorithm and scores can help physicians decide when to hospitalize or discharge patients during the pandemic. Therefore, predictive analytics appear to also provide insights that enhance treatment.

Many additional articles (such as one article from Health IT Analytics) and published studies recommend predictive analytics for its potential benefits. As with any technology, however, it is not without its risks. The use of AI brings about concerns for privacy, especially since hospitals must properly steward patient data and comply with HIPAA regulations. But there are several other considerations identified in a recent Deloitte analysis (see Figure 1), not the least of which is ensuring the algorithm doesn’t introduce bias that disproportionately harms minorities and communities of color. Predictive analytics may also present evaluation challenges. Once algorithms are validated, their widespread use in clinical settings should be confirmed for their efficacy, which requires measuring the absence of disease.

Figure 1.

The potential benefits of predictive analytics are variable and significant; however, as healthcare learns to integrate AI technologies, it will be important to keep its risks in mind and address them accordingly. The MVC Coordinating Center endeavors to assist its members through their data analytics journey by providing insights into specific data sets. When pursuing additional technologies or analytic tools, the Coordinating Center encourages members to volunteer as a sounding board and resource for other members. If your hospital or physician organization is currently utilizing AI or considering it with your patient data, we encourage you to reach out so MVC can share your experience with others. You can reach the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.