23
Dec 2021
0
MVC Shares National Action Plan with COPD Workgroup Attendees
The Michigan Value Collaborative (MVC) held a bi-monthly virtual workgroup recently on chronic obstructive pulmonary disease (COPD), a condition that accounts for the majority of deaths from chronic lower respiratory diseases and is continuously a leading cause of death in the United States. Notably, COPD is nearly two times as prevalent in rural areas as it is in urban areas; therefore, MVC members in rural areas may be dealing with significant inequities within their patient populations. The workgroup presentation and discussion focused on the COPD National Action Plan (CNAP). To the Coordinating Center’s surprise, many workgroup participants had not previously heard of the CNAP, making this event a great opportunity for practice sharing and discussion among members.
Overcoming barriers to prevention, early diagnosis, treatment, and management of COPD is necessary to improve quality of life and reduce mortality. To address these barriers, the U.S. Congress; National Heart, Lung, and Blood Institute; and Centers for Disease Control and Prevention convened a town hall where they asked federal and nonfederal partners to develop an action plan. These partners were tasked with identifying the efforts needed to change the course of COPD. The result was the development of the COPD National Action Plan (CNAP), which was released in 2017 and updated in 2019. It consists of five goals, which were outlined and discussed during the workgroup (see Figure 1).
Figure 1. Slide from COPD Workgroup Presentation
Goal 1 calls for promoting more public awareness and understanding of COPD, especially among patients and their caregivers. Key opportunities include patient and caregiver education that is sustainable and culturally appropriate, technological support mechanisms, and connecting patients and caregivers to local and state resources.
Goal 2 focuses on increasing the skills and education of healthcare providers so they are better equipped to provide comprehensive care. This goal is supported by the development and dissemination of patient-centric, clinical practice guidelines for care delivery, the use of technological support mechanisms, and consideration of home-based pulmonary rehabilitation programs. It’s important to note that studies have found no statistically or clinically significant differences for health-related quality of life and exercise capacity among patients who have completed home-based vs. outpatient-based pulmonary rehabilitation.
Goal 3 encourages increased data collection, analysis, and sharing to create a better understanding of disease patterns. Opportunities within this goal include supporting pharmaceutical and clinical COPD research; identifying and delivering comprehensive, evidence-based, culturally appropriate interventions; and disseminating findings to a variety of audiences (from patients to national policymakers).
Goal 4 aims to increase and sustain COPD research to improve understanding of the disease and its diagnosis and treatment. It’s vital that clinicians, researchers, and health policy experts foster research across the COPD continuum (prevention, diagnosis, treatment, management). Workgroup attendees agreed that there are opportunities to improve equity among COPD patients through more data on diagnosed and undiagnosed COPD in disadvantaged patients. Another vital component of this goal is supporting and sustaining pharmaceutical research for COPD medications since none of the existing medications for COPD have been shown to reduce the progressive decline in lung function.
Goal 5 calls for federal and nonfederal partners to collaborate to meet the objectives of the CNAP and translate its recommendations into research and action. Workgroup attendees highlighted the importance of implementing CNAP equitably among both urban and rural regions and implementing COPD strategies at all health policy levels (national, state, local). Such opportunities could improve access to cost-effective and affordable COPD support services and expand support for and access to pulmonary rehabilitation services (including home-based PR), thus reducing health inequities among COPD patients.
Each of the five CNAP goals is equally important and vital in reducing COPD health disparities. Although many of the MVC workgroup participants had not heard of the CNAP before, they were interested in sharing its goals and opportunities with others in their healthcare organization. If you would like to learn more about this patient-centered national action plan, you can read the full published report here. If your organization has addressed the CNAP goals or implemented any of the discussed opportunities, the MVC Coordinating Center would like to hear about the successes, challenges, and lessons learned. If you would like to share this information or present at an upcoming MVC workgroup, please email MVC at michiganvaluecollaborative@gmail.com.
Reports Identify Opportunity to Reduce Preoperative Testing
December 9, 2021 | 0 Comments | preoperative testing
MVC distributed its final push report of 2021 this week when the Coordinating Center distributed preoperative testing reports to members. It provided recipients with refreshed data using only Blue Cross Blue Shield of Michigan claims in order to provide the most up-to-date and granular preoperative testing information available.
In general, the report demonstrated significant variation in testing rates between members, with preoperative testing rates ranging from 20% to over 90%. The average overall testing rate was 56% when looking at only the BCBSM payers, whereas the rate was 62% when looking at all payers in the earlier version of the report from February of 2021. The report included overall testing rate (Figure 1), preoperative testing rate trends over time (Figure 1), and rates for specific tests and procedures.
Figure 1. Blinded Preoperative Testing Push Report Graphs
Due to the amount of variation, MVC suspects that preoperative testing is overused at the state level such that even hospitals that are average or below average may still have significant opportunities to safely reduce preoperative testing.
Preoperative testing, especially in low-risk surgical procedures, often provides no clinical benefits to patients. Despite this, these services continue to be ordered regularly at hospitals across Michigan. Eliminating unnecessary and, in some cases, potentially harmful preoperative testing represents a clear opportunity to improve value in surgery. The MVC Coordinating Center uses administrative claims data and engagement with MVC members to try and reduce the use of unnecessary preoperative testing for surgical procedures to improve quality, reduce cost, and improve equity of care delivery throughout Michigan. The MVC Coordinating Center’s work on this issue is supported by a stakeholder working group to advise ongoing activity and provide insights on the best approaches to improve member awareness and practices.
This latest preoperative testing report also marked the conclusion of one year’s worth of activity in support of MVC’s Preoperative Testing Value Coalition Campaign. As part of MVC’s commitment to improve the health of Michigan through sustainable, high-value healthcare, the Coordinating Center developed specific focus areas to drive improvement. These are termed ‘Value Coalition Campaigns’ (VCCs).
In an effort to communicate progress on its Preoperative Testing VCC, the Coordinating Center recently compiled a 2021 Preoperative Testing Progress Report (see Figure 2) and included it as an attachment with the most recent report communications. Accomplishments included the development of educational flyers and resources, a published manuscript, partnerships with fellow Collaborative Quality Initiatives (CQIs), and custom analytics prepared for members. In addition, the Coordinating Center set several goals for 2022, such as developing provider-level reporting and hosting a dedicated symposium or workgroup, among others.
Figure 2. MVC 2021 Preoperative Testing VCC Progress Report
The Michigan Value Collaborative is eager to reduce unnecessary preoperative testing. If you are interested in a more customized report on preoperative testing practices at your hospital or physician organization or you want to learn more about the stakeholder working group, please contact the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.
Studies Find Value in Virtual Reality for Pain Management
Pain management is a critical component of effective care for patients. Amidst the opioid epidemic, however, pain management is highly nuanced for clinicians balancing their patient’s needs and wishes with state and hospital guidelines for prescribing. Although these guidelines are designed to curb opioid misuse—over 10 million patients misused prescription opioids in 2019—they are sometimes at odds with patient-based considerations. One research article, for example, found that, “many physicians expressed appreciation for opioid prescribing guidelines and simultaneously voiced concern about opioid restrictions that obviate the application of clinical reasoning.” In addition, some studies have called into question whether policies aimed at curbing overprescribing of opioids have a meaningful effect. One study noted that joint replacement surgeries from 2014 to 2017 saw increases in the percent of patients receiving opioids without clinically meaningful improvements in post-operative pain.
Therefore, when non-opioid pain management methods emerge in the medical literature as efficacious, there is a significant potential for impact coupled with great interest in its feasibility. Around the time the opioid epidemic was declared a public health emergency by the U.S. Department of Health and Human Services, one such pain management method emerged within medical research: virtual reality therapy.
Virtual reality therapy entails wearing virtual reality goggles and participating in an immersive, three-dimensional computer environment that distracts the patient from their pain. In some instances, it was proven effective for decreasing opioid use during painful wound procedures, and in other cases for helping patients learn how to manage chronic pain and achieve decreases in reported pain scores. Amid this excitement, one research team endeavored to measure the, "cost and effectiveness thresholds [virtual reality] therapy must meet to be cost-saving as an inpatient pain management program." They found that inpatient virtual reality therapy could reduce costs for a hospital if the length of stay was reduced because of its use; reductions in opioid use and related reimbursements were not enough in isolation to overcome the costs of virtual reality. This study found cost savings achieved in 89% of the trials it investigated.
Once studies have determined that a treatment is effective, the next question is whether it is effective for a more heterogeneous population—often, the patients included in medical research are white, relatively advantaged patients with higher-than-average education and literacy. With a growing focus in healthcare on health equity, it is important to determine whether virtual reality therapy also has potential in diverse patient populations. Just two months ago, a study from UC San Francisco was published that investigated the use of virtual reality among frontline pain management clinicians, particularly those in safety-net healthcare settings. The study found that clinicians and leadership in these healthcare settings were very interested in virtual reality therapy as a safer alternative to opioids. However, they also noted a need for significant tailoring for various cultures, languages, and technical abilities. They also expressed concerns about obtaining reimbursements and integrating the technology into complex workflows.
Virtual reality may offer potential savings as well as greater patient satisfaction for some hospitals and health systems right now. For others, it may take time and collaboration before virtual reality therapy is a feasible pain management alternative. The MVC Coordinating Center is interested in documenting how its members are approaching pain management and rising technologies like virtual reality. If your hospital or physician organization has found success in offering virtual reality therapy to patients or implemented other successful opioid-reduction interventions, please share your story with the MVC Coordinating Center (michiganvaluecollaborative@gmail.com) so other MVC members may benefit from your experience.
25
Nov 2021
Happy Thanksgiving!
November 25, 2021 | 0 Comments
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.
CHF Workgroup Discusses Value of Outpatient Intravenous Diuresis
The Michigan Value Collaborative (MVC) holds bi-monthly virtual workgroups on six different clinical areas of focus. The goal of these workgroups is to bring collaborative members together to discuss current quality improvement initiatives and challenges. These six different clinical areas include chronic disease management (CDM), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes, joint, and sepsis. At the most recent MVC CHF workgroup, the discussion centered around inpatient versus outpatient intravenous diuresis for the acute exacerbation of CHF.
The prevalence of heart failure in the United States is increasing, with one study indicating it affects more than 5.7 million people. The study reports that up to 80% of patients with acute decompensated heart failure (ADHF) visit their emergency departments and that 91.5% of those patients were thereafter readmitted to the hospital for diuresis.
With increasing prevalence comes greater direct and indirect healthcare costs associated with CHF, accounting for approximately $40 billion annually in the United States. For patients over the age of 65, it is a leading cause of hospitalization with annual costs of $11 billion.
Despite significant costs and healthcare burden associated with this condition, the same study finds that no official guidance exists regarding an appropriate location for therapy. Since hospital readmission reduction programs seek to incentivize reductions in readmissions, it is important to simultaneously provide guidance to providers and patients on safe and effective options for outpatient treatment and therapy.
To address this concern, the workgroup discussed the benefits and safety of outpatient intravenous (IV) diuresis and how the outpatient administration of furosemide can be safe and effective. MVC members shared their experiences with setting up these clinics, their inclusion criteria, and other protocols. A standard diuretic protocol could include each patient being given an IV furosemide bolus with continuous infusion within the most appropriate outpatient setting, which could include the patient’s home or in a mobile clinic.
While in the outpatient setting, patients undergoing this treatment would be monitored via cardiac telemetry and appropriate blood panels before and after the infusion. Patients on maintenance medications are instructed to continue their standard dose in the outpatient setting as appropriate based on their individualized treatment protocol. Patients should follow up with their cardiology and primary care teams to maintain their treatment and care maintenance plans. Following the outpatient IV diuresis encounter, the study reported patients had lower costs, fewer hospital stays, and lower mortality risk than CHF patients who did not receive outpatient IV diuresis.
Overall, studies indicate that outpatient CHF IV diuresis treatment is a safe and effective method of relieving CHF symptoms with a low risk of adverse events. The MVC members in attendance had positive thoughts and experiences regarding outpatient IV diuresis clinics and would recommend further discussion on them. The outpatient mobile CHF diuresis clinic was of notable interest to the MVC members in attendance and will be considered for a specialty topic in future workgroups and blog posts.
The MVC Coordinating Center is interested in hearing how your organization is improving CHF patient care and reducing CHF hospital readmissions. If you would like to present at or attend an upcoming MVC workgroup, please contact the MVC Coordinating Center at the michiganvaluecollaborative@gmail.com.
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.
04
Nov 2021
Introducing MVC Engagement Associate Chelsea Andrews, MPH
November 4, 2021 | 0 Comments
I would like to take this opportunity to introduce myself as the Michigan Value Collaborative’s (MVC) new Engagement Associate. As the Engagement Associate, I will work closely with the Site Engagement Manager and Site Engagement Coordinator to foster collaboration among members and other stakeholders and drive outreach efforts that facilitate statewide cross-institutional learning. I am excited to join the MVC Coordinating Center and look forward to getting to know our sites and members.
Colleagues would call me a well-versed health and wellness leader with an authentic and collaborative approach to program management who creates a positive and high-performing culture. I have worked in healthcare and health research in various capacities over the past 11 years, ranging from direct patient care to administration, and have co-authored multiple medical encyclopedia entries and actively contributed to NIH research. I’m a Michigan State University alumna with a pre-medical Bachelor of Science in human biology; a specialization in bioethics, humanities, and society; and a Spanish minor. After working as a nurse assistant in various specialties, I left the state of Michigan to earn my Master’s in Public Health in health systems, management and policy at the University of Colorado. While in Colorado, I was part of the administrative team for Colorado Medicine’s Department of Obstetrics and Gynecology - Division of Maternal Fetal Medicine. Since my return to Michigan in 2019 and prior to joining the MVC, I worked at the University of Michigan School of Nursing as Program Coordinator for the Alliance to Advance Patient-Centered Cancer Care, where I defined and executed project goals and acted as a liaison between the national program office teams, grantees, and board members.
I am passionate about comprehensive patient-centric operational procedures, community engagement, and reducing healthcare disparities. When I’m not working, you can find me playing with my dog and three cats, adventuring outside, working on cars, or reading next to a fire (I’m always accepting book recommendations). If you have any questions, please reach out to me at andreche@umich.edu.
28
Oct 2021
October 2021 MVC Semi-Annual: Virtual Meeting Recap
October 28, 2021 | 0 Comments
The Michigan Value Collaborative (MVC) held its second virtual semi-annual meeting of 2021 on Friday, October 22nd. A total of 221 leaders from a variety of healthcare disciplines attended Friday’s virtual meeting, representing 70 different hospitals and 23 physician organizations (POs) from across the state of Michigan. These participants came together to hear about the planned adjustments to the MVC Component of the Blue Cross Blue Shield of Michigan (BCBSM) Pay-for-Performance (P4P) Program for Program Year 2021 in light of COVID-19 and to discuss “the social risk and health equity dilemma” - a growing priority within the healthcare system generally, as well as within the MVC Coordinating Center.
MVC’s Director, Dr. Hari Nathan, started Friday’s meeting with an update from the MVC Coordinating Center, welcoming new collaborative members Munson Healthcare Manistee and Paul Oliver Memorial Hospital, and MVC’s newest Coordinating Center team members: Jana Stewart, Kristen Palframan, and Carla Novak. Dr. Nathan also highlighted some of the recent successes achieved by the Coordinating Center, including the launch of MVC’s new health equity report, increased custom analytic reporting, and the completion of over 50 virtual site visits with members this year.
Dr. Mike Thompson, MVC’s Co-Director, then shared information on the MVC Component of the BCBSM P4P Program with attendees. In investigating the impact of COVID-19 throughout the state in 2020, 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. 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 team found that episodes of COVID-19 patients are generally more expensive than typical episodes. In addition, COVID-19 was not present in the baseline year of 2018 that hospitals stand to be evaluated against. Therefore, with approval from BCBSM, Dr. Thompson announced that, for Program Year 2021 only, the Coordinating Center will be removing 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 (see Figure 1). Looking ahead, a summary of participant selections for Program Years 2023 and 2024 were also shared, showing joint replacement as the most common condition selection, closely followed by congestive heart failure (CHF).
Figure 1. MVC Slide on Updates to MVC Component of BCBSM P4P Program for PY21
At MVC’s last semi-annual meeting in May, the Coordinating Center announced that Michigan Medicaid data had been added to MVC data sources and that the MVC Coordinating Center would be spending the subsequent months validating the data and getting it ready for member use. This work has now concluded and MVC’s Manager of Data Analytics shared what this new data source looks like. Michigan Medicaid now represents MVC’s third-largest data source, accounting for over 319,000 episodes since 2015, covering 256,889 beneficiaries, and making up 19.4% of all MVC episodes. With this new addition, MVC data sources now comprise over 80% of Michigan’s insured population, all of which are available for members to utilize on the MVC registry.
To set the scene for our guest speakers, MVC Analyst Bonnie Cheng provided an overview of MVC’s recent health equity report (see Figure 2), highlighting racial, ethnic, and dual-eligibility variation across Michigan. The MVC Coordinating Center will look to build on this new report and undertake new activities in this area to support member activity moving forward. This will be supported by the Michigan Social Health Interventions to Eliminate Disparities (MSHIELD) collaborative – a new group recently launched as part of the Collaborative Quality Initiative (CQI) portfolio. With this in mind, MVC was joined by MSHIELD Program Manager Carol Gray to introduce this new collaborative and describe how MSHIELD will seek to interface with the health system and local communities to drive change (see Figure 3).
Figure 2. MVC Slide on New MVC Health Equity Report
Figure 3. MSHIELD Slide on MSHIELD's Role as a CQI
After hearing from MSHIELD, MVC welcomed guest speaker Dr. Nicole J. Franklin from McLaren Flint hospital. Dr. Franklin provided insight as to how McLaren Flint has devoted time and effort to bridge the gap between health and social care. This placed particular emphasis on the use of six representative sub-committees (employee resource, patient outcomes, community outreach, employee education, talent acquisition, and cultural calendar) to achieve McLaren Flint’s commitment to creating an inclusive and equitable environment where everyone is valued and empowered for success. Representing the Integrated Health Association (IHA), Leah Corneail shared how IHA has worked to actively screen and address patient social influencers of health (SIOH). This emphasized the importance of collecting actionable data through IHA’s SIOH questionnaire and the use of these data through an interactive population health dashboard (see Figure 4). The last guest speaker of the day was Melissa Gary, Community Liaison for Great Lakes Physicians Organization (GLPO). As well as providing an overview of GLPO, Melissa detailed how the organization has used a social determinants of health questionnaire and monthly tracking log to address the needs of over 2000 patients in 2020 alone.
Figure 4. IHA Slide on Social Influencers of Health Dashboard
To conclude Friday’s meeting, MVC Communications Specialist Jana Stewart provided a synopsis of the day and highlighted key upcoming activities. The slides from Friday’s meeting are available here and a recording of the meeting is available here. If you have questions about anything that was discussed at the semi-annual or are interested in finding out more about MVC’s offerings, please reach out to the MVC Coordinating Center (michiganvaluecollaborative@gmail.com). In the meantime, we look forward to seeing you all in person again soon.
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
- 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
- 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
- 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
- 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
- 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
- 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
- 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