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MVC Rural Health Meeting Summary: Delivering Value in Rural and Northern Michigan

MVC Rural Health Meeting Summary: Delivering Value in Rural and Northern Michigan

This Wednesday, the Michigan Value Collaborative (MVC) held its first collaborative-wide rural health meeting for members. With over 50 participants representing rural and critical access hospitals (CAH), physician organizations (POs), and participating quality networks, this virtual meeting was dedicated to discussing the unique quality improvement efforts and challenges that exist within rural healthcare.

MVC Director Hari Nathan, MD, PhD, kicked off Wednesday’s meeting with an update from the MVC Coordinating Center (see slides). Honoring MVC’s 10-year anniversary, Dr. Nathan highlighted important milestones from the last decade that contributed to MVC’s continued efforts to deliver high-value healthcare in all areas of Michigan. Dr. Nathan shared updates pertaining to the launch of MVC’s new emergency department (ED)-based episodes, the recent addition of a CAH comparison group in its reporting, expanded CAH membership (Figure 1), and MVC’s plan to offer a rural health workgroup series in 2024.

Figure 1.

Following Dr. Nathan’s introduction and collaborative-wide updates, MVC Senior Analyst Julia Mantey, MPH, MUP, provided an in-depth presentation of MVC’s new ED-based episodes, which were developed in collaboration with the Michigan Emergency Department Improvement Collaborative (MEDIC). Read this recent blog post for more information on MVC’s ED-based episode structure and utilization or view Ms. Mantey’s slides here.

After introducing the components of MVC’s ED-based episodes, Ms. Mantey presented an unblinded data session illustrating ED-based episode data for MVC’s rural hospital members. When considering both rural non-CAH ED-based episodes and CAH ED-based episodes, chest pain was the most frequent condition observed. Due to its high volume in the ED, MVC produced unblinded rural hospital data using ED-based episodes for 30-day secondary ED visits among patients with a primary diagnosis of chest pain. In analyzing this data, MVC analysts discovered a correlation between patient follow-up rates and 30-day secondary ED visit rates. Patients who receive follow-up care are less likely to return to the ED in the 30 days following their initial index discharge, and the rate of secondary ED visits is smallest among patients who received follow-up care within one week of discharge (Figure 2).

Figure 2.

Following the unblinded data presentation, MVC received input from participants about additional analyses that would be useful, such as evaluating the correlation between the availability of nearby urgent care facilities and the rates of primary and secondary ED visits. Such suggestions were noted as MVC works to expand its CAH and ED-based episode data reporting.

Following the unblinded data session, Ross Ramsey, MD, CPEM, FAAFP, President and Chief Executive Officer of Scheurer Health, delivered a presentation on common rural health challenges and Scheurer Health’s recent efforts to improve the quality of care for its rural population. Dr. Ramsey emphasized that rural areas are associated with higher poverty rates, larger proportions of elderly individuals, a higher percentage of patients who are uninsured, and a higher prevalence of chronic health problems such as substance abuse and illnesses related to environmental exposures. Dr. Ramsey highlighted several focus areas at Scheurer Health to improve the value of care for its patients: wellness visits, transitional care management, remote patient monitoring, and ED follow up. As seen in Figure 3, Scheurer Health increased wellness visit participation by 32.8% over the last six years. For more details about Scheurer Health’s strategies and success stories, view Dr. Ramsey’s slides here.

Figure 3.

After Dr. Ramsey’s insightful presentation, MVC welcomed Mariah Hesse, MSN, CENP, President of the Michigan Critical Access Hospital Quality Network (MICAH QN) and Chief Nursing Officer at Sparrow Clinton Hospital. Her presentation (see slides) provided an overview of core components of the quality network, highlighting its foundational pillars of success (Figure 4), in addition to featuring the network’s accomplishments and the benefits of participation by Michigan’s 37 CAHs. MICAH QN ensures representation for CAHs on national and state committees and serves as a resource to Michigan CAHs on performance improvement tools and measures. Her presentation also referenced several key priorities for healthcare in rural Michigan, such as meaningful benchmarking focused on outpatient care, recovery from challenges experienced during the pandemic, and improving healthcare access and equity.

Figure 4.

MVC looks forward to continued partnership with members based in rural communities to support the delivery of sustainable, high-value care through high-quality data analytics, collaboration, and innovation.

The slides from Wednesday’s meeting have been posted to the MVC website and a recording of the meeting is available here. If you have questions about any of the topics, contact the MVC Coordinating Center. MVC’s next collaborative-wide meeting will be in person on Friday, October 20, 2023, in Lansing, MI.

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Study Shows Lasting Impact of a Modifier 22 Initiative on Opioid Use Among Vasectomy Patients

Study Shows Lasting Impact of a Modifier 22 Initiative on Opioid Use Among Vasectomy Patients

The opioid epidemic continues to harm individuals and communities worldwide; over-prescribing, overuse, and related overdose deaths persist in the United States and abroad. Without proper intervention, the proliferation of opioid use disorder and its negative impact on population health will continue. Healthcare professionals and stakeholders eager to stem this crisis are investing in the development and iteration of interventions that improve control of opioid distribution. As part of this effort, one team of healthcare researchers recently published a paper in Urology investigating the impact of an insurance payer’s novel opioid reduction intervention on the adoption of opioid-sparing pathways.

The authors of this publication, including lead author Dr. Catherine S. Nam, M.D., and her colleagues from Michigan Medicine, sought to compare the percentage of patients who filled peri-procedural opioid prescriptions before and after Blue Cross Blue Shield of Michigan (BCBSM) launched a modifier 22 incentive for opioid-sparing vasectomies in Michigan. This program incentivized the utilization of an opioid-sparing post-operative pathway developed by the Michigan Opioid Prescribing Engagement Network (OPEN) by allowing the use of the modifier 22 reimbursement code for vasectomies performed with minimal or no post-operative opioids. Previous literature has demonstrated success in this approach for other medical procedures. The use of modifier 22 as an opioid reduction intervention was first launched by BCBSM in 2018 for select procedures and was expanded to include vasectomies in 2019. Typically, modifier 22 can be applied to select insurance claims with the primary procedure code when the work attributed to that procedure or medical intervention exceeds the typical amount of required labor. When approved, insurance companies may provide additional reimbursements of up to 35%.

The expanded eligibility for the modifier 22 into vasectomy presented substantial quality improvement potential given both how commonly this procedure is performed—approximately half a million times annually across the US—and the fact that a 2019 survey indicated more than half of urologists prescribed opioids for patients receiving a vasectomy, even though the procedure can be completed without them. For a vasectomy procedure to qualify for the modifier 22 program, a surgeon must intend to follow an opioid-free peri-procedural course as well as provide additional counseling to patients about post-procedural pain expectations, proper opioid disposal, and non-opioid pain management strategies.

Given the novel quality incentive for opioid-sparing pathway application to vasectomy with implications for payers, providers, patients, and policymakers, Dr. Nam and her colleagues were interested in evaluating the impact this policy change had within the state of Michigan.

To perform this analysis, Dr. Nam and colleagues leveraged Michigan Value Collaborative (MVC) administration claims data from beneficiaries in BCBSM’s preferred provider organization (PPO) plan. The data provided by MVC included men ages 20 to 64 who participated in urologic procedures between Feb. 1, 2018, and Nov. 16, 2020.

Between these dates, Dr. Nam and colleagues identified 4,559 men who underwent office-based vasectomies and 4,679 men in the control group, which consisted of men who underwent cystourethroscopies, prostate biopsies, circumcision, and transurethral destruction of prostate tissue. These procedures are all office-based and not eligible for opioid-sparing modifier 22, thus providing a point of comparison.

The results of the analysis demonstrated a strong association between the implementation of modifier 22 for vasectomies and filled opioid prescriptions. Before July 1, 2019—prior to the implementation of the expanded modifier 22 policy—32.5% of men filled an opioid prescription after receiving a vasectomy, whereas after implementation only 12.6% of men filled an opioid prescription post-procedure (see Figure 1). As highlighted in the figure below, Dr. Nam and colleagues found a 19.9% absolute reduction and 61% relative reduction in the percentage of vasectomy patients who filled peri-procedural opioid prescriptions.

Figure 1. Percent of Patients Filling Opioid Prescriptions Before and After Implementation of Modifier 22

Among the vasectomy patients in the analysis, for every three opioid prescriptions filled before the implementation of modifier 22, only one was filled after the initiative was implemented. They did not find a significant decrease in the percentage of patients who filled peri-procedural opioid prescriptions in the control group.

In addition to the decreased frequency of men filling peri-procedural opioid prescriptions for vasectomies, Dr. Nam and colleagues also found a significant decrease in the prescribed amount. After the implementation of modifier 22 for vasectomies, the oral morphine equivalents (OME) of peri-procedural opioid prescriptions fills dropped from 89.7 OME per prescription to 27.1 OME per prescription. Dr. Nam and colleagues estimated that this decrease in prescription size led to the distribution of approximately 8,473 fewer oxycodone 5mg pills in Michigan.

When asked about the significance of these findings, Dr. Nam explained, “This estimate helped us grasp the impact of the Modifier 22 policy change for patients as well as the community. If this was the impact in a bit over a year for a single procedure in one state, how large could this impact be annually? What could the impact be when quality incentive is expanded to additional procedures? What if the quality incentive could be expanded to other states?”

These findings suggest that the modifier 22 incentive does decrease the percentage of patients who fill peri-procedural prescriptions after a vasectomy and its implementation correlates with a reduction in the number of opioids circulating within the community. In addition to reducing the unnecessary presence of opioids in communities, this initiative also emphasizes a shift to refocus healthcare interactions on the patient. The required additional education about pain management and proper use of pain management medications implemented as part of the modifier 22 initiative provides patients with a better understanding of their care and encourages physicians to consistently deliver high-value care.

Despite the significant findings of this study, a question remained. If these practice changes were initiated by incentivized modifier 22 interventions, what would happen if BCBSM terminated the incentive? Since the publication of Dr. Nam and colleagues’ original study, BCBSM terminated the financial incentive using modifier 22 for opioid-sparing vasectomies on Dec. 31, 2021. This termination provided the group with an opportunity to observe the long-term impact modifier 22 had on physician prescribing patterns and patient opioid use after the incentive was no longer in place.

Dr. Nam and colleagues performed another interrupted time series analysis before and after the termination of modifier 22 using the same vasectomy and control groups. After analyzing the data provided by MVC, they observed no significant changes in the opioid fill rate compared to the rate observed when the modifier 22 program was in effect. This was true for both the vasectomy group and the control group (see Figure 2). The persistence of reduced opioid prescription sizes was also observed following termination of modifier 22. Prior to incentive termination, the mean opioid prescription amount was 59 OME, and after termination the mean further reduced to 36 OME.

Figure 2. Percent of Patients Filling Opioid Prescriptions Before and After Termination of Modifier 22

These critical findings demonstrate that physician opioid prescribing behavior remained constant after the removal of financial incentives. More research still needs to be done on the long-term impact of programs such as modifier 22; however, Dr. Nam and colleagues suggest that other payers could implement incentive programs like BCBSM’s modifier 22 initiative in order to spur similar changes in prescribing patterns and are hopeful that short-term financial incentives are part of the solution to creating lasting practice changes.

“This is the first example of a novel quality incentive targeting physicians to provide high-value care by incentivizing opioid-sparing pain pathway,” she said. “However, this incentive can be adapted to incentivize other high-value care – could we recognize physicians that are providing guideline-based care? How about ensuring that appropriate lab and imaging tests are ordered for patients as part of their care plan? And if so, could it be possible for there to be an investment made from the insurance companies to champion high-value care for a short period of time to have lasting effects?”

MVC is committed to using data to improve the health of Michigan through sustainable, high-value healthcare. Therefore, one of MVC’s core strategic priorities is intentional partnerships with fellow Collaborative Quality Initiatives (CQIs) and quality improvement collaborators. In partnering with clinical, administrative, and CQI experts to leverage MVC data for analyses, MVC aims to identify best practices and innovative interventions that help all members improve the quality and cost of care.

Publication Authors

Catherine S. Nam, MD; Yen-Ling Lai, MSPH, MS; Hsou Mei Hu, PhD, MBA, MHS; Arvin K. George, MD; Susan Linsell, MHSA; Stephanie Ferrante; Chad M. Brummett, MD; Jennifer F. Waljee, MD; James M. Dupree, MD, MPH

Full Citation

Nam, C. S., Lai, Y.-L., Hu, H. M., George, A. K., Linsell, S., Ferrante, S., Brummett, C. M., Waljee, J. F., & Dupree, J. M. (2022). Less is more: Fulfillment of opioid prescriptions before and after implementation of a modifier 22 based quality incentive for opioid-free vasectomies. Urology, 171, 103–108. https://doi.org/10.1016/j.urology.2022.09.023.

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HMS CQI Receives Endorsements from National Quality Forum

HMS CQI Receives Endorsements from National Quality Forum

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Figure 1.

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

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

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

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

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


Welcoming Fall with Quality Improvement Week

October brings celebrations of Fall – with pumpkins, trips to the orchard for apple picking, and Halloween - and also Healthcare Quality Week (October 16 – 22), a time for healthcare teams to highlight their efforts to improve the quality of care for patients and families.

Over the years, various improvement methodologies have been applied in healthcare settings to advance the quality of care, reduce costs, and improve patient outcomes. Here is a look at some of the models and how they could bring value to your organization.

Six Sigma uses statistics and data analysis to reduce errors and improve processes. Originally developed in the 1980s, Six Sigma has grown over the years into an industry standard, with training and certification programs too. The Six Sigma methodology leverages the DMAIC (Define, Measure, Analyze, Improve, Control) approach (Figure 1). Following the five steps of DMAIC provides teams with a framework for identifying, addressing, and improving processes.

Figure 1: The Six Sigma DMAIC

Lean, a methodology borrowed from the automobile industry, optimizes an organization’s people, resources, and effort to create value for customers (Figure 2). Lean’s focus is on sustaining improved levels of quality, safety, satisfaction, and morale through a consistent management system. With a goal to promote, evaluate, and implement ongoing process improvements, Lean uses Value Stream Mapping (VSM) to create a visual map of each step in a workflow, allowing teams to identify opportunities for efficiency.

Figure 2: Lean Process Improvement

Additionally, Lean encourages teams to focus on continuous improvement through the Plan Do Check Act (PDCA) model, an interactive form of problem-solving used to improve processes and implement change. In a PDCA cycle, teams work through four key steps: 1) identify the problem and create a solution plan (Plan), 2) implement a small-scale test (Do), 3) review the test performance (Check), and 4) decide to adjust or implement the test on a larger scale or adjust (Act/Adjust).

Figure 3: PDCA Cycle

Total Quality Management (TQM) is a management approach for long-term success through customer satisfaction. Originally used by the Naval Air System Command, TQM is based on the principles of behavioral sciences; qualitative and quantitative analysis; economic theories, and process analysis. Using the TQM methodology allows organizations to be customer-focused, with all employees participating and engaging in continual improvement. By utilizing strategy, data, and effective communication, TQM becomes integrated into the organizational culture and activities (Figure 4).

Figure 4: Total Quality Management

With a goal to optimize activities that generate value and reduce waste, the Kaizen approach is based on the belief that continuous, incremental improvement adds up to substantial change over time (Figure 5).

Figure 5: Kaizen (Continuous Improvement) Principles

The MVC Coordinating Center supports hospital and physician organization members across the state in identifying opportunities for improvement and facilitating a collaborative learning environment for members to exchange best practices. If you are interested in discussing improvement opportunities for your site, please contact the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.

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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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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.