Scaling the Mountain of Pain Management: Why Virtual Reality is the New Pathway

By Gerry Stanley, M.D. , May 5, 2022

There may be many ways to summit Mount Everest, but the safest route is to follow an established path with the help of a seasoned guide. The same advice holds true for exploring the latest and most promising innovation for treating patients suffering from chronic and acute pain: virtual reality.  

Published Results for Vx(R) Therapy

The combination of virtual reality and behavioral health is a novel and effective option for resolving pain in the workplace, according to results of an article published on October 16, 2021, in the peer-reviewed journal "Pain and Therapy." Study authors included myself, Chief Medical Officer, Harvard MedTech; A. Abd-Elsayed, Department of Anesthesiology, School of Medicine and Public Health, University of Wisconsin; and N. Hussain, Department of Pain Medicine, Beth Israel, Deaconess Medical Center, Harvard Medical Center.

The results reported in "Pain and Therapy" were achieved with a cohort of adult workers' compensation patients aged 18 – 65 who were treated for acute or chronic workplace injuries from April 2019 to April 2020. All patients were referred to and overseen by a prescribing physician and referred to the Harvard MedTech Vx Pain Relief Program by orthopedic specialists, pain specialists, primary care physicians and occupational health providers.

Patients considerably reduced mean pain scores each week, averaging a reduction of 40% while using the virtual reality headset. In addition, their mean daily time spent thinking about pain symptoms decreased from 9.78 hours at the start of therapy to 2.76 hours after completing the 12-week program, representing a 72% reduction.

69% of Vx Patients Reported Decrease in Opioid Use

Reduction in reliance on opioids for pain control was also recorded, with 69% of patients reporting decreased opioid use. Patients experienced a 115% increase in their sleep duration and a 280% increase in the subjective quality of their sleep. Little attention is paid to sleep architecture and sleep hygiene in the workers' compensation field. But when patients report that they are doubling the number of hours they are sleeping, it naturally translates into an environment where their depression, anxiety, PTSD and pain will improve, not to mention the underlying physical ailment driving their workplace injury.

As a result of these findings, we concluded that the Vx program - combining VR Therapy plus counseling - appears to provide meaningful reductions in pain and opioid use while improving the psychosocial aspects of trauma and pain, such as sleep, behavior, and physical activity.

Why Virtual Reality by Itself Isn't Enough 

Virtual reality has been explored for health care purposes for decades. Three factors are making it so impactful now:

Consider the mindset of a typical injured worker, someone who is depressed and isolated and removed from their familiar world. Imagine if you could allow that injured worker to disappear into a virtual world. They could leap down the rabbit hole for situational relief but not develop the skills necessary to achieve long-term healing. Combining that powerful escape mechanism with the guidance provided by a behavioral health specialist allows the patient to traverse their injury - both physical and psychological- without getting lost down the rabbit hole.

Moving Beyond Drugs and Surgery

Until now, the primary way to treat people with chronic pain or the effects of trauma was to use a biologically focused regimen of drugs, surgery, or a combination of both. Now we understand that targeted therapy using virtual reality and customized coaching can help the brain override the experience of pain, anxiety, and depression, without the potential dangers of drugs or surgery. 

The impact of the virtual reality experience is supported by the Gate Control Theory of pain, which posits that alternative stimuli can reduce the intensity of physical pain by blocking pain messages at nerve gates in the spinal cord. 

In essence, Vx Therapy has the ability to reprioritize the signals we are processing in our brains to promote long-term resiliency in patients.

Who Pays for This New Therapy? 

As with any breakthrough solution, payment for these services is key to widespread adoption. Reimbursement for Vx Therapy is expanding among payers who recognize its value, especially when comparing it to the cost of prescription drug addiction, ongoing and even lifetime treatment, and/or additional surgeries that may not work. It's especially gaining traction within workers' compensation, where most injuries involve pain that, left untreated, can become long-term and expensive cases. It is important that a physician and or medical group partners with an experienced Vx provider who can work with them to ensure appropriate coding and reimbursement.

A New Model for Workplace Trauma

The combination of virtual reality and behavioral coaching within the Vx Therapy model activates the bio-psycho-social model for healthcare, first described by Dr. George Engle in 1977. So much of modern healthcare is focused on the biologic or physical aspects of disease. Now, the confluence of guided technology with behavioral coaching allows clinicians to engage and address the patient's underlying psychologic and social factors.  

The timing of this solution corresponds to the growing awareness of the role of behavioral health and recovery. The Orthopedic Forum recently published an article trying to understand and address the psychosocial determinants of health that derail orthopedic procedures. Many medical groups are trying to address this very topic. Vx Therapy has leaped to the forefront as a useful tool in addressing these silent aspects of patient care.

About the Author:  Gerry Stanley, M.D., is Senior Vice President and Chief Medical Officer for Harvard MedTech. For more information, visit www.Harvardmedtech.com.

Value-Based Care and Care Coordination: Five Key Takeaways from WakeMed Key Community Care and UC San Diego Health

By Claire Thayer, April 12, 2022

Healthcare organizations face increasing pressures to meet demands of population health and effective care management.  Recently, we hosted a panel discussion webinar, co-sponsored by MCG Health, that identified some of the challenges to delivering value-based care and how providers are leveraging MCG Health solutions for care coordination to develop high-quality care programs.

We caught up with speakers Lindsey Pierce, MSN, RN, CCN, Assistant Director, Population Health UC San Diego Health and Kathryn Tarquini, PhD, RN, CCM, Director, Clinical Services, WakeMed Key Community Care on five key takeaways:

1. How did COVID-19 impact your organizations?

According to the CDC, an estimated 41% of US adults with one underlying medical condition avoided seeking care in 2020. This number jumps to over 50% for people with two of more underlying medical conditions. The COVID-19 pandemic is at least partly to blame for these gaps.

Lindsey Pierce: During the pandemic, we saw that patients were either delaying care or switching over to telehealth visits, and they weren't being screened as adequately. Patients were also very scared and often socially isolated, so there was a further need to use MCG psychosocial assessments to address these new gaps. Like so many organizations, we also had issues with staffing. Nursing students were unable to graduate at a time when we needed nurses, so we took a twofold approach, and we started a nursing student clinical program with our population health team who contacted patients during this time.

Amid the pandemic, we were also starting new programs and making changes to better serve our patients, and it was difficult to get everyone aligned around the needed cultural change. This is something that takes time and it's important to remember to communicate the ‘why’ behind value-based care and make sure that your team understands it. Starting out, it took a little bit of time even for providers to understand that our care managers are part of the care team and we're here to help them. Using physician champions and patient advocates helped to break down those barriers, build rapport across the teams, and now every provider wants our team involved in the patient’s care.

Kathryn Tarquini: One of the challenges we faced was launching a renewed service line - new teams, models, platforms, and tools - in early 2020, alongside the start of a pandemic. We learned to leverage our strong foundation built on the mission and vision of the ACO and the care management model. This meant we had to learn to engage virtually and build and strengthen relationships that way, using multimodal messaging to educate partners and providers about our service lines.

We also listened to what providers and practices were experiencing and needed, especially around the pandemic with things like vaccinations and other care interventions so we could provide solutions to address them when possible. Our technology platform and tools allow for transparency of our care management work, which also helped.

2. How is the transition to value-based care affecting your organization?

Lindsey Pierce: Overall the transition to value-based care has been a tremendously positive impact for UC San Diego Health (UCSD). It's allowed us to help drive some cultural changes that really benefit our patients, and it also gives us the opportunity to generate some revenue or share savings. We found that population health services have been at the forefront for helping to drive cultural change in strategy for value-based care, and we see that for interdisciplinary teams risk stratification and utilization oversight are essential to the success of the care program.

We began in 2016 as the organization started to shift towards growing our value-based contracts. We started in Medicare Shared Savings about three years ago and it helped us to expand and grow our network within San Diego, and we now have around 60% of insured lives under a value-based care arrangement. Before this shift, UCSD was performing significantly higher than the national average on hospital admissions per thousand. Over our three-year journey of aligning workflows, integrating technology, and improving processes, we’ve really been able to bring down avoidable hospital admissions to considerably below the national average.

For organizations who are starting out on this journey, it can seem like a difficult transition going from fee-for-service to value-based care. But at its core value-based care is simple, it's quality divided by cost, and this helps support high quality and cost effective care delivery. Through our population health services, we’re able to provide wrap around services to our patients and that helps us to support high quality of care. I do think we'll see this more in the future in healthcare in the coming years and it’s something that I'm excited to be a part of.

Kathryn Tarquini: WakeMed Key Community Care is an ACO formed in 2014 as a joint venture between WakeMed Health and Hospitals and the Key Physicians Group of independent physicians in the Raleigh, North Carolina area. These organizations came together because they realized the importance of delivering high quality care in a value-based care model. Since the ACO was formed eight years ago, our primary care physicians have come to understand the value of value-based care. They’re now highly experienced and have become strong advocates for this model. In 2020, we brought all population health services in-house and this resulted in the formation of new centralized teams for care management – which is when we began using MCG and Arcadia for our care management needs. This has also helped us to provide higher quality care. The overall effect on the organization is based on the results that we’ve seen in quality, achieving and exceeding quality measures, being able to provide coordinated care, and using tools to proactively care for patients. Currently, there are also a variety of population health and quality initiatives within many departments of the hospital system that are value-based, such as hospital or home and navigator programs. We're working together to align some of these initiatives and connect the leaders to more formally collaborate and create some synergy for greater success. 

3. What role have your technology partners played in supporting your transition to value-based care?

Kathryn Tarquini: Our primary partners that have made our program successful are MCG and Arcadia. These two partners have been critical to creating a strong foundation, and there's a lot of synergy that comes from the alignment and integration of these two. We use MCG guidelines for clinical decision support integrated into Arcadia’s Care management platform to document, track, and manage the care management work and the care managers’ workload – this is at the core of what we do with care management.

Arcadia also provides for our data analytics and management system and allows for data exchange with each other. We have close to 20 different EMRs in our ACO and so it collects and exchanges data with the EMRs to provide proactive tools. For example, a pre-visit planning tool to proactively manage risk and a predictive analytics tool using data from claims, the EMR and census data to identify those patients who are most likely to benefit from care management. The Arcadia platform also provides a way to see the status of quality measures – specifically which quality measures are completed and which ones have a gap – so that the practices can proactively address those by reaching out to patients. It promotes care coordination with the providers and the practice partners by allowing all members of the health care team to view all aspects of the care management process in real time.

The partnership with MCG supports the team with accurate and efficient assessment tools that are easy to read and follow, written in a conversational tone, and with many evidence-based assessment options to choose from. Using MCG also allows us to have standard work at the point of care, and this is especially helpful for our team with diverse experience and expertise. We have a multidisciplinary team of RNs and LCSWs, and what we call case management representatives. Using MCG ensures that everyone is deploying the evidence-based guidelines consistently, which leads to an efficient workflow and positive work experience. 

Lindsey Pierce: It’s important to have partners that understand your organization’s vision and provide tools that allow the team to be organized, efficient and perform at the top of their clinical license. In 2021, we integrated MCG care guidelines into Epic Healthy Planet, and our team was involved from the very beginning. We had super users to make sure that the product worked efficiently. We also have health coaching through text message and remote blood pressure monitoring, so we've created really nice wrap around service for our patients.

With MCG’s partnership, we refined and made sure the workflows were seamless, and it was great from a patient perspective as well. It was an absolute journey, but one of the things we always look for, whether it's the community partner and affiliated provider or vendor, it's making sure that you have a partner who's willing to work with you and reach the ultimate goal and is willing to adapt and change - in healthcare you have to be adaptable and willing to adjust as needed. We found that really great partnership with MCG. We got help and support every step of the way with our Epic super users and from our team who were working on integrating the assessments. In 2024, we're hoping to get population health accredited through NCQA, and I think that will be very well supported based upon the integration of MCG’s assessments. Our text-based health coaching platform also uses MCG’s education materials, so that's fantastic because the patients are hearing the same information consistently whether it's through the text messaging program or if we mail our educational materials. Building strategic partnerships with community organizations, network-affiliated providers, or vendors, it's really important that all are aligned to avoid duplication of services, waste, and coordinate a really seamless experience for our patients. That's something that we've certainly found through the relationships that we've developed with MCG and our other partners.

4. In what ways has predictive analytics helped your organization to improve patient outcomes?

Lindsey Pierce: It’s important to have data analytics that identifies gaps in care opportunities, performs risk stratification and identifies patients most likely to benefit from the program, and turns patient clinical data into actionable information. I think oftentimes as we enter into more value-based care contracts, each will have nuances of the data analytics they're looking for. If you can synthesize down to one overarching goal, this can help to simplify a target for your care team, and that way your team members and providers aren't feeling confused about what they're working towards. We've done that with UC San Diego Health - simplified to just a few simple goals - and we apply them to all of our value-based care agreements and our team is really clear on what we're working towards. They're easy to measure, and it gives us a good place to work on process improvement. We focus primarily on one goal that's lowering all costs: hospital admissions per thousand. We do this because it's very well-defined, easy to measure, and is a metric where our team can make a direct impact. There might be some goals that you maybe don't have great data analytics on; even though it might be a good goal, if you can't share the outcomes, that can make that goal really difficult to work towards.

Kathryn Tarquini: We use data analytics in real-time and just-in-time opportunities to optimize care and proactively manage risk to drive population health management, and predict which patients are most likely to benefit from care management services. One tool that our practices use is the ‘pre-visit planning tool,’ which helps the care team identify quality care gaps and risk coding opportunities just before an office visit. So far, this has helped us achieve exceptional quality scores and lower readmission rates across numerous payers, and we’ve been able to distribute shared savings to participating providers each year. For example, between 2016 and 2019, we distributed nearly $120 million in shared savings from BCBSNC contracts alone.

5. What are some of the major milestones, key players, and successes you’ve seen implementing enterprise-wide value-based care model?

Lindsey Pierce: Key milestones were the development of our community network (community partnerships), growing our team and getting our workflows to be standards-based, along with integration with telemedicine to extend our reach without adding FTEs. We needed involvement from every level, physician champions, leadership, great vendors that can address gaps, and care managers. We found that having solid relationships with our network is one of the first steps we needed to take, and it was really important for us to regularly meet and facilitate goal alignment with that network. That way we were able to share performance milestones and make sure that every provider within the network understood the benefits and also the potential risk. We really focus on having our care team members work to the top of their licensed scope of practice and we also want to give them the tools to have a direct impact on process improvement for our team. We sent them all to LEAN 6 Sigma training and this just helps the team to understand the tools and resources on how to create change as you work towards standardized work in a new program. We joke all the time on our team that the only thing that's consistent is change because we're continually refining our workflows to be lean and patient-centered.

Kathryn Tarquini: There are two main factors that contribute to our success. The first is our providers, and the fact that we’re a physician-led ACO. Our providers are experienced advocates for value-based care – and we have strong relationships with them and their practices. Our model places the patient/PCP relationship at the core of our work. Providers review patients who've been identified for care management by our predictive analytics, and when possible, they alert patients of our pending outreach.

Another factor contributing to our success is the compassionate and highly-skilled care management team we’ve assembled. We help them have a positive experience, professional fulfillment, and joy through this work by equipping them with MCG and other tools, educating them about strategies, skills and trends, and we problem-solve together. By creating a work environment that focuses on continuous quality improvement, fosters collaboration and innovation, and where it's safe to learn and grow from opportunities, we’re able to fulfill our mission and deliver timely, high-quality care to our patients.

We've been seeing upwards of 50-70% engagement with patients through care management, and we have numerous patient stories demonstrating how the team has been able to make a difference in our patients’ lives. We decided last year to reinvest shared savings to provide actual solutions to identify social determinants of health (SDOH)-related barriers. We've been excited to launch two initiatives this year, including a rideshare for transportation support, and a meal service for delivering medically-tailored meals to patients’ homes. We are really looking forward to seeing some of the specific examples and impact that these and other interventions are having on our patients’ health and their health outcomes.

If you missed this informative webinar, we invite you to watch this short recap video here. Additionally, below is a list of webinar supplemental material that may interest you: 

MCG White Paper. Populations at Risk: Optimizing Post-Acute Care Management

On-Demand Physician Leader Webinar Series. Populations at Risk: Optimizing Post-Acute Care Management

MCG White Paper. Population Health: Engaging Patients to Improve Healthcare Outcomes

The MCG Guide to Efficient Care Coordination & Patient Throughput

Developing Excellence in Primary Care

By Dr. Seleem R. Choudhury, October 13, 2021

Nearly half of all Americans suffer from at least one chronic disease, and that number is growing (American Association of Retired Persons; Fried, 2017; Tinker, 2017).  Chronic diseases—including cancer, diabetes, hypertension, stroke, heart disease, respiratory diseases, arthritis, obesity, and oral diseases—can lead to hospitalization, long-term disability, reduced quality of life, and death.  Additionally, chronic diseases often require a long period of supervision, observation, or care (Rothman, & Wagner, 2003). To make matters more complicated, many patients have multiple morbidities, creating particular challenges for healthcare providers (Braillard, Slama-Chaudhry, Joly, Perone, & Beran, 2018).

As Reynolds, et al, explain in their 2018 article, “the defining features of primary care (including continuity, coordination, and comprehensiveness) makes this setting suitable for managing chronic conditions” (Reynolds, Dennis, Hasan, Slewa, Chen, et al., 2018).  High-performing primary care teams keep the “quadruple aim” of primary care—enhancing the care experience, improving the health of the population, reducing costs, and improving the work-life of the team—at the forefront of their work (Haverfield, Tierney, Schwartz, Bass, Brown-Johnson, et al, 2020). Studies repeatedly bear this out, demonstrating that an integrated approach with an aim to improve the quality of life of patients—as well as those caring for them—can enhance chronic disease outcomes and management.  As the healthcare industry continues to evolve, it cannot afford not to invest in primary care.

Bodenheimer’s Building Blocks

Current literature discussing characteristics of best primary care practices supports three well-proven methods:

1. Patient-Centered Medical Home (PCMH) standards from the National Committee on Quality Assurance (Hahn, Gonzalez, Etz, & Crabtree, 2014),
2. the Peterson Center on Health Care’s “America’s Most Valuable Care: Primary Care” (Peterson Center on Health Care, & Stanford Medicine Clinical Excellence Research Center, 2014), and
3. the Building Blocks framework commonly known as Bodenheimer’s Building Blocks. (Bodenheimer, Ghorob, Willard-Grace, & Kevin Grumbach, 2014).

Each of these models is similar, often reinforcing one another yet each with its unique benefits.  Inspired by a conversation with Tanya Kapka, MD, MPH, FAAFP, a leader in healthcare transformation, this article will focus on four specific areas within Bodenheimer’s Building Blocks: Engaged Leadership, Data-Driven Improvement, Empanelment, and Team-Based Care (see graphic). These four blocks are foundational in the quest for clinical excellence in primary care.

 

Block 1: Engaged leadership

One of the most commonly cited reasons for failed PCMH change efforts is a lack of leadership support (Qureshi, Quigley, & Hays, 2020).  Active, engaged, supportive leadership is not a new necessity, nor is its importance limited to healthcare. The role is critical in Comprehensive Primary Care transformation (Altman Dautoff, Philips, & Manning, 2013). Leaders are the ones who drive and inspire change.  Without a leader to champion the change and navigate teams through its complexities, then the aspiration for developing excellence will never be attained.

Block 2: Data-Driven Improvement

 Evidence of what constitutes quality care is always evolving; this is a good thing for patients and the health of our communities. This necessitates that providers regularly re-evaluate and change their practices in order to stay current (Agency for Healthcare Research and Quality, 2018).  This, of course, assumes that this evidence will lead to improved patient care and outcomes.  The challenge is typically about finding a balance regarding data. When making choices about care practices, too much data becomes daunting, too little leads to uncertainty. The goal is to hit a sweet spot where all members of the team feel like they have enough data to make informed decisions to enhance clinical excellence (Coppersmith, Sarkar, & Chen, 2019).

Block 3: Empanelment

Empanelment is a foundational strategy for building or improving primary health care systems by linking patients to a primary care provider. This strategy is a “critical pathway” for achieving optimal outcomes, effective universal health coverage, and population health management (Bearden, Ratcliffe, Sugarman, Bitton, & Anaman, 2019). To effectively promote patient engagement or, in some circumstances, patient re-engagement, the care team must remain coordinated, data must be up to date, and patient coordination and communication consistent. These elements are essential for excellence in primary care (McGough, Chaudhari, El-Attar, & Yung, 2018).

Block 4: Team-Based Care

The concept of a team approach in primary care is not new. However, it is often assumed that it is occurring. And though team-based care may occur, few organizations effectively and regularly evaluate its success and consider how their care teams might become even higher-performing.  Namely, organizations should assess whether the required knowledge, skills, and abilities are present on the team (Larson, 2009), the team members are in their optimal roles (Luig, Asselin, Sharma, & Campbell-Schererand, 2018), and the team is striving for improvement together (Shukor, Edelman, Brown, & Rivard, 2018).

The identity of High-Quality, Comprehensive Primary Care, mid- and post-COVID

The past year and a half of providing care in a pandemic has starkly highlighted the importance of primary care. “During a pandemic, primary care is the first line of defense. It is able to reinforce public health messages, help patients manage at home, and identify those in need of hospital care” (Krist, DeVoe, Cheng, Ehrlich, & Jones, 2020).

At the onset of the pandemic, primary care was forced to transform from a person-visiting-a-clinic modality to a telemedicine program (Jaklevic, 2020). Interestingly, healthcare systems and primary care practices had tried to coax this change prior to the pandemic, but many experienced resistance.  The reasons for this resistance were complex and varied, yet literally overnight these changes occurred (Nittari, Khuman, Baldoni, Pallotta, Battineni, et al, 2020; Kaplan, 2020). Some would say the change occurred too quickly.

Initially, these programs demonstrated success with continuity of care, improved or plateaued outcomes, and reimbursement from payers (Rosen, Joffe, & Kelz, 2020). However, cracks present within team cohesion before the pandemic combined with overnight forced change highlighted vulnerabilities and tension in teams that were inadequately lead, staffed, managed, and skilled. It is evident that while teams with the aforementioned gaps struggled or continue to struggle today, high-performing teams pre-pandemic continued to transition successfully (Contreras, Baykal, & Abid, 2020).

The characteristics of high-quality primary care in the midst of COVID and post-COVID requires providers to get back to basics. Providers need to set their sights on the quadruple aim of enhancing the care experience, improving the health of the population, reducing costs, and improving the work-life of the team, as well as ensuring that the foundational building blocks of the Bodenheimer model are firmly in place.  

Health systems must invest in the primary care infrastructure. This begins with team leadership that endorses engagement and satisfaction, sufficient and easily-accessible data, the appropriate application of a patient panel that promotes appropriate ratio of patient acuity that leads to population health management in and out of the clinic, and a fully staffed team that fosters cohesion, camaraderie, and continual desire to improve.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com

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Safety Net Medical Home Initiative. Altman Dautoff D, Philips KE, Manning C. Engaged Leadership: Strategies for Guiding PCMH Transformation. In: Phillips KE, Weir V, eds. Safety Net Medical Home Initiative Implementation Guide Series. 2nd ed. Seattle, WA: Qualis Health and The MacColl Center for Health Care Innovation at the Group Health Research Institute; 2013. https://www.safetynetmedicalhome.org/sites/default/files/Implementation-Guide-Engaged-Leadership.pdf

Shukor, A. R., Edelman, S., Brown, D., & Rivard, C. (2018). Developing community-based primary health care for complex and vulnerable populations in the Vancouver Coastal Health region: HealthConnection Clinic. The Permanente Journal, 22. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6141648/

Tinker A. How to Improve Patient Outcomes for Chronic Diseases and Comorbidities. [(accessed on 30 December 2017)]; Available online: http://www.healthcatalyst.com/wp-content/uploads/2014/04/How-to-Improve-Patient-Outcomes.pdf

Optimizing Post-Acute Care Management: Four Key Takeaways from MCG Health Experts

By Claire Thayer, August 4, 2021

Recently, MCG Health’s Suzanne Doran, Managing Editor and Emily Ferguson, Associate Managing Editor, joined us in a webinar discussion on ways to engage patients, identify social determinants of health, and ultimately improve health outcomes while managing costs.  We caught up with Suzanne and Emily on four key takeaways:

1. Do you have more than one assessment to address Social Determinants of Health?

Suzanne Doran and Emily Ferguson: MCG Health currently has 9 assessments that address Social Determinants of Health. These assessments screen for needs such as food insecurity, homelessness, and social support. Based on individual needs, a plan of care is then generated to assist the patient and care manager address any barriers to care.

2. How are Accountable Care Organizations utilizing evidence-based care guidelines to help improve quality of care for their patients?

Suzanne Doran and Emily Ferguson: Accountable Care Organizations are using evidence-based care guidelines for coordinating care for patients across care settings, including chronic disease management and transitions of care. Evidence-based interventions allow providers to focus on giving their patient the care they need, at the right time. Patient care and quality are improved as a result of evidence guiding practices to improve adherence to preventative services and reduce complications associated with chronic disease. Here are links to some real-world case studies of ACOs using evidence-based guidelines and achieving success: Delaware Valley ACO and UnityPoint Accountable Care.

3. Can you share more information on how you approach building a plan of care for patients?

Suzanne Doran and Emily Ferguson: Care planning is individualized to the patient’s specific care needs and goals in order to incorporate the patient’s personal preferences and account for the patient’s unique medical and psychosocial situation. From the individualized self-care plan, case managers can provide the patient with specific and appropriate education, support, and timely follow-up in a manner that adapts to the patient’s capabilities and needs, versus a general plan that may overwhelm the patient because it’s too much information provided too soon:

4. Tell us more about the teach-back method and best practices for initiating patient understanding using this technique.

Suzanne Doran and Emily Ferguson: The teach-back method clarifies the learner’s understanding of instructions by having the patient give a return demonstration or vocally repeat (in his or her own words) what the patient just learned to assure comprehension of material.  An example of teach-back could be having a patient demonstrate how to administer self-injections by using an insulin syringe to inject an orange. This method has been shown to be effective in discharge planning as well as the patient’s vocalization of what medications they should take, when their next appointment is, or warning signs of a problem to their case manager.

If you missed this informative webinar presentation, Populations at Risk: Optimizing Post-Acute Care Management, we invite you to watch the full On-Demand webinar video or short webinar re-cap video.

COVID Wars: Attack of the Variants

By Dr. Seleem R. Choudhury

As an increasing portion of the global population continues to receive the COVID vaccine, public health experts, government officials, and healthcare professionals continue to monitor variants emerging around the world. With recent spikes of infections in India that have brought devastating death tolls and an overwhelmed healthcare system, it is clear that reaching the “end” of COVID and moving forward into a sense of normalcy will not be a straightforward process.

What are mutations?

Mutations are tiny errors in our genome sequencing, and are often drivers within evolution (Carlin, 2011). As a child I was occasionally naughty, and as punishment I recall having to write lines. I would have to write and repeat whatever words were deemed necessary for me to learn my lesson and change my behavior. However, as I wrote the lines, slight changes in my handwriting occurred on a word here or a letter there. Though the message remained the same, these accidental small changes caused some lines to look different.

All viruses evolve and change over time.  This allows a virus to not only survive, but thrive (Tajouri, 2020).  Just like my handwriting, these changes, or mutations, happen accidentally and cause the virus’s genome sequence to look different. When a virus undergoes one or two mutations, this is called a “variant.”  Occasionally, the virus will mutate in such a way that the virus can copy itself more efficiently or enter our cells more easily (Cleveland Clinic, 2021). With more than 141 million infections worldwide at the time of this publication—a number that continues to climb—the virus has ample opportunity to mutate.

Current COVID mutations

Currently, there are many different versions, or variants, of COVID circulating. As with any virus, most variants come and go; others persist but don’t spread widely among the population. However, several prominent variants present themselves and gain notoriety, and eventually cause concern.

It is important in any discussion of variants of this virus to make clear that while variants are referred to as “the U.K. strain” or “South African variant,” the actual origin of any given mutation is difficult to prove, and individual countries should not be blamed for variants bearing their name (Ellyatt, 2021).

The World Health Organization (WHO) calls the variants in the graphic above “variants of concern,” signifying “strains that pose additional risks to public health” (Gale, 2021). Recently joining the list of variants of concern is the Indian variant called B1617 (Roberts, G., 2021).  The WHO has also coined the term “emerging variants of interest” for mutations that “warrant close monitoring because of their potential risk” (Gale, 2021).

These variants of concern are worrisome for varying reasons and degrees, but are primarily related to ease of transmission, severity of the illness for those infected, the likelihood the variant will infect people who have already contracted COVID, potential impact on vaccination efficacy, and the prevalence of the mutation in the population (Gale, 2021; Centers for Disease Control and Prevention, 2021).

Tracking these variants is vitally important in order to improve the design of vaccines to be effective against new variants. However, changes to those vaccines take several months, and are a mid- to long- term solution. More pressing in the short term is the increase of sequencing efforts, which experts have criticized for being “small and uncoordinated,” in order to “adequately track where variants are spreading and how quickly” (Zimmer, 2021; Zimmer, & Weiland, 2021).

The vaccine and mutation

There is anxiety regarding the unpredictability of COVID variations and the efficacy of the vaccine against such mutations. While data on the Indian variants is scarce at the time of this article’s publication, a recent study of people worldwide who had received the Pfizer vaccine, including 44,000 people in South Africa who were predominantly exposed to the B.1.351 variant, found that the vaccine was 100 percent effective against severe disease and death (Business Wire, 2021). Additional Pfizer data showed that the vaccine is “97 percent effective against symptomatic COVID-19, hospitalizations, and death” (Business Wire, 2021). The vaccine also “held up against the B.1.1.7 variant” (Ries, 2021). The Moderna, AstraZeneca, and Johnson & Johnson data demonstrated similar levels of effectiveness (Business Wire, 2021; Laguipo, 2021; Deutsche Welle, 2021). 

There are also ongoing trials with unpublished data that demonstrates a booster shot given to previously vaccinated individuals improved the antibody titer responses against several variants of concern (Hippensteele, 2021). Moreover, leading pharmaceutical companies have discussed adapting the vaccine to deal with variants. Recently the first “tweaked vaccine” announced by Moderna successfully neutralized several variants in lab trials (Boseley, 2021).

In short, vaccines offer effective protections against the variants of concern, especially in terms of preventing serious symptoms and death (Ries, 2021).  The World Health Organization states that the COVID “vaccines that are currently in development or have been approved are expected to provide at least some protection against new virus variants because these vaccines elicit a broad immune response involving a range of antibodies and cells.  Therefore, changes or mutations in the virus should not make vaccines completely ineffective (World Health Organization, 2021).”

The future of the virus

One of the challenges for public health experts is understanding what the end of the virus will look like and, furthermore, how it will be measured: daily deaths, hospital admissions, vaccination rates, percentage of the population who have been vaccinated, etc. Regardless of the measurements used, variants have a major impact on the endpoint. Rather than widespread, rapid transmission of the virus, we may see more “sporadic and localized” outbreaks (Joseph, & Branswell, 2021). 

Vaccine hesitancy around the globe, in addition to the emergence of new variants, makes herd immunity unlikely (Aschwanden, 2021). However, there is growing evidence that vaccines not only protect people from contracting COVID, but also reduce transmission of the virus (Joseph, & Branswell, 2021).  Even so, the probability exists that the only way to mitigate outbreaks is with regular booster vaccines due to more transmissible future mutations of the virus (Faulconbridge, 2021).  Though COVID will not be eliminated in the near future, there is a strong likelihood that it can be managed.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com    

Resources

Aschwanden, C. (2021). Five reasons why COVID herd immunity is probably impossible. Nature.

Boseley, S. (2021). Tweaked Moderna vaccine ‘neutralises Covid variants in trials.’ The Guardian.

Business Wire (2021). Moderna COVID-19 Vaccine Retains Neutralizing Activity Against Emerging Variants First Identified in the U.K. and the Republic of South Africa. Business Wire.

Business Wire (2021). Pfizer and BioNTech Confirm High Efficacy and No Serious Safety Concerns Through Up to Six Months Following Second Dose in Updated Topline Analysis of Landmark COVID-19 Vaccine Study. Business Wire. 

Business Wire (2021). Real-World Evidence Confirms High Effectiveness of Pfizer-BioNTech COVID-19 Vaccine and Profound Public Health Impact of Vaccination One Year After Pandemic Declared. Business Wire.

Carlin, J. L. (2011) Mutations Are the Raw Materials of Evolution. Nature Education Knowledge 3(10):10.

Centers for Disease Control and Prevention (2021). Global Variants Report. Centers for Disease Control and Prevention.

Centers for Disease Control and Prevention (2021). SARS-CoV-2 Variant Classifications and Definitions. Centers for Disease Control and Prevention.

Cleveland Clinic (2021). What Does It Mean That the Coronavirus Is Mutating? The Cleveland Clinic.

Deutsche Welle (2021). WHO experts advise J&J jab for coronavirus mutants. DW.

Ellyatt, H. (2021). Coronavirus mutations: Here are the major Covid strains we know about. CNBC.

Faulconbridge, G. (2021). Exclusive: Regular booster vaccines are the future in battle with COVID-19 virus, top genome expert says. Reuters.

Gale, J. (2021). Why the Mutated Coronavirus Variants Are So Worrisome. Bloomberg Quint.

Hippensteele, A. (2021). Moderna Releases Positive Initial COVID-19 Vaccine Booster Data Against Variants of Concern. Pharmacy Times.

Joseph, A., & Branswell, H. (2021). The short-term, middle-term, and long-term future of the coronavirus. Stat News.

Laguipo, A.B.B. (2021). Oxford-AstraZeneca vaccine effective against B.1.1.7 SARS-CoV-2 variant. News Medical.

Ries, J. (2021). COVID-19 Vaccines Are Still Effective Amid Rising Number of Variants. Healthline.

Roberts, G. (2021). Everything we know about the Indian COVID-19 variant so far. World Economic Forum.

Roberts, M. (2021). What are the Indian, Brazil, South Africa and UK variants? BBC News.

Tajouri, L. (2020). What is a virus? How do they spread? How do they make us sick? The Conversation.

Woodward, A. (2021). One chart shows how well COVID-19 vaccines work against the 3 most worrisome coronavirus variants. Business Insider.

World Health Organization (2021). Tweet: Will #COVID19 vaccines work against new virus variants? Twitter: 1/19/2021.

Zimmer, C., & Weiland, N. (2021). C.D.C. Announces $200 Million ‘Down Payment’ to Track Virus Variants. New York Times.

Zimmer, C. (2021). U.S. Is Blind to Contagious New Virus Variant, Scientists Warn. New York Times.U.S. Is Blind to Contagious New Virus Variant, Scientists Warn

Nanoparticles On My Mind

By Kim Bellard, March 24, 2021

Nanoparticles are everywhere! By that I mean, of course, that there seems to be a lot of news about them lately, particularly in regard to health and healthcare. But, of course, literally they could be anywhere and everywhere, which helps account for their potential, and their potential danger.

Let’s start with one of the more startling developments: a team at the University of Miami’s College of Engineering, led by Professor Sakhrat Khizroev, believes it has figured out a way to use nanoparticles to “talk” to the brain without wires or implants. They use “a novel class of ultrafine units called magnetoelectric nanoparticles (MENPs)” to penetrate the blood-brain barrier.

Professor Khizroev has been working on the technology for over a decade, and has received funding from Darpa as part of its Next Generation Non-surgical Neurotechnology (N3) program (also known as BrianSTORMs), the goal of which is “to develop high-performance, bi-directional brain-machine interfaces for able-bodied service members.” The team got Phase II funding last November in order to build working devices.

“Right now, we’re just scratching the surface,” Dr. Khizroev says. “We can only imagine how our everyday life will change with such technology.” Some of what he does imagine, though, is:

We will learn how to treat Parkinson’s, Alzheimer’s, and even depression. Not only could it revolutionize the field of neuroscience, but it could potentially change many other aspects of our health care system.

Lest anyone think this is either an easy or a solved problem, Darpa points out: “N3 researchers are working to develop solutions that address challenges such as the physics of scattering and weakening of signals as they pass through skin, skull, and brain tissue, as well as designing algorithms for decoding and encoding neural signals that are represented by other modalities such as light, acoustic, or electro-magnetic energy.”

But that’s not all the nanoparticle news from just this week. In no particular order:

· Researchers from Cleveland Clinic and Chungbuk National University tested a COVID-19 vaccine (on ferrets) using antigens attached to nanoparticles.

· Another research team, from Scripps and Temple, also tested using nanoparticles to deliver antigens for COVID-19, using three self-assembling protein nanoparticle (SApNP) platforms

· A research team at the University of Manchester used nanoparticles to discover previously unseen blood markers: This might allow earlier and more definitive diagnoses of Alzheimer’s.

· A research team at the University of Science and Technology China are testing “acid-responsive nanoparticles composed solely of membrane-disruptive macromolecules” to treat pancreatic cancer.

· Russian and Israeli researchers “have developed hybrid nanostructured particles that can be magnetically guided to the tumor, tracked by their fluorescence and pushed to release the drug on demand by ultrasound.

· Another Chinese research team is using nanoparticles to deliver antimicrobial peptides (AMPs) for the treatment of deep infections.

· An international team of researchers assert: “The potential of nanotechnology in fighting this deadly disease [COVID-19] has not only been realized in context of developing a nano-vaccine but by delivering the nano-based anti-viral agents.”

· Spanish researchers have been able to observe autonomous nanobots in vivo — inside the bladders of a living mouse — using Positron Emission Tomography (PET).

Again, that’s just this week, and only health-related nano news.

I’m no expert on nanoparticles, or any kind of nanotechnology. I understand that the technology has a long way to go yet. I realize that there are risks, included unintended health effects, to using nanotechnology. All that being said, too much of our health treatments are “shotgun” approaches that often cause as much collateral damage as beneficial impacts. Nanoparticles offer the promise of “rifle” approaches that offer precise targeting — like using smart bombs instead of carpet bombing.

Within my lifetime, and hopefully within the decade, we’ll have nano-delivered drugs that will greatly increase their efficacy. We’ll have nanobots swimming around in us, for a variety of therapeutic purposes. And we should have nanoparticle mediated brain-computer interfaces too.

Exciting stuff.

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

A global pandemic calls for global response: The importance of equitable global vaccine distribution

By Dr. Seleem R. Choudhury, March 11, 2021

According to the United Nations, 75% of all COVID-19 vaccinations have been administered among just 10 countries, while 130 countries have not received even a single dose of the vaccine, as of mid-February 2021 (Al Jazeera, 2021). Global health and political leaders have condemned this unbalanced distribution of vaccines and are taking action to ensure vaccine equity. Dr. Tebros Adhanom Ghebreyesus, director-general of the World Health Organization (WHO), said in a recent address, “The world is on the brink of a catastrophic moral failure—and the price of this failure will be paid with lives and livelihoods in the world’s poorest countries” (United Nations, 2021).

Vaccine equity is the global intent to ensure that all have fair access to the COVID vaccine in order to overcome the virus that is threatening every nation. Unless the roadblocks to success for international cooperation on equitable vaccine access and delivery are removed, the world risks prolonging the pandemic by creating a two-tier vaccine system—the haves and the have-nots, the eternal battle of rich versus poor. Many rich nations have set the lofty goal of vaccinating at least 80% of their populations. Even if these countries were to achieve this goal, without the equitable distribution of vaccines to poorer nations, they run the risk in a global economy of contracting a COVID-19 variant more immune to the vaccine and bringing it back to their own nation, thus perpetuating the pandemic.

The movement to increase the distribution of vaccines to poorer nations has gained momentum under WHO’S 100-day challenge (United Nations, 2021). In February 2021, G7 leaders pledged to intensify cooperation on COVID-19 and increase their contribution to vaccine-sharing initiative COVAX (Parker, Williams, Peel, & Chazan, 2021). As the WHO’s January 2021 Vaccine Equity Declaration states:

“We must act swiftly to correct this injustice. Multiple variants are showing increased transmissibility and even resistance to the health tools needed to tackle this virus. The best way to end this pandemic, stop future variants, and save lives is to limit the spread of the virus by vaccinating quickly and equitably, starting with health workers.” (World Health Organization, 2021).

The data of equity

As of this article’s publication, over two million people have died from COVID-19. As a New York Times article puts into perspective, that is more than the population of the state of Nebraska, and nearly equal to the population of the entire country of Slovenia (Santora & Wolfe, 2021).

Though it has been several months since the first COVID vaccine was administered, the virus continues to spread despite the vaccine, especially in the poorer nations. Vaccine supplies are low due to richer countries purchasing more vaccines than they could distribute in the required time frame.  As a result, some experts predict that many low-income countries may not be able to reach mass immunization until 2024. Worse, some nations may never get there (Safi, 2021).

To support the equitable distribution of the vaccine moving forward, the WHO established the Covid-19 vaccine allocation plan—known as COVAX—at the end of 2020 (World Health Organization, 2020). COVAX’s goal is to ensure that the research, purchase, and distribution of any new vaccine is shared equally between the world’s richest countries and those in the developing world.  According to the WHO, 172 economies are engaged in discussions about participation in the COVAX initiative (World Health Organization, 2020).

The variants

Catalyzing vaccine distribution in poorer countries is essential to prevent the development of new variants of COVID that could cost more lives around the world. It is the natural state of RNA viruses such as the coronavirus to evolve and change gradually. The flu, for example, is an ever-adapting virus, which is why people must receive a new vaccination each year.  Viruses are primed to change, but occasionally a mutation occurs that alters how rapidly the virus spreads, its level of infectiousness, or the severity of the disease (Gray, 2021).

This is the primary concern with new variants of COVID emerging in different countries. The most recent variations of the disease in South Africa and Brazil are concerning epidemiologists as they show signs that the virus may be “adapting to evade immunity in some people” (Gray, 2021).  To stay ahead of the evolution of the virus, scientists are evaluating each new mutation to determine which ones are likely to be most impactful (Callaway, 2020).

We have established that a partially immunized population runs the risk being impacted by variants that are transmitted more easily and are more likely to result in death for those infected with the virus (Toy, 2021).  Embracing vaccine equity is the best solution to guard against this.  If nations insist on focusing only on their own populations, new variants will perpetually threaten them, necessitating changes to the vaccine.  If countries continue to choose not to share, then this ludicrous process starts again.  If everyone has immunity through vaccination, then variants’ effects will be diminished, with virtually no virus circulating or adapting (Toy, 2021).

Next steps

The COVAX initiative is a good start to addressing vaccine equity.  It has gained strength now that the US has joined under its new presidential administration (The White House, 2021). Additionally, at a virtual G7 meeting, leaders pledged $7.5 billion to the WHO-led collaboration (Parker, Williams, Peel, & Chazan, 2021).  This crucial financial backing will allow COVAX to accomplish its aim of securing and equitably allocating 2 billion doses of COVID vaccines, starting with healthcare workers and other high-risk groups as defined by the WHO, by the end of 2021 (Kettler, 2021).

While equitable distribution is being addressed globally, individual nations must also grapple with the challenges of vaccine distribution within their own populations (Liao, 2021).  The WHO has proposed a “Roadmap For Prioritizing Uses Of COVID-19 Vaccines In The Context Of Limited Supply” to aid countries in their own vaccine equity efforts. The Roadmap considers priority populations for vaccination based on epidemiologic setting and vaccine supply scenarios (World Health Organization, 2020).

Summary

Interestingly, several countries are filling the gap created by the United States and the other G7 countries. India, Russia, China and Israel appear to be waging a strategy of soft power towards global health (Mashal & Yee, 2021). It is hard to imagine populations of countries not being grateful to those that help towards timely vaccinations, and it could leave recipients obligated to repay in other ways. This could potentially realign global alliances and change geopolitics.

It is hard to ignore WHO Director-General Ghebreyesus’s concerns about the irreconcilable cost of the moral failure of continued inequitable vaccine distribution.  The world’s poorest countries will be disproportionately affected, and richer nations will continue to have on-again-off-again economies as variants of the virus wreak havoc on the health of their own populations.

The immediate sharing of doses will reduce the chance of ongoing variants and begin to revive the global economy.  The only way to vaccinate the majority of the world’s population with urgency is to do it together.  A global pandemic requires a global neighbourhood philosophy and response with no strings attached.

Read more from Dr. Seleem Choudhury at seleemchoudhury.com  

Resources

Al Jazeera (2021). ‘Wildly unfair’: UN boss says 10 nations used 75% of all vaccines. Al Jazeera.

Callaway, E. (2020). The coronavirus is mutating — does it matter? Nature.

Gray, R. (2021). This is how new Covid-19 variants are changing the pandemic. BBC.

Haseltine, W. (2021). How The Covid-19 Virus Changes. Forbes.

Hernandez, J. (2021). Two Members of W.H.O. Team on Trail of Virus Are Denied Entry to China. New York Times.

Kettler, H. (2021). What is COVAX? Path.

Liao, K. (2021). What Is Vaccine Equity? Global Citizen.

Mashal, M. & Yee, V. (2021). The Newest Diplomatic Currency: Covid-19 Vaccines. New York Times.

Parker, G., Williams, A., Peel, M., & Chazan, G. (2021). G7 leaders vow to boost vaccine supplies to developing world. Financial Times.

Safi, M. (2021). Most poor nations 'will take until 2024 to achieve mass Covid-19 immunisation.’ The Guardian.

Santora, M. & Wolfe, L. (2021). Covid-19: Over Two Million Around the World Have Died From the Virus. New York Times.

The White House (2021). National Security Memorandum on United States Global Leadership to Strengthen the International COVID-19 Response and to Advance Global Health Security and Biological Preparedness. The White House.

Toy, S. (2021). Covid-19 Vaccination Delays Could Bring More Virus Variants, Impede Efforts to End Pandemic. The Wall Street Journal. 

United Nations (2021). WHO chief warns against ‘catastrophic moral failure’ in COVID-19 vaccine access. UN News.

World Health Organization (2021). Call to Action: Vaccine Equity Declaration. World Health Organization.

World Health Organization (2021). COVID-19 Vaccine Equity Declaration. World Health Organization.

World Health Organization (2020). Fair allocation mechanism for COVID-19 vaccines through the COVAX Facility. World Health Organization.

World Health Organization (2020). WHO SAGE Roadmap For Prioritizing Uses Of COVID-19 Vaccines In The Context Of Limited Supply. World Health Organization.

World Health Organization (2020). 172 countries and multiple candidate vaccines engaged in COVID-19 vaccine Global Access Facility. World Health Organization.172 countries and multiple candidate vaccines engaged in COVID-19 vaccine Global Access Facility

Need Care, Should Travel

By Kim Bellard, February 25, 2021

I find myself thinking once more about our inability to distinguish quality in our health care. I live in Cincinnati (OH).  The metro area has five hospital systems. Most Cincinnati residents go their entire lives getting all their medical care here. That’s the problem.

If, for example, someone in Cincinnati had a serious heart issue, he/she/they should really go to The Cleveland Clinic.  It is known worldwide for its cardiac care and is ranked #1 in the country for it by U.S. News & World Report.   No Cincinnati hospital is nationally ranked in this field. 

For that matter, The Cleveland Clinic is top 10 ranked in 11 other adult specialties as well, plus top 50 in two others.  It’s the #2 hospital in the nation overall (The Mayo Clinic is #1).  Frankly, if something is wrong with you, it would seem worthwhile to drive up to Cleveland to get care there.  But most don’t. 

If that drive is too far, you could go to Columbus, which is only about half as far, where The OSU Wexner Medical Center/The James Hospital is nationally ranked in 9 adult specialties, still higher than any Cincinnati hospital.  Again, though, most don’t.

Whatever state/city you live in, there’s probably a similar dynamic.  There may be many reasons why most care remains local.  For one thing, the ratings almost certainly aren’t as accurate as one would like; there is more subjectivity/ambiguity in them than anyone would like.  For another thing, a large chunk of hospital admissions come from emergency room visits, and driving two to three hours to a “better” hospital during an emergency is usually ill-advised.  Travel is a barrier generally.. 

Most importantly, though, most people don’t really understand that there might be differences in the quality of care they might expect from different hospitals.  They might be aware of The Cleveland Clinic’s reputation, or have heard of The Mayo Clinic, but the thought of travelling to either doesn’t occur to most.  People in Cincinnati, like people most places, think the care here is just fine, thank you very much.

For most care, that’s probably fine. But if you need a heart transplant or have a rare form of cancer, you should probably be thinking seriously about travelling. The trouble is that there’s no good way to help us distinguish these situations.  For which cases should I be seriously weighing going up to Cleveland for my care? I don’t know, you don’t know, and even “experts” are likely to disagree. 

What we need is what I’ll call a “quality matrix,” indicating when which type of condition needs what “quality” of care.   It might be based on the potential variation in outcomes patients might face based on using different hospitals/physicians. 

Using the USN&WR system, “low variability” conditions could be treated at any hospital (or outpatient by their physicians), but for “medium variability” conditions patients should consider hospitals that are rated at least “high performing,” and for “high variability” conditions, care should be directed to nationally ranked hospitals. 

I know: we don’t have the data.  We don’t have good data on outcomes for most conditions; we don’t quite understand the interplay between the institutions and the specific clinicians practicing within those institutions (e.g., it’s unlikely that every Cleveland Clinic heart surgeon is better than any Cincinnati heart surgeon).  No patients are the same, outcomes can’t be predicted, and so on. 

In other words, the same excuses we’ve been using for the past fifty years.   

Of course, there would be non-trivial financial implications to such a change.  Frankly, I believe our seeming indifference to actually measuring and acting on quality of care is an overarching problem in our healthcare system.  

I challenge hospitals and health plans to focus on getting patients to the right places for their condition, not just enabling patients’ desire to stay local.  And I challenge more patients to demand better. All politics, as they say, is local, but all health care shouldn’t be. 

This post is an abridged version of the original posting in Medium. Please follow Kim on Medium and on Twitter (@kimbbellard)

Influenza Joins The 1%ers – The One Bit of Good COVID News

By Clive Riddle, February 12, 2021

It’s been widely discussed that influenza spread this flu season is significantly lower, due in great part to COVID-19 induced mask wearing, hand washing, physical distancing and reduced travel by a good portion (but certainly not all) of our population.  

Now that we’re progressing through this influenza season, it’s interesting to do a side-by-side comparison for 2021 vs 2020 as of week five of the calendar year (40 cumulative weeks for the flu season).

Summing up the numbers from the CDC Weekly Surveillance Report totals through the 40^th week of the season for both years, here’s the jaw-dropping difference:

• 2019-2020 Positive Cases through Week 40: 129,997
• 2020-2021 Positive Cases through Week 40:    1,364
• 2019-2020 Flu Test Positivity Rate through Week 40: 17.6% (738,331 tests)
• 2020-2021 Flu Test Positivity Rate through Week 40:   0.2% (593,570 tests)

So this season’s positive cases of influenza are running at 1% of last season!

Comparing the CDC Weekly Surveillance Report charts for these two snapshots in time, stark as the difference appears, actually doesn’t do the comparison justice as the scale for the current season had to be changed for the graph to be readable (the y axis grid for number of positive specimens is in increments of 50 for the 2020-2021 season, vs increments of 2,000 for the 2019-2020 season.)

Monitoring the safety and effectiveness of COVID-19 vaccines

By Dr. Seleem R. Choudhury, January 14, 2021  

Next to clean water, no single intervention has had such a dramatic effect on decreasing mortality as has the widespread introduction of vaccines (Howson, Howe, & Fineberg, 1991). The World Health Organization (WHO) describes immunization as a “key component of primary health care and an indisputable human right,” as well as “one of the best health investments money can buy” (World Health Organization, 2020). Vaccines play a critical role in the prevention and management of the outbreak of infectious diseases.  The rapid spread of COVID-19 during the months-long wait for a vaccine have highlighted their importance to public health. 

If COVID-19 were a Shakespearean play, the administration of the vaccine would ideally be the final act, and widespread adoption and effectiveness, the epilogue. However, just like Shakespeare’s Timon of Athens, this play may be also be left unfinished. According to the WHO, at least 198 COVID-19 vaccines are currently in the development pipeline, with 44 currently undergoing clinical evaluation (2020). National Institute of Allergy and Infectious Diseases Director Anthony Fauci, M.D., recently stated a date to a possible “normal” is tricky at best (McCarthy, 2020). He explains: 

“If the vaccine is reasonably if not quite effective, but not a very large proportion of the population take it, then that would really be unfortunate because it wouldn’t provide that umbrella of protection over the community so that you could feel reasonably certain that when you go to a family function, a wedding, or the like, that there’s not going to be a couple of people in there that are actually infected.”

Continued monitoring: Reasons and methods

The effectiveness of the COVID-19 vaccine to usher in a “new normal” hinges on its widespread administration. Continuous and transparent monitoring is essential to encourage the maximum number of people to choose to be vaccinated.  This article was written fully acknowledging that the SARS-CoV-2 variant exists, yet the implications of the variant remains unclear and the impact upon the vaccines remains unknown (Public Health England, 2020). 

Reasons for monitoring the vaccine

The primary reason for conducting additional vaccine effectiveness assessments is to ensure a vaccine “protects people from getting a disease under real-world conditions, outside of the strict setting of clinical trials” (National Center for Immunization and Respiratory Diseases, 2020). Numerous factors, such as how a vaccine is transported, the method of storage, or even the way patients are vaccinated, can affect a vaccine’s effectiveness in real-world situations.  

Even after administration trials of the COVID-19 vaccine, organizations will continue to monitor longer-term safety and efficacy (Cyranoski, 2020).  Teams of experts will evaluate the effectiveness of the vaccine in real-world conditions, outside of more controlled clinical environments (WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation, 2020).  Furthermore, underlying medical conditions not present in patients who participated in the clinical trials can also change the effectiveness of the vaccine in real-world use, or in groups not included or represented in clinical trials, such as children under 12, or pregnant or lactating women (National Center for Immunization and Respiratory Diseases, 2020).   

Additionally, transparent monitoring will prove essential to improve the public’s trust in the vaccine so that people will choose to vaccinate. Public trust in the storied public health institutions cited above is now deeply compromised. According to recent polls, 62% of Americans worry the U.S. Food & Drug Administration (FDA) will rush to approve vaccines without adequately assuring safety and effectiveness because of political pressure (Hamel, Kearney, Kirzinger, Lopes, Muñana, & Brodie, 2020; Miller, Ross, & Mello, 2020).  Only 25% of Americans have “a great deal” of trust in the Centers for Disease Control and Prevention (CDC), and only 21% definitely plan to get vaccinated, while 49% probably or definitely will not (Tyson, Johnson, & Funk, 2020). 

Vaccine safety is a significant concern for many, given the uncommonly rapid development and testing process, underlying suspicion about vaccines in general among segments of the population, and mistrust of the government’s pandemic response thus far (DeRoo, Pudalov, & Fu, 2020).  Efforts to provide the population with ample information addressing these reasons for apprehension should be made before and during vaccine program rollout. 

In addition to widespread misinformation about vaccines, health organizations must also contend with mistrust of vaccines borne out of the U.S.’s historical mistreatment of people of color in the spread and prevention of infectious diseases. This includes actions such as using ethnic minorities as test subjects for medical advances in the 20th century, or giving blankets laced with smallpox to indigenous peoples in Jamestown in the 1700s, to name a few examples.  In fact, some studies link mistrust of the health care system and fears of experimentation among some African American people to historical and contemporary mistreatment and disparities in care (Yancy, 2020). 

Methods for monitoring the vaccine

Clinical trial results show whether vaccines are effective.  The FDA evaluates the data from the clinical trials, as well as manufacturing information, to assess the safety and effectiveness of vaccines, then decides whether to approve a vaccine or authorize it for emergency use in the United States (National Center for Immunization and Respiratory Diseases, 2020; U.S. Food & Drug Administration, 2018). 

However, even after a vaccine is approved by the FDA and released for public use, more assessments are necessary. According to the CDC, the goal of these assessments is “to understand more about the protection a vaccine provides under real-world conditions, outside of clinical trials” (2020).  This is accomplished by comparing groups of people who do and don’t get vaccinated, and people who do and don’t contract the COVID-19 virus to assess how well COVID-19 vaccines are working to protect people compared to other protection measures (National Center for Immunization and Respiratory Diseases, 2020). 

Future implications and vaccine resistance

These vaccine monitoring activities are the norm, but they will take place on a larger scale during this pandemic. The post-licensure vaccine evaluation will be a crucial component of an evidence-based vaccine program. This should include four aspects.

1. Collecting exposure data for COVID-19 vaccines.

The data when reviewing the efficacy of the trial is thus far encouraging and builds confidence in the continued effectiveness of the vaccine. Dedicated trials will be needed to deepen our understanding of the impact of COVID-19 vaccines among different groups, specifically children, pregnant women, and black, indigenous and people of color (Hodgson, Mansatta, Mallett, Harris, Emary, & Pollard, 2020). 

Additionally, data must be collected to assess the effectiveness of a promising administration method: heterologous prime-boost vaccination. A heterologous prime-boost vaccination is a “repeated immunization regimen designed to increase and sustain vaccine-induced immune responses” involving “sequential delivery of different vaccine platforms” (Jeyanathan, Afkhami, Smaill, Miller, Lichty, & Xing, 2020). This method has proven effective with vaccines for other diseases such as hepatitis B24 and Ebola virus (Logunov, Dolzhikova, Zubkova, Tukhvatullin, Shcheblyakov, & Dzharullaeva, et al., 2020). In past studies of other coronaviruses, “prime-boost regimens using different viral vectors expressing the same recombinant antigen proved very efficient in enhancing the target antigen-specific immune responses” (Schulze, Staib, Schätzl, Ebensen, Erfle, & Guzmana, 2008).

2. Adopting specific safety signal detection and management measures.

A vaccine safety signal is “information that indicates a potential link between a vaccine and an event previously unknown or incompletely documented, that could affect health” (World Health Organization, 2020). Experts monitor this data to decide whether changes are needed in U.S. vaccine recommendations in order to ensure that the benefits continue to outweigh the risks for people who receive vaccines (National Center for Immunization and Respiratory Diseases, 2020; European Medicines Agency, 2020). 

3. Using real-world evidence (RWE) from clinical practice.

At the beginning of the pandemic, there were well documented errors made by many countries, including notable errors in the U.S. from the CDC, the Trump administration, and hospitals (New York Times, 2020; Nather, 2020; Evans & Berzon, 2020). As a nation, the U.S. was slow to respond and react to an ever-evolving situation. Real-world evidence gathered from longitudinal studies of COVID-19 patients and vaccine recipients will play a crucial role in responding to new information quickly and effectively in clinical practice. 

4. Applying exceptional transparency measures.

The combination of data and technology makes it possible to conduct near real-time analyses of healthcare trends and, for the first time, create a more robust and accurate understanding of disease and treatments (Christian & Reynolds, 2020). This data will have to be shared in its entirety, with no detail withheld or deemed unimportant. The data must be open to criticism and analysis so that trust can be allowed to grow, and fear subsides (Nature, 2020).

Summary

Dr. Seleem R. Choudhury receiving his 1st dose of Pfizer COVID vaccine.

The COVID-19 vaccine will not be able to single-handedly eliminate the virus from our lives. It will not necessarily allow us to return to the life we led before the pandemic reared its ugly head, but it has great potential to save countless lives and make a way forward into a new normal.  The key to making this a reality is continuous monitoring of the vaccine’s effectiveness and high levels of transparency to build public trust. 

Research indicates that a majority of Americans may trust scientific research findings more if data and information were publicly shared (Funk, Hefferon, Kennedy, & Johnson, 2019; Miller, Ross, & Mello, 2020). It is essential to widen public access to information about vaccine clinical trial design, conduct, and data. This exchange of information will provide the necessary transparency and ease of interpretation of data.  

Big pharma will need to be comfortable understanding the public hesitancy and be prepared to counter this reluctance with openness and a level of transparency never seen before as the stakes could not be higher: “History has shown that once public trust in vaccines has been compromised it is difficult to win back” (Nature, 2020).

Read more from Dr. Seleem Choudhury at seleemchoudhury.com  

Resources:

Christian, J.B., & Reynolds, M.W. (2020). Combatting COVID-19 With Real-World Evidence. American Journal of Managed Care.  

Cyranoski, D. (2020). Why emergency COVID-vaccine approvals pose a dilemma for scientists. Nature, 588, 18-19. 

DeRoo, S.S., Pudalov, N.J., & Fu, L.Y. (2020). Planning for a COVID-19 Vaccination Program. JAMA Network. 

European Medicines Agency (2020). COVID-19 vaccines: development, evaluation, approval and monitoring. European Medicines Agency. 

European Medicines Agency (2020). Pharmacovigilance Plan of the EU Regulatory Network for

COVID-19 Vaccines. European Medicines Agency. 

Evans, M., & Berzon, A. (2020). Why Hospitals Can’t Handle Covid Surges: They’re Flying Blind. The Wall Street Journal. 

Funk, C., Hefferon, M., Kennedy, B., & Johnson, C. (2019). 3. Americans say open access to data and independent review inspire more trust in research findings. Pew Research Center. 

Hamel, L., Kearney, A., Kirzinger, A., Lopes, L., Muñana, C., & Brodie, M. (2020). KFF Health Tracking Poll - September 2020: Top Issues in 2020 Election, The Role of Misinformation, and Views on A Potential Coronavirus Vaccine. KFF. 

Hodgson, S. H., Mansatta, K., Mallett, G., Harris, V., Emary, K. R., & Pollard, A. J. (2020). What defines an efficacious COVID-19 vaccine? A review of the challenges assessing the clinical efficacy of vaccines against SARS-CoV-2. The Lancet Infectious Diseases. 

Howson, C.P., Howe, C.J., & Fineberg, H.V., editors. Adverse Effects of Pertussis and Rubella Vaccines: A Report of the Committee to Review the Adverse Consequences of Pertussis and Rubella Vaccines. (1991). Institute of Medicine (US) Committee to Review the Adverse Consequences of Pertussis and Rubella Vaccines. National Academies Press.

McCarthy, M. (2020). Fauci and Other Experts Debate When Our COVID-19 Lives Will Return to Normal. Healthline. 

Jeyanathan, M., Afkhami, S., Smaill, F., Miller, M.S., Lichty, B.D., & Xing, Z. (2020). Immunological considerations for COVID-19 vaccine strategies. Nature Reviews Immunology, 20. 

Logunov, D.Y., Dolzhikova, I.V., Zubkova, O.V., Tukhvatullin, A.I., Shcheblyakov, D.V., & Dzharullaeva, A.S., et al. (2020). Safety and immunogenicity of an rAd26 and rAd5 vector-based heterologous prime-boost COVID-19 vaccine in two formulations: two open, non-randomised phase 1/2 studies from Russia. The Lancet, 396(10255). 

Miller, J.E., Ross, J.S., Mello, M.M. (2020). Far more transparency is needed for Covid-19 vaccine trials. Stat News. 

Nather, D. (2020). Trump's war on the public health experts. Axios. 

National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases (2020). Ensuring COVID-19 Vaccines Work. U.S. Centers for Disease Control and Prevention. 

National Center for Immunization and Respiratory Diseases (NCIRD), Division of Viral Diseases (2020). Ensuring the Safety of COVID-19 Vaccines in the United States. U.S. Centers for Disease Control and Prevention. 

Nature (2020). COVID vaccine confidence requires radical transparency. Nature, 586(8). 

New York Times (2020). The Unique U.S. Failure to Control the Virus. New York Times. 

Public Health England (2020). PHE investigating a novel strain of COVID-19. Public Health England. 

Schulze, K., Staib, C., Schätzl, H.M., Ebensen, T., Erfle, V., & Guzmana, C.A. (2008). A prime-boost vaccination protocol optimizes immune responses against the nucleocapsid protein of the SARS coronavirus. Vaccine, 26(51). 

Tyson, A., Johnson, C., & Funk, C. (2020). U.S. Public Now Divided Over Whether To Get COVID-19 Vaccine. Pew Research Center. 

U.S. Food & Drug Administration (2018). Step 3: Clinical Research. U.S. Health and Human Services.

WHO Ad Hoc Expert Group on the Next Steps for Covid-19 Vaccine Evaluation (2020). Placebo-Controlled Trials of Covid-19 Vaccines — Why We Still Need Them. New England Journal of Medicine. 

World Health Organization (2020). Draft landscape of COVID-19 candidate vaccines.  

World Health Organization (2020). Investigation of safety signals. World Health Organization. 

World Health Organization (2020). Vaccines and immunization: Overview. 

Yancy, C.W. (2020). COVID-19 and African Americans. JAMA Network.

A New Era in Psychiatric Hospital Accreditation: Four Questions for DNV GL Healthcare

By Claire Thayer, November 19, 2020

Recently, we hosted a Healthcare Web Summit webinar discussion with DNV GL Healthcare to learn about why CMS awarded it 4 years of deeming authority to provide accreditation services to Psychiatric Hospitals. We caught up with DNV GL Healthcare’s Thomas Quinn and Barry Smith on four key takeaways from the webinar:

1. Why did CMS award DNV GL Healthcare 4 years of deeming authority to provide accreditation services to Psychiatric hospitals?

DNV GL Healthcare: CMS will deem an organization between 2 and 6 years for the accreditation service that they are providing. Four years seems to be our initial experience with any newly deemed service we have offered.

2. What are some of the types and different roles for Surveyors?

DNV GL Healthcare: There are 3 different surveyors on each annual survey. We have our clinical surveyor, our generalist surveyor and our physical environment surveyor. The clinical surveyor is going to be focused on patient care units, the clinical setting, chart review, seeing what is going on in a unit, and observing patient and staff interactions. The generalist surveyor is focused on quality management issues, how your quality management system functions, medication management, and they are also involved in reviewing competency and utilization review. The Physical Environment surveyor’s role is to look at the entire physical plant of the organization – they will look at HVAC, fire drills, emergency management, biomed, safety and more.

3. Briefly tell us more about the accreditation process and what can Psychiatric hospitals expect in terms of onsite involvement?

DNV GL Healthcare: The accreditation process begins with the hospital completing a confidential application at no charge.  Once the hospital accepts the pricing and terms, DNV GL Healthcare will add the hospital to our schedule for an unannounced survey.  Initial surveys will consist of an onsite survey by a DNV GL Healthcare survey team.

The NIAHO® and ISO surveys are done together through Tracer Methodology as well as staff and patient interviews. While surveying the hospital to the NIAHO® Requirements, DNV GL Healthcare surveyors also ensure the application of the ISO 9001 standard. Tracer Methodology has been a staple of ISO 9001 audits since ISO 9001’s inception in 1987. All areas of the hospital are surveyed, both clinical and non-clinical. The number of surveyors and the mix of qualifications are determined specifically for each hospital and type of survey being performed. 

The hospital will receive a final report from DNV GL Healthcare within ten business days. The hospital will then have ten calendar days to submit its Corrective Action Plan with timelines for implementation. Once the Corrective Action Plan has been approved, the documentation is submitted to the Accreditation Committee for the final accreditation decision. 

Upon approval by the Accreditation Committee, DNV GL’s accreditation is typically effective on the date of receipt of an approved corrective action plan.  Individual survey results vary and certain circumstances may impact the initial accreditation effective date.  For hospitals new to the Medicare program, or applying for new provider status, the effective date for Medicare participation is always determined by CMS.

4. Where can we learn more about your standards and what's included in the application process?

DNV GL Healthcare: You can view and download all of our standards free of charge at this link: https://www.dnvgl.us/assurance/healthcare/standards.html  

You can also contact us at contacthc@dnvgl.com to request a short conversation to go over the application process and what all you will need to have in order to apply for DNV GL Psychiatric Hospital Accreditation.  Again, all of our standards are available at no charge as is the application.

If you missed this informative webinar presentation, Psychiatric Hospitals Now Have a Choice on Who They Partner With for Their Accreditation, we invite you to watch the full On-Demand webinar video or short webinar re-cap video.

Managing the effects of pandemic-induced burnout among healthcare professionals

By Dr. Seleem R. Choudhury

As the COVID-19 pandemic continues, healthcare workers face unprecedented levels of stress, fear, and anxiety. Situations that trigger chronic stress have always been present within the important and weighty work of caring for patients, but routine stressors are now intensified by the serious risks of working on the frontlines of a pandemic. Together, this creates a perfect storm of heightened risk of burnout.

Accounts of non-healthcare workers experiencing burnout from the challenges of working during a pandemic, such as learning to work remotely, constant technological mediation, and navigating new family schedules, are well documented. Though the phenomenon of burnout among healthcare professionals stretches back decades, the literature and recent data for U.S. healthcare workers during the pandemic is scarce (Jha, Shah, Calderon, Soin, & Manchikani, 2020).

Burnout: definitions and warning signs

The term “burnout” emerged in the early 1980s, and is defined by psychologists as “exhaustion that workers can experience when they have low job satisfaction and feel powerless and overwhelmed at work” (Mathieu, 2012).  A definition from a recent study by Dr. Sachin Jha, et al., emphasizes the root cause of burnout as long-term job stress, resulting in a “mixture of fatigue, cynicism, and exposure to inefficacy” (2020). Though often thought of as a form of primarily emotional exhaustion, the impact of burnout can go beyond mental health, manifesting in physical ailments (Figley, 1995). 

Burnout among healthcare professionals specifically has long been a concern.  The Bureau of Labor Statistics projects 200,000 RNs will be needed per year over the next six years. But, according to Nursing Solutions Inc., since 2015, the average hospital has turned over nearly 90 percent of its workforce—these are all pre-COVID-19 numbers (2020).

Although burnout has been around for many decades, it has been exacerbated by the unique challenges of the pandemic, and exposes the insufficient methods that have historically been used to mitigate the symptoms of burnout among healthcare workers.

COVID-related burnout

Numerous personal accounts and experiences regarding providing care during COVID include feelings of being overwhelmed and powerless. According to a survey of nearly 60,000 nurses by the National Order of Nurses, a French nursing union, 57 percent of France’s nurses have described their condition as a “state of professional exhaustion” since the beginning of the pandemic (2020). 

In the U.S., median self-reported stress, measured on a scale from 0 to 10, among intensive care unit clinicians increased from 3 to 8 during the pandemic (Society of Critical Care Medicine, 2020).

There are many root causes of the skyrocketing levels of burnout during the pandemic. Feelings of powerlessness are practically inevitable when, despite you and your colleagues’ constant efforts to fight the virus, you continue to see the same symptoms and give the same diagnosis repeatedly.

An article from researchers at Texas A&M University explains other sources of stress:

“Health care workers are experiencing added stress from multiple areas. Many of them are working longer shifts and experiencing more loss of life. The lack of personal protective equipment (PPE) and training on how to use new equipment causes many professionals to question if they have been exposed. This leads to fear that they could infect their family and loved ones. In addition to those fears, there is anxiety surrounding job security. To reduce the spread of infection, many states have stopped elective procedures and consequently, many health care professionals have been laid off or had their hours reduced” (Salazar, 2020). 

Additionally, Amnesty International has released new data showing that an estimated 7,000 health workers have died due to COVID-19 around the world so far (2020).  As of September 2020, the United States has suffered the second-highest death toll worldwide with 1,077 health workers dying from COVID, while the United Kingdom has the next-highest number of deaths at 649 (McCarthy, 2020).  Working in such a high-risk job—especially when you entered into the profession assuming that it would not cost you your life—must have an impact on an individual's psychological well-being. 

Responding to burnout

These are stressful times to be a healthcare professional. At all times, but especially under current circumstances, it is essential to be proactive to remain healthy mentally and physically and prevent burnout.

Individuals may benefit from the following strategies:

• Focus on meaning. Remember why you chose the healthcare profession.
• Try to set boundaries. In a global pandemic this is especially challenging, but where possible set time to disconnect from work.
• Strengthen your resilience. Take a 5-minute breather. Focus inward through journaling, yoga, etc.
• Practice mindfulness. Many studies show that mindfulness programs mitigate burnout symptoms.
• Stay positive, but also be realistic. Burnout is worsened when you expect too much of yourself.
• Practice gratitude. Gratitude has the power to improve our psychological health. Studies have shown it increases personal and professional well-being, boosts happiness, and helps to prevent depression (Chowdhury, 2020).
• Reach out to trusted peers or friends and talk it out (Rogers, Polonijo, & Carpiano, 2016).

Though individuals must recognize the importance of guarding themselves against burnout, healthcare organizations bear a great weight of responsibility in caring for their employees, creating an empathetic and supportive work environment, and providing resources to help their employees cope with the stresses of the pandemic.

Organizations should consider adopting the following strategies:

• Where possible, make sure that staff and providers have the necessary resources and skills to meet expectations. This is a crucial consideration, especially in regard to PPE.
• Organizations must understand that if staff and providers are working many hours, burnout is inevitable, and so provisions and appropriate support must be provided (Centers for Disease Control and Prevention, 2020).
• Organizational leaders need to express authentic empathy (Moss, 2020).
• There should be a robust support mechanism that is known, supported, and promoted consistently by leaders.  This process needs to be ready to employ when a staff member expresses a need (Moss, 2020).
• Ask the question: “Are you doing ok?” Pause and listen for the response. Don’t be afraid to hear what is said, and don’t take the response personally. Associate no stigma with struggling with burnout.
• Prioritize and organize workloads. Be sensitive to what is happening and ensure that priorities match the situation. Be judicious with the number of priorities.

There are many factors that have contributed to the sudden increase in burnout among healthcare professionals, including issues with the initial management of the virus outbreak such as rapidly increased workload hours, inadequate PPE, and a lack of consistently updated guidelines (Wang, Zhou, & Liu, 2020). Even with some of these early issues resolved, many others remain, and I join many other healthcare leaders in our concern that “the constant exposure may result in a permanent fracture in the mental health of many healthcare professionals” (Wang, Zhou, & Liu, 2020).

As leaders of healthcare organizations, we must reprioritize what is important to us at the organizational level.  Trying to do and focus on too many things will overload our teams at such a fragile time for their mental health. We must listen to ensure we fully understand the essential needs of our frontline staff during COVID-19, as stressors may also exist outside work that may contribute to the feelings of powerlessness.

Navigating this pandemic brings prolific uncertainty. It is essentially impossible to get away from the constant stressors in and out of work, and even the most resilient among us are not immune to the effects of burnout. It is imperative for the long-term health of our teams and organizations that we go above and beyond to offer support and resources to our employees on a continual basis.

Resources

2020 NSI National Health Care Retention & RN Staffing Report. Published by: NSI Nursing Solutions, Inc. March, 2020.

Chowdhury, Madhuleena Roy, BA. The Neuroscience of Gratitude and How It Affects Anxiety & Grief. January 9, 2020.

Clinicians Report High Stress in COVID-19 Response. Society of Critical Care Medicine. May 2020. 

COVID19: The National Order of Nurses warns of the situation of 700,000 nurses in France as the epidemic accelerates again. Ordres National des Infirmier. October 11, 2020.

Employees: How to Cope with Job Stress and Build Resilience During the COVID-19 Pandemic. Centers for Disease Control and Prevention. May 5, 2020.

Figley, C.R. (Ed). (1995) Compassion Fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel.

Global: Amnesty analysis reveals over 7,000 health workers have died from COVID-19. Amnesty International. September 3, 2020. 

Jha, Sachin “Sunny”, MD; Shah, Shalini, MD; Calderon, Michael David, MS; Soin, Amol, MD; and Manchikanti, Laxmaiah, MD (2020). The effect of COVID-19 on interventional pain management practices: A physician burnout survey. Pain physician, 23, S271-S282.

Mathieu, F., (2012) The Compassion Fatigue Workbook. New York: Routledge.

McCarthy, Niall. Where Most Health Workers Have Died From Covid-19. Statista. September 3, 2020.

Moss, Jennifer. Preventing Burnout Is About Empathetic Leadership. Harvard Business Review. September 28, 2020.

Rogers, E., Polonijo, A. N., & Carpiano, R. M. (2016). Getting by with a little help from friends and colleagues: testing how residents’ social support networks affect loneliness and burnout. Canadian Family Physician, 62(11), e677-e683.

Salazar, Alexandra. Infecting the mind: Burnout in health care workers during COVID-19. ScienceDaily. May 13, 2020.

Simmons, Micha’le. Three things executives can do to get ahead of leader burnout amidst Covid-19. Advisory Board. April 7, 2020.

Wang J., Zhou M., Liu F. Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China [published online ahead of print, 2020 Mar 6]. J Hosp Infect. 2020; pmid:32147406

Read more from Dr. Seleem Choudhury at seleemchoudhury.com 

Management and Rehabilitation of Long-Term Effects of COVID-19

By Dr. Seleem R. Choudhury, October 12, 2020

As a society, we have been enduring life in a pandemic for over half a year. Though we have been feeling the effects of COVID-19 for a long time, medically speaking the disease is still very new to us. It is important to remember that our knowledge is still developing regarding the virus and much remains unknown—specifically the long-term effects of the disease.

There is a common misconception that once a patient infected with COVID has a negative test, the issue is resolved.  It is often repeated that according to the World Health Organization, about 80% of COVID-19 infections are mild or asymptomatic, and patients typically recover after two weeks (Carfì, Bernabei, & Landi, 2020). 

Yet there are tens of thousands of people who have joined support groups on Slack and Facebook, who call themselves “long-termers” or “long-haulers” who are wrestling with serious COVID-19 symptoms a month or more after being infected with the disease (Yong, 2020). 

There are essentially two types of COVID patients experiencing who appear to be experiencing long-term effects of the virus—those who were ventilated due to critical symptoms and those who have residual symptoms despite having “mild” symptoms while infected with the disease (Liu, Yan, Wan, Xiang, Le, & Liu, 2020).

Critical care teams know that the longer patients remain in the intensive care unit (ICU), the more likely they are to suffer “long-term physical, cognitive and emotional effects of being sedated” (Edwards, 2020). In fact, those effects have a name: "post-intensive care syndrome (PICS)," also referred to as post-ICU delirium. PICS is an ongoing challenge even in non-pandemic conditions. An article in 2019 described PICS resulting in cognitive impairment in 30–80% of ICU survivors, the severity may vary and often lasts for years (Colbenson, Johnson, & Wilson, 2019).

As a hypothesis based upon 2019 post-ICU delirium numbers together with an increased number of patients on ventilators due to COVID, and then combined with non-hospitalized virus survivors who are experiencing long-term symptoms, our current circumstances potentially present a public health crisis (Vittori, Lerman, Cascella, Gomez-Morad, Marchetti, Marinangeli, & Picardo, 2020).  This presents hospitals, community practices, and mental health support agencies with an opportunity to expand their care services to meet a growing—and likely lasting—need.

Long-term effects of COVID-19

Four-fifths of those diagnosed with COVID experience mild symptoms.  A “mild” case is defined as two weeks or more of symptoms such as fever, cough, sore throat, malaise, and myalgias.  Beyond these flu-like symptoms, some patients have gastrointestinal issues, including anorexia, nausea, and diarrhea (Gandhi, Lynch, & del Rio, 2020). 

But experts are finding that patients who had mild symptoms can experience more than just a decline in physical health. Between 30% and 50% of people infected with COVID that have clinical manifestations will face some form of mental health issues, according to an estimate from Dr. Teodor Postolache, a professor of psychiatry at the University of Maryland School of Medicine (Goldberg, 2020; Advisory Board, 2020).  Those affected may experience anxiety or depression but also “nonspecific symptoms that include fatigue, sleep, and waking abnormalities, a general sense of not being at your best, not being fully recovered in terms of the abilities of performing academically, occupationally, [and] potentially physically” (Cooney, 2020).

Anecdotally, this matches what healthcare professionals are hearing from “long-haulers.” In addition to widely-reported fatigue reported by those healing post-COVID, these patients are experiencing neuropsychological problems ranging from headache, dizziness, and lingering loss of smell or taste to mood disorders and deeper cognitive impairment. Early reports from clinicians in China and Europe describe those infected with the disease suffering from lingering depression and anxiety, and in some cases muscle weakness and nerve damage preventing the ability to walk (Cooney, 2020).

Some COVID patients experiencing critical symptoms such as difficulty breathing were admitted to an Intensive Care Unit and placed on a ventilator.  On average in the U.S., approximately 0.8 million people every year receive this treatment in critical care; it can be reasonably assumed that this number will drastically increase in 2020 with the spread of COVID (Jaffri, 2020).

There are years of substantial data indicating that people requiring mechanical ventilation experience adverse effects after they are discharged from care (Wunsch, Linde-Zwirble, Angus, Hartman, Milbrandt, & Kahn, 2010).  People who survive up to two years after discharge from critical care are readmitted to nursing care, a rehabilitation facility, or to an ICU at up to a rate of 80%. Patients who have similarities to morbidities and the acute respiratory distress experienced by COVID-19 survivors are readmitted into these types of care at a higher rate (Jaffri, 2020). 

Additionally, a study published by the American Thoracic Society found that other issues such as physical impairment, physical deconditioning, and muscle weakness can affect those who required mechanical ventilation for up to a year after their removal from the ventilator (Ruhl, Lord, Panek, Colantuoni, Sepulveda, & Chong, 2014). Some also report difficulties returning to work or maintaining financial stability.  According to a 2018 study, 33% of individuals placed on a ventilator are unable to drive, limiting their mobility and social responsibilities, even up to a year after being discharged from critical care (Ohtake, Lee, Scott, Hinman, & Ali, 2018).

Solutions and opportunities

There is growing consensus that COVID-19 has potentially serious long-term physical and mental effects for survivors, regardless of whether symptoms at the time of infection were mild or critical.  Simple analytics should be able to ascertain the need. This review is important as It is the responsibility and opportunity of the healthcare community to respond to this potential health crisis within its community. 

The European Respiratory Society and American Thoracic Society-coordinated International Task Force recommends that clinicians follow up with all COVID-19 patients who were hospitalized because of the infection 6 to 8 weeks after their discharge from care (Spruit, Holland, Singh, Tonia, Wilson, & Troosters, 2020).

In response, COVID-19 rehabilitation clinics are being formed to focus on assessing patients’ cognitive ability, mental health, mobility, and ability to perform daily activities. These clinics offer mental health, physical therapy, and occupational therapy services, as well as pediatric rehabilitation medicine to address the needs of those dealing with long-term effects of the virus (Spruit, Holland, Singh, Tonia, Wilson, & Troosters, 2020).

The Spaulding Rehabilitation Network has engaged a multidisciplinary physician-led team of physiatrists, physical therapists, occupational therapists, speech language pathologists, and case managers to establish a dedicated outpatient clinic for those who are recovering or were hospitalized for COVID-19.  The Kennedy Krieger Institute is introducing a rehabilitation clinic for those children and adolescents under age 21 who have “recovered from the virus but need additional support to regain lost neurological and physical function as a result of the illness.”  The Shirley Ryan Ability Lab has been offering rehabilitation services for decades, and has already opened their services to those dealing with impairments as a result of COVID-19.

“Long-haulers” are experiencing the effects of a debilitating illness, and it will be vitally important for them to receive rehabilitation care, whether in person or via telehealth, to return to full health and quality of life (Urban, 2020).  As was stated in the European Respiratory Journal: “Considering the expected high burden of respiratory, physical and psychological impairment following the acute phase of COVID-19, a huge number of patients should be referred early to a rehabilitation program” (Polastri, Nava, Clini, Vitacca, & Gosselink, 2020).

Early data from health authorities in the United Kingdom and Italy, two countries hit hard with COVID-19, has shown that a structured rehabilitation program in-clinic, in the home, or virtually can mitigate post-ICU symptoms for those treated for COVID-19, thus resulting in improvements in daily function and independence. This success can also be extended to those with milder symptoms and reduce alienation that victims of the disease have reported experiencing, and ensure physical, emotional and cognitive functioning and recovery.

In the U.S. hospitals have been so focused on the present crisis, that they have not developed the capacity to deal with patients and their post-COVID needs. This could create a potential health crisis down the road. It is time to transition out of crisis-mode and begin to form a strategy to serve the needs of patients who are experiencing long-term effects of COVID-19.

Resources:

• Coronavirus Disease 2019 Pandemic Acute Respiratory Distress Syndrome Survivors: Pain After the Storm?, by Alessandro Vittori, MD, Jerrold Lerman, MD, Marco Cascella, MD, Andrea D. Gomez-Morad, MD, Giuliano Marchetti, MD, Franco Marinangeli, PhD, MD, and Sergio G. Picardo, MD (2020), International Anesthesia Research Society
• COVID-19: Interim Guidance on Rehabilitation in the Hospital and Post-Hospital Phase from a European Respiratory Society and American Thoracic Society-coordinated International Task Force, by Martijn A. Spruit, Anne E. Holland, Sally J. Singh, Thomy Tonia, Kevin C. Wilson, and Thierry Troosters (2020), European Respiratory Journal
• COVID-19 and pulmonary rehabilitation: preparing for phase three, by Massimiliano Polastri, Stefano Nava, Enrico Clini, Michele Vitacca, Rik Gosselink (2020), European Respiratory Journal
• COVID-19 Can Last for Several Months, by Ed Yong (2020), The Atlantic
• COVID-19 Support Group (2020), Body Politic
• COVID-19 Survivor Corps (2020), Facebook
• 'Covid fog': The latest emerging, long-term symptom of Covid-19 (2020), Advisory Board
• COVID Recovery & Rehabilitation (2020), Shirley Ryan Ability Lab
• For long-haulers, COVID-19 takes a toll on mind as well as body, by Emma Goldberg (2020), The Baltimore Sun
• Health Care Resource Use and Costs of Two-Year Survivors of Acute Lung Injury. An Observational Cohort Study, by A. Parker Ruhl, Robert K. Lord, Julia A. Panek, Elizabeth Colantuoni, Kristin A. Sepulveda, Alexandra Chong, Victor D. Dinglas, Carl B. Shanholtz, Peter J. Pronovost, Donald M. Steinwachs, and Dale M. Needham (2014), Annals of the American Thoracic Society
• Long after the fire of a Covid-19 infection, mental and neurological effects can still smolder, by Elizabeth Cooney (2020), Stat News
• Mild or Moderate COVID-19, by Rajesh T. Gandhi, M.D., John B. Lynch, M.D., M.P.H., and Carlos del Rio, M.D. (2020), The New England Journal of Medicine
• Pediatric Post COVID-19 Rehabilitation Clinic (2020), Kennedy Krieger Institute
• Persistent Symptoms in Patients After Acute COVID-19, by Angelo Carfì, MD; Roberto Bernabei, MD1 Francesco Landi, MD, PhD; et al (2020), JAMA Network
• Physical Impairments Associated With Post-Intensive Care Syndrome: Systematic Review Based on the World Health Organization's International Classification of Functioning, Disability and Health Framework, by Patricia J. Ohtake, Alan C. Lee, Jacqueline Coffey Scott, Rana S. Hinman, Naeem A. Ali, Carl R. Hinkson, Dale M. Needham, Lori Shutter, Helene Smith-Gabai, Mary C. Spires, Alecia Thiele, Clareen Wiencek, and James M. Smith (2018), Journal of the American Physical Therapy Association
• Post COVID-19 Outpatient Rehabilitation Program (2020), Spaulding Rehabilitation Network
• Post-Intensive care syndrome and COVID-19: crisis after a crisis?, by Abbis Jaffri (2020), Heart and Lung: The Journal of Cardiopulmonary and Acute Care
• Post-intensive care syndrome: impact, prevention, and management. Colbenson, G. A., Johnson, A., & Wilson, M. E. (2019). Breathe 2019
• Rehabilitation Care is Needed for Many COVID-19 Patients, by Kylie Urban (2020), University of Michigan Health Lab
• The epidemiology of mechanical ventilation use in the United States, by Hannah Wunsch, Walter T. Linde-Zwirble, Derek C. Angus, Mary E. Hartman, Eric B. Milbrandt, and Jeremy M. Kahn (2010), Critical Care Medicine
• 'They're Not Actually Getting Better,' Says Founder Of COVID-19 Long-Haulers Support Group by Robin Young and Serena McMahon (2020), wbur
• Viral dynamics in mild and severe cases of COVID-19, by Yang Liu, Li-Meng Yan, Lagen Wan, Tian-Xin Xiang, Aiping Le, Jia-Ming Liu, et al. (2020), The Lancet Infection Diseases
• Why some coronavirus patients could have problems after recovery, by Erika Edwards (2020), 7News

Read more from Dr. Seleem Choudhury at seleemchoudhury.com.

Four Key Takeaways About Stroke Program Certification

By Claire Thayer

Tim Hehr, Stroke Technical Advisor, Stroke Program Development, DNV GL Healthcare and Debbie Camp, Stroke Program Manager, Piedmont Newnan Hospital, participated in a recent Healthcare Web Summit webinar: Stroke Program Certification: Positive Impacts on Safety and Quality Care in the Piedmont Healthcare System.  Piedmont Healthcare is a large hospital system in the Atlanta area, four of their hospitals are DNV GL Healthcare certified stroke centers – a designation they have held for the last 5 years. The discussion offered an overview of the process to achieve a DNV GL Stroke Program Certification as well as focused on how certification has positively impacted the Piedmont Healthcare System.   If you missed this engaging webinar presentation, you’ll want to be sure to watch the Webinar Video. After the webinar, we interviewed the speakers on four key takeaways: 

1. How many levels of stroke certification are offered by DNV GL Healthcare? 

Tim Hehr: There are 4 levels of stroke certification offered by DNV-GL Healthcare:  Acute Stroke Ready, Primary Stroke Center, Primary Stroke Center Plus, and Comprehensive Stroke Center

2. What are a few of the sources and guidelines utilized in the development of the DNV GL Healthcare stroke certification standards? 

Tim Hehr: There are several sources utilized in developing DNV-GL Stroke Center Certification standards including The American Stroke Association, The Brain Attack Coalition, The American Association of Neuroscience Nurses, and The Society of NeuroInterventional Surgery.

3. Describe some of the advantages of DNV GL stroke certification for an organization like Piedmont Healthcare.

Debbie Camp: The biggest advantage is the annual on-site surveys and the collaborative/partnership that is provided by subject matter experts (surveyors’) who truly understand the job we do. The surveyors share best practices from around the country with our Team which has greatly improved our stroke program throughout our system.

4. Can you share examples of specific guidelines that were reviewed at Piedmont and describe how they positively impacted stroke care in that organization?

Debbie Camp: The ppt went through some of the process improvement (PI) initiatives for the non-conformities (NC1-2) and/or opportunities for improvement (OFI’s) that we received from our survey’s.

Because of the PI process being implemented at a system level we are able to ensure best practices across the system.

Below are examples of some of the Standards that matched the PI initiatives that were presented on the webinar.

NC-1 QM.7 (CR.2i) (Door to Monitored Bed)/Code Alteplase

NC-2-1 PC.10 Patient Care Plan of Care (CR.1) /(CR.1g)/Stroke Bleeding Precautions & Documenting Modifiable Risk Factors

NC-2-2 PC.8 Patient Care Protocols/Pre & Post Alteplase Parameters met

NC-2-3 PC.12 Patient Care Diagnostic Testing /Development of the Stroke Narrator to capture MD @ BSD prior to CT

NC-1-2 QM.7 (Quality Mgt Systems) Measurement, Monitoring, Analysis, PC.12 (Pt Care Services), Diagnostic Test, MS.1 (Medical Staff) Admissions Requirements/Development of Stroke Narrator

NC-1-1 PC.4 Patient Care Services Emergency Department/Developing Alteplase Audit Handoff Tool

NC-1-1 Protocols PC.8/CR.3a   &   Required Documentation (MR.4)/(CR.6b)/Standardized S/P CEA order sets and Documentation of V/S & Neuro Checks  

To view the full webinar, Stroke Program Certification: Positive Impacts on Safety and Quality Care in the Piedmont Healthcare System  – click here.

Deploying SDoH Factors in the COVID Battle

By Clive Riddle, April 3, 2020

PWC’s Health Research Institute recent released: COVID-19: Six things health organizations should be considering (but might not be) offering six strategies that could be deployed in the fight against the pandemic. Number five on that list was SDoH:

“Strategies on social determinants of health can be an advantage in pandemic response. Trust-based relationships are important when people and communities are scared and unsure of what to do. Coalitions developed for pandemic response, much like social determinants of health interventions, should include trusted community organizations and providers that have access to hard-to-serve or underserved communities that may not be able to get information and support from traditional sources such as their employer or local government.”

A companion graphic noted "Less than 50% of primary care physicians said their practices coordinate with the right social service agencies.”

Health plans have come to embrace the SDoH component of removing economic barriers in treatment of COVID-19. While initially announcing waiver of any out-of-pocket costs for testing, more recently many health plans have issued announcements of waiving all treatment costs to consumers, including Aetna’s announcement on March 25^th,   Humana’s announcement and Cigna’s announcement on March 30^th, followed by UnitedHealthcare on March 31^st and Anthem on April 1^st.

Also, numerous health plans are making sizeable donations to COVID-19 relief efforts in their markets, including these:

Harvard Pilgrim Health Care Foundation Gives More Than $3 Million for Covid-19 Relief Efforts

Medica Donates $1 Million to Minnesota Non-Profits to Meet Emergency Needs from the Coronavirus

21 Organizations to Receive First $500K of $1M Committed by the Tufts Health Plan Foundation

Health Net Rolls Out $5.9 Million in COVID-19 Assistance for Those Serving Medi-Cal Members

But a more proactive approach in leveraging SDoH in the COVID-19 battle is being offered by analytics technology companies. Two such approaches were profiled in the April Care Technology Edition of Care Analytics News, discussing Jvion’s new COVID Community Vulnerability Map and Clarify’s COVID-19 Elderly Vulnerability Population Index (EVI) and the Clarify COVID-19 Patient Risk Profile

Jvion’s  COVID Community Vulnerability Map is built on Microsoft Azure maps, and enables healthcare providers and communities to identify the social determinants of health (SDoH) that put populations at greater risk during the COVID pandemic. Jvion states the map’s purpose is to inform “community planning and resource allocation to proactively mitigate the risk to vulnerable populations.” The Jvion COVID Community Vulnerability Map is available at https://covid19.jvion.com,

The interactive map identifies populations down to the census block level that are at risk for severe outcomes upon contracting a virus like COVID. Severe outcomes include hospitalization, organ failure and mortality. Additionally, the map surfaces the socioeconomic and environmental factors, such as lack of access to transportation or nutritious food, that put patients at greater risk. The map is also overlaid with points of interest, such as hospitals, food sources and transportation, in relation to the at-risk communities. These insights can help inform providers, public health organizations and community support agencies as they look to deploy interventions, outreach and other services to keep individuals from contracting the virus and, once infected, manage their care towards a positive outcome.

The map can quickly help local health departments prioritize their limited resources for response planning and adapt their tactics to the needs of neighborhoods and communities. By understanding the differentiated needs within their population, health systems can more adequately plan for healthcare utilization, deploy preventive or mitigating care resources, and anticipate the short-, mid- and long-term impacts of public health decisions, such as school and business closures.

Clarify Health announced that it launched two new critical applications in response to the needs of customers at the forefront of providing care to the communities impacted by COVID-19. The company is deploying the Clarify COVID-19 Elderly Vulnerability Population Index (EVI) and the Clarify COVID-19 Patient Risk Profile to healthcare organizations across the US to equip them with the patient risk insights that are needed to inform resource planning, interventions, and community initiatives.

The two applications leverage Clarify’s patient dataset, covering over 300 million lives, and AI capabilities. The solutions will reduce blind spots in patient risk by giving healthcare organizations access to an actionable COVID-19 vulnerability score for their elderly patients and a drill-down view into individual risk profiles and comorbidities at the point of care. Clarify’s COVID-19 EVI measures ZIP codes on relative vulnerability of seniors to severe coronavirus infection and delivers insights into their comorbidities, such as, cardiac diseases, respiratory diseases (including COPD), and cancer. The EVI provides hospitals, emergency services, health plans, and government agencies with the ability to identify neighborhoods which could benefit from greater testing or support services and prepare to take action quickly in high risk areas.

Clarify’s COVID-19 Patient Risk Profile is a web-based interface that highlights known risk factors for severe illness related to COVID-19. This capability is critical as frontline care providers struggle to proactively manage capacity and care for COVID-19 suspicious patients.

Quantum Theory of Health

By Kim Bellard, January 30, 2020

We’re pretty proud of modern medicine.  However, there has been increasing awareness of the impact our microbiota has on our health, and I think modern medicine is reaching the point classical physics did when quantum physics came along.  

Classical physics pictured the atom as kind of a miniature solar system, with well-defined particles revolving in definite orbits around the solid nucleus.  In quantum physics, though, particles don’t have specific positions or exact orbits, combine/recombine, get entangled, and pop in and out of existence.  At the quantum level everything is kind of fuzzy, but quantum theory itself is astoundingly predictive.  We’re fooled into thinking our macro view of the universe is true, but our perceptions are wrong.   

So it may be with modern medicine.  Our microbiota (including both the microbiome and mycobiome) both provide the fuzziness and dictate a significant portion of our health.   

Two articles in Science illustrate how we’re still just scratching our understanding of their impact.  The first, from Rodrigo Pérez Ortega, reports on two new studies. 

The first study found that the genetic structure of gut microbiome was more predictive of health than one’s own genes.  It was especially better for “complex” diseases that are attributed to both environmental and genetic factors.  Gut microbes are impacted sooner by environmental factors and thus serve as better predictors for such diseases. 

The second study found that a person’s microbiome could be used to predict their death 15 years later.  Presence of a certain family of bacteria led to a 15% higher mortality rate in the next 15 years.  Whether the bacteria are the cause of the mortality or a side effect of other factors is not clear. 

The second article was a study from B.B. Finlay, et. alia, that speculated that so-called non-communicable diseases (NCD) might actually be communicable, via the microbiome.  Their paper concludes:  “These findings could serve as a solid framework for microbiome profiling in clinical risk prediction, paving the way towards clinical applications of human microbiome sequencing aimed at prediction, prevention, and treatment of disease.”

Dr. Finlay says: “If our hypothesis is proven correct, it will rewrite the entire book on public health.”

Still, it is too early to get overly excited.   Everyone agrees more research is necessary.  Timothy Caulfield, the Research Director of the Health Law Institute at the University of Alberta, warns: “Gut hype is everywhere.”  He acknowledges that this is an exciting field with great promise, but cautions “it is still early days for microbiome research.”  

Think of modern medicine, with its germ theory of disease and its understanding of our body’s biomechanics, as classical physics.  Our recent discoveries about our microbiota are upending our notions about what disease is, what causes it, and how we should best deal with it.  Our supposed precision in medicine is illusionary.  

Modern medicine loves its antibiotics, despite the devastating impact they wreak on our microbiome.  It is fascinated with our genome, despite the fact that our microbiota’s genes greatly outweigh our own, and have more diversity.  Our microbiota change in ways that we don’t understand and, as yet, can’t even really track, much less predict the effect of. 

We need the equivalent of a quantum theory of health.  

Modern medicine is in the stage physics was in the early part of the 20th century, when the concept of quanta was known but the consequences of it were yet to be discovered.  

Modern medicine has had its Newtons, maybe even its Einsteins, but now it needs a new generation of scientists to develop more accurate theories of our health, no matter how counter-intuitive they might be.  

Welcome to a quantum theory of health.

This post is an abridged version of the original posting in The Health Care Blog.

Fifteen Things to Know from the 2019 America’s Health Rankings Report

By Clive Riddle, December 6, 2019

Vermont is number one in health, Mississippi is in last place, and New York gets most improved. Smoking is down, obesity is up, along with diabetes, drug death, and suicides. Fortunately the supply of mental health providers is increasing as well. These indicators and countless more come courtesy of the 2019 America’s Health Rankings Annual Report.

 

The United Health Foundation, affiliated with UnitedHealth Group, has released their 118-page 2019 America’s Health Rankings Annual Report, marking their 30th annual study that "has grown from ranking states across 16 measures of health to 35 measures in 2019." This year’s report was developed in partnership with the American Public Health Association.

The Foundation share these key findings from their report:

1. In the past year, improvements have been made in lowering the rates of smoking (decreasing 6%), children in poverty (decreasing 2%), and increasing the supply of mental health providers (increasing 5%).
2. In the past two years, infant mortality has declined, resulting in 1,200 fewer deaths (decreasing 2%).
3. Obesity prevalence among Americans is now at 30.9%, up 11% since 2012.
4. Diabetes is now at 10.9% of the U.S. population, up 4% in the past year.
5. The rate of drug deaths increased 37% from 14.0 to 19.2 deaths per 100,000 – equating to more than 53,000 additional deaths over a three-year period.
6. The suicide rate increased 4% nationally in the past year, and is up in a total of 30 states.
7. Smoking among adults has decreased 45% since 1990. Today, 16.1% of adults report that they smoke.
8. Infant mortality has decreased 43% since 1990, with declines in all 50 states.
9. Obesity has increased 166% over the past 30 years, from 11.6% to 30.9%.
10. Diabetes has reached the highest prevalence since 1996, increasing 148% among adults.
11. The national suicide rate has increased 17% since 2012.
12. Drug deaths have increased 104% since 2007.
13. Vermont topped the list of healthiest states in 2019, followed by Massachusetts (No. 2), Hawaii (No. 3), Connecticut (No. 4) and Utah (No. 5).
14. Mississippi ranks No. 50 this year, followed by Louisiana (No. 49), Arkansas (No. 48), Alabama (No. 47) and Oklahoma (No. 46).
15. New York has made the most progress since the Annual Report was first released in 1990, improving 29 ranks from No. 40 to No. 11.

Getting More Precise About Precision Medicine

By Clive Riddle, October 16, 2019

The October Care Intervention Edition of Care Analytics News profiled Dr. Jen Buhay, Precision Medicine Clinical Program Manager for The US Oncology Network. The term “Precision Medicine” can sound straight-forward, yet for those not directly involved in this arena, there is not always a clear understanding of its current scope.

So the first question asked of Doctor Buhay was simply “What is Precision Medicine?” she replied: “In the simplest terms, Precision Medicine is the “right test for the right patient at the right time.” But the practice of Precision Medicine is not so simple. A physician must choose from an array of complicated tests that are appropriate for a diagnosis and the creation of a treatment plan for their patient in a timely manner. That’s a lot of separate data and time points to manage for one patient, so how do we connect these individual patients together with their own personalized sets of tests and outcomes to improve population health?”

It can also help to take a glimpse of the background of someone in the field. Jen leads biomarker testing, education, and operational efforts at The US Oncology Network, “to support personalized patient care for oncology. Previously, she led precision medicine initiatives in a community hospital setting and worked as a laboratory scientist for commercial and academic molecular diagnostic laboratories. Dr. Buhay holds a PhD in Integrative Biology (molecular genetics and computational biology) from Brigham Young University, an MS in Biology from Eastern Kentucky University, and a BS in Animal Behavior from Juniata College. She is board-certified as a Molecular Biologist through the American Society for Clinical Pathology.”

Dr Buhay cites breast cancer as an area where Precision Medicine can really help, and “has resulted in the development and evolution of standard biomarker testing guidelines, risk assessment and screening protocols, and treatment plans that are now widely recognized and used. This clinical application of Precision Medicine has resulted in the avoidance of unnecessary and ineffective testing and treatment, rapid identification of targeted treatments with good responses in similar populations, and the proactive screening of families at high risk for breast cancers.”

Regarding future potential, Jen says “the big picture comes together in Precision Medicine when clinical outcomes are linked to the biomarker testing choices, disease screening methods, and targeted treatment plans for large groups of patients as part of clinical trials and translational research. With the analysis of “big data” comes new and updated biomarker testing recommendations, patient care models, disease screening protocols, and treatment guidelines by professional medical societies. These guidelines reflect the most recent technological advances in laboratory science from the bench to the bedside, and this information is continually evolving with new studies leading to better survival rates, increased detection, and improved treatments for future patients. Precision Medicine efforts will continue to expand across many diseases as more physicians learn the lessons of how breast cancer incorporated biomarker testing, disease screening, and targeted therapies into standard practices and guidelines for the betterment of individuals, families, and populations.”

Five Sterile Processing Questions for Stephen Cuthbertson, College Medical Center and Jeremy Gibson-Roark, DNV GL Healthcare: Post-Webinar Interview

By Claire Thayer, April 18, 2019

Improvement, Regulatory Compliance & Case Management of College Medical Center in Long Beach California, and Jeremy Gibson-Roark, a lead clinical and certification surveyor with DNV GL Healthcare, participated in a Healthcare Web Summit discussion on sterile processing.

If you missed this informative webinar, Is Your Sterile Processing Department Safe? Risks and Opportunities in Sterile Processing, watch the On-Demand version here. After the webinar, we interviewed Stephen and Jeremy on five key takeaways from the webinar: 

1. What are a few of the opportunities you've identified in sterile processing departments for quality improvement? 

Jeremy Gibson-Roark: 

• IUSS use
• Tray Completion – All instruments accounted for and delivered
• Instrument Quality
• Instrument/Set Availability
• Tray Management – Removing and repurposing of trays not being utilized
• Tray Management – Condensing of trays to reduce volume of processing  

2. How does the certification in sterile processing benefit the patient? 

Jeremy Gibson-Roark: It allows an organization to ensure that a Quality Management System (QMS) is in place in the sterile processing department.  This system should be designed to achieve continual improvement in the department.  The benefit to the patient is the assurance that the organization has dedicated the resources and leadership to the processing of surgical/medical instrumentation. 

3. Why were you interested in obtaining Sterile Processing Program Certification for your hospital? 

Stephen Cuthbertson: We wanted a certification to set us apart from our local area hospitals. After review of the SPPC standards, we felt confident we could achieve the certification. We don’t have the volume for attempting, stroke, VAD, or hip and knee, etc… 

4. What are some of the key steps involved in the certification process? 

Stephen Cuthbertson: I think the biggest key steps are first understanding that the standards speak to and expect to see data, policies, QMS, etc.., specific to the SPD. The document review is extensive and the tour of the various departments affected by SPD are the other big steps. It’s also important to realize that the nonconformities aren’t a bad thing, they assist the organization in improving their patient safety related to SPD. 

5. Is certification only available for Hospital? 

Jeremy Gibson-Roark: This is the only certification available for the Sterile Processing Department in the United States. While individual certification is available through other organizations, DNV GL is the only organization that will certify a hospitals SPD.

Medication Nonadherence: Data and Analytics Can Make an Impact

By Claire Thayer, May 16, 2018

Over two-thirds of hospital readmissions are directly due to medication nonadherence.  Many factors contribute to patients not taking their medications, including fear of side effects, out-of-pocket costs, and misunderstanding intended use.  Interventions targeted at understanding the underlying causes on nonadherence are critical to improving chronic disease outcomes.  Successful interventions include: educating patients on purpose and benefits of treatment regimen, reducing barriers to obtain medication, as well as use of health IT tools to improve decision making and communication during and after office visits. 

This weeks’ edition of the MCOL infoGraphoid, co-sponsored by DST Health, explores how data and analytics can provide insight to drive behavior change to improve adherence.

MCOL’s weekly infoGraphoid is a benefit for MCOL Basic members and released each Wednesday as part of the MCOL Daily Factoid e-newsletter distribution service – find out more here.