Blog from July, 2018

Jack Murtha


Digital behavioral interventions can cut down the kind of overprescribing that empowers antibiotic-resistant bacteria — superbugs — in a cost-effective manner, according to a new study.

The report, published this week in the Journal of General Internal Medicine, found that three behavioral economics interventions can reduce the number of inappropriate antibiotic prescriptions, increasing quality of life and decreasing antibiotic resistance and its associated costs.

Researchers from the University of Southern California (USC) Schaeffer Center for Health Policy and LA BioMed, a California-based innovation incubator, undertook the research to help curb a growing public health crisis. Antibiotic-resistant superbugs have infected more than 2 million people worldwide, in part because roughly half of American outpatient antibiotic prescriptions are unnecessary, according to the study.


“Healthcare needs more studies such as these, targeted to identify successful initiatives that are both cost-saving and life-saving,” said David Meyer, Ph.D., who leads LA BioMed.

For the study, researchers analyzed three interventions, including: 1) Suggested alternatives, which leverage digital clinical decision support tools to suggest treatments that don’t use antibiotics; 2) Accountable justification, which requires prescribers to justify their use of antibiotics in a patient’s electronic health record (EHR); and 3) Peer comparison, which entails sending emails to clinicians regarding how their prescribing rates stack up to their colleagues.

These three tactics had already proved effective in reducing the number of erroneous antibiotic prescriptions over an 18-month period.

So, USC and LA BioMed researchers designed a study using the 30-year Markov model, with inputs from the literature and U.S. Centers for Disease Control and Prevention surveillance data. They homed in on 45-year-old adults who had shown signs of acute respiratory infections, for which patients sometimes inappropriately receive antibiotic prescriptions.

Then providers received the three aforementioned digital tools, along with training on guidelines for treatments for acute respiratory infections.

Measuring discounted costs, quality-adjusted life years and cost-effectiveness, researchers found that the strategies were not only successful but also adept at cutting costs. The total cost of each training intervention was $178.21, while suggested alternatives ran $173.22, accountable justification ran $172.82 and peer comparison ran $172.52, according to the study. What’s more, the training group experienced 14.68 quality-adjusted life years, falling short of 14.73, 14.74 and 14.74 for the three groups that received behavioral economic interventions.

The study and others like it could have big consequences. Public health officials are growing increasingly concerned about the potential effects of antibiotic resistance. Some experts have claimed that the phenomenon could result in the next great outbreak. But, as this study suggests, part of the answer could lie in the EHR and a provider’s email account.

Jessica Kent


What are the best population health management strategies for addressing common chronic diseases?

Chronic diseases are among the most costly, prevalent, and avoidable ailments impacting population health.

Conditions such as diabetes, hypertension, and opioid addiction claim thousands of lives and billions of dollars each year. The Centers for Disease Control and Prevention (CDC) reports that chronic diseases account for seven of the top 10 causes of death in the US and consume 86 percent of the nation’s annual healthcare spending.

The increasing prevalence and rising costs of these conditions make chronic disease management one of healthcare’s most challenging and urgent endeavors.

Yet many healthcare professionals struggle to find the time, tools, and resources to meet the holistic needs of patients.

The close association between chronic disease and patients’ social determinants of health adds to the complexity of treating and preventing these disorders.

Providers must consider and address the conditions in which their patients live, work, and play, as well as their ability to exercise regularly and access healthy food, in order to effectively manage and deter chronic diseases.

To confront common chronic diseases and the many factors that contribute to them, stakeholders from across the healthcare continuum will need to develop population health strategies that will improve patient outcomes.

What are some of the most common chronic diseases affecting patients in the United States, and which population health strategies should healthcare stakeholders use to manage these conditions?

DIABETES

According to the CDC, over 29 million Americans are currently living with diabetes. Another 84 million are prediabetic, and even more may be undiagnosed and untreated. The condition also accounts for more than 20 percent of healthcare spending.

Diabetes risk is significantly tied to social and economic circumstances. It is more common among non-white populations, with black, Hispanic, and Native American populations experiencing the disease at much higher rates than whites.

Medication non-adherence is an issue that leads to additional complications for many diabetic patients, and it is also linked to non-clinical factors. A 2016 report from IMS Health found that nearly half of Medicare diabetic patients are unable to keep up with medication adherence due to limited financial resources, language barriers, and insufficient care access.

To increase medication adherence rates, providers can work to engage and educate patients about their medications by developing personalized adherence plans.  

Additionally, providers can coordinate with community, pharmacy, and public health resources to improve adherence rates.

A 2016 study demonstrated that medication adherence interventions that take place at  retail pharmacies can help patients stay on track with their therapies, reduce preventable hospitalizations, and reduce overall healthcare costs.

“Community pharmacists are uniquely positioned to help mitigate the high risk of medication discontinuation and improve adherence for patients initiating therapy because of their access to prescription refill information and frequent interactions with patients,” the study stated.

Managing diabetes goes beyond adhering to medications, however. Patients must also make healthy food and lifestyle choices and regularly check their glucose levels to maintain their health.

To ensure patients are on track with managing their diabetes, providers can engage patients with text messages and mHealth communications. Providers can use these tools to remind patients about upcoming appointments, ensure they are making healthier lifestyle choices, and keep them on track with blood sugar testing.

Healthcare payers can also employ this strategy and launch mHealth programs to improve diabetes treatment, as UnitedHealth Group recently did for its Medicaid Advantage members.

HYPERTENSION

One in every three American adults has hypertension, the CDC states. The condition is strongly correlated with other cardiovascular conditions, including heart disease and stroke, two of the leading causes of death in the US.

The condition is most commonly seen in non-Hispanic black males, and black individuals are twice as likely to die from the condition as whites are.

Improving hypertension rates will require a collaborative approach, according to the CDC.

“Using team-based care that includes the patient, primary care provider, and other health care providers is a recommended strategy to reduce and control blood pressure,” the organization notes.  

A number of health systems and community organizations have taken this approach, working to engage patients and deliver hypertension care directly to underserved populations across the country.

The University of Michigan Health System collaborated with Meijer pharmacies in 2016 to provide more accessible care to adults with hypertension, offering patients treatment and monitoring services in their own communities.

Additionally, researchers at Cedars-Sinai Medical Center recently enlistedover 50 barbershops in the LA area to offer blood pressure checks and pharmacist-led consultations to customers, aiming to enhance chronic disease management tools within the community.

The researchers found that hypertensive customers who met directly with pharmacists significantly lowered their blood pressure rates.

Organizations can also take an analytics-based approach to hypertension management, as Kaiser Permanente illustrated with its Hypertension Program Improvement Process.

Healthcare organizations can utilize clinical analytics and the EHR to create a registry of high-risk individuals who may benefit from lifestyle changes, as well as use clinical analytics algorithms to determine the best treatment methods for hypertension patients.

OPIOID ADDICTION

Opioid addiction is one of the nation’s biggest health crises. Providers can act as the first line of defense against opioid abuse, and organizations such as the FDA have considered addressing the epidemic with mandatory opioid education for all healthcare professionals.

Clinicians have a responsibility to recognize signs of opioid misuse in patients, prescribe alternate treatments, and prescribe opioids more judiciously to avoid long-term consequences.

Providers can utilize state Prescription Drug Monitoring Program (PDMP) data to determine if their patients may be abusing opioids. These programs have shown considerable promise in reducing unnecessary prescription rates and raising provider awareness about potential opioid misuse.

Opioid abuse is also significantly tied to social and economic circumstances, with those suffering from addiction often having deeply rooted social or mental health problems.

As a result, treating and managing this disease requires efforts not only from providers, but also from government officials and community organizations.  

Pennsylvania’s Opioid Data Dashboard, a government initiative to combat the opioid crisis, gives health officials, lawmakers, and the public access to real-time data to help identify trends for future community needs.

The dashboard also helps build predictive analytics models to deliver a comprehensive picture of the epidemic in Pennsylvania.

In addition, CMS recently released a document explaining how states can use telemedicine to treat Medicaid beneficiaries in rural or underserved areas struggling with opioid misuse.

The organization also recommended that states receive federal support to create shared electronic health plans between providers and patients, which would allow both parties to set goals for pain management regimens and counseling.

COPD AND ASTHMA

The CDC reports that nearly 15.7 million Americans have received a chronic obstructive pulmonary disease (COPD) diagnosis, while asthma affects about 25 million individuals in the US.

These chronic conditions cost the healthcare industry billions each year. They are also heavily associated with individuals’ environmental circumstances and are often exacerbated by exposure to air pollutants in the home and workplace.

Research has shown that public health officials can use EHR data from local hospitals to identify specific geographic areas where there is a high risk for asthma.

Once they have identified high-risk areas, public health officials can assess the air quality, and environmental inspectors can evaluate the hazards in the area.

Officials could also use EHR data to identify patients with severe asthma. By developing a registry of patients who are frequently admitted to the hospital for asthma, officials can flag those most in need of care coordination and individuals who might benefit from home visits.

Community care strategies that utilize sensor applications can significantly improve the health of patients with asthma and COPD, as well as identify the environmental factors that can affect patients’ quality of life.

A 2017 program in Louisville, Kentucky doubled the amount of symptom-free days for asthma and COPD patients by attaching a sensor directly to patients’ inhalers to track the number of puffs used per day, how many times patients experienced symptoms, and where they experienced those symptoms.

Nearly 82 percent of participants saw a decrease in inhaler use, while Louisville officials were able to identify high-risk areas and work to improve air quality in these places.

DEPRESSION AND OTHER MOOD DISORDERS

Between 2009 and 2012, depression affected 7.6 percent of Americans aged 12 and older. The mood disorder is more prevalent among minority and lower-income populations, and is also associated with higher rates of chronic disease.

Despite the correlation between mental illness and chronic conditions, only 30 percent of mentally ill patients are screened for chronic disease.

Integrated care delivery that considers a patient’s mental and physical health can significantly improve mental health outcomes and ensure these patients are receiving the care they need.

Organizations can place behavioral health and primary care providers in the same location to improve patient engagement, foster patient self-management, and address the social determinants of health.

Additionally, providers can use web-based risk assessment tools to stratify high-risk individuals and increase depression screenings for patients, particularly for those who are not often screened in traditional settings.

Providers can then deliver proactive, preventative care to these patients, and gather insights on the factors that most often contribute to depression and other mood disorders.

Chronic disease management is a challenging task that can be made easier by collaborative efforts from primary care providers, community organizations, and other healthcare stakeholders.

By working together to develop population health management strategies and manage and treat patients suffering from common chronic diseases, stakeholders can reduce and prevent the prevalence and cost of these conditions.


Tina Reed


An electronic medical record system is being credited with helping a public health system in Ohio reduce its opioid prescriptions for acute pain by more than 60% in the last 18 months.

Officials from Cleveland-based MetroHealth System said they also cut opioid prescriptions by 25% for chronic pain. In all, they estimate they cut opioid prescriptions by 3 million pills.

How'd they do it? Officials pointed to the alerts they set up in the EMR system.

In particular, those alerts for prescribers were set up to flag patients who may be at risk for addiction to guide them toward alternative drugs and lower doses. They also had an alert to add a prescription for the antidote drug Naloxone when prescribing opioids. That alert led to a 5,000% increase in Naloxone prescribing in the past three months.

Beyond the EMRs, officials said every provider that is licensed to prescribe narcotics is required to be trained in alternatives for pain relief and attend mandatory town hall meetings to identify processes and tools for safe opioid prescribing. The health system implemented a safe opioid prescribing simulation program to allow providers to practice difficult discussions with patients seeking opioids.

“We’ve been tackling the opioid epidemic for a long time. Not until recently, did we recognize that providers can do a lot more,” said Akram Boutros, M.D., president and CEO of MetroHealth.

The health system also opened a Pain & Healing Center, which includes alternative pain management therapies such as acupuncture, infusion therapy, reiki, pain management, neurology, psychology and psychiatry.

This comes a year after MetroHealth created an Office of Opioid Safety to focus on education, advocacy and treatment.

It's also part of a broader shift in MetroHealth's approach. In January, MetroHealth began transforming its campus to include far more green space, designing it as a "hospital in a park." At the time, officials said the change wasn't just about beautifying its campus but about incorporating more holistic healing strategies.

Frank Landman


Technology has changed communication and consumerism so fast that we barely notice it anymore. Less than a decade ago, most people couldn’t imagine things like smart homes and augmented reality. Now, they’re regular consumer products.

In healthcare, though, technology’s impact hasn’t been so subtle. As costs rise at nearly unbearable rates and patients become more involved in their care, new technologies play an increasingly vital role in helping healthcare organizations improve the quality of care they provide.

Patients, or the consumers in the healthcare industry, have benefited most from the industry’s technology race. From preventive treatments to virtual care and more effective disease management, these are just a few ways healthcare leaders can leverage tech to transform the industry:


1. Use data and machine learning to prevent catastrophe.

Data collection and machine learning have been two of the biggest disruptions in healthcare, and predictive analytics is the most notable reason why. By using AI to analyze data on patient and population health trends, providers can more accurately predict health crises and pinpoint their origins to prevent the spread of illness.

This tech was put into action last spring when Pariveda Solutions, a strategic services and information technology consulting company, and a Texas-based pediatric healthcare system used predictive analytics to help stop an infectious, hospital-borne disease that was spreading through the hospital at the time. They collected data on who cared for, saw and delivered medicine to the impacted children and tracked the movements of everyone on that list. In four weeks, predictive analytics determined the problem was central line-associated bloodstream infection (CLABSI), and the hospital was able to prevent it from spreading further

2. Make essential care more accessible with telemedicine, while decreasing data security risks.

For patients who experience mobility issues or who live in rural areas, telemedicine has provided a way to seek medical care more conveniently and given patients more choice in healthcare providers. They can schedule their appointments online with a laptop or mobile device, videoconference with providers to avoid unnecessary trips to the doctor’s office and even rely on internet-connected devices for remote health-related monitoring.

On the other hand, telemedicine may expose a healthcare organization and its patients to security risks involving HIPAA-protected information. Hackers and ransomware are rampant, so organizations must ensure their communications are protected. Fortunately, tech has stepped up to help with that as well, as evidenced by companies like Paubox, which specializes in a HIPAA-compliant email encryption service to protect against data breaches.

3. Provide more accurate, cost-effective treatment through electronic record keeping.

Since electronic medical records began to become standard in 2014, accuracy in medications and treatments throughout a patient’s care cycle has improved significantly. When patients move or must visit a specialist provider, EMRs are even more important in reducing errors. Computerized physician’s orders are easier to understand, patients’ compliance with those orders is easier to track and health conditions are being treated without wasting money on needless procedures.

According to an Institute of Medicine report, $210 billion is spent annually on unnecessary medical care each year. Fortunately, electronic patient records can play a role in reducing this waste. The positive effects of EMRs can be seen at Virginia Mason Medical Center, where an analysis of medical claims data found that high-cost treatments for conditions like back pain, headaches and sinus problems were being driven by expensive MRIs and CT scans, many of which were unneeded. Harvard Business Review reports that when the center embedded an evidence-based checklist for ordering advanced imaging into its EMRs, the use of these costly tests fell 25 percent.

4. Use video games and virtual reality to help with rehabilitation.

When video games become physically interactive with the Nintendo Wii, consumers realized that video games could actually help improve their physical health. Because the Wii’s controllers are operated with motion, games that involve movement — such as running, jumping, swinging a racket or rolling or throwing a ball — force players to get up and move to play. It didn’t take long for healthcare organizations to see the potential benefits of the Wii for everything from poststroke rehabilitation to promoting physical fitness in long-term care facilities.

Meanwhile, some in the medical field have envisioned benefits beyond getting exercise. A study published in the Journal of Geriatric Physical Therapy showed that bowling on the Wii helped elderly patients reduce their risks of falling and suffering an injury. Now, rehabilitation experts routinely use video games and virtual reality to help patients recover from serious injuries, cardiovascular disease, trauma and much more. The Creative Media and Behavioral Health Center at the University of Southern California, for instance, has found virtual reality and video games can help motivate patients who do at-home physical therapy.

Among industries increasing their tech use, healthcare has seen some of the most significant transformations from widely implementing advanced technology. The exciting thing is that technology continues to evolve, and with a firm grip on today’s leading advancements, the medical field is poised to transform even further.