Category Archives: Health Care Quality
This week, NewPublicHealth will run a series on new and creative public health campaigns that aim to improve the health of communities across the country through the use of public service announcements, infographics and more. Stay tuned to learn more about a new campaign each day.
As the country turns increasingly gray, more and more adults are experiencing the stresses and strains of caring for aging family members. It has long been a silent struggle for many of the nation’s 42 million unpaid caregivers, but the full impact of family caregiving is starting to come out from the shadows thanks to a major ongoing campaign from the AARP and the Ad Council first launched in 2012. Through a series of ads for television, radio, print media and digital venues, the campaign aims to raise awareness of the ripple effects of family caregiving and to steer overwhelmed families toward resources that may ease the pressure.
The public service advertisements (PSAs) depict the sense of isolation, responsibility and frustration family caregivers often feel as they tend to their loved ones—providing reassurance that they are not alone with these challenges. The ads also highlight a community of experts set up by the AARP to help caregivers take better care of themselves while caring for others and to encourage caregivers to access online tools or call a toll-free hotline (877-333-5885). The website includes resources on planning for long-term care (legally, financially and in other ways) and advice on dealing with emotional issues such as grief and loss.
Nearly 30 percent of caregivers report feeling sad or depressed, and 33 percent isolate themselves by avoiding people or social situations, according to a 2013 AARP report, Caregivers: Life Changes and Coping Strategies. Moreover, 38 percent of those caring for a loved one say they sleep less since they became caregivers, and 44 percent admit they try to squelch their feelings. An earlier survey by the AARP and the Ad Council, involving 500 caregivers between the ages of 40 and 60, revealed that 31 percent describe their caregiving tasks as extremely or very difficult; 21 percent say they don’t feel like they have the support they need; and 26 percent don’t feel confident about knowing where to turn to find support and information for unpaid caregivers.
“Only those who care for others know what it’s really like to care for others—that’s why we created a community where caregivers can connect with experts and others facing similar challenges,” said AARP CEO Barry Rand. “We hope this campaign will help the millions of family caregivers in the U.S. feel heard and supported, in turn, helping them better care for themselves and for the ones they love.”
As an offshoot of the Caregiver Assistance PSAs, the AARP and Ad Council also launched the “Thanks Project”, a digital opportunity for family members and friends to publicly acknowledge and appreciate how much they value the contributions from the caregivers in their lives. The idea is that a note of thanks can mean a lot to caregivers.
>>Bonus link: Read a NewPublicHealth interview with Gail Sheehy, author of “Passages in Caregiving: Turning Chaos into Confidence.”
Toby Cosgrove, MD, CEO of the Cleveland Clinic, spoke about bringing a business lens to health during a panel discussion this morning at the Spotlight: Health expansion program of the Aspen Ideas Festival. In an article in this month’s Harvard Business Review, he wrote that “Fixing health care will require a radical transformation, moving from a system organized around individual physicians to a team-based approach focused on patients.”
NewPublicHealth spoke to Cosgrove about this transformation just before the Spotlight: Health conference.
Toby Cosgrove: The first thing we did is that for the last decade we’ve been very transparent around our quality, and we’ve released books on quality outcomes which are available both in paperback form and on our website. The second thing that we’ve done is we’ve consolidated services. For example, we started out having six hospitals in the system that provided obstetrics care, and now we’ve got three and are about to have two. And each time we’ve consolidated we’ve increased the volume of patients and improved the quality. We’ve done consolidations with pediatrics, cardiac surgery, rehabilitation, psychiatry, trauma and obstetrics. We think that it’s called the practice of medicine—the more you practice at it, the better you get at it, and every time we’ve done that we’ve seen that happen.
In Cleveland, for example, we partnered with Metro Health, a large network of health providers. We previously had five trauma centers in Cleveland. Now we have three and as we’ve done that, the mortality rate has improved 20 percent. So there are real activities that have begun to drive the business approach.
NPH: What are other ways that the Cleveland Clinic has been able to respond to consumer needs using a business model?
Cosgrove: We think you’ve got to do three things. You’ve got to have improved access, quality and affordability. The access is not just having insurance—the access is actually getting to see a provider, and last year we provided about one million same-day appointments in addition to our scheduled ones. We also took our emergency room wait times from 43 minutes to 11 by changing the system that we use. And in our call center we’ve reduced the number of dropped calls and improved the speed of answers. All of that is aimed at giving patients access to the caregivers. We also reorganized our internal system so that when you, say, have a neurologic problem, instead of coming to see a neurologist and then a neurosurgeon, you come into the neurologic institute where you can be seen in one location under one leadership of neurology, neurosurgery and psychiatry, so that you are seamlessly seen with all the specialties right there in one location.
Idea Gallery is a recurring editorial series on NewPublicHealth in which guest authors provide their perspective on issues affecting public health. In this Idea Gallery, Brian C. Quinn, PhD, the Robert Wood Johnson Foundation’s Assistant Vice President, Research-Evaluation-Learning, provided his perspective on how to address medical conspiracies and other controversial narratives when developing a Culture of Health.
You may have recently seen the headline “Half of Americans believe in medical conspiracy theories”—or one like it—on your favorite news outlet. Or even on The Onion.
When the Robert Wood Johnson Foundation decided to fund the study responsible for grabbing these headlines, we wanted to know much more than just how many—as in, “How many Americans believes in health conspiracies?” We wanted to answer many other “how” questions, too. How do these beliefs spread? How do they correlate with people’s health behaviors? How should providers and others approach treating and talking to those who hold these beliefs?
>>What can medical conspiracy theories tell us about improving health and health care? A lot, as you’ll hear in this conversation between RWJF's Brian Quinn and University of Chicago political scientist Eric Oliver.
It’s important to note that this study’s authors did not set out to pass judgment on these controversial narratives—or those who hold them. In fact, it was critical to the researchers’ success that they remain agnostic in that regard. The bottom line is nearly half of Americans believe in at least one health conspiracy, such as the government is hiding evidence that cell phones cause cancer or the U.S. Food and Drug Administration is intentionally suppressing natural cures for cancer. And, if we are serious about building a Culture of Health, we cannot afford to ignore the perspective of one in every two Americans.
I recently enjoyed a fascinating conversation with the study’s lead researcher, University of Chicago political scientist Eric Oliver, and came away with a few such insights that should enlighten—and may even surprise—some of you.
With the passage of the Mental Health Parity Act and the implementation of the Affordable Care Act (ACA), behavioral health experts are pushing to improve the quality of that care so that people seeking help—some for the first time—receive evidence-based care that best suits their individual needs. As part of that conversation, the U.S. Senate Health, Education, Labor and Pension committee held a hearing this week on mental health treatment trends in the United States.
Sen. Tom Harkin (D-Iowa) the committee chair opened the hearing by “pointing to disturbing new trends [including]...significant increases in the prescribing of psychotropic medications, while the use of behavioral and psychological treatments among children and youth has increased only slightly, and has actually decreased among adults.”
According to committee research on recent use of psychotropic drugs, use of antipsychotic medications has increased eight-fold among children and five-fold among adolescents, and has doubled among adults between 1993 and 2009.
The key witness at the hearing was William Cooper, MD, MPH, a professor of pediatrics and health policy at the Vanderbilt University School of Medicine who conducts population-based studies of medication use in children. Cooper told the committee about a nine-year-old boy he treated for weight gain—which turned out to be a side effect of a psychotropic drug the child had been prescribed by a primary care provider given for disturbing the classroom. No mental illness diagnosis had been made for the child, and no mental illness was detected after evaluation at Vanderbilt.
Cooper said that in recent years the United States has seen a tremendous increase in the numbers of children diagnosed with mental health disorders.
“Whether this is a result of increased awareness, improved diagnosis, or other factors is not clearly understood,” said Cooper, who added that “while we must acknowledge that a part of the increase could be due to over-diagnosis, there is no disputing the fact that a large number of children and their families suffer significantly because of mental illness.”
Furthermore, added Cooper, given the fact that suicide is the second leading cause of death for children ages 12-17, “tragic consequences of childhood mental health disorders highlight our sense of urgency in addressing this important problem.”
Cooper added that treating mental health disorders can be challenging and that 50-75 percent of the care for children with mental health disorders occurs in primary care settings “making it critical that consultation and communication between primary care professionals and experts in mental health be enhanced.”
Significantly, Cooper told the panel that despite guidelines, much of the mental health care for children occurs in a manner “inconsistent with optimal practice,” including:
- Use of medications for diagnoses for which there is little evidence of benefit.
- Use of multiple medications at the same time, especially among particularly vulnerable children such as children in foster care, where a recent study found multiple psychiatric medications in up to 75 percent of children being treated.
- Use of medications alone without proven psychotherapies.
Cooper attributed the problems to several factors, among them:
- Many general practice doctors are unaware of current mental health treatment guidelines.
- Inadequate mental health resources to provide best treatments.
- Too few professionals with training in providing mental health care to children.
- Barriers to treatment, including cost or the need to travel long distances.
- Stigma associated with mental illness, which may reduce families’ willingness to acknowledge a mental health disorder and seek treatment.
The HELP committee plans to hold additional hearings to address mental health issues. Other attention to the issues addressed at the hearing include a recent meeting in Washington, D.C. among professionals who conduct psychiatric clinical trials. They stressed the need to involve patients and families more in trial design and access, as well as to work with trial designers on mental health needs not currently being met.
The Substance Abuse and Mental Health Services Administration, a federal agency, recently announced several new funding grants to help individual groups facing mental health concerns including:
- A grant program for residential treatment of pregnant and postpartum women.
- A grant program to expand and sustain comprehensive community mental health services for children and their families, in order to improve behavioral health outcomes for children and youth with serious emotional disturbances, as well as improve the health and well-being of their families.
- A grant program to provide tribal and urban American Indian and Alaskan Native communities with tools and resources to plan and design a holistic, community-based coordinated system of care approach to support mental health and wellness for children, youth and families.
Read more about mental health on NewPublicHealth.
What’s that cute blue thing shining its lights in the patient rooms and hallways of the National Institutes of Health’s (NIH) clinical center in Bethesda, Md.? A literal life saver.
Tru-D, a new robot now gainfully employed at the NIH, shoots beams of ultraviolet (UV) light. The rays kill a range of pathogens, including many of the bacterial strains—such as MRSA and C.diff—that have been linked to 90,000 health system deaths each year, according to the U.S. Centers for Disease Control and Prevention (CDC).
Manual disinfecting rids surfaces of about half of the bacteria in an area. Limitations of human cleaning squads include the probability they can miss a few—or many—spots and that disinfectants must remain wet on a surface for a full ten minutes to fully do their job and then be rinsed away. That time commitment is often very costly for hospitals that typically need to turn over patient rooms quickly. But incomplete disinfection can leave a lot of disease. MRSA, for example, can remain on surfaces for as long as nine months.
The UV light units work by disrupting the DNA structure of pathogens, which destroys some and makes others harmless.
Tru-D is just one of several UV light units on the market. It has been getting some attention recently both because of the NIH purchase and because it has some especially interesting features, including a cloud-computing system that lets it link up to health system records and automatically chart which rooms have been disinfected.
UV light doesn’t come cheap. Units, which come in different sizes that determine how wide a space they can disinfect simultaneously, can range from about $60,000 to $120,000. But hospitals also consider what they’re saving by making the purchase—such as new fines under the Affordable Care Act for some hospital readmissions before thirty days after a discharge. And some of those readmissions are for infections acquired during a hospital stay.
The units won’t displace the human cleaning staff, says Steve Streed, system director of Epidemiology/Infection Control at the Lee Memorial Health System in Fort Myers, Fla. and a member of the Association for Professionals in Infection Control and Epidemiology For example, the robots can’t rid spaces of blood and other substances humans leave behind.
UV units can disinfect a space in ten or twenty minutes. One limitation on their power and cleaning time is the wattage in hospitals. Units can be made more powerful but would blow out a hospital’s circuits. Streed says one company is working on a hybrid unit that would use both electricity and battery to amp up the wattage—and likely reduce the time needed—to disinfect hospital spaces.
Streed says recent studies have found that human disinfecting still leaves 50 percent of residual bacteria and UV light gets rid of 99 percent of what remains. Another disinfecting system, fogging rooms with hydrogen peroxide, gets rid of 99.9 percent, but takes more time since air ducts have to be closed before it use and then reopened afterwards. Either option gets rid of sufficient bacteria, says Streed. What remains is generally not in high enough levels to infect a patient.
>>Bonus Link: Read a CDC Vital Signs Report on Hospital Acquired Infections.
Caring for the millions of people acquiring health coverage under the Affordable Care Act will require many more primary care providers than are currently available. At a session today on New Models and Workforce Innovations for Primary Care Access at the 2014 National Health Policy Conference convened by AcademyHealth, presenters talked about emerging specialists for primary care, including nurses, physician assistants and care coordinators, who are also known as community health workers.
Pharmacists are also included in that provider model. Jeffrey Kang, MD, MPH, senior vice president of health and wellness at Walgreens, presented data on a model program the pharmacy chain has at more than a dozen hospitals which is helping reduce hospital readmissions. Walgreens has pharmacies at dozens of hospitals across the United States and with its pilot program, called WellTransitions, works with hospital discharge staff on medicine instructions and then follows up with phone calls once patients are home.
Kang said a key question is whether someone is taking the right medicine. In the medication orders system there is no procedure, other than patient initiative, for stopping a previously prescribed medication. For example, if a patient had been taking a blood pressure medication before a hospital stay and then is prescribed a new one in the hospital, they may still have vials of the drug at home, and studies show they commonly continue taking the drug, either instead of, or in addition to the drug prescribed during the recent hospital stay.
With the WellTransitions program, drugs are delivered to the patient before discharge, avoiding a trip to the pharmacy, and pharmacists follow up at 9 days and 25 days.
Walgreens launched the program in 2012 and released data late last year that showed that early results indicate that within the first 6 months that WellTransitions was operational in five hospitals, the 30-day readmission rate for patients in the program was 9.4 percent, compared with 14.3 percent for patients not participating in the program.
The Alliance for Health Reform will hold a briefing today in Washington, D.C. on an increasing trend at hospitals of "observing"—instead of admitting—Medicare beneficiaries to hospitals. The briefing follows an AARP report issued earlier this month, Rapid Growth in Medicare Hospital Observation Services: What’s Going On?. The report found that a key reason for the rise in hospital observations among Medicare beneficiaries is that under the Affordable Care Act hospitals can face penalties of 2 percent of hospital charges for patients readmitted to the hospital before thirty days after discharge—which don’t apply if the patient is observed rather than admitted.
Observation status is a long-standing one. For decades it has allowed emergency room staff to determine whether it’s safe for the patient to be sent home. But patients may face higher charges in the emergency room than they would as an inpatient, and may not qualify for Medicare-covered nursing home care after their hospital stay if they were observed and not admitted.
The AARP report analyzed the frequency and duration of the use of observation status for Medicare beneficiaries between 2001 and 2009. It found more than 100 percent growth over nine years, and an even greater percentage increase in the length of time spent in observation, with visits longer than 48 hours increasing the most.
“The dramatic increase in the use of observation status for Medicare patients deserves a closer look,” said Debra Whitman, AARP Executive Vice President for Policy, Strategy and International Affairs. “The clinical benefit of long-term observation remains questionable. And for Medicare patients who remain in the hospital under observation, they may not realize the high out-of-pocket costs they'll have to pay.”
Bipartisan legislation has been introduced in both the House and Senate to count the time spent in observation toward the three-day stay requirement.
>>Bonus Link: The focus of this month’s issue of Health Affairs is the future of emergency medicine.
>>Bonus Content: Follow the briefing on Twitter: #ObservationStatus
The Public Health Quality Improvement Exchange (PHQIX) is an online communication hub for public health professionals interested in learning and sharing information about quality improvement in public health. Created by RTI International and funded by The Robert Wood Johnson Foundation, PHQIX launched in September of 2012 with the goal of sustaining national efforts at quality improvement by providing public health practitioners with the opportunity to learn from the experiences of their colleagues. PHQIX includes:
- An online database of quality improvement efforts by public health departments across the country
- Search and query functions to help users find relevant examples for their own work
- A forum for dialogue on quality improvement
A recent initiative shared on the site called Operation Chuckwagon looked at the maintaining quality control of food safety for mobile food trucks in Northern Kentucky.
Food trucks are growing in popularity across the country as an inexpensive way to try different cuisines, and following some of the weather disasters this past year, some municipalities dispatched food trucks, with cost covered for residents, to areas without power and in need of food. Safety is critical. A recent report in the Morbidity and Mortality Weekly Report from the Centers for Disease Control and Prevention found an outbreak of 91 salmonella cases linked to lunch trucks in Alberta, Canada. An investigation by food inspectors found many food storage and handling violations.
The Kentucky project increased the percentage of properly licensed mobile food vendors to 100 percent from a baseline of 25 percent, and also achieved a 100 percent compliance rate with required temperature controls, which had been a big problem during initial inspections.
NewPublicHealth recently spoke with Ted Talley, environmental health manager at the health department, about the quality improvement initiative.
NewPublicHealth: What’s novel about how you’ve approached the food trucks and made it easier for them to have food safety inspections?
Last week, efforts to add a ten year old with cystic fibrosis to the list of adult patients waiting to get donated lungs, increasing her chances of a transplant, made big news. NewPublicHealth had planned to write about the urgent need for citizens to step up and sign on to become organ donors and help whittle down the long lists of patients desperately waiting for hearts, lungs, kidneys and other organs. But our colleagues at the The Public’s Health, a well-worth-reading public health blog hosted by the Philadelphia Inquirer, beat us to it. We urge you to read the post by Michael Yudell, one of the blog’s writers as well as an associate professor at the Drexel University School of Public Health.
"…The demand for organs in the United States far outpaces the supply. There are currently 75,650 active candidates (meaning they are medically suitable for a transplant) waiting for organs in the United States. But 18 people die every day, on average, waiting for an organ transplant."
To what lengths will hospitals go to make sure their employees are washing their hands? The answer for North Shore University Hospital on Long Island, N.Y., is thousands of miles to India where far-flung employees check their monitors, trained on the hospital floors, to find workers who skip the sinks on their way to the hospital’s intensive care units. According to a recent article in the New York Times, that is just one of many ways hospitals are working to increase hand washing and stop the spread of germs that can kill hospitalized patients. Other methods include free pizza and coffee incentives for frequent hand-washers and embedded chips on hospital employees that emit an alarm when a doctor bypasses a sink outside a patient room.
A March report from the Centers for Disease Control and Prevention (CDC) easily explains the increasing emphasis on hospital hand washing. According to the report, a family of bacteria called Carbapenem-Resistant Enterobacteriaceae, which includes e.coli, have become increasingly resistant to last-resort antibiotics during the past decade, and more hospitalized patients are developing incurable infections. CDC researchers found that during the first half of 2012, 4 percent of hospitals and 18 percent of long-term care facilities treated a patient with this type of infection.
Some hospitals have incentive ideas that employers and families can adopt including buttons that say, “Ask me if I’ve washed my hands?”
>>Read the article.