Chicago is getting healthier. How do we know this? Because Chicago residents are living longer. L... more Chicago is getting healthier. How do we know this? Because Chicago residents are living longer. Life expectancy has long been one of the most commonly used measures of a population’s general health as it is a reflection of a number of overall indicators which include quality of care, access to care, health behaviors and the environment. This report shows a dramatic increase in our City’s life expectancy over the past two decades. A Chicago resident born today can expect to live to 77.8 years of age, a new high for our City and more than seven years longer than a resident born in 1990. Not only are Chicagoans living longer, but we are outpacing the nation. Since 1990, our life expectancy has grown twice as fast as the U.S. rate overall. True, the U.S. rate is still slightly higher, but that gap is closing quickly. Furthermore, as this report demonstrates, the improvements in life expectancy are being felt across our great city. In fact, we have seen significant increases in life expe...
Building organizational capacity is critical for hospitals participating in payment models such a... more Building organizational capacity is critical for hospitals participating in payment models such as bundled payments and accountable care organizations, particularly "co-participant" hospitals with experience in both models. This study used a national survey of American Hospital Association member hospitals with bundled payment experience, with (co-participant hospitals) or without (bundled payment hospitals) accountable care organization experience. Questions examined capacity in 4 domains: performance feedback, postacute care provider utilization, care management, and health information technology. Of 424 hospitals, 38% responded. Both co-participant and bundled payment hospitals reported high capacity for performance feedback and risk stratification and predictive risk assessment using health information technology systems. The hospital groups did not differ in care management capacity, but bundled payment hospitals reported higher postacute care provider utilization capacity. Experience with multiple payment models may prompt hospitals to make different investments or adopt different strategies than hospitals with experience in a single model.
Background and Aims Opioid substitution treatment is used in many countries as an effective harm ... more Background and Aims Opioid substitution treatment is used in many countries as an effective harm minimization strategy. There is a need for more information about patient safety incidents and the resulting harm relating to this treatment. We aimed to characterize patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care by: (i) identifying the sources and nature of harm and (ii) describing and interpreting themes to identify priorities to focus future improvement work. Design Mixed-methods study examining patient safety incident reports involving opioid substitution treatment with either methadone or buprenorphine in community-based care. Setting Data submitted between 2005 and 2015 from the National Reporting and Learning System (NRLS), a national repository of patient safety incident reports from across England and Wales. Participants A total of 2284 reports were identified involving patients receiving community-based opioid substitution treatment. Measurements Incident type, contributory factors, incident outcome and severity of harm. Analysis involved data coding, processing and iterative generation of data summaries using descriptive statistical and thematic analysis. Findings Most risks of harm from opioid substitution treatment came from failure in one of four processes of care delivery: prescribing opioid substitution (n = 151); supervised dispensing (n = 248); non-supervised dispensing (n = 318); and monitoring and communication (n = 1544). Most incidents resulting in harm involved supervised or non-supervised dispensing (n = 91 of 127, 72%). Staff-(e.g. slips during task execution, not following protocols) and organization-related (e.g. poor working conditions or poor continuity of care between services) contributory factors were identified for more than half of incidents. Conclusions Risks of harm in delivering opioid substitute treatment in England and Wales appear to arise out of failures in four processes: prescribing opioid substitution, supervised dispensing, non-supervised dispensing and monitoring and communication.
IMPORTANCE An association between social and neighborhood characteristics and health outcomes has... more IMPORTANCE An association between social and neighborhood characteristics and health outcomes has been reported but remains poorly understood owing to complex multidimensional factors that vary across geographic space. OBJECTIVES To quantify social determinants of health (SDOH) as multiple dimensions across the continental United States (the 48 contiguous states and the District of Columbia) at a small-area resolution and to examine the association of SDOH with premature mortality within Chicago, Illinois. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, census tracts from the US Census Bureau from 2014 were used to develop multidimensional SDOH indices and a regional typology of the continental United States at a small-area level (n = 71 901 census tracts with approximately 312 million persons) using dimension reduction and clustering machine learning techniques (unsupervised algorithms used to reduce dimensions of multivariate data). The SDOH indices were used to estimate age-adjusted mortality rates in Chicago (n = 789 census tracts with approximately 7.5 million persons) with a spatial regression for the same period, while controlling for violent crime. MAIN OUTCOMES AND MEASURES Fifteen variables, measured as a 5-year mean, were selected to characterize SDOH as small-area variations for demographic characteristics of vulnerable groups, economic status, social and neighborhood characteristics, and housing and transportation availability at the census-tract level. This SDOH data matrix was reduced to 4 indices reflecting advantage, isolation, opportunity, and mixed immigrant cohesion and accessibility, which were then clustered into 7 distinct multidimensional neighborhood typologies. The association between SDOH indices and premature mortality (defined as death before age 75 years) in Chicago was measured by years of potential life lost and aggregated to a 5-year mean. Data analyses were conducted between July 1, 2018, and August 30, 2019. RESULTS Among the 71 901 census tracts examined across the continental United States, a median (interquartile range) of 27.2% (47.1%) of residents had minority status, 12.1% (7.5%) had disabilities, 22.9% (7.6%) were 18 years and younger, and 13.6% (8.1%) were 65 years and older. Among the 789 census tracts examined in Chicago, a median (interquartile range) of 80.4% (56.3%) of residents had minority status, 10.2% (8.2%) had disabilities, 23.2% (10.9%) were 18 years and younger, and 9.5% (7.1%) were 65 years and older. Four SDOH indices accounted for 71% of the variance across all census tracts in the continental United States in 2014. The SDOH neighborhood typology of extreme poverty, which is of greatest concern to health care practitioners and policy advocates, comprised only 9.6% of all census tracts across the continental United States but characterized small areas of known public health crises. An association was observed between all SDOH indices and age-adjusted premature mortality rates in Chicago (R 2 = 0.63; P < .001), even after accounting for violent crime and spatial structures. (continued) Key Points Question How do social determinants of health vary across multiple dimensions and geographic space? Findings In this cross-sectional study of 71 901 census tracts with approximately 312 million persons across the continental United States, multivariate social determinants of health measures were reduced to 4 indices reflecting advantage, isolation, opportunity, and mixed immigrant cohesion and accessibility and were clustered into 7 neighborhood typologies that included an extreme poverty group. Social determinants of health indices were associated with premature mortality rates in Chicago, Illinois. Meaning The use of multidimensional geospatial approaches to quantify social determinants of health rather than the use of a singular deprivation index may better capture the complexity and spatial heterogeneity underlying these determinants.
On any given day, 1 in every 25 hospitalized patients has a health careassociated infection (HAI)... more On any given day, 1 in every 25 hospitalized patients has a health careassociated infection (HAI) (1). These infections affect patient care, add costs to the U.S. health care system, and challenge hospitals that struggle to achieve substantive reductions in infection rates. Several national efforts, including collaborations among the Health Research & Educational Trust (HRET), the University of Michigan, and other partners (2, 3), have focused on HAI prevention. Overall, hospitals and long-term care facilities have made enormous progress in driving down preventable HAIs. However, hospitals must work to close the remaining performance gaps, and to identify novel and sustainable approaches to addressing this issue. The HAI National Action Plan goals framed the Centers for Disease Control and Prevention (CDC) vision for the STRIVE (States Targeting Reduction in Infections via Engagement) program (4). This 3-year program (20152018) focused on improving infection control practices and strengthening key stakeholder relationships to improve infection control efforts at the hospital and statewide levels. The HRET recruited 462 hospitals in 28 states and the District of Columbia, with 443 hospitals completing the 12-month program. STRIVE used evidence-based HAI reduction strategies and relationship-based methods to address HAI rates in hospitals with a high cumulative attributable difference rate in Clostridioides difficile and at least one other HAI (central lineassociated bloodstream infection, catheter-associated urinary tract infection, or methicillin-resistant Staphylococcus aureus infection). The HRET collaborated with the CDC, Association for Professionals in Infection Control and Epidemiology, American Society for Health Care Engineering, Society of Hospital Medicine, University of Michigan, and other experts to provide technical assistance and guidance. This national program team built a structured, stepwise curriculum for all enrolled hospitals to reduce HAIs and, in doing so, developed new alliances. The curriculum emphasized horizontal (called foundational) infection prevention strategies, such as hand hygiene and environmental cleaning, that cut across all HAIs (5), as well as socioadaptive solutions, such as team building and leadership engagement, to address the attitudinal and cultural changes that must occur to ensure consistent application of evidence-based guidelines (6). STRIVE also encouraged statewide collaboration on HAI reduction efforts for hospitals by bringing together state hospital associations, state health departments, and quality innovation networks/quality improvement organizations. The STRIVE materials and techniques focused on embedding evidence-based infection prevention practices across teams. For example, one module in the curriculum promoted team engagement across multiple departments. Program education emphasized changing traditional communication methods in order to break the cycle of infections. Standardized protocols to promote accountability and reduce the spread of nosocomial infections were emphasized throughout. A dedicated patient and family engagement module highlighted how patients and families can be active partners to improve care. The curriculum reinforced the importance of using standardized processes in a complex system, such as a hospital, to ensure patient safety. Results showed some hospitals realized some improvements in outcome and process measures, and some maintained or achieved zero infections during the intervention period. However, in aggregate, there was no statistically significant change over time during the program intervention period compared with the baseline period for any of the HAIs (710). So we asked, Why not? Various explanations, including limitations of data collection and analysis as well as inconsistent engagement due to competing priorities and high staff turnover, are possible. Also, because some hospitals began with low HAI rates, the ability to see a statistically significant change over time may have been reduced. Qualitative findings did show stronger stakeholder relationships had been established that could align and sustain HAI prevention across the entire patient continuum of care (11). Did our program accelerate the journey to zero preventable HAIs? Although all hospitals worked hard at this effort, some achieved greater success than others. This reality begs the question: Why is HAI prevention so difficult? Many reasons have been cited in the literature that include the immense financial and workforce challenges and staff turnover experienced by participating hospitals. These challenges can be especially difficult for hospitals that need resources to educate staff on standardized, evidence-based practices shown to reduce HAIs. Access to HAI consistent staff training and development and other evidence-based guidelines and systems to easily implement them and review data sounds like a simple solution, but in reality, HAI…
Success in reducing rates of catheter-associated urinary tract infection (CAUTI) and unnecessary ... more Success in reducing rates of catheter-associated urinary tract infection (CAUTI) and unnecessary urinary catheter use has varied over time, by clinical setting, by CAUTI definition, and by data source used for tracking these metrics (16). Although meta-analyses of the published peer-reviewed literature indicate that up to approximately 50% of CAUTIs can be prevented, many hospitals have had less success (7, 8). To help hospitals that still struggle with CAUTI, as well as other health careassociated infections (HAIs), the Centers for Disease Control and Prevention (CDC) funded the STRIVE (States Targeting Reduction in Infections via Engagement) initiative (9). Beginning in June 2016, the STRIVE initiative rapidly engaged multiple state organizations to partner and facilitate the implementation of a curriculum to prevent HAIs among 4 cohorts of hospitals experiencing high burdens of HAIs, as defined by National Healthcare Safety Network (NHSN) metrics reported by the CDC (Appendix Table). This curriculum included a focus on horizontal infection prevention practices as the foundation (13), as well as vertical approaches targeting prevention of specific HAIs, including CAUTI, central line-associated bloodstream infection (CLABSI), Clostridioides difficile, and hospital-onset methicillin-resistant Staphylococcus aureus bloodstream infection. Appendix Table. The CAUTI Metric With an increasing number of studies describing multicomponent strategies to prevent CAUTI, it can be difficult for hospital teams to choose among interventions to reduce CAUTI. Informed by recent literature reviews and guidelines for prevention of CAUTI in multiple clinical settings, our multidisciplinary team applied a tiered approach to organize and prioritize CAUTI prevention interventions for STRIVE hospitals. This article summarizes the evidence base and development of the tiered approach to prioritize CAUTI interventions. Project Structure With extensive experience in performing and publishing literature reviews focused on CAUTI prevention, team members from the University of Michigan reviewed and summarized several recent and comprehensive literature reviews as well as recent guidelines. This literature review included 3 systematic reviews funded in recent years by the Agency for Healthcare Research and Quality (AHRQ) to summarize the evidence for CAUTI prevention in the acute care, intensive care unit (ICU), and long-term care settings (7, 14, 15). The studies reviewedincluding design, intervention details, and outcomesare described thoroughly in these publications and their appendix tables. Multiple guidelines were also reviewed and consulted: the 2009 guideline from the Healthcare Infection Control Practices Advisory Committee (HICPAC) that provides guidance to the U.S. Department of Health and Human Services and the CDC (16), including application of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system approach for evaluating quality of evidence and determining strength of recommendations; the 2009 CAUTI International Clinical Practice Guidelines from the Infectious Diseases Society of America (IDSA) (17); the 2014 CAUTI guideline update coming jointly from the IDSA and the Society for Healthcare Epidemiology of America (18); the 2008 European and Asian guidelines for CAUTI prevention (19); and the 2015 evidence-based tool and guidance document from the American Nurses Association (20). We were also guided by the literature review performed and expert recommendations generated in the published Ann Arbor criteria (21), as well as the preliminary results of a similarly performed literature review and appropriateness panel ratings for use of catheters in general surgery and orthopedic surgery patients (22). In contrast to the literature assessing prevention of CLABSI, the great majority of the current literature on CAUTI prevention reports nonrandomized study designs that are of relatively low quality (14). Only a few CAUTI studies used the more robust randomized, controlled trial design, and those were often limited to the evaluation of single technological interventions, such as a new securement device or antimicrobial catheter (1416, 18). Consequently, in the 2009 CAUTI prevention guideline from HICPACwhere formal study quality assessment was performed (16)even the most basic and often perceived as critical interventions for CAUTI prevention (for example, placing indwelling catheters only for appropriate reasons, promptly removing when no longer needed, aseptic insertion and maintenance technique, and implementing quality improvement programs for reducing CAUTI) were given a HICPAC category 1B recommendation (defined as a strong recommendation supported by low- to very-low-quality evidence). No CAUTI prevention strategies were given the strongest recommendation of category 1A, reserved for interventions supported by high- to moderate-quality evidence. Other strategies (such as using alternatives to…
This chapter starts by explaining a current trend in the transformation of the role of hospitals ... more This chapter starts by explaining a current trend in the transformation of the role of hospitals in advancing health in the community. The change is the result of demographic change and disease burden shifts which are moving away from acute to chronic. And hospitals and health systems are, as a result, leading an unprecedented transformation to re-envision their role and extend their impact beyond the clinic walls. They are working to create new models of care that prioritize teaming and partnership with the aim of engaging in true population health: advancing health and well-being by bridging care and community. The key, the chapter argues, is to promote affordability while enhancing value. The chapter concludes by stating that hospitals and health systems play an important role in the health of communities across the United States. While that role is changing and will likely continue to evolve, the importance of these institutions as anchors in their communities is likely to incre...
The Joint Commission Journal on Quality and Patient Safety
The Joint Commission's hospital antimicrobial stewardship (AS) standards became effective in ... more The Joint Commission's hospital antimicrobial stewardship (AS) standards became effective in January 2017. Surveyors' experience to date suggests that almost all hospitals have established AS leadership commitment and organized structures. Thus, The Joint Commission sought to examine advances in AS interventions and measures that hospitals could implement to strengthen their existing AS programs. METHODS The Joint Commission and Pew Charitable Trusts sponsored a meeting to bring together experts and key stakeholder organizations from around the country to identify leading practices for AS interventions and measurement. Presenters were asked to summarize the AS activities they thought were most important for the success of their own AS program and leading practices that all hospitals should be able to implement. RESULTS The panel highlighted two interventions as leading practices that go beyond current guidelines and established practices (that is, preauthorization and prospective audit and feedback). The first is diagnostic stewardship. This type of intervention addresses errors in diagnostic decision making that lead to inappropriate antibiotic prescribing. The second is handshake stewardship, a method of engaging frontline providers on a regular basis for education and discussions about barriers to AS from the clinician's perspective. The panel identified days of therapy (or defined daily dose, when days of therapy is not possible), Clostridioides difficile rates, and adherence to facility-specific guidelines as the preferred measures for assessing stewardship activities. CONCLUSION The practices highlighted should be given greater emphasis by The Joint Commission in their efforts to improve hospital AS, and the Centers for Disease Control and Prevention will be updating the Core Elements of Hospital Antibiotic Stewardship Programs.
Journal of cancer education : the official journal of the American Association for Cancer Education, Jan 14, 2017
Health literacy is critical for cancer patients as they must understand complex procedures or tre... more Health literacy is critical for cancer patients as they must understand complex procedures or treatment options. Caregivers' health literacy also plays a crucial role in caring for cancer patients. Low health literacy is associated with low adherence to medications, poor health status, and increased health care costs. There is a growing interest in the use of mobile health applications (apps) to improve health literacy. Mobile health apps can empower underserved cancer patients and their caregivers by providing features or functionalities to enhance interactive patient-provider communication and to understand medical information more readily. Despite the potentiality of improving health literacy through mobile health apps, there exist several related concerns: no equal access to mobile technology, no familiarity or knowledge of using mobile health apps, and privacy and security concerns. These elements should be taken into account for health policy making and mobile apps design ...
More than 1500 hospitals recently signed the American Hospital Association's 123forEquity ple... more More than 1500 hospitals recently signed the American Hospital Association's 123forEquity pledge and have begun implementing strategies to address economic and racial disparities in health care provision and outcomes. Despite these institutional commitments to equity, evidence suggests that the current growth in value-based payment models may counter these efforts, unintentionally worsening health care disparities by disadvantaging hospitals caring for socially at-risk populations (1). Because alternative payment models account for a mounting proportion of payments, equity will remain elusive unless explicitly incorporated into what we measure and pay for in health care. How can we move toward universal high performance standards while narrowing disparities? Much of the onus has fallen on how to actuarially adjust payments and penalties using socioeconomic risk factors (24). This method is insufficient for a few reasons. First, current socioeconomic risk measures have considerable limitations: We can adjust only what we can measure, and we may not be measuring the right exposures. Take Medicare data, a key driver of payment reform, in which sociodemographics are limited to race/ethnicity, dual eligibility for Medicaid and Medicare, and residency in rural or low-income areas. Although these measures are often good proxies for socioeconomic risk, others may better explain between-population variations in health outcomes, cost, and quality. Second, some experts are justifiably concerned that adjusting for socioeconomic risk, regardless of the measures used, may lower quality standards altogether, disincentivizing hospitals to improve performance (2). Therein lies the rub: The health care industry cannot ignore true instances of poor quality, but it also should not worsen health care for at-risk populations. To address this tension, value-based payment models should adopt a disparities-sensitive frame shift to integrate measures of equity into hospitals' financial calculus, incentivizing hospitals to tackle the disparities challenge without losing sight of quality. Achieving this frame shift requires us to continue determining which metrics matter most when addressing disparities in health care delivery and outcomes, both to improve risk adjustment and to establish which measures are actionable. To avoid underpaying hospitals that disproportionately serve socially at-risk patients, we should assess how risk adjustments would perform if they accounted for factors like socioeconomic position, social relationships, and community context, which the National Academy of Medicine has identified as key domains affecting health care outcomes (1, 5). The Medicaid payment formula used in Massachusetts is an example of how incorporating medical and social risk factors (such as mental health and housing instability) improved payments to hospitals by matching predicted to actual costs for high risk patients better (6). Practice-level coding of existing International Classification of Diseases, 10th Revision, codes for conditions like homelessness (Z59.0) and extreme poverty (Z59.5) may improve documentation and shift us toward adopting these billable diagnoses as a substantive component of hospital payment. These examples also highlight real-world laboratories in which to continue refining our approach to health equity: Which social risk factors most affect health outcomes? Which (alone or combined) provide the highest value, when modified, to produce cost savings or better outcomes? Concurrently, we should start paying hospitals to reduce disparities directly. Evidence indicates that hospitals with previously poor performance made the most gains in quality within alternative payment models (7), but we do not universally reward them for these gains. We certainly do not reward them for gains in equity. Furthermore, hospitals with poor patients are at a disadvantage. For example, under Medicare's Hospital Readmission Reduction Program, 86% of hospitals with poorer patients have been penalized in 2017, compared with 66% of those serving wealthier patients, a consistent pattern across the program's first 5 years (8). We believe that improving the financial outlook for hospitals that disproportionately care for high-risk populations (particularly rewarding hospitals that do this well) can reduce such stark disparities between hospitals. One approach is to pay for improvements in health care outcomes for populations we know have high social risksminority, low-income, and dual-eligible patientsa strategy already embedded in high-risk management programs used by accountable care organizations (9). Another approach ensures that hospitals address disparities by paying directly for services that disproportionately affect high-risk communities. For example, mental health is underpaid and likely a driver of disparities (10). Yet rather than incentivizing mental health treatment, value-based payment models have promoted spending on…
Academic medicine : journal of the Association of American Medical Colleges, Jan 24, 2018
For millions of Americans living in vulnerable rural and urban communities, their hospital is an ... more For millions of Americans living in vulnerable rural and urban communities, their hospital is an important, and often their only, source of health care. As transformation in the hospital and health care field continues, some communities may be at risk of losing access to health care services and the opportunities and resources they need to improve and maintain their health. Integrated, comprehensive strategies to reform health care delivery and payment, within which vulnerable communities can make individual choices based on their needs, support structures, and preferences, are needed.In this Invited Commentary, the authors outline characteristics and parameters of vulnerable communities as well as the essential health care services that hospitals should strive to maintain locally identified by the American Hospital Association Task Force on Ensuring Access in Vulnerable Communities. They also describe four of nine emerging strategies-recommended by the task force-to reform health c...
BACKGROUND The 340B Drug Pricing Program entitles qualifying hospitals to discounts on outpatient... more BACKGROUND The 340B Drug Pricing Program entitles qualifying hospitals to discounts on outpatient drugs, increasing the profitability of drug administration. By tying the program eligibility of hospitals to their Disproportionate Share Hospital (DSH) adjustment percentage, which reflects the proportion of hospitalized patients who are low-income, the program is intended to expand resources for underserved populations but provides no direct incentives for hospitals to use financial gains to enhance care for low-income patients. METHODS We used Medicare claims and a regression-discontinuity design, taking advantage of the threshold for program eligibility among general acute care hospitals (DSH percentage, >11.75%), to isolate the effects of the program on hospital-physician consolidation (i.e., acquisition of physician practices or employment of physicians by hospitals) and on the outpatient administration of parenteral drugs by hospitalowned facilities in three specialties in which parenteral drugs are frequently used. For low-income patients, we also assessed the effects of the program on the provision of care by hospitals and on mortality. RESULTS Hospital eligibility for the 340B Program was associated with 2.3 more hematologist-oncologists practicing in facilities owned by the hospital, or 230% more hematologist-oncologists than expected in the absence of the program (P = 0.02), and with 0.9 (or 900%) more ophthalmologists per hospital (P = 0.08) and 0.1 (or 33%) more rheumatologists per hospital (P = 0.84). Program eligibility was associated with significantly higher numbers of parenteral drug claims billed by hospitals for Medicare patients in hematology-oncology (90% higher, P = 0.001) and ophthalmology (177% higher, P = 0.03) but not rheumatology (77% higher, P = 0.12). Program eligibility was associated with lower proportions of low-income patients in hematology-oncology and ophthalmology and with no significant differences in hospital provision of safety-net or inpatient care for low-income groups or in mortality among low-income residents of the hospitals' local service areas. CONCLUSIONS The 340B Program has been associated with hospital-physician consolidation in hematology-oncology and with more hospital-based administration of parenteral drugs in hematology-oncology and ophthalmology. Financial gains for hospitals have not been associated with clear evidence of expanded care or lower mortality among low-income patients.
In 2016, Keyes and Galea issued 9 foundational principles of population health science and invite... more In 2016, Keyes and Galea issued 9 foundational principles of population health science and invited further deliberations by specialists to advance the field. This article presents 7 foundational principles of population health policy whose intersection with health care, public health, preventive medicine, and now population health, presents unique challenges. These principles are in response to a number of overarching questions that have arisen in over a decade of the authors' collective practice in the public and private sectors, and having taught policy within programs of medicine, law, nursing, and public health at the graduate and executive levels. The principles address an audience of practitioners and policy makers, mindful of the pressing health care challenges of our time, including: rising health-related expenditures, an aging population, workforce shortages, health disparities, and a backdrop of inequities rooted in social determinants that have not been adequately tra...
Reducing Emergency Department use Requires Interventions at Multiple Levels In a recent Wall Stre... more Reducing Emergency Department use Requires Interventions at Multiple Levels In a recent Wall Street Journal article “Why ER visits for nonemergencies are not going away”, the author Dr. Paul Auerbach makes the argument that the Emergency Department (ED) is the only reliable access to healthcare for many patients [1]. Dr. Auerbach argues that the increased presence of newly insured Medicaid patients has not diminished the frequency of ED visits. In fact, the author argues that the ED remains the only reliable access to healthcare. In a welllaid out thesis, Dr.Auerbach contends that while emergency departments are a good entry point for healthcare, building primary care and specialists' capacity to see patients is critical in addressing the cost of providing healthcare. In order to address the need to shift care from the ED to primary care settings, we often ignore the patients' ability to access healthcare in a timely manner namely through paid sick leave. The U.S. is the only developed industrialized country in the world that does not have paid sick leave. It is estimated that about 40 million individuals working in private sector in the U.S. do not have access to paid sick leave 2 Empirical studies have shown that paid sick leave is associatedwith increased use of preventative care, cost-saving for employers, employee retention, healthier workforce, and overall job growth. Recent studies show workers with paid sick leave are less likely to visit ED and more likely to take time off for illness or injury compared to workers with paid sick leave [3–4]. In the last two years, increasing number of U.S. states and cities are enacting legislations for the provision of paid sick leave policy [2]. More recently, President Barack Obama signed an executive order to enact a federal law requiring the private sector companies that work with the federal government to provide annual paid sick leave for up to seven days or more to their employees, including paid leave for the purpose of preventative care, family care, child care, parents care etc. With half of the women in the U.S. workforce and the aging society, availability of paid sick leave can significantly impact the use of emergency care. Additionally, theU.S. is suffering from shortage andmaldistribution of primary care providers. The current expansion of Medicaid coverage under the Affordable Care Act., may not guarantee access to care for the new enrollees.Many primary care providers are not acceptingMedicaid patients due to their low reimbursement. These new enrollees are most likely ending up using EDs as a regular source of care. Despite having a positive impact on improving access to primary care without compromising quality, more than half of the U.S. states do not allow non-clinician providers like nurse practitioners to practice medicine without physician supervision [5].
ABSTRACT According to the 2012 Behavioral Risk Factor Surveillance System, 8.1% of Chicago adults... more ABSTRACT According to the 2012 Behavioral Risk Factor Surveillance System, 8.1% of Chicago adults are estimated to have diabetes, disproportionately affecting some socio-demographic groups. As diabetes is a public health priority with complex prevention and management concerns, the Chicago Department of Public Health (CDPH) formed a partnership in 2011 with the University of Chicago Center for Diabetes Translation Research (CCDTR), focused on diabetes prevention and improving the quality of diabetes care, one of the few partnerships of its kind among Diabetes Translation Research Programs. This robust relationship allows for sharing of expertise to achieve health outcomes, including reduction in rates of negative behavioral risk factors, diabetes incidence and diabetes-related complications, and process outcomes, including creation and evaluation of policy, developing and sharing datasets and expanding a strong partnership network. Through shared vision, the CCDTR-CDPH group has identified high-impact research priorities that have potential to be translated into practice. In 2014, CDPH will launch a novel, city-wide health survey, allowing researchers to investigate the effect of the Affordable Care Act on diabetes management and care. Additionally, our team is evaluating the impact of new school physical education policies on diabetes precursors in children. Finally, through data sharing and neighborhood geocoding, we are able to measure disparities in Type 2 and gestational diabetes more accurately and develop targeted interventions to address them. This poster will discuss how the collaborative, practice-oriented and academically rigorous nature of this partnership provides a framework for innovative and impactful diabetes research and practice.
Chicago is getting healthier. How do we know this? Because Chicago residents are living longer. L... more Chicago is getting healthier. How do we know this? Because Chicago residents are living longer. Life expectancy has long been one of the most commonly used measures of a population’s general health as it is a reflection of a number of overall indicators which include quality of care, access to care, health behaviors and the environment. This report shows a dramatic increase in our City’s life expectancy over the past two decades. A Chicago resident born today can expect to live to 77.8 years of age, a new high for our City and more than seven years longer than a resident born in 1990. Not only are Chicagoans living longer, but we are outpacing the nation. Since 1990, our life expectancy has grown twice as fast as the U.S. rate overall. True, the U.S. rate is still slightly higher, but that gap is closing quickly. Furthermore, as this report demonstrates, the improvements in life expectancy are being felt across our great city. In fact, we have seen significant increases in life expe...
Building organizational capacity is critical for hospitals participating in payment models such a... more Building organizational capacity is critical for hospitals participating in payment models such as bundled payments and accountable care organizations, particularly "co-participant" hospitals with experience in both models. This study used a national survey of American Hospital Association member hospitals with bundled payment experience, with (co-participant hospitals) or without (bundled payment hospitals) accountable care organization experience. Questions examined capacity in 4 domains: performance feedback, postacute care provider utilization, care management, and health information technology. Of 424 hospitals, 38% responded. Both co-participant and bundled payment hospitals reported high capacity for performance feedback and risk stratification and predictive risk assessment using health information technology systems. The hospital groups did not differ in care management capacity, but bundled payment hospitals reported higher postacute care provider utilization capacity. Experience with multiple payment models may prompt hospitals to make different investments or adopt different strategies than hospitals with experience in a single model.
Background and Aims Opioid substitution treatment is used in many countries as an effective harm ... more Background and Aims Opioid substitution treatment is used in many countries as an effective harm minimization strategy. There is a need for more information about patient safety incidents and the resulting harm relating to this treatment. We aimed to characterize patient safety incidents involving opioid substitution treatment with methadone or buprenorphine in community-based care by: (i) identifying the sources and nature of harm and (ii) describing and interpreting themes to identify priorities to focus future improvement work. Design Mixed-methods study examining patient safety incident reports involving opioid substitution treatment with either methadone or buprenorphine in community-based care. Setting Data submitted between 2005 and 2015 from the National Reporting and Learning System (NRLS), a national repository of patient safety incident reports from across England and Wales. Participants A total of 2284 reports were identified involving patients receiving community-based opioid substitution treatment. Measurements Incident type, contributory factors, incident outcome and severity of harm. Analysis involved data coding, processing and iterative generation of data summaries using descriptive statistical and thematic analysis. Findings Most risks of harm from opioid substitution treatment came from failure in one of four processes of care delivery: prescribing opioid substitution (n = 151); supervised dispensing (n = 248); non-supervised dispensing (n = 318); and monitoring and communication (n = 1544). Most incidents resulting in harm involved supervised or non-supervised dispensing (n = 91 of 127, 72%). Staff-(e.g. slips during task execution, not following protocols) and organization-related (e.g. poor working conditions or poor continuity of care between services) contributory factors were identified for more than half of incidents. Conclusions Risks of harm in delivering opioid substitute treatment in England and Wales appear to arise out of failures in four processes: prescribing opioid substitution, supervised dispensing, non-supervised dispensing and monitoring and communication.
IMPORTANCE An association between social and neighborhood characteristics and health outcomes has... more IMPORTANCE An association between social and neighborhood characteristics and health outcomes has been reported but remains poorly understood owing to complex multidimensional factors that vary across geographic space. OBJECTIVES To quantify social determinants of health (SDOH) as multiple dimensions across the continental United States (the 48 contiguous states and the District of Columbia) at a small-area resolution and to examine the association of SDOH with premature mortality within Chicago, Illinois. DESIGN, SETTING, AND PARTICIPANTS In this cross-sectional study, census tracts from the US Census Bureau from 2014 were used to develop multidimensional SDOH indices and a regional typology of the continental United States at a small-area level (n = 71 901 census tracts with approximately 312 million persons) using dimension reduction and clustering machine learning techniques (unsupervised algorithms used to reduce dimensions of multivariate data). The SDOH indices were used to estimate age-adjusted mortality rates in Chicago (n = 789 census tracts with approximately 7.5 million persons) with a spatial regression for the same period, while controlling for violent crime. MAIN OUTCOMES AND MEASURES Fifteen variables, measured as a 5-year mean, were selected to characterize SDOH as small-area variations for demographic characteristics of vulnerable groups, economic status, social and neighborhood characteristics, and housing and transportation availability at the census-tract level. This SDOH data matrix was reduced to 4 indices reflecting advantage, isolation, opportunity, and mixed immigrant cohesion and accessibility, which were then clustered into 7 distinct multidimensional neighborhood typologies. The association between SDOH indices and premature mortality (defined as death before age 75 years) in Chicago was measured by years of potential life lost and aggregated to a 5-year mean. Data analyses were conducted between July 1, 2018, and August 30, 2019. RESULTS Among the 71 901 census tracts examined across the continental United States, a median (interquartile range) of 27.2% (47.1%) of residents had minority status, 12.1% (7.5%) had disabilities, 22.9% (7.6%) were 18 years and younger, and 13.6% (8.1%) were 65 years and older. Among the 789 census tracts examined in Chicago, a median (interquartile range) of 80.4% (56.3%) of residents had minority status, 10.2% (8.2%) had disabilities, 23.2% (10.9%) were 18 years and younger, and 9.5% (7.1%) were 65 years and older. Four SDOH indices accounted for 71% of the variance across all census tracts in the continental United States in 2014. The SDOH neighborhood typology of extreme poverty, which is of greatest concern to health care practitioners and policy advocates, comprised only 9.6% of all census tracts across the continental United States but characterized small areas of known public health crises. An association was observed between all SDOH indices and age-adjusted premature mortality rates in Chicago (R 2 = 0.63; P < .001), even after accounting for violent crime and spatial structures. (continued) Key Points Question How do social determinants of health vary across multiple dimensions and geographic space? Findings In this cross-sectional study of 71 901 census tracts with approximately 312 million persons across the continental United States, multivariate social determinants of health measures were reduced to 4 indices reflecting advantage, isolation, opportunity, and mixed immigrant cohesion and accessibility and were clustered into 7 neighborhood typologies that included an extreme poverty group. Social determinants of health indices were associated with premature mortality rates in Chicago, Illinois. Meaning The use of multidimensional geospatial approaches to quantify social determinants of health rather than the use of a singular deprivation index may better capture the complexity and spatial heterogeneity underlying these determinants.
On any given day, 1 in every 25 hospitalized patients has a health careassociated infection (HAI)... more On any given day, 1 in every 25 hospitalized patients has a health careassociated infection (HAI) (1). These infections affect patient care, add costs to the U.S. health care system, and challenge hospitals that struggle to achieve substantive reductions in infection rates. Several national efforts, including collaborations among the Health Research & Educational Trust (HRET), the University of Michigan, and other partners (2, 3), have focused on HAI prevention. Overall, hospitals and long-term care facilities have made enormous progress in driving down preventable HAIs. However, hospitals must work to close the remaining performance gaps, and to identify novel and sustainable approaches to addressing this issue. The HAI National Action Plan goals framed the Centers for Disease Control and Prevention (CDC) vision for the STRIVE (States Targeting Reduction in Infections via Engagement) program (4). This 3-year program (20152018) focused on improving infection control practices and strengthening key stakeholder relationships to improve infection control efforts at the hospital and statewide levels. The HRET recruited 462 hospitals in 28 states and the District of Columbia, with 443 hospitals completing the 12-month program. STRIVE used evidence-based HAI reduction strategies and relationship-based methods to address HAI rates in hospitals with a high cumulative attributable difference rate in Clostridioides difficile and at least one other HAI (central lineassociated bloodstream infection, catheter-associated urinary tract infection, or methicillin-resistant Staphylococcus aureus infection). The HRET collaborated with the CDC, Association for Professionals in Infection Control and Epidemiology, American Society for Health Care Engineering, Society of Hospital Medicine, University of Michigan, and other experts to provide technical assistance and guidance. This national program team built a structured, stepwise curriculum for all enrolled hospitals to reduce HAIs and, in doing so, developed new alliances. The curriculum emphasized horizontal (called foundational) infection prevention strategies, such as hand hygiene and environmental cleaning, that cut across all HAIs (5), as well as socioadaptive solutions, such as team building and leadership engagement, to address the attitudinal and cultural changes that must occur to ensure consistent application of evidence-based guidelines (6). STRIVE also encouraged statewide collaboration on HAI reduction efforts for hospitals by bringing together state hospital associations, state health departments, and quality innovation networks/quality improvement organizations. The STRIVE materials and techniques focused on embedding evidence-based infection prevention practices across teams. For example, one module in the curriculum promoted team engagement across multiple departments. Program education emphasized changing traditional communication methods in order to break the cycle of infections. Standardized protocols to promote accountability and reduce the spread of nosocomial infections were emphasized throughout. A dedicated patient and family engagement module highlighted how patients and families can be active partners to improve care. The curriculum reinforced the importance of using standardized processes in a complex system, such as a hospital, to ensure patient safety. Results showed some hospitals realized some improvements in outcome and process measures, and some maintained or achieved zero infections during the intervention period. However, in aggregate, there was no statistically significant change over time during the program intervention period compared with the baseline period for any of the HAIs (710). So we asked, Why not? Various explanations, including limitations of data collection and analysis as well as inconsistent engagement due to competing priorities and high staff turnover, are possible. Also, because some hospitals began with low HAI rates, the ability to see a statistically significant change over time may have been reduced. Qualitative findings did show stronger stakeholder relationships had been established that could align and sustain HAI prevention across the entire patient continuum of care (11). Did our program accelerate the journey to zero preventable HAIs? Although all hospitals worked hard at this effort, some achieved greater success than others. This reality begs the question: Why is HAI prevention so difficult? Many reasons have been cited in the literature that include the immense financial and workforce challenges and staff turnover experienced by participating hospitals. These challenges can be especially difficult for hospitals that need resources to educate staff on standardized, evidence-based practices shown to reduce HAIs. Access to HAI consistent staff training and development and other evidence-based guidelines and systems to easily implement them and review data sounds like a simple solution, but in reality, HAI…
Success in reducing rates of catheter-associated urinary tract infection (CAUTI) and unnecessary ... more Success in reducing rates of catheter-associated urinary tract infection (CAUTI) and unnecessary urinary catheter use has varied over time, by clinical setting, by CAUTI definition, and by data source used for tracking these metrics (16). Although meta-analyses of the published peer-reviewed literature indicate that up to approximately 50% of CAUTIs can be prevented, many hospitals have had less success (7, 8). To help hospitals that still struggle with CAUTI, as well as other health careassociated infections (HAIs), the Centers for Disease Control and Prevention (CDC) funded the STRIVE (States Targeting Reduction in Infections via Engagement) initiative (9). Beginning in June 2016, the STRIVE initiative rapidly engaged multiple state organizations to partner and facilitate the implementation of a curriculum to prevent HAIs among 4 cohorts of hospitals experiencing high burdens of HAIs, as defined by National Healthcare Safety Network (NHSN) metrics reported by the CDC (Appendix Table). This curriculum included a focus on horizontal infection prevention practices as the foundation (13), as well as vertical approaches targeting prevention of specific HAIs, including CAUTI, central line-associated bloodstream infection (CLABSI), Clostridioides difficile, and hospital-onset methicillin-resistant Staphylococcus aureus bloodstream infection. Appendix Table. The CAUTI Metric With an increasing number of studies describing multicomponent strategies to prevent CAUTI, it can be difficult for hospital teams to choose among interventions to reduce CAUTI. Informed by recent literature reviews and guidelines for prevention of CAUTI in multiple clinical settings, our multidisciplinary team applied a tiered approach to organize and prioritize CAUTI prevention interventions for STRIVE hospitals. This article summarizes the evidence base and development of the tiered approach to prioritize CAUTI interventions. Project Structure With extensive experience in performing and publishing literature reviews focused on CAUTI prevention, team members from the University of Michigan reviewed and summarized several recent and comprehensive literature reviews as well as recent guidelines. This literature review included 3 systematic reviews funded in recent years by the Agency for Healthcare Research and Quality (AHRQ) to summarize the evidence for CAUTI prevention in the acute care, intensive care unit (ICU), and long-term care settings (7, 14, 15). The studies reviewedincluding design, intervention details, and outcomesare described thoroughly in these publications and their appendix tables. Multiple guidelines were also reviewed and consulted: the 2009 guideline from the Healthcare Infection Control Practices Advisory Committee (HICPAC) that provides guidance to the U.S. Department of Health and Human Services and the CDC (16), including application of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system approach for evaluating quality of evidence and determining strength of recommendations; the 2009 CAUTI International Clinical Practice Guidelines from the Infectious Diseases Society of America (IDSA) (17); the 2014 CAUTI guideline update coming jointly from the IDSA and the Society for Healthcare Epidemiology of America (18); the 2008 European and Asian guidelines for CAUTI prevention (19); and the 2015 evidence-based tool and guidance document from the American Nurses Association (20). We were also guided by the literature review performed and expert recommendations generated in the published Ann Arbor criteria (21), as well as the preliminary results of a similarly performed literature review and appropriateness panel ratings for use of catheters in general surgery and orthopedic surgery patients (22). In contrast to the literature assessing prevention of CLABSI, the great majority of the current literature on CAUTI prevention reports nonrandomized study designs that are of relatively low quality (14). Only a few CAUTI studies used the more robust randomized, controlled trial design, and those were often limited to the evaluation of single technological interventions, such as a new securement device or antimicrobial catheter (1416, 18). Consequently, in the 2009 CAUTI prevention guideline from HICPACwhere formal study quality assessment was performed (16)even the most basic and often perceived as critical interventions for CAUTI prevention (for example, placing indwelling catheters only for appropriate reasons, promptly removing when no longer needed, aseptic insertion and maintenance technique, and implementing quality improvement programs for reducing CAUTI) were given a HICPAC category 1B recommendation (defined as a strong recommendation supported by low- to very-low-quality evidence). No CAUTI prevention strategies were given the strongest recommendation of category 1A, reserved for interventions supported by high- to moderate-quality evidence. Other strategies (such as using alternatives to…
This chapter starts by explaining a current trend in the transformation of the role of hospitals ... more This chapter starts by explaining a current trend in the transformation of the role of hospitals in advancing health in the community. The change is the result of demographic change and disease burden shifts which are moving away from acute to chronic. And hospitals and health systems are, as a result, leading an unprecedented transformation to re-envision their role and extend their impact beyond the clinic walls. They are working to create new models of care that prioritize teaming and partnership with the aim of engaging in true population health: advancing health and well-being by bridging care and community. The key, the chapter argues, is to promote affordability while enhancing value. The chapter concludes by stating that hospitals and health systems play an important role in the health of communities across the United States. While that role is changing and will likely continue to evolve, the importance of these institutions as anchors in their communities is likely to incre...
The Joint Commission Journal on Quality and Patient Safety
The Joint Commission's hospital antimicrobial stewardship (AS) standards became effective in ... more The Joint Commission's hospital antimicrobial stewardship (AS) standards became effective in January 2017. Surveyors' experience to date suggests that almost all hospitals have established AS leadership commitment and organized structures. Thus, The Joint Commission sought to examine advances in AS interventions and measures that hospitals could implement to strengthen their existing AS programs. METHODS The Joint Commission and Pew Charitable Trusts sponsored a meeting to bring together experts and key stakeholder organizations from around the country to identify leading practices for AS interventions and measurement. Presenters were asked to summarize the AS activities they thought were most important for the success of their own AS program and leading practices that all hospitals should be able to implement. RESULTS The panel highlighted two interventions as leading practices that go beyond current guidelines and established practices (that is, preauthorization and prospective audit and feedback). The first is diagnostic stewardship. This type of intervention addresses errors in diagnostic decision making that lead to inappropriate antibiotic prescribing. The second is handshake stewardship, a method of engaging frontline providers on a regular basis for education and discussions about barriers to AS from the clinician's perspective. The panel identified days of therapy (or defined daily dose, when days of therapy is not possible), Clostridioides difficile rates, and adherence to facility-specific guidelines as the preferred measures for assessing stewardship activities. CONCLUSION The practices highlighted should be given greater emphasis by The Joint Commission in their efforts to improve hospital AS, and the Centers for Disease Control and Prevention will be updating the Core Elements of Hospital Antibiotic Stewardship Programs.
Journal of cancer education : the official journal of the American Association for Cancer Education, Jan 14, 2017
Health literacy is critical for cancer patients as they must understand complex procedures or tre... more Health literacy is critical for cancer patients as they must understand complex procedures or treatment options. Caregivers' health literacy also plays a crucial role in caring for cancer patients. Low health literacy is associated with low adherence to medications, poor health status, and increased health care costs. There is a growing interest in the use of mobile health applications (apps) to improve health literacy. Mobile health apps can empower underserved cancer patients and their caregivers by providing features or functionalities to enhance interactive patient-provider communication and to understand medical information more readily. Despite the potentiality of improving health literacy through mobile health apps, there exist several related concerns: no equal access to mobile technology, no familiarity or knowledge of using mobile health apps, and privacy and security concerns. These elements should be taken into account for health policy making and mobile apps design ...
More than 1500 hospitals recently signed the American Hospital Association's 123forEquity ple... more More than 1500 hospitals recently signed the American Hospital Association's 123forEquity pledge and have begun implementing strategies to address economic and racial disparities in health care provision and outcomes. Despite these institutional commitments to equity, evidence suggests that the current growth in value-based payment models may counter these efforts, unintentionally worsening health care disparities by disadvantaging hospitals caring for socially at-risk populations (1). Because alternative payment models account for a mounting proportion of payments, equity will remain elusive unless explicitly incorporated into what we measure and pay for in health care. How can we move toward universal high performance standards while narrowing disparities? Much of the onus has fallen on how to actuarially adjust payments and penalties using socioeconomic risk factors (24). This method is insufficient for a few reasons. First, current socioeconomic risk measures have considerable limitations: We can adjust only what we can measure, and we may not be measuring the right exposures. Take Medicare data, a key driver of payment reform, in which sociodemographics are limited to race/ethnicity, dual eligibility for Medicaid and Medicare, and residency in rural or low-income areas. Although these measures are often good proxies for socioeconomic risk, others may better explain between-population variations in health outcomes, cost, and quality. Second, some experts are justifiably concerned that adjusting for socioeconomic risk, regardless of the measures used, may lower quality standards altogether, disincentivizing hospitals to improve performance (2). Therein lies the rub: The health care industry cannot ignore true instances of poor quality, but it also should not worsen health care for at-risk populations. To address this tension, value-based payment models should adopt a disparities-sensitive frame shift to integrate measures of equity into hospitals' financial calculus, incentivizing hospitals to tackle the disparities challenge without losing sight of quality. Achieving this frame shift requires us to continue determining which metrics matter most when addressing disparities in health care delivery and outcomes, both to improve risk adjustment and to establish which measures are actionable. To avoid underpaying hospitals that disproportionately serve socially at-risk patients, we should assess how risk adjustments would perform if they accounted for factors like socioeconomic position, social relationships, and community context, which the National Academy of Medicine has identified as key domains affecting health care outcomes (1, 5). The Medicaid payment formula used in Massachusetts is an example of how incorporating medical and social risk factors (such as mental health and housing instability) improved payments to hospitals by matching predicted to actual costs for high risk patients better (6). Practice-level coding of existing International Classification of Diseases, 10th Revision, codes for conditions like homelessness (Z59.0) and extreme poverty (Z59.5) may improve documentation and shift us toward adopting these billable diagnoses as a substantive component of hospital payment. These examples also highlight real-world laboratories in which to continue refining our approach to health equity: Which social risk factors most affect health outcomes? Which (alone or combined) provide the highest value, when modified, to produce cost savings or better outcomes? Concurrently, we should start paying hospitals to reduce disparities directly. Evidence indicates that hospitals with previously poor performance made the most gains in quality within alternative payment models (7), but we do not universally reward them for these gains. We certainly do not reward them for gains in equity. Furthermore, hospitals with poor patients are at a disadvantage. For example, under Medicare's Hospital Readmission Reduction Program, 86% of hospitals with poorer patients have been penalized in 2017, compared with 66% of those serving wealthier patients, a consistent pattern across the program's first 5 years (8). We believe that improving the financial outlook for hospitals that disproportionately care for high-risk populations (particularly rewarding hospitals that do this well) can reduce such stark disparities between hospitals. One approach is to pay for improvements in health care outcomes for populations we know have high social risksminority, low-income, and dual-eligible patientsa strategy already embedded in high-risk management programs used by accountable care organizations (9). Another approach ensures that hospitals address disparities by paying directly for services that disproportionately affect high-risk communities. For example, mental health is underpaid and likely a driver of disparities (10). Yet rather than incentivizing mental health treatment, value-based payment models have promoted spending on…
Academic medicine : journal of the Association of American Medical Colleges, Jan 24, 2018
For millions of Americans living in vulnerable rural and urban communities, their hospital is an ... more For millions of Americans living in vulnerable rural and urban communities, their hospital is an important, and often their only, source of health care. As transformation in the hospital and health care field continues, some communities may be at risk of losing access to health care services and the opportunities and resources they need to improve and maintain their health. Integrated, comprehensive strategies to reform health care delivery and payment, within which vulnerable communities can make individual choices based on their needs, support structures, and preferences, are needed.In this Invited Commentary, the authors outline characteristics and parameters of vulnerable communities as well as the essential health care services that hospitals should strive to maintain locally identified by the American Hospital Association Task Force on Ensuring Access in Vulnerable Communities. They also describe four of nine emerging strategies-recommended by the task force-to reform health c...
BACKGROUND The 340B Drug Pricing Program entitles qualifying hospitals to discounts on outpatient... more BACKGROUND The 340B Drug Pricing Program entitles qualifying hospitals to discounts on outpatient drugs, increasing the profitability of drug administration. By tying the program eligibility of hospitals to their Disproportionate Share Hospital (DSH) adjustment percentage, which reflects the proportion of hospitalized patients who are low-income, the program is intended to expand resources for underserved populations but provides no direct incentives for hospitals to use financial gains to enhance care for low-income patients. METHODS We used Medicare claims and a regression-discontinuity design, taking advantage of the threshold for program eligibility among general acute care hospitals (DSH percentage, >11.75%), to isolate the effects of the program on hospital-physician consolidation (i.e., acquisition of physician practices or employment of physicians by hospitals) and on the outpatient administration of parenteral drugs by hospitalowned facilities in three specialties in which parenteral drugs are frequently used. For low-income patients, we also assessed the effects of the program on the provision of care by hospitals and on mortality. RESULTS Hospital eligibility for the 340B Program was associated with 2.3 more hematologist-oncologists practicing in facilities owned by the hospital, or 230% more hematologist-oncologists than expected in the absence of the program (P = 0.02), and with 0.9 (or 900%) more ophthalmologists per hospital (P = 0.08) and 0.1 (or 33%) more rheumatologists per hospital (P = 0.84). Program eligibility was associated with significantly higher numbers of parenteral drug claims billed by hospitals for Medicare patients in hematology-oncology (90% higher, P = 0.001) and ophthalmology (177% higher, P = 0.03) but not rheumatology (77% higher, P = 0.12). Program eligibility was associated with lower proportions of low-income patients in hematology-oncology and ophthalmology and with no significant differences in hospital provision of safety-net or inpatient care for low-income groups or in mortality among low-income residents of the hospitals' local service areas. CONCLUSIONS The 340B Program has been associated with hospital-physician consolidation in hematology-oncology and with more hospital-based administration of parenteral drugs in hematology-oncology and ophthalmology. Financial gains for hospitals have not been associated with clear evidence of expanded care or lower mortality among low-income patients.
In 2016, Keyes and Galea issued 9 foundational principles of population health science and invite... more In 2016, Keyes and Galea issued 9 foundational principles of population health science and invited further deliberations by specialists to advance the field. This article presents 7 foundational principles of population health policy whose intersection with health care, public health, preventive medicine, and now population health, presents unique challenges. These principles are in response to a number of overarching questions that have arisen in over a decade of the authors' collective practice in the public and private sectors, and having taught policy within programs of medicine, law, nursing, and public health at the graduate and executive levels. The principles address an audience of practitioners and policy makers, mindful of the pressing health care challenges of our time, including: rising health-related expenditures, an aging population, workforce shortages, health disparities, and a backdrop of inequities rooted in social determinants that have not been adequately tra...
Reducing Emergency Department use Requires Interventions at Multiple Levels In a recent Wall Stre... more Reducing Emergency Department use Requires Interventions at Multiple Levels In a recent Wall Street Journal article “Why ER visits for nonemergencies are not going away”, the author Dr. Paul Auerbach makes the argument that the Emergency Department (ED) is the only reliable access to healthcare for many patients [1]. Dr. Auerbach argues that the increased presence of newly insured Medicaid patients has not diminished the frequency of ED visits. In fact, the author argues that the ED remains the only reliable access to healthcare. In a welllaid out thesis, Dr.Auerbach contends that while emergency departments are a good entry point for healthcare, building primary care and specialists' capacity to see patients is critical in addressing the cost of providing healthcare. In order to address the need to shift care from the ED to primary care settings, we often ignore the patients' ability to access healthcare in a timely manner namely through paid sick leave. The U.S. is the only developed industrialized country in the world that does not have paid sick leave. It is estimated that about 40 million individuals working in private sector in the U.S. do not have access to paid sick leave 2 Empirical studies have shown that paid sick leave is associatedwith increased use of preventative care, cost-saving for employers, employee retention, healthier workforce, and overall job growth. Recent studies show workers with paid sick leave are less likely to visit ED and more likely to take time off for illness or injury compared to workers with paid sick leave [3–4]. In the last two years, increasing number of U.S. states and cities are enacting legislations for the provision of paid sick leave policy [2]. More recently, President Barack Obama signed an executive order to enact a federal law requiring the private sector companies that work with the federal government to provide annual paid sick leave for up to seven days or more to their employees, including paid leave for the purpose of preventative care, family care, child care, parents care etc. With half of the women in the U.S. workforce and the aging society, availability of paid sick leave can significantly impact the use of emergency care. Additionally, theU.S. is suffering from shortage andmaldistribution of primary care providers. The current expansion of Medicaid coverage under the Affordable Care Act., may not guarantee access to care for the new enrollees.Many primary care providers are not acceptingMedicaid patients due to their low reimbursement. These new enrollees are most likely ending up using EDs as a regular source of care. Despite having a positive impact on improving access to primary care without compromising quality, more than half of the U.S. states do not allow non-clinician providers like nurse practitioners to practice medicine without physician supervision [5].
ABSTRACT According to the 2012 Behavioral Risk Factor Surveillance System, 8.1% of Chicago adults... more ABSTRACT According to the 2012 Behavioral Risk Factor Surveillance System, 8.1% of Chicago adults are estimated to have diabetes, disproportionately affecting some socio-demographic groups. As diabetes is a public health priority with complex prevention and management concerns, the Chicago Department of Public Health (CDPH) formed a partnership in 2011 with the University of Chicago Center for Diabetes Translation Research (CCDTR), focused on diabetes prevention and improving the quality of diabetes care, one of the few partnerships of its kind among Diabetes Translation Research Programs. This robust relationship allows for sharing of expertise to achieve health outcomes, including reduction in rates of negative behavioral risk factors, diabetes incidence and diabetes-related complications, and process outcomes, including creation and evaluation of policy, developing and sharing datasets and expanding a strong partnership network. Through shared vision, the CCDTR-CDPH group has identified high-impact research priorities that have potential to be translated into practice. In 2014, CDPH will launch a novel, city-wide health survey, allowing researchers to investigate the effect of the Affordable Care Act on diabetes management and care. Additionally, our team is evaluating the impact of new school physical education policies on diabetes precursors in children. Finally, through data sharing and neighborhood geocoding, we are able to measure disparities in Type 2 and gestational diabetes more accurately and develop targeted interventions to address them. This poster will discuss how the collaborative, practice-oriented and academically rigorous nature of this partnership provides a framework for innovative and impactful diabetes research and practice.
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Papers by Jay Bhatt