Hospital administrators seeking solutions to continuity of care challenges but who don't know where to begin, may not realize that innovative problem solvers are nearby—maybe in their own communities.
The Massachusetts Institute of Technology is known worldwide for science and engineering, not for health services research. Now it is bringing the two together with the launch of its Health Care Delivery Innovation Competition.
The project joins a growing list of other self-described innovation efforts aimed at finding new ways to solve long-standing problems in healthcare.
For the past several years, hospitals have been appointing chief innovation officers to identify and update outdated approaches to care. They've set up programs with names such as Accelerator Zone, and iHub, which uses the web address "disruptingmedine.org."
But the winners of the MIT innovation competition are doing work outside hospital doors. As facilities are held responsible for episodes of care that extend beyond discharge, they'll be looking for partners—and solutions.
They may find them in community health programs that say they have been hacking healthcare for years.
Hospital administrators who don't know where to begin, or who think innovation only involves expensive technology and high risks can start by working with groups in their own communities, such as CareOregon. This organization, which notes on its website that it has been pushing innovation since 1994, serves Medicare and Medicaid enrollees.
MIT funded the group to measure the impact of a program that addresses problems such as housing, poor nutrition or "social isolation" – the social determinants of health that contribute to a patient's illness or injury.
"Most people, when they think of social determinants, they think very far upstream," says Rose Englert, head of the group's Community Health Innovation Programs. "We are looking at it differently. What is the acute medical condition that social support can address?"
CareOregon considers social needs as much a part of a patient's treatment as prescription drugs. Recent changes in reimbursement rules allows it to use Medicaid funds to address those needs.
Key to that effort is collaboration between all the community's providers, including hospitals, Englert said.
One way health systems can contribute to and benefit from that effort would be to routinely screen patient for social needs, she says. Every hospital is different, but Englert suggests they look for ways to insert a few questions about housing or food into the existing workflow.
"If we don't know the people are food insecure, how can we address it?" she says.
The MIT announcement notes that the funds will also allow the Boston-based Commonwealth Care Alliance to test the use of financial incentives "to engage some of its highest-need, but most difficult-to-reach patients."
Toyin Ajayi, MD, the group's chief medical officer, said she thinks hospitals have been late to the innovation game. They've seen inpatient care as a kind of "mecca" of healthcare, she said.
"That is why hospitals are reeling in his new accountable care world, where they ae saying 'How can I possibly be responsible for readmissions? I don't know anything about what happens to the patient when they leave here. How can you ask me to be responsible for them 28 days from now?'"
As healthcare moves away from a hierarchical model, hospitals will be better able to address those issues by working with community innovators, Ajayi says.
"They should recognize, that in many places, we actually have a rich system of community-based and primary care support for vulnerable patients."
Population health programs and other changes may offer solutions to long-standing healthcare disparities, research suggests.
Bundled payments, the push for population health, and other ongoing reforms offer tools for hospitals to address persistent health care disparities, according to researchers.
A report from the Institute for Healthcare Improvement (IHI) notes that health systems will need to address disparities in outcomes as they manage "population-level financial risk."
"Making health equity a strategic priority is greatly facilitated by sustainable funding through new payment systems at both the federal and state levels," the report notes.
The IHI report represents a growing awareness of the obstacles that limit health systems' ability to address long-standing disparities in care around "race, gender, age, sexual orientation, gender identity, disability status, and physical appearance such as height or weight."
But it offers more than a moral argument; it also makes a business case.
The committee that produced the report was chaired by Ronald Wyatt, MD, the medical director of The Joint Commission's Office of Quality and Patient Safety.
The Toll of Limited English Proficiency
The report notes "racial/ethnic minorities and individuals with limited English proficiency in the US are more likely to suffer an adverse event, have inappropriate and often costly tests ordered, have a longer length of stay in the hospital, be readmitted to the hospital, and have ambulatory-sensitive hospitalizations (i.e., admissions due to illnesses that can often be managed effectively.)"
So, Wyatt said, hospitals need to be aware of the need for interpretive services.
"If you don't have interpretive services in your emergency department (ED), and you are relying on taxi drivers and family members and children of patients or other employees, I may get a bevy of tests, which becomes a quality issue on the overuse side or on the under-use side."
That can lead to recurring visits to the ED or readmissions, he says. Health systems need to be aware of the financial risk associated with disparities in health outcomes, because according to the report: "Meeting pay-for-performance targets for common chronic conditions such as diabetes will not be achievable without reducing disparities."
Making the business case for health equity can be "challenging," they note, but the report offers advice on how hospitals can address financial concerns. The document also advises hospitals to make equity a priority, address institutional racism, and make connections in the community.
Data analysis is key to this effort, Wyatt says. Lisa A. Cooper, MD, agrees. She is the vice president for health care equity for John Hopkins Medicine and the lead author of a study in the current issue of Health Affairs.
"If there is a certain subset of your population that you are responsible for that isn't doing well, it is important for you to find out who those people are what the problem is so you can really target your programs appropriately," she said.
"Otherwise you are going to get penalized for your overall population metric not meeting goals based on these disparities."
Her group's paper notes that some healthcare interventions designed to address disparities "fall short because of gaps in knowledge and translation." The gaps they identify—such as links to community services—mirror many of the recommendations in the IHI reports.
Under, fee-for-service, some hospitals struggling for a financially comfortable mix of patients may have failed to address the needs of underserved patients, many of whom are covered by Medicaid, the federal health plan for low-income and disabled patients.
'Last-Decade Thinking'
That will no longer be an option, Wyatt says. "The shift has gone to value and outcomes, so that whole idea about limiting your Medicare or Medicaid or uninsured patients really is last-decade thinking."
The IHI report suggests that the effort needs to go beyond patients. Hospitals need to look at how they treat their own staff. And, the push has to come from the top.
According to the report: "Health care leaders must be explicit that improving health equity is an organizational priority, both to support resource allocation for this work and to demonstrate that the organization is serious about reducing health disparities."
A new study finds that front-loaded home care combined with physician office visits shows promise in reducing HF readmissions.
For years, hospitals and researchers have been searching for the right combination of care needed to prevent the readmission of heart failure patients. Still, a 2015 study found that only one in 70 hospitals has been able to bring the readmission rate for these complex patients below 20%.
With penalties for readmissions rising, the search is still on. Options include better discharge planning, implantable pulmonary artery pressure monitors, and early, intensive home health care—often described as "front-loaded" care.
And while better home health makes intuitive sense, its impact on readmissions has not been well-studied. Which is why researchers from the Center for Home Care Policy and Research in New York City decided to look specifically at heart failure readmissions of patient receiving follow-up home health care. They compared three interventions: early, intensive home health nursing; physician follow-up within a week; and a combination of the two.
The findings, published in the journal Health Services Research, suggest that neither intervention has much impact alone. But, the combination of a visit to the doctor and multiple home nursing visits in the week following discharge reduced the probability of readmission by roughly eight percentage points. That's a drop from approximately 20% of patients to roughly 12%. (However, the researchers note that the percent reduction could fall into a range between 4.1 to 12.3 points.)
The study validates the benefits of a specific approach to front-loaded care, said lead researcher Christopher Murtaugh, Associate Director, VNSNY Center for Home Care Policy and Research.
"There is very little research evidence to support [front-loaded care] despite the fact that the industry feels that it is likely to be important," he said.
His team consulted with providers for help defining early intervention and physician follow-up. They then used data from more than 98,000 Medicare heart failure patients who were discharged from hospitals to home care. Of the sample, 40.1% received neither treatment, 23.0% received only nursing care, 24.3% physician care only, and 12.6% both home health and physician care.
The adoption of the combination of treatments is dependent on "timely action during the hospital stay," according to the study. The findings call for "closer coordination between medical and home health providers in the clinical management of HF patients immediately after hospital discharge." Often, that is not the case, Murtaugh said.
"The information that is actually available to the home health agency is very scanty," he said, sometimes no more than the patient's name and discharge date.
"The agency needs to follow up and make sure they get all the clinical information," Murtaugh said. "But, historically, the [hospital's] practice has not been to give the home care agency rapid, timely complete clinical information about a patient."
Efforts by the Centers for Medicare & Medicaid Services recognize the need for better post-acute care coordination, he said.
Adrian Hernandez, MD, is a cardiologist and director of health services and outcomes research at the Duke University Medical Center Clinical Research Institute. His team has looked at heart failure and readmissions.
"There will need to be a multi-modal approach towards preventing readmission," he wrote in an email after reviewing the study: "There isn't a silver bullet and we will need engagement from different perspectives. More integration of care with new models that go from hospital to home and back may be very helpful. Having more continuous engagement and disease management can help optimize care and provide better pathways for patients if or when they get worse."
An analysis of Medicare data for 25,000 surgeons concludes that specialization may be a stronger of measure of quality than volume.
Strong evidence and common sense support the idea that volume is a measure of surgical competency.
A group of academic medical centers have even taken the volume pledge, agreeing not to perform high-risk procedures if they don't have the volume. They encourage others to do the same.
But there has been pushback.
Smaller hospitals wonder whether they'll meet volume thresholds. Others say the possible, unintended consequence of volume rules could lead to consolidation of services and limited access.
Now comes a study suggesting that the link between surgical volume and quality may be more complicated than a function of practice-makes-perfect.
An analysis of Medicare data for 25,000 surgeons concludes that "specialization" may be a stronger of measure of quality than volume.
Volume is measured as the number of times a surgeon performs a procedure. Specialization is defined by researchers as the number of times a surgeon has performed a certain procedure, divided by the number of times a physician has performed any surgical procedure.
While the two measures dovetail, specialization predicts 30-day mortality independent of volume.
John Birkmeyer, MD, of the Dartmouth Institute for Health Policy and Clinical Practice in Lebanon, NH is one of the study authors. He performed much of the research supporting volume as a quality measure, and is a proponent of the volume pledge.
The new findings do not mean specialization should replace volume as a quality measure, says co-author and Harvard University economist Nikhil Sahni. "We are by no means saying that volume should be replaced by this metric. We are saying that this is a nice metric to have alongside it."
One big benefit: Like volume, specialization is simple and inexpensive to measure.
While the researchers used data from Medicare claims, hospitals have access to discharge data from all payers. So they can use their own health information technology systems to measure different surgeon's specialization and share it with referring physicians, Sahni says.
Relative Risk Reduction
The researchers looked at the impact of specialization on 30-day mortality rates for four cardiac procedures and four cancer operations. Measured by relative risk, the ratio of overall risk to the risk of mortality with a specialist, they found that the relative risk reduction from greater specialization ranged from 15% for coronary artery bypass grafting to 46% for valve replacement.
For the four cancer surgeries, the relative risk reduction in mortality ranged from 28% for lung resection to 48% for esophagectomy, removal of all or part of the esophagus.
For the six procedures with "statistically significant relative risk reduction," the absolute risk reduction—the difference between overall risk and risk of mortality with a specialist—ranged from 0.3% for carotid endarterectomy to 2.8% for abdominal aortic aneurysm repair.
The research may offer good news for smaller hospitals that have a hard time reaching volume thresholds.
"You have a critical access hospital in the mountains, and you're only going to see so many heart attacks," Sahni says. "With specialization, because it is independent of volume, it brings up this point: Maybe I just have my surgeons specialize instead of having a cardiovascular department with ten different surgeons. Each of them does whatever (cases) come in."
Since specialization is easy to measure and independent of volume, it could offer a way for smaller hospitals to improve mortality rates. It could also guide hiring decisions, Sahni said.
The BMJ paper is important because volume is an incomplete measure of quality, said David Chang, PhD, MPH, MBA, of the Codman Center for Clinical Effectiveness in Surgery, at Massachusetts General Hospital in Boston. He is one of the authors of an editorial entitled: The Hidden Consequences of the Volume Pledge: "No Patient Left Behind"? and posted pre-publication in Annals of Surgery.
Chang agrees that the paper offer options for smaller hospitals that may suffer under volume restrictions.
"The implication would be, if you are a low volume hospital/surgeon, you may be able to compensate by specializing," he says. "Again, the research is incomplete there."
The research may also be welcomed by providers suffering under the growing number of quality measures, who worry this might just be another one.
Chang says the reason there are so many quality measures is that the measures in use are imprecise. Before adding more incomplete measures, "we should take a step back and really be thinking about how we measure quality."
Loss of independence after surgery affects a patient's functional status, mobility, and care needs and occurs frequently, especially in older patients, researchers determine.
What can hospitals learn from patients about how to prevent readmissions? One group of researchers decided to find out, and their results offer insights that may benefit patients, providers, and payers.
Older patients who report a loss of independence after surgery are more likely to die or be readmitted within 30 days, according to findings published in JAMA Surgery. The research is based on data collected from more than 5,000 patients on post-surgery function, cognition, mobility, and decision-making.
The researchers report that "loss of independence," or LOI, occurred frequently and was more common in older patients.
After adjusting for risk, researchers concluded that LOI was associated with a 1.7-fold increased risk for readmission and a roughly 6.7-fold increased risk for death after discharge.
The findings suggest that efforts to preserve mobility and recruit social support services could help keep even frail patients from declining after surgery, says lead author Julia R. Berian, MD, a clinical researcher with the American College of Surgeons.
The study describes LOI as a "patient-centered outcome," as opposed to more common outcome measures such as readmissions. That's because most patients don't measure the success of their care by the fact that they were not readmitted, Berian says.
"I'm trying to couch our study in terms that matter to most patients—their living situations," she said. "Their ability to live independently – that is extremely important to some of them."
Mobility, Function, Cognition Undervalued
And while LOI might seem like an unavoidable outcome for complex patients, that is often not the case, Berian says.
Providers think "they were sick to begin with, or were likely to have a problem from the get-go, so there is likely nothing that I could have done," she said. "But, I think we undervalue mobility and function and cognition."
While these factors can be difficult to measure, Berian says, they can often be addressed with simple efforts such as making sure patients are walked down the hall during recovery to improve mobility.
The researchers used an ACS clinical registry with data from 26 hospitals. Loss of independence was defined as a decline in one or all of three areas: functional status, mobility, and care needs.
They compared patient capacity for bathing, dressing, grooming, eating, and using the toilet before and after surgery. The defined care needs based on discharge destination and the need for support in the home.
Loss of independence was found to increase with age, ranging from 50% of patients 65 to 74 years old and 84% of patients older than 85. After post-surgical complications, LOI was the biggest factor in readmissions.
Researchers also found that LOI was strongly associated with mortality, along with other factors including emergency operations and age.
And while hospital physical therapy programs can help, in some cases, simply having a geriatrician or hospitalist involved with surgical patients is enough to improve LOI.
These clinicians can to make sure that patients are getting out of bed regularly and can talk with patients about the impact of their surgery on non-medical aspects of their lives, Berian says.
"We have traditionally counseled people with the model, 'You have a problem, we are going to fix it, and you are going to back to your normal life,'" she says.
"One of the factors patient often care about but isn't discussed, she says, is what is a patient's life "going to look like after surgery?"
Mobile devices allow telemedicine providers to virtually assess patients, and have the potential to improve stroke care and reduce emergency department traffic.
Smartphones and tablets often come with the promise that advanced technology and more powerful cellular networks will lead to better connections and faster streaming video.
But those promise could mean a lot more in a medical emergency.
Clearer pictures and reliable connectivity are making telemedicine more mobile and more reliable. The result: better tools for pre-hospital providers and the emergency department teams they work with.
In Houston, the city's EMT-trained firefighters now take connected tablets on 911 calls so they can allow a doctor to assess and triage patients via video.
And an ambulance-based tablet system may allow neurologists to accurately diagnose patients with stroke symptoms before they arrive at the hospital. That could speed care to patients, a key factors in better stroke outcomes.
Using an iPad and commercial cellular networks, doctors in rural Virginia and San Francisco were able to perform accurate neurologic exams after connecting with ambulance staff via video, according to a preliminary study in the journal Neurology.
The research used simulated scenarios—medical students working from scripts, as opposed to actual patients—to compare bedside and mobile assessments.
Every minute that care is delayed can have an impact on stroke outcomes, says Andrew Southerland, MD, the University of Virginia Health System doctor who led the study.
"So if we can perform pre-hospital telemedicine—virtually putting the neurologist in the back of the ambulance to evaluate patients—then, theoretically, we may be able to decrease the amount of time to get them diagnosed and in treatment," he said.
And while speed is key to stroke care, so is triage.
A subgroups of stroke patients can now benefit from an endovascular procedure known as "mechanical thrombectomy." For about 10% of patients, a doctor can use a catheter to access the brain and remove blood clots and limit stroke damage.
Those patients, however, need to be assessed and delivered to a hospital with the capacity to perform the procedure.
Southerland says that requires EMS providers, whether they are career paramedics or volunteer firefighters, to make important triage decisions. The tablet system would allow them to consult with a neurologist first.
The UVA team has been getting calls from other health systems interested in their approach.
Southerland tells them they can try to mimic the program, but he would rather they get involved in the research. Southerland's team is in the process of enrolling patients into the next phase of the research with the hope of eventually launching a multi-site clinical trial.
"We don't want it to be thrown out there without the requisite amount of amount of rigor that we put into it," he said.
For example, his team spent two years looking the connectivity on the ambulance routes to make sure they had the broadband capacity to make the system work.
Houston's ETHAN
Just five years ago, programs like this may not have been possible, according to Michael G. Gonzalez, MD, medical director of Houston's ETHAN Project (Emergency TeleHealth And Navigation).
The clarity and processing speeds of the current devices, along with the cellular networks make the teleconference encounter virtually identical to an in-person encounter, he wrote in an email response to questions from Health Leaders. His system uses a Panasonic Toughpad
"The physician can direct the paramedic or firefighter on scene to direct the image toward a sprained, swollen ankle, or concerning rash, and the image quality enables the physician to make an appropriate decision regarding the best, most appropriate level of care," he wrote.
For patients who don't need to emergency care, the paramedics offer to set up an appointment with a doctor and pay for a roundtrip taxi.
"With ETHAN… we have demonstrated that real-time, direct visualization and interview of patients in the pre-hospital setting is not only possible, but potentially time-saving and efficient," he wrote.
"The potential for videoconferencing and similar technologies in the prehospital/EMS world is limitless."
Medicare's Oncology Care Model looks to be better for many patients, but oncologists are concerned that it does not account for stage of cancer or drug costs.
Medicare's oncology bundled payment program, which began July 1, will benefit many cancer patients, giving them 24/7 access to doctors and navigators to guide them from one appointment to the next.
But the benefits of the Oncology Care Model to hospitals and oncologists may be harder to find.
Some physicians worry that the payments don't account for the high cost of some drugs. And if high quality care ultimately means less inpatient care, hospitals will end up with empty beds.
The University of Michigan Comprehensive Cancer Center, got a head start on implementing elements of the OCM program, which provides performance-based payments for episodes of care triggered by the start of chemotherapy.
The academic medical center is home to one of the nearly 200 oncology practices trying out the program.
Participating practices have to offer a range of services. One is patient navigation. While some hospitals offer the service as a "marketing tool," at UMCC a customized navigation program is offered, says center director Alon Weizer, MD.
One approach is taken with educated, insured patients who don't need much help and another with patients who lack resources, such the homeless.
While it would be great to have all patients engaged in their care, that's not always the case, he says. Some need help lining up the social supports they need to get through cancer treatment.
"We spend a lot of time trying to figure out how are they going to get a ride, how are we going to pay for things. Are they getting their other medications? What does their nutrition look like at home?" Weizer says.
He's excited about the positive changes, but he acknowledges that adopting OCM might be a challenge for hospitals. Unnecessary emergency rooms visits and end-of-life inpatient care are high costs services that often don't improve outcomes.
Other changes, such as early palliative care and symptom management, may also mean a drop in admissions, Weizer says.
Still, he thinks that hospitals will benefit from the program in the long term as payers move away from a fee-for-service toward a value-based payment models.
The hospitals with practices participating in the program range from academic medical systems such as the University of Michigan, which is comprised of three hospitals with a total of 1,000 beds, to the 148-bed Coosa Valley Medical Center in Sylacauda, Alabama.
Blase Polite, MD, is the chair of American Society of Clinical Oncologists government relations committee. He is also the chief quality officer for oncology at University of Chicago Medicine, 568-bed system that is also participating in the OCM.
ASCO has been suggesting that CMS adopt its physician payment model, which the group believes "better matches payments to the work performed by oncologists and their care teams."
Some Concerns
One of the key concerns about OCM is that the payments do not account for the costs of drugs, Polite says. Payments are based on diagnosis alone. For example, they do not account for stage of cancer or genetic mutations that require specific medications.
"If someone comes in with a driver mutation in lung cancer, all of the sudden they are relegated to a much more expensive chemotherapy," he said. "Within the same cancer, you can have wildly different costs."
A large system like his should have the volume to bear those costs. But Polite says the OCM could hurt smaller practices with a large percentage of patients who need expensive drugs.
Weizer of Michigan says one of the biggest barriers will be culture change—getting the entire care team on board with the OCM. Still, he thinks the program will improve patient care.
Weizer specializes in bladder and other urologic cancers and sees a lot of patients who come in for surgery or second opinions because they have received care that was of no benefit.
"One of the reasons that I think this is exciting is [that] hopefully, it is going to allow us to be paid for doing the right things for patients as opposed to doing more for patients," he said.
For emergency medicine clinicians who learned to defer to patients' privacy on sexual orientation and gender identification, asking questions is a major culture change.
As HHS moves toward advancing healthcare equality, patients are generally comfortable with emergency department physicians and nurses asking about sexual orientation and gender identity (SO/GI).
But 80% of ED providers surveyed said they are hesitant to ask for fear of offending patients.
The survey of 1,617 emergency room patients and 429 providers found that only 11% of patients said they would object to a doctor or nurse's query about SO/GI.
"The providers say, 'I am going to treat everyone the same,'" said Adil Haider, MD, of Brigham and Women's Hospital in Boston. "But, that's not what the patients want. They want to be recognized for who they are."
The data was released in Boston on Wednesday at the Academy Health annual meeting of health services researchers.
It comes from an ongoing study comparing two approaches to collecting the SO/GI information to determine "the best patient-centered approach."
The research is taking place at emergency departments at two academic medical centers and two community settings.
The preliminary report comes as the Department of Health and Human Services moves toward requiring the option to record a patient's SO/GI in electronic health records.
The researchers are comparing two approaches: In one group, a nurse asks for the information. In the other, patients have the option to self-report while filling out the registration form.
Potentiality Stigmatizing
Jeremiah Schuur, MD, an emergency medicine physician at Brigham and Women's, told a story of a pregnant patient who came in after being hit by a golf ball. Schuur addressed the man in the room as her husband, only to find out that the other woman in the room was the patient's wife.
"This revisited on me the importance of doing this in a systemic way," he said.
"I am quite well informed, but in our normal operations, there are many ways that we are set up to not acknowledge people for who they are."
Schuur said he was taught that SO and GI were potentiality stigmatizing and could negatively affect a patient's life or work if disclosed.
Asking for the information is even more complicated in the ED where care is often delivered in hallways or behind curtains, and providers don't have established relationships with patients, he said.
Listening to Patients
"In general, we are more resistant to asking for confidential information in the ED," he said, but reading the narratives of some of the patients in the survey has changed his mind.
Two of the comments presented at the meeting:
"If you are counted, if you are visible, it's sort of another form of recognition at and institutional level." – 47-year-old "queer female"
"It helps avoid an uncomfortable situation that may arise. Opens the door to communication between the doctor and the patient." – 40-year-old white, male physician
Still, asking these questions represents a major cultural change at a time when ED staff are dealing with other demands. Schuur said it is hard to predict how staff will respond.
"We have advanced practices around LGBT health care and LGBT practices for employees, yet we had the [greatest] challenge (of the four cited) in getting nurses to adopt this practice," he said.
Hospital administrators will need to work with both staff and the LGBT community to identify what needs to be done to prepare for SO/GI reporting.
There is no "one-size-fits-all" solution, Haider said.
But, hospitals need to realize that this kind of reporting is becoming routine: "The patients want it, the regulators want it, so we need to do it."
Researchers call for combining the efforts of military and civilian trauma systems to "achieve zero preventable deaths" after traumatic injury and mass casualty events.
Hospitals need to consider emergency medical teams as care providers, not just ambulance drivers, according to a new report from the National Academies of Sciences on the lessons for civilians from combat trauma care.
The report, released last week, calls for combining the efforts of military and civilian trauma systems to "achieve zero preventable deaths after injury" and notes that recent "mass casualty incidents" lend urgency to the effort.
"You saw what happened in Orlando," committee chairman Donald Berwick, MD, said during a live, online teleconference on release of the report.
"You saw what happened with the marathon bombings in Boston. Those improvements largely rest on lessons learned in the military that were effectively brought into the design and conduct of civilian emergency responses."
Berwick, a former Centers for Medicare & Medicaid Services administrator, is a senior fellow at the Institute for Healthcare Improvement in Cambridge, MA.
Despite innovations and improved outcomes, and an estimate that 20% of trauma-related deaths are preventable, the report authors note that there are "serious limitations in the thoroughness of the diffusion of those gains..."
Goal: Zero Preventable Deaths
The researchers found that accountability for civilian trauma care capabilities is "fragmented" and variable "resulting in a patchwork of systems for trauma care in which mortality varies twofold between the best and worst trauma centers in the nation."
The report calls on the White House to set a national goal of zero preventable deaths and to act as a convener of the many public and private entities involved trauma care. Recommendations also call for efforts to develop best practices and improve electronic medical systems and research programs.
Furthermore, the report calls for the formal designation of EMS programs as care providers, not just as transporters. And the report calls on CMS to modify ambulance payments to better link the quality of prehospital care to payment and reform efforts.
"We can't get the job of zero preventable deaths done without thinking of trauma care as a system," Berwick said.
"As important as hospital are in the system, it is important for them to think of themselves as part of a pathway of care that begins at the point of injury and includes prehospital as well a post-hospital care."
David King, MD, is a surgeon at Massachusetts General Hospital in Boston who served with the Army in Afghanistan and Iraq. He was on his way home after running the 2013 Boston Marathon when he heard news of the explosions and headed back into town to help with the victims.
He said many of the report's recommendations have been proposed before, but "like any other unfunded mandate, they go nowhere."
King agrees that prehospital care needs to be better integrated into the system so patients can be tracked from injury to rehab or death. Scanning data from prehospital reports into an electronic medical records system can be a challenge, for example.
King supports the idea of White House leadership on the issue.
"Individually, no one is going to do it," he said in a phone interview. "There needs to be high level government leadership for this, with funding, to make it happen."
King is involved in The Hartford Consensus, a group formed after the 2012 Newtown shootings to examine medical readiness for mass casualties. The group identified uncontrolled bleeding or hemorrhage as a major cause of death in these incidents and launched a program called "Stop the Bleeding" that promotes the use of tourniquets and "bleeding control kits" by both first responders and bystanders.
He doesn't think that the Orlando shooting this month—the deadliest mass shooting in US history—or general concerns about gun violence have generated any momentum for the effort to improve the trauma system.
Many doctors and patients don't talk about how to handle the pain, disability, or despair that may accompany a serious illness or imminent death. Hospital leaders can push for greater competency in advanced planning among clinicians.
Medicare may reimburse primary care physicians for end-of-life talks with patients, but those conversations between seriously ill patients and their doctors often don't occur, even when patients are being treated for serious illnesses.
A survey by the Massachusetts Coalition for Serious Illness Care shows that 85% of Massachusetts residents believe that physicians and their patients should talk about end-of-life care, but only 15% have actually had such conversations.
Working with healthcare delivery systems will be one of the coalition's most important tasks, according to Atul Gawande, the coalition's co-chair and a surgeon at Brigham and Women's Hospital in Boston.
Gawande, who responded to email questions from HealthLeaders, is also author of the bestseller on end-of-life care, Being Mortal.
"Hospital leaders have an opportunity to reduce suffering and improve patient well-being by making these conversations a routine part of care," he wrote.
"To do that, they can train clinicians to have these conversations, adopt processes to identify at-risk patients who would most benefit from these conversations, and invest in systems that support the clinicians, patients, and families."
Some forms of end-of-life care are improving, he acknowledges. The percentage of patients getting hospice services and other forms of palliative care has been rising steadily.
The more persistent problem, however, is poorly executed or over-aggressive end-of-life treatment, which may occur well before a patient qualifies for hospice.
ASCO: No Abatement Seen in Aggressive End-of-Life Cancer Care
Those with serious or chronic conditions may not want more therapeutic care if it means a reduced quality of life, a painful procedure, or an expensive long shot at a cure.
The survey suggests that many doctors and patient don't routinely talk about how to handle the pain, disability, or despair that may accompany a serious illness or imminent death.
Training providers to have those conversations is the biggest challenge of improving end-of-life programs, says Patricia M. Noga, the vice president for clinical affair for the Massachusetts Hospital Association, which is a member of the serious illness coalition.
Everyone on the care teams need to be both competent and comfortable talking to patients, she says.
Conversation Works Both Ways
Patients need to be open to discussing issues as well. But the Massachusetts survey found that 34% were uncomfortable talking about the topic. Another 21% said they preferred to wait for doctors to start the conversation.
The coalition's efforts fit into much of the work the MHA has been doing for since 2009. Noga says. It has made advanced planning and end-of-life care a priority by educating members, participating in research, and working closely with other groups.
The topic has surfaced in discussions about how to prevent hospital readmissions. Currently, the group is working on a survey that will ask members how they are implementing end-of-life programs.
Nationally, other hospital, healthcare and caretaker organizations are also working on the issue. The American Hospital Association lists 11 state programs on its website including Texas, California, and New Hampshire.
More than 90 million Americans live with at least one chronic illness, and seven out of ten Americans die from chronic disease, according to the Dartmouth Atlas of Health Care.
Low Patient Satisfaction
Hospitals concerned about patient's satisfaction should know that 30% of survey respondents said that providers did not follow a friend or family member's end-of-life wishes. Twenty percent described the end-of-life care they witnessed as fair or poor.
Source: Massachusetts Coalition for Serious Illness Care
Ultimately, advanced planning is something that needs to be built into training for all members of the care teams, including physicians, nurses, physician assistants, nurse practitioners, social workers and case manages, Noga says, echoing Gawande.
It needs to be a "a competency you achieve through educations, that you achieve in your practice, and is supported in your care setting," she says.
