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Physician couples draft wills, face tough questions amid COVID-19
Not long ago, weekends for Cornelia Griggs, MD, meant making trips to the grocery store, chasing after two active toddlers, and eating brunch with her husband after a busy work week. But life has changed dramatically for the family since the spread of COVID-19. On a recent weekend, Dr. Griggs and her husband, Robert Goldstone, MD, spent their days off drafting a will.
“We’re both doctors, and we know that health care workers have an increased risk of contracting COVID,” said Dr. Griggs, a pediatric surgery fellow at Columbia University Irving Medical Center in New York. “It felt like the responsible thing to do: Have a will in place to make sure our wishes are clear about who would manage our property and assets, and who would take care of our kids – God forbid.”
Outlining their final wishes is among many difficult decisions the doctors, both 36, have been forced to make in recent weeks. Dr. Goldstone, a general surgeon at Massachusetts General Hospital in Boston, is no longer returning to New York during his time off, said Dr. Griggs, who has had known COVID-19 exposures. The couple’s children, aged 4 and almost 2, are temporarily living with their grandparents in Connecticut to decrease their exposure risk.
“I felt like it was safer for all of them to be there while I was going back and forth from the hospital,” Dr. Griggs said. “My husband is in Boston. The kids are in Connecticut and I’m in New York. That inherently is hard because our whole family is split up. I don’t know when it will be safe for me to see them again.”
Health professional couples across the country are facing similar challenges as they navigate the risk of contracting COVID-19 at work, while trying to protect their families at home. From childcare dilemmas to quarantine quandaries to end-of-life considerations, partners who work in health care are confronting tough questions as the pandemic continues.
The biggest challenge is the uncertainty, says Angela Weyand, MD, an Ann Arbor, Mich.–based pediatric hematologist/oncologist who shares two young daughters with husband Ted Claflin, MD, a physical medicine and rehabilitation physician. Dr. Weyand said she and her husband are primarily working remotely now, but she knows that one or both could be deployed to the hospital to help care for patients, if the need arises. Nearby Detroit has been labeled a coronavirus “hot spot” by the U.S. Surgeon General.
“Right now, I think our biggest fear is spreading coronavirus to those we love, especially those in higher risk groups,” she said. “At the same time, we are also concerned about our own health and our future ability to be there for our children, a fear that, thankfully, neither one of us has ever had to face before. We are trying to take things one day at a time, acknowledging all that we have to be grateful for, and also learning to accept that many things right now are outside of our control.”
Dr. Weyand, 38, and her husband, 40, finalized their wills in March.
“We have been working on them for quite some time, but before now, there has never been any urgency,” Dr. Weyand said. “Hearing about the high rate of infection in health care workers and the increasing number of deaths in young healthy people made us realize that this should be a priority.”
Dallas internist Bethany Agusala, MD, 36, and her husband, Kartik Agusala, MD, 41, a cardiologist, recently spent time engaged in the same activity. The couple, who work for the University of Texas Southwestern Medical Center, have two children, aged 2 and 4.
“The chances are hopefully small that something bad would happen to either one of us, but it just seemed like a good time to get [a will] in place,” Dr. Bethany Agusala said in an interview. “It’s never an easy thing to think about.
Pediatric surgeon Chethan Sathya, MD, 34, and his wife, 31, a physician assistant, have vastly altered their home routine to prevent the risk of exposure to their 16-month-old daughter. Dr. Sathya works for the Northwell Health System in New York, which has hundreds of hospitalized patients with COVID-19, Dr. Sathya said in an interview. He did not want to disclose his wife's name or institution, but said she works in a COVID-19 unit at a New York hospital.
When his wife returns home, she removes all of her clothes and places them in a bag, showers, and then isolates herself in the bedroom. Dr. Sathya brings his wife meals and then remains in a different room with their baby.
“It’s only been a few days,” he said. “We’re going to decide: Does she just stay in one room at all times or when she doesn’t work for a few days then after 1 day, can she come out? Should she get a hotel room elsewhere? These are the considerations.”
They employ an older nanny whom they also worry about, and with whom they try to limit contact, said Dr. Sathya, who practices at Cohen Children’s Medical Center. In a matter of weeks, Dr. Sathya anticipates he will be called upon to assist in some form with the COVID crisis.
“We haven’t figured that out. I’m not sure what we’ll do,” he said. “There is no perfect solution. You have to adapt. It’s very difficult to do so when you’re living in a condo in New York.”
For Dr. Griggs, life is much quieter at home without her husband and two “laughing, wiggly,” toddlers. Weekends are now defined by resting, video calls with her family, and exercising, when it’s safe, said Dr. Griggs, who recently penned a New York Times opinion piece about the pandemic and is also active on social media regarding personal protective equipment. She calls her husband her “rock” who never fails to put a smile on her face when they chat from across the miles. Her advice for other health care couples is to take it “one day at a time.”
“Don’t try to make plans weeks in advance or let your mind go to a dark place,” she said. “It’s so easy to feel overwhelmed. The only way to get through this is to focus on surviving each day.”
Editor's Note, 3/31/20: Due to incorrect information provided, the hospital where Dr. Sathya's wife works was misidentified. We have removed the name of that hospital. The story does not include his wife's employer, because Dr. Sathya did not have permission to disclose her workplace and she wishes to remain anonymous.
Not long ago, weekends for Cornelia Griggs, MD, meant making trips to the grocery store, chasing after two active toddlers, and eating brunch with her husband after a busy work week. But life has changed dramatically for the family since the spread of COVID-19. On a recent weekend, Dr. Griggs and her husband, Robert Goldstone, MD, spent their days off drafting a will.
“We’re both doctors, and we know that health care workers have an increased risk of contracting COVID,” said Dr. Griggs, a pediatric surgery fellow at Columbia University Irving Medical Center in New York. “It felt like the responsible thing to do: Have a will in place to make sure our wishes are clear about who would manage our property and assets, and who would take care of our kids – God forbid.”
Outlining their final wishes is among many difficult decisions the doctors, both 36, have been forced to make in recent weeks. Dr. Goldstone, a general surgeon at Massachusetts General Hospital in Boston, is no longer returning to New York during his time off, said Dr. Griggs, who has had known COVID-19 exposures. The couple’s children, aged 4 and almost 2, are temporarily living with their grandparents in Connecticut to decrease their exposure risk.
“I felt like it was safer for all of them to be there while I was going back and forth from the hospital,” Dr. Griggs said. “My husband is in Boston. The kids are in Connecticut and I’m in New York. That inherently is hard because our whole family is split up. I don’t know when it will be safe for me to see them again.”
Health professional couples across the country are facing similar challenges as they navigate the risk of contracting COVID-19 at work, while trying to protect their families at home. From childcare dilemmas to quarantine quandaries to end-of-life considerations, partners who work in health care are confronting tough questions as the pandemic continues.
The biggest challenge is the uncertainty, says Angela Weyand, MD, an Ann Arbor, Mich.–based pediatric hematologist/oncologist who shares two young daughters with husband Ted Claflin, MD, a physical medicine and rehabilitation physician. Dr. Weyand said she and her husband are primarily working remotely now, but she knows that one or both could be deployed to the hospital to help care for patients, if the need arises. Nearby Detroit has been labeled a coronavirus “hot spot” by the U.S. Surgeon General.
“Right now, I think our biggest fear is spreading coronavirus to those we love, especially those in higher risk groups,” she said. “At the same time, we are also concerned about our own health and our future ability to be there for our children, a fear that, thankfully, neither one of us has ever had to face before. We are trying to take things one day at a time, acknowledging all that we have to be grateful for, and also learning to accept that many things right now are outside of our control.”
Dr. Weyand, 38, and her husband, 40, finalized their wills in March.
“We have been working on them for quite some time, but before now, there has never been any urgency,” Dr. Weyand said. “Hearing about the high rate of infection in health care workers and the increasing number of deaths in young healthy people made us realize that this should be a priority.”
Dallas internist Bethany Agusala, MD, 36, and her husband, Kartik Agusala, MD, 41, a cardiologist, recently spent time engaged in the same activity. The couple, who work for the University of Texas Southwestern Medical Center, have two children, aged 2 and 4.
“The chances are hopefully small that something bad would happen to either one of us, but it just seemed like a good time to get [a will] in place,” Dr. Bethany Agusala said in an interview. “It’s never an easy thing to think about.
Pediatric surgeon Chethan Sathya, MD, 34, and his wife, 31, a physician assistant, have vastly altered their home routine to prevent the risk of exposure to their 16-month-old daughter. Dr. Sathya works for the Northwell Health System in New York, which has hundreds of hospitalized patients with COVID-19, Dr. Sathya said in an interview. He did not want to disclose his wife's name or institution, but said she works in a COVID-19 unit at a New York hospital.
When his wife returns home, she removes all of her clothes and places them in a bag, showers, and then isolates herself in the bedroom. Dr. Sathya brings his wife meals and then remains in a different room with their baby.
“It’s only been a few days,” he said. “We’re going to decide: Does she just stay in one room at all times or when she doesn’t work for a few days then after 1 day, can she come out? Should she get a hotel room elsewhere? These are the considerations.”
They employ an older nanny whom they also worry about, and with whom they try to limit contact, said Dr. Sathya, who practices at Cohen Children’s Medical Center. In a matter of weeks, Dr. Sathya anticipates he will be called upon to assist in some form with the COVID crisis.
“We haven’t figured that out. I’m not sure what we’ll do,” he said. “There is no perfect solution. You have to adapt. It’s very difficult to do so when you’re living in a condo in New York.”
For Dr. Griggs, life is much quieter at home without her husband and two “laughing, wiggly,” toddlers. Weekends are now defined by resting, video calls with her family, and exercising, when it’s safe, said Dr. Griggs, who recently penned a New York Times opinion piece about the pandemic and is also active on social media regarding personal protective equipment. She calls her husband her “rock” who never fails to put a smile on her face when they chat from across the miles. Her advice for other health care couples is to take it “one day at a time.”
“Don’t try to make plans weeks in advance or let your mind go to a dark place,” she said. “It’s so easy to feel overwhelmed. The only way to get through this is to focus on surviving each day.”
Editor's Note, 3/31/20: Due to incorrect information provided, the hospital where Dr. Sathya's wife works was misidentified. We have removed the name of that hospital. The story does not include his wife's employer, because Dr. Sathya did not have permission to disclose her workplace and she wishes to remain anonymous.
Not long ago, weekends for Cornelia Griggs, MD, meant making trips to the grocery store, chasing after two active toddlers, and eating brunch with her husband after a busy work week. But life has changed dramatically for the family since the spread of COVID-19. On a recent weekend, Dr. Griggs and her husband, Robert Goldstone, MD, spent their days off drafting a will.
“We’re both doctors, and we know that health care workers have an increased risk of contracting COVID,” said Dr. Griggs, a pediatric surgery fellow at Columbia University Irving Medical Center in New York. “It felt like the responsible thing to do: Have a will in place to make sure our wishes are clear about who would manage our property and assets, and who would take care of our kids – God forbid.”
Outlining their final wishes is among many difficult decisions the doctors, both 36, have been forced to make in recent weeks. Dr. Goldstone, a general surgeon at Massachusetts General Hospital in Boston, is no longer returning to New York during his time off, said Dr. Griggs, who has had known COVID-19 exposures. The couple’s children, aged 4 and almost 2, are temporarily living with their grandparents in Connecticut to decrease their exposure risk.
“I felt like it was safer for all of them to be there while I was going back and forth from the hospital,” Dr. Griggs said. “My husband is in Boston. The kids are in Connecticut and I’m in New York. That inherently is hard because our whole family is split up. I don’t know when it will be safe for me to see them again.”
Health professional couples across the country are facing similar challenges as they navigate the risk of contracting COVID-19 at work, while trying to protect their families at home. From childcare dilemmas to quarantine quandaries to end-of-life considerations, partners who work in health care are confronting tough questions as the pandemic continues.
The biggest challenge is the uncertainty, says Angela Weyand, MD, an Ann Arbor, Mich.–based pediatric hematologist/oncologist who shares two young daughters with husband Ted Claflin, MD, a physical medicine and rehabilitation physician. Dr. Weyand said she and her husband are primarily working remotely now, but she knows that one or both could be deployed to the hospital to help care for patients, if the need arises. Nearby Detroit has been labeled a coronavirus “hot spot” by the U.S. Surgeon General.
“Right now, I think our biggest fear is spreading coronavirus to those we love, especially those in higher risk groups,” she said. “At the same time, we are also concerned about our own health and our future ability to be there for our children, a fear that, thankfully, neither one of us has ever had to face before. We are trying to take things one day at a time, acknowledging all that we have to be grateful for, and also learning to accept that many things right now are outside of our control.”
Dr. Weyand, 38, and her husband, 40, finalized their wills in March.
“We have been working on them for quite some time, but before now, there has never been any urgency,” Dr. Weyand said. “Hearing about the high rate of infection in health care workers and the increasing number of deaths in young healthy people made us realize that this should be a priority.”
Dallas internist Bethany Agusala, MD, 36, and her husband, Kartik Agusala, MD, 41, a cardiologist, recently spent time engaged in the same activity. The couple, who work for the University of Texas Southwestern Medical Center, have two children, aged 2 and 4.
“The chances are hopefully small that something bad would happen to either one of us, but it just seemed like a good time to get [a will] in place,” Dr. Bethany Agusala said in an interview. “It’s never an easy thing to think about.
Pediatric surgeon Chethan Sathya, MD, 34, and his wife, 31, a physician assistant, have vastly altered their home routine to prevent the risk of exposure to their 16-month-old daughter. Dr. Sathya works for the Northwell Health System in New York, which has hundreds of hospitalized patients with COVID-19, Dr. Sathya said in an interview. He did not want to disclose his wife's name or institution, but said she works in a COVID-19 unit at a New York hospital.
When his wife returns home, she removes all of her clothes and places them in a bag, showers, and then isolates herself in the bedroom. Dr. Sathya brings his wife meals and then remains in a different room with their baby.
“It’s only been a few days,” he said. “We’re going to decide: Does she just stay in one room at all times or when she doesn’t work for a few days then after 1 day, can she come out? Should she get a hotel room elsewhere? These are the considerations.”
They employ an older nanny whom they also worry about, and with whom they try to limit contact, said Dr. Sathya, who practices at Cohen Children’s Medical Center. In a matter of weeks, Dr. Sathya anticipates he will be called upon to assist in some form with the COVID crisis.
“We haven’t figured that out. I’m not sure what we’ll do,” he said. “There is no perfect solution. You have to adapt. It’s very difficult to do so when you’re living in a condo in New York.”
For Dr. Griggs, life is much quieter at home without her husband and two “laughing, wiggly,” toddlers. Weekends are now defined by resting, video calls with her family, and exercising, when it’s safe, said Dr. Griggs, who recently penned a New York Times opinion piece about the pandemic and is also active on social media regarding personal protective equipment. She calls her husband her “rock” who never fails to put a smile on her face when they chat from across the miles. Her advice for other health care couples is to take it “one day at a time.”
“Don’t try to make plans weeks in advance or let your mind go to a dark place,” she said. “It’s so easy to feel overwhelmed. The only way to get through this is to focus on surviving each day.”
Editor's Note, 3/31/20: Due to incorrect information provided, the hospital where Dr. Sathya's wife works was misidentified. We have removed the name of that hospital. The story does not include his wife's employer, because Dr. Sathya did not have permission to disclose her workplace and she wishes to remain anonymous.
Use of an Electronic Alert Tool to Prevent Readmissions Following Coronary Artery Bypass Graft Surgery
From the University of North Carolina at Wilmington School of Nursing (Dr. Smith and Dr. Turrise), the New Hanover Regional Medical Center Heart Center (Mr. Jordan), the Coastal Carolinas Health Alliance and Coastal Connect Health Information Exchange (Ms. Robertson), and Coastal Thoracic Surgical Associates (Dr. Kane), Wilmington, NC.
Abstract
Objective: Cardiothoracic (CT) surgeons at our medical center were not receiving timely notification when their coronary artery bypass graft (CABG) surgery patients were admitted to the medical center or to other hospitals. The CT surgical team worked with a health alliance in southeastern North Carolina to implement health information exchange (HIE) real-time electronic notifications for their CABG patients who presented to the hospital’s emergency department (ED) or any ED affiliated with the medical center. The alert tool notifies team members about patient encounters, driving timely clinical engagement.
Methods: The CT team provided the HIE team with the names of CABG surgery patients, which were loaded into the alert tool. When a patient on the list presented to the hospital ED or its affiliates, the alert tool sent a real-time electronic notification to the Cardiac Surgical Services nurse coordinator. This intervention prompted the assessment and disposition of CABG patients, while in the ED, by the CT surgical team.
Results: Over a 16-month period (September 2017-December 2018), the names of 614 post-CABG patients were input into the HIE for tracking. Of these patients, 47 were treated and discharged from the ED; 31 were admitted for observation; 44 were readmitted for inpatient care; and 492 did not have a qualifying event requiring a notification alert. Following implementation of this practice change, the 30-day readmission rate for patients who underwent CABG at our institution decreased from 10% to 7.2%.
Conclusion: Utilizing a real-time alert tool resulted in immediate notification of the CT team when 1 of their patients presented to the ED. This afforded the CT surgical team an opportunity to intervene in the care of their patients, which in turn led to improved quality of care, physician communication and collaboration, and patient outcomes, such as preventable 30-day readmissions.
Keywords: electronic health record; real-time electronic notification; CABG; process improvement.
Unplanned 30-day hospital readmissions of patients who have undergone coronary artery bypass graft (CABG) surgery contribute to higher overall health care costs. CABG is 1 of the conditions/procedures that the Centers for Medicare and Medicaid Services (CMS) monitors for excess readmissions.1 Readmission rates for CABG-related conditions at 30 days post-surgery are reported to be between 16% and 20% for US hospitals.2 Readmissions are not only financially costly, but also have been associated with worse patient outcomes and decreased patient satisfaction.3 Common diagnoses for post-CABG admission include atrial fibrillation, pleural effusion, and wound infection.
The facility where this project was implemented had a 10% post-CABG admission rate for patients across all payers. While this rate is below the national average of 13.2%, the cardiothoracic (CT) surgical team was not being notified in a timely manner when their post-CABG patients were readmitted. The Lean team used the A3 problem-solving process to develop strategies that would reduce these readmissions and improve the care of their patients.
We explored the use of electronic alerts in managing post-CABG patients by conducting a literature search using the terms electronic alerts in patient care, patient engagement in the emergency department, electronic alerts in CABG, real-time notifications to prevent readmission, and CABG readmission. Databases searched were PubMed, Google Scholar, Cumulative Index of Nursing and Allied Health Literature, ProQuest, and ScienceDirect. This search resulted in studies focused on the use of electronic health record (EHR) alerts as a clinical decision-support tool; for example, patient demographic and assessment data are entered into the EHR, and the clinician is prompted with “performance” recommendations (eg, consider electrocardiogram and aspirin).4 In a paper by Engelman and Benjamin,5 the authors discuss the importance of the engaged physician and note that, in their emergency department (ED), an electronic notification is sent when a postoperative patient presents; however, the notification goes to the inpatient service for timely review and disposition. There was no literature that discussed the use of an electronic alert tool as a real-time patient engagement strategy that resulted in a practice change specific to the CT surgical team.
Our process improvement project focused on alerting the CT surgical team when a post-CABG patient presented to the ED, allowing them to evaluate the patient in real time and determine whether the chief complaint was related to the CABG and whether further evaluation by the CT surgeon was required. Specifically, we wanted to determine whether a real-time electronic alert that notified the CT surgical team about post-op CABG patients presenting to the ED would result in timely patient engagement, avoidance of readmissions, and an enhanced patient experience. During this project, alerts were sent to the CT surgical team notifying them of a post-CABG patient presenting to the ED or being directly admitted from home on physician orders, a provider’s office, or inpatient rehabilitation; however, the focus of this article is specifically on the notification regarding post-CABG patients presenting to the ED.
Prior to implementing the electronic notification project, the team developed and implemented several internal and external readmission reduction and prevention strategies for CABG patients. An in-house strategy involved a process whereby patients would receive their discharge medications prior to being discharged from the hospital post-CABG, thereby avoiding potential delays in the patient obtaining medications. When examining post-CABG patient readmissions, the primary conditions that led to readmission were fluid overload, pleural effusion, and atrial fibrillation. As such, a second in-house strategy was developed for post-CABG patients presenting to the ED with atrial fibrillation. The newly established protocol allowed patients to be monitored and treated in the cardiac observation unit. In addition, external strategies, including an outpatient furosemide protocol for home health nurses and an outpatient thoracentesis program and order set, were established (eg, for patients with congestive heart failure, shortness of breath).
Methods
Setting
The regional medical center where this project was implemented is the ninth largest hospital in North Carolina and the largest county-owned public hospital in the state. It is a tertiary care center and teaching hospital with 3 hospital campuses and 855 licensed beds. The medical center was included in the 100 Safecare Hospitals list by the Safecare Group; received a grade “A” Hospital Safety Score from the Leapfrog Group; and is 1 of America’s Top 100 Hospitals for Patient Experience.
Real-Time Notification Project
A regional hospital alliance in southeastern North Carolina established a health information exchange (HIE) with its member hospitals and office-based physicians to enable electronic exchange of patient information to improve quality, safety, and efficiency in health care delivery. Our medical center is part of this alliance. The HIE is a digital platform that facilitates the sharing of information between disparate connected EHR systems, and offers a portal for practices and hospitals to access patient information across North Carolina, South Carolina (via SC HIE), and nationwide (select dialysis centers). More specifically, approved providers and team members are able to access, in real time, patient-care encounter documents from other care settings (eg, acute, post-acute, ambulatory) via the HIE. Additionally, approved care entities can query-retrieve web portal information to support patient outcome improvement strategies. A partnership discussion highlighted the opportunity to utilize the HIE’s capabilities, such as real-time notification, to facilitate workflow (eg, when a patient presents to the ED, the HIE can provide access to health information at the point of care). In this capacity, the alert tool notifies care team members about patient encounters to drive timely clinical engagement for care transitions.
In January 2017, we began discussions on using the HIE to facilitate real-time electronic tracking in the Cardiac Surgical Services department at our medical center. Persons involved in these discussions included the cardiovascular (CV) team (comprised of case managers, department managers and coordinators, program coordinators, administrators, and support services [eg, pre-admission testing and home health staff]) and CT surgeons. At that time, CABG readmissions were manually tracked, and the real-time notification tool was being used in other departments (eg, in case management for tracking readmissions). The entire team was part of the initial decision meeting to pursue this possibility. The CV team reached consensus in June 2017 and proposed extending the use of the alert tool to the post-CABG population presenting to the ED (or any ED affiliated with the medical center) or admitted directly to the medical center.
The HIE staff met with the Cardiac Surgical Services team to tailor and develop the logistics of the project, such as who would be notified and how. The goals of the project were to support appropriate care intervention, reduce preventable hospital readmissions, and improve quality of care through enhanced provider communication and engagement. To achieve these goals, on the day of discharge the Cardiac Surgical Services coordinator provided the HIE team with the names of patients who had undergone CABG surgery. This patient list was loaded into the alert tool and continually updated. At 31 days, patient names were removed from the list. When a patient on the list presented to the hospital ED, the alert tool sent 2 real-time electronic notifications, an email and a text message, to the Cardiac Surgical Services coordinator, noting that a patient event occurred. Personal information was not included in the alert in order to protect patient information and comply with Health Insurance Portability and Accountability Act regulations.
The alert prompted the Cardiac Surgical Services coordinator to securely access patient information to identify and, if necessary, visit the patient. Then, based on the information gathered by the Cardiac Surgical Services coordinator, a Situation-Background-Assessment-Recommendation report was relayed to the CT surgeon, who then determined whether intervention by the CT surgical team was warranted. This process, on average, took approximately 30 minutes to complete. This was a key change in processes, one that allowed post-CABG patients to be seen by the CT surgical team while in the ED. If the issue was related to the CABG surgery, the CT surgeons could then determine an appropriate course of action, including admission or implementation of another protocol, such as the home furosemide protocol. For patients directly admitted, the surgeon contacted the admitting provider to discuss the level of care required (ie, observation or inpatient admission and treatment).
Biweekly CV team meetings were conducted during the implementation of the real-time notification alert tool. At each meeting, updates were provided on notifications received, patients who were missed by the notification process, and how well the real-time alerts were working to enhance care and appropriate disposition.
Measurements
Clinical performance data included total notifications, total number of ED visits, ED disposition (inpatient admission, observation, discharge), total number of direct admissions, direct admissions to observation, direct inpatient admissions, and patients missed by the notification process (eg, due to data entry errors, omissions of information [suffix of junior or senior], as well as programming bugs). Finally, the number of observation admissions converted to inpatient admissions was collected and further analyzed to inform needed process changes.
The Cardiac Surgical Services coordinator collected, entered, and maintained data using Excel. Data were obtained from the EHR, recorded in Excel, and analyzed using basic descriptive statistics in an ongoing fashion. Particular attention was focused on problems with the notification process (eg, patients being missed due to errors in data entry) and summarizing information to keep the Cardiac Surgical Services team updated on the progress of the process improvement. This project did not require staff protections or considerations, and because this was not a research study Institutional Review Board approval was not required.
Results
This practice change was implemented in September 2017 and led to improvements in care quality, as evidenced by improved physician communication and collaboration. In the 16-month period from implementation through December 2018, the names of 614 post-CABG patients were input into the HIE for tracking. Of these patients, 47 were treated and discharged from the ED; 31 were admitted for observation; and 44 were readmitted for inpatient care. The remaining 492 patients did not have a qualifying event requiring a notification alert. Clinical performance data from this period included 70 ED visits, 21 direct admissions, 19 direct admissions to observation, 5 patients missed by the notification process, and 4 observation admissions converted to inpatient admissions. A reduction in the CABG readmission rate from 10% in September 2017 to 7.2% in December 2018 was also noted.
Discussion
The aim of this process improvement project was to determine whether a real-time electronic alert that notified the CT surgical team about post-op CABG patients presenting to the ED would result in timely patient engagement, avoidance of readmissions, and an enhanced patient experience. This practice change has been successful, following 16 months of implementation and process refinement. Integrating a real-time electronic alert with a supporting action plan and care protocols resulted in timely patient engagement and avoidance of readmission of post-CABG patients.
Early notification of possible post-CABG readmissions became a standard-of-care process within the Cardiac Surgical Services department, with expansion to all CT post-op patients. Leveraging HIE technology to support quality improvement processes was also viewed by other departments as relevant and beneficial. For example, the hospital stroke and orthopedic-spine teams established their own processes for receiving real-time alerts.
There were several lessons learned during this project. First, gaining 100% physician buy-in to collaborative communication proved to be critical to the project’s success. The CV team was surprised by the length of time (approximately 8-10 months) it took for the practice change to be adopted by the physicians. In part, some of this delay in adoption resulted from medical staff turnover, primarily in the medical resident training rotations. Collaborative communication was key. The CT surgeons spoke with ED leadership and hospitalist services to explain the readmission reduction project and the use of an electronic alert tool. The CT surgeons also communicated to the ED physicians, hospitalists, and cardiologists that the Cardiac Surgical Services coordinator would be involved in the process and discussions regarding patientss care. Additionally, the CT surgeons authored the furosemide protocol and then committed to its use in the home health setting, further highlighting the role of collaborative communication in avoiding readmissions.
Another key step in this quality improvement project was determining who should receive the alert notifications. At the onset of the project, all notifications were sent to 1 person, the Cardiac Surgical Services coordinator. While this seemed logical in the initial stage of the project, it was unsustainable, as the receipt of the alert and the subsequent notification of the CT surgeon depended on 1 person and their availability. Approximately 10 months into the project, the notification process was further refined, with the cardiovascular intensive care unit charge nurse becoming the point of contact for the alerts. The Cardiac Surgical Services coordinator, in collaboration with nursing leaders and CT surgeons, completed a Lean Standard Work template outlining the major steps and the associated responsibilities (for the cardiovascular intensive care unit charge nurse, CT surgeon and on-call surgeon, Cardiac Surgical Services coordinator) in the process of receiving notifications, collecting patient assessment data, and reporting notifications to the CT surgeons.
Establishing adequate support mechanisms during a practice change is also important. For instance, we had to dedicate personnel time for data collection and analysis and involve additional nursing or other qualified personnel in the new process to avoid depending on a single person for the project’s success. Additional considerations were establishing criteria for surgeon notification and defining an appropriate time frame for notification (eg, urgent versus next-day notifications). We accomplished these activities approximately 10 months into the project, after it became apparent at CV team meeting discussions that further clarification of criteria and timelines was needed.
Some aspects of the project unfolded as planned, while others presented opportunities for improvement. For example, the alert notification process worked as envisioned; however, as previously mentioned, the process needed to be more inclusive to ensure there is always a charge nurse on duty to receive the alert notification, rather than just the Cardiac Surgical Services coordinator, who may not always be at the hospital. The outpatient thoracentesis program was well planned and effectively implemented. This program provided an avenue for patients who had symptoms of pleural effusion to be treated in an outpatient setting, rather than requiring an inpatient stay. Opportunities for improvement included addressing the inconsistent use of the home health furosemide protocol (developed in 2016), and the need for continued interprofessional and interdepartmental communication and coordination. For example, we had to inform the ED physicians and staff who rotate or are new to the ED about established processes and protocols in place for managing post-CABG patients who present to the ED.
The primary limitation of this project was the inability to measure the enhanced patient experience, which was 1 of the stated project goals. This goal became secondary because of more pressing issues, specifically, interorganizational collaboration (eg, hospital EHR, HIE, and CT surgical team) and tailoring the functionality of the electronic alert tool to the project. Developing and implementing measures of enhanced patient experience were not feasible during this implementation. Additionally, because this was not a research study, it was not possible to determine cause and effect or to control for confounders, such as a sicker, older cohort with more comorbid conditions, during the comparison period. Finally, although this process improvement project was conducted at a regional medical center that is the only facility performing CABG within the region, patients may have presented to another facility for an event that led to a readmission. Because readmissions to other facilities could not be captured, it is possible that the actual readmission rate was higher than the rate reported here.
Conclusions and Implications
Utilizing a real-time alert from the HIE to the CT surgical team resulted in CT surgeons being immediately made aware when their patients presented to the ED, allowing the CT surgical team the opportunity to intervene, as appropriate, in the care of their patients. Furthermore, this real-time notification and intervention resulted in timely patient engagement and, in some cases, avoidance of readmissions. Currently, patients are monitored for readmission within 30 days of discharge. In the future, the time will expand to 91 days, in preparation for participation in the CMS bundle payment program for CABG surgery.
This practice change can be used in organizations that do not have or participate in a HIE. In fact, these real-time alert applications may be available through an EHR already in use within the organization. The use of the alert requires collaborative communication and having supporting protocols in place to guide decision-making and care of post-CABG patients presenting to the ED.
There appears to be a gap in the literature discussing the use of an electronic alert tool as a real-time patient engagement strategy for post-CABG patients presenting to the ED. As such, this project contributes important results and lessons learned for other hospital service lines/departments that might consider implementing a similar process. Next steps include designing and conducting methodologically rigorous research studies based on this process improvement project to examine mortality rates as an outcome, and designing a more specific measure of patient experience, as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey only provides hospital-level data.
Corresponding author: Stephanie D. Smith, PhD, RN, UNCW School of Nursing, 601 South College Road, Wilmington, NC 28403; [email protected].
Funding disclosures: None.
1. Hannan EL, Zhong Y, Lahey SJ, et al. 30-day readmissions after coronary artery bypass graft surgery in New York State. JACC Cardiovasc Interv. 2011;4:569-576.
2. Feng TR, White R, Gaber-Baylis L, et al. Coronary artery bypass graft readmission rates and risk factors- A retrospective cohort study. Int J Surg. 2018;54 (Part A):7-17.
3. Donndorf P, Kaminski A. “Return to sender” or “consider it done”?! The importance of reducing hospital readmission after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2017;154:1298-1299.
4. Sequist TD, Morong SM, Marston A, et al. Electronic risk alerts to improve primary care management of chest pain: A randomized, controlled trial. J Gen Intern Med. 2012;27:438-444.
5. Engelman D, Benjamin EM. Physician engagement: The “secret sauce” to success in bundled health care. Am J Med Qual. 2018;33:100-102.
From the University of North Carolina at Wilmington School of Nursing (Dr. Smith and Dr. Turrise), the New Hanover Regional Medical Center Heart Center (Mr. Jordan), the Coastal Carolinas Health Alliance and Coastal Connect Health Information Exchange (Ms. Robertson), and Coastal Thoracic Surgical Associates (Dr. Kane), Wilmington, NC.
Abstract
Objective: Cardiothoracic (CT) surgeons at our medical center were not receiving timely notification when their coronary artery bypass graft (CABG) surgery patients were admitted to the medical center or to other hospitals. The CT surgical team worked with a health alliance in southeastern North Carolina to implement health information exchange (HIE) real-time electronic notifications for their CABG patients who presented to the hospital’s emergency department (ED) or any ED affiliated with the medical center. The alert tool notifies team members about patient encounters, driving timely clinical engagement.
Methods: The CT team provided the HIE team with the names of CABG surgery patients, which were loaded into the alert tool. When a patient on the list presented to the hospital ED or its affiliates, the alert tool sent a real-time electronic notification to the Cardiac Surgical Services nurse coordinator. This intervention prompted the assessment and disposition of CABG patients, while in the ED, by the CT surgical team.
Results: Over a 16-month period (September 2017-December 2018), the names of 614 post-CABG patients were input into the HIE for tracking. Of these patients, 47 were treated and discharged from the ED; 31 were admitted for observation; 44 were readmitted for inpatient care; and 492 did not have a qualifying event requiring a notification alert. Following implementation of this practice change, the 30-day readmission rate for patients who underwent CABG at our institution decreased from 10% to 7.2%.
Conclusion: Utilizing a real-time alert tool resulted in immediate notification of the CT team when 1 of their patients presented to the ED. This afforded the CT surgical team an opportunity to intervene in the care of their patients, which in turn led to improved quality of care, physician communication and collaboration, and patient outcomes, such as preventable 30-day readmissions.
Keywords: electronic health record; real-time electronic notification; CABG; process improvement.
Unplanned 30-day hospital readmissions of patients who have undergone coronary artery bypass graft (CABG) surgery contribute to higher overall health care costs. CABG is 1 of the conditions/procedures that the Centers for Medicare and Medicaid Services (CMS) monitors for excess readmissions.1 Readmission rates for CABG-related conditions at 30 days post-surgery are reported to be between 16% and 20% for US hospitals.2 Readmissions are not only financially costly, but also have been associated with worse patient outcomes and decreased patient satisfaction.3 Common diagnoses for post-CABG admission include atrial fibrillation, pleural effusion, and wound infection.
The facility where this project was implemented had a 10% post-CABG admission rate for patients across all payers. While this rate is below the national average of 13.2%, the cardiothoracic (CT) surgical team was not being notified in a timely manner when their post-CABG patients were readmitted. The Lean team used the A3 problem-solving process to develop strategies that would reduce these readmissions and improve the care of their patients.
We explored the use of electronic alerts in managing post-CABG patients by conducting a literature search using the terms electronic alerts in patient care, patient engagement in the emergency department, electronic alerts in CABG, real-time notifications to prevent readmission, and CABG readmission. Databases searched were PubMed, Google Scholar, Cumulative Index of Nursing and Allied Health Literature, ProQuest, and ScienceDirect. This search resulted in studies focused on the use of electronic health record (EHR) alerts as a clinical decision-support tool; for example, patient demographic and assessment data are entered into the EHR, and the clinician is prompted with “performance” recommendations (eg, consider electrocardiogram and aspirin).4 In a paper by Engelman and Benjamin,5 the authors discuss the importance of the engaged physician and note that, in their emergency department (ED), an electronic notification is sent when a postoperative patient presents; however, the notification goes to the inpatient service for timely review and disposition. There was no literature that discussed the use of an electronic alert tool as a real-time patient engagement strategy that resulted in a practice change specific to the CT surgical team.
Our process improvement project focused on alerting the CT surgical team when a post-CABG patient presented to the ED, allowing them to evaluate the patient in real time and determine whether the chief complaint was related to the CABG and whether further evaluation by the CT surgeon was required. Specifically, we wanted to determine whether a real-time electronic alert that notified the CT surgical team about post-op CABG patients presenting to the ED would result in timely patient engagement, avoidance of readmissions, and an enhanced patient experience. During this project, alerts were sent to the CT surgical team notifying them of a post-CABG patient presenting to the ED or being directly admitted from home on physician orders, a provider’s office, or inpatient rehabilitation; however, the focus of this article is specifically on the notification regarding post-CABG patients presenting to the ED.
Prior to implementing the electronic notification project, the team developed and implemented several internal and external readmission reduction and prevention strategies for CABG patients. An in-house strategy involved a process whereby patients would receive their discharge medications prior to being discharged from the hospital post-CABG, thereby avoiding potential delays in the patient obtaining medications. When examining post-CABG patient readmissions, the primary conditions that led to readmission were fluid overload, pleural effusion, and atrial fibrillation. As such, a second in-house strategy was developed for post-CABG patients presenting to the ED with atrial fibrillation. The newly established protocol allowed patients to be monitored and treated in the cardiac observation unit. In addition, external strategies, including an outpatient furosemide protocol for home health nurses and an outpatient thoracentesis program and order set, were established (eg, for patients with congestive heart failure, shortness of breath).
Methods
Setting
The regional medical center where this project was implemented is the ninth largest hospital in North Carolina and the largest county-owned public hospital in the state. It is a tertiary care center and teaching hospital with 3 hospital campuses and 855 licensed beds. The medical center was included in the 100 Safecare Hospitals list by the Safecare Group; received a grade “A” Hospital Safety Score from the Leapfrog Group; and is 1 of America’s Top 100 Hospitals for Patient Experience.
Real-Time Notification Project
A regional hospital alliance in southeastern North Carolina established a health information exchange (HIE) with its member hospitals and office-based physicians to enable electronic exchange of patient information to improve quality, safety, and efficiency in health care delivery. Our medical center is part of this alliance. The HIE is a digital platform that facilitates the sharing of information between disparate connected EHR systems, and offers a portal for practices and hospitals to access patient information across North Carolina, South Carolina (via SC HIE), and nationwide (select dialysis centers). More specifically, approved providers and team members are able to access, in real time, patient-care encounter documents from other care settings (eg, acute, post-acute, ambulatory) via the HIE. Additionally, approved care entities can query-retrieve web portal information to support patient outcome improvement strategies. A partnership discussion highlighted the opportunity to utilize the HIE’s capabilities, such as real-time notification, to facilitate workflow (eg, when a patient presents to the ED, the HIE can provide access to health information at the point of care). In this capacity, the alert tool notifies care team members about patient encounters to drive timely clinical engagement for care transitions.
In January 2017, we began discussions on using the HIE to facilitate real-time electronic tracking in the Cardiac Surgical Services department at our medical center. Persons involved in these discussions included the cardiovascular (CV) team (comprised of case managers, department managers and coordinators, program coordinators, administrators, and support services [eg, pre-admission testing and home health staff]) and CT surgeons. At that time, CABG readmissions were manually tracked, and the real-time notification tool was being used in other departments (eg, in case management for tracking readmissions). The entire team was part of the initial decision meeting to pursue this possibility. The CV team reached consensus in June 2017 and proposed extending the use of the alert tool to the post-CABG population presenting to the ED (or any ED affiliated with the medical center) or admitted directly to the medical center.
The HIE staff met with the Cardiac Surgical Services team to tailor and develop the logistics of the project, such as who would be notified and how. The goals of the project were to support appropriate care intervention, reduce preventable hospital readmissions, and improve quality of care through enhanced provider communication and engagement. To achieve these goals, on the day of discharge the Cardiac Surgical Services coordinator provided the HIE team with the names of patients who had undergone CABG surgery. This patient list was loaded into the alert tool and continually updated. At 31 days, patient names were removed from the list. When a patient on the list presented to the hospital ED, the alert tool sent 2 real-time electronic notifications, an email and a text message, to the Cardiac Surgical Services coordinator, noting that a patient event occurred. Personal information was not included in the alert in order to protect patient information and comply with Health Insurance Portability and Accountability Act regulations.
The alert prompted the Cardiac Surgical Services coordinator to securely access patient information to identify and, if necessary, visit the patient. Then, based on the information gathered by the Cardiac Surgical Services coordinator, a Situation-Background-Assessment-Recommendation report was relayed to the CT surgeon, who then determined whether intervention by the CT surgical team was warranted. This process, on average, took approximately 30 minutes to complete. This was a key change in processes, one that allowed post-CABG patients to be seen by the CT surgical team while in the ED. If the issue was related to the CABG surgery, the CT surgeons could then determine an appropriate course of action, including admission or implementation of another protocol, such as the home furosemide protocol. For patients directly admitted, the surgeon contacted the admitting provider to discuss the level of care required (ie, observation or inpatient admission and treatment).
Biweekly CV team meetings were conducted during the implementation of the real-time notification alert tool. At each meeting, updates were provided on notifications received, patients who were missed by the notification process, and how well the real-time alerts were working to enhance care and appropriate disposition.
Measurements
Clinical performance data included total notifications, total number of ED visits, ED disposition (inpatient admission, observation, discharge), total number of direct admissions, direct admissions to observation, direct inpatient admissions, and patients missed by the notification process (eg, due to data entry errors, omissions of information [suffix of junior or senior], as well as programming bugs). Finally, the number of observation admissions converted to inpatient admissions was collected and further analyzed to inform needed process changes.
The Cardiac Surgical Services coordinator collected, entered, and maintained data using Excel. Data were obtained from the EHR, recorded in Excel, and analyzed using basic descriptive statistics in an ongoing fashion. Particular attention was focused on problems with the notification process (eg, patients being missed due to errors in data entry) and summarizing information to keep the Cardiac Surgical Services team updated on the progress of the process improvement. This project did not require staff protections or considerations, and because this was not a research study Institutional Review Board approval was not required.
Results
This practice change was implemented in September 2017 and led to improvements in care quality, as evidenced by improved physician communication and collaboration. In the 16-month period from implementation through December 2018, the names of 614 post-CABG patients were input into the HIE for tracking. Of these patients, 47 were treated and discharged from the ED; 31 were admitted for observation; and 44 were readmitted for inpatient care. The remaining 492 patients did not have a qualifying event requiring a notification alert. Clinical performance data from this period included 70 ED visits, 21 direct admissions, 19 direct admissions to observation, 5 patients missed by the notification process, and 4 observation admissions converted to inpatient admissions. A reduction in the CABG readmission rate from 10% in September 2017 to 7.2% in December 2018 was also noted.
Discussion
The aim of this process improvement project was to determine whether a real-time electronic alert that notified the CT surgical team about post-op CABG patients presenting to the ED would result in timely patient engagement, avoidance of readmissions, and an enhanced patient experience. This practice change has been successful, following 16 months of implementation and process refinement. Integrating a real-time electronic alert with a supporting action plan and care protocols resulted in timely patient engagement and avoidance of readmission of post-CABG patients.
Early notification of possible post-CABG readmissions became a standard-of-care process within the Cardiac Surgical Services department, with expansion to all CT post-op patients. Leveraging HIE technology to support quality improvement processes was also viewed by other departments as relevant and beneficial. For example, the hospital stroke and orthopedic-spine teams established their own processes for receiving real-time alerts.
There were several lessons learned during this project. First, gaining 100% physician buy-in to collaborative communication proved to be critical to the project’s success. The CV team was surprised by the length of time (approximately 8-10 months) it took for the practice change to be adopted by the physicians. In part, some of this delay in adoption resulted from medical staff turnover, primarily in the medical resident training rotations. Collaborative communication was key. The CT surgeons spoke with ED leadership and hospitalist services to explain the readmission reduction project and the use of an electronic alert tool. The CT surgeons also communicated to the ED physicians, hospitalists, and cardiologists that the Cardiac Surgical Services coordinator would be involved in the process and discussions regarding patientss care. Additionally, the CT surgeons authored the furosemide protocol and then committed to its use in the home health setting, further highlighting the role of collaborative communication in avoiding readmissions.
Another key step in this quality improvement project was determining who should receive the alert notifications. At the onset of the project, all notifications were sent to 1 person, the Cardiac Surgical Services coordinator. While this seemed logical in the initial stage of the project, it was unsustainable, as the receipt of the alert and the subsequent notification of the CT surgeon depended on 1 person and their availability. Approximately 10 months into the project, the notification process was further refined, with the cardiovascular intensive care unit charge nurse becoming the point of contact for the alerts. The Cardiac Surgical Services coordinator, in collaboration with nursing leaders and CT surgeons, completed a Lean Standard Work template outlining the major steps and the associated responsibilities (for the cardiovascular intensive care unit charge nurse, CT surgeon and on-call surgeon, Cardiac Surgical Services coordinator) in the process of receiving notifications, collecting patient assessment data, and reporting notifications to the CT surgeons.
Establishing adequate support mechanisms during a practice change is also important. For instance, we had to dedicate personnel time for data collection and analysis and involve additional nursing or other qualified personnel in the new process to avoid depending on a single person for the project’s success. Additional considerations were establishing criteria for surgeon notification and defining an appropriate time frame for notification (eg, urgent versus next-day notifications). We accomplished these activities approximately 10 months into the project, after it became apparent at CV team meeting discussions that further clarification of criteria and timelines was needed.
Some aspects of the project unfolded as planned, while others presented opportunities for improvement. For example, the alert notification process worked as envisioned; however, as previously mentioned, the process needed to be more inclusive to ensure there is always a charge nurse on duty to receive the alert notification, rather than just the Cardiac Surgical Services coordinator, who may not always be at the hospital. The outpatient thoracentesis program was well planned and effectively implemented. This program provided an avenue for patients who had symptoms of pleural effusion to be treated in an outpatient setting, rather than requiring an inpatient stay. Opportunities for improvement included addressing the inconsistent use of the home health furosemide protocol (developed in 2016), and the need for continued interprofessional and interdepartmental communication and coordination. For example, we had to inform the ED physicians and staff who rotate or are new to the ED about established processes and protocols in place for managing post-CABG patients who present to the ED.
The primary limitation of this project was the inability to measure the enhanced patient experience, which was 1 of the stated project goals. This goal became secondary because of more pressing issues, specifically, interorganizational collaboration (eg, hospital EHR, HIE, and CT surgical team) and tailoring the functionality of the electronic alert tool to the project. Developing and implementing measures of enhanced patient experience were not feasible during this implementation. Additionally, because this was not a research study, it was not possible to determine cause and effect or to control for confounders, such as a sicker, older cohort with more comorbid conditions, during the comparison period. Finally, although this process improvement project was conducted at a regional medical center that is the only facility performing CABG within the region, patients may have presented to another facility for an event that led to a readmission. Because readmissions to other facilities could not be captured, it is possible that the actual readmission rate was higher than the rate reported here.
Conclusions and Implications
Utilizing a real-time alert from the HIE to the CT surgical team resulted in CT surgeons being immediately made aware when their patients presented to the ED, allowing the CT surgical team the opportunity to intervene, as appropriate, in the care of their patients. Furthermore, this real-time notification and intervention resulted in timely patient engagement and, in some cases, avoidance of readmissions. Currently, patients are monitored for readmission within 30 days of discharge. In the future, the time will expand to 91 days, in preparation for participation in the CMS bundle payment program for CABG surgery.
This practice change can be used in organizations that do not have or participate in a HIE. In fact, these real-time alert applications may be available through an EHR already in use within the organization. The use of the alert requires collaborative communication and having supporting protocols in place to guide decision-making and care of post-CABG patients presenting to the ED.
There appears to be a gap in the literature discussing the use of an electronic alert tool as a real-time patient engagement strategy for post-CABG patients presenting to the ED. As such, this project contributes important results and lessons learned for other hospital service lines/departments that might consider implementing a similar process. Next steps include designing and conducting methodologically rigorous research studies based on this process improvement project to examine mortality rates as an outcome, and designing a more specific measure of patient experience, as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey only provides hospital-level data.
Corresponding author: Stephanie D. Smith, PhD, RN, UNCW School of Nursing, 601 South College Road, Wilmington, NC 28403; [email protected].
Funding disclosures: None.
From the University of North Carolina at Wilmington School of Nursing (Dr. Smith and Dr. Turrise), the New Hanover Regional Medical Center Heart Center (Mr. Jordan), the Coastal Carolinas Health Alliance and Coastal Connect Health Information Exchange (Ms. Robertson), and Coastal Thoracic Surgical Associates (Dr. Kane), Wilmington, NC.
Abstract
Objective: Cardiothoracic (CT) surgeons at our medical center were not receiving timely notification when their coronary artery bypass graft (CABG) surgery patients were admitted to the medical center or to other hospitals. The CT surgical team worked with a health alliance in southeastern North Carolina to implement health information exchange (HIE) real-time electronic notifications for their CABG patients who presented to the hospital’s emergency department (ED) or any ED affiliated with the medical center. The alert tool notifies team members about patient encounters, driving timely clinical engagement.
Methods: The CT team provided the HIE team with the names of CABG surgery patients, which were loaded into the alert tool. When a patient on the list presented to the hospital ED or its affiliates, the alert tool sent a real-time electronic notification to the Cardiac Surgical Services nurse coordinator. This intervention prompted the assessment and disposition of CABG patients, while in the ED, by the CT surgical team.
Results: Over a 16-month period (September 2017-December 2018), the names of 614 post-CABG patients were input into the HIE for tracking. Of these patients, 47 were treated and discharged from the ED; 31 were admitted for observation; 44 were readmitted for inpatient care; and 492 did not have a qualifying event requiring a notification alert. Following implementation of this practice change, the 30-day readmission rate for patients who underwent CABG at our institution decreased from 10% to 7.2%.
Conclusion: Utilizing a real-time alert tool resulted in immediate notification of the CT team when 1 of their patients presented to the ED. This afforded the CT surgical team an opportunity to intervene in the care of their patients, which in turn led to improved quality of care, physician communication and collaboration, and patient outcomes, such as preventable 30-day readmissions.
Keywords: electronic health record; real-time electronic notification; CABG; process improvement.
Unplanned 30-day hospital readmissions of patients who have undergone coronary artery bypass graft (CABG) surgery contribute to higher overall health care costs. CABG is 1 of the conditions/procedures that the Centers for Medicare and Medicaid Services (CMS) monitors for excess readmissions.1 Readmission rates for CABG-related conditions at 30 days post-surgery are reported to be between 16% and 20% for US hospitals.2 Readmissions are not only financially costly, but also have been associated with worse patient outcomes and decreased patient satisfaction.3 Common diagnoses for post-CABG admission include atrial fibrillation, pleural effusion, and wound infection.
The facility where this project was implemented had a 10% post-CABG admission rate for patients across all payers. While this rate is below the national average of 13.2%, the cardiothoracic (CT) surgical team was not being notified in a timely manner when their post-CABG patients were readmitted. The Lean team used the A3 problem-solving process to develop strategies that would reduce these readmissions and improve the care of their patients.
We explored the use of electronic alerts in managing post-CABG patients by conducting a literature search using the terms electronic alerts in patient care, patient engagement in the emergency department, electronic alerts in CABG, real-time notifications to prevent readmission, and CABG readmission. Databases searched were PubMed, Google Scholar, Cumulative Index of Nursing and Allied Health Literature, ProQuest, and ScienceDirect. This search resulted in studies focused on the use of electronic health record (EHR) alerts as a clinical decision-support tool; for example, patient demographic and assessment data are entered into the EHR, and the clinician is prompted with “performance” recommendations (eg, consider electrocardiogram and aspirin).4 In a paper by Engelman and Benjamin,5 the authors discuss the importance of the engaged physician and note that, in their emergency department (ED), an electronic notification is sent when a postoperative patient presents; however, the notification goes to the inpatient service for timely review and disposition. There was no literature that discussed the use of an electronic alert tool as a real-time patient engagement strategy that resulted in a practice change specific to the CT surgical team.
Our process improvement project focused on alerting the CT surgical team when a post-CABG patient presented to the ED, allowing them to evaluate the patient in real time and determine whether the chief complaint was related to the CABG and whether further evaluation by the CT surgeon was required. Specifically, we wanted to determine whether a real-time electronic alert that notified the CT surgical team about post-op CABG patients presenting to the ED would result in timely patient engagement, avoidance of readmissions, and an enhanced patient experience. During this project, alerts were sent to the CT surgical team notifying them of a post-CABG patient presenting to the ED or being directly admitted from home on physician orders, a provider’s office, or inpatient rehabilitation; however, the focus of this article is specifically on the notification regarding post-CABG patients presenting to the ED.
Prior to implementing the electronic notification project, the team developed and implemented several internal and external readmission reduction and prevention strategies for CABG patients. An in-house strategy involved a process whereby patients would receive their discharge medications prior to being discharged from the hospital post-CABG, thereby avoiding potential delays in the patient obtaining medications. When examining post-CABG patient readmissions, the primary conditions that led to readmission were fluid overload, pleural effusion, and atrial fibrillation. As such, a second in-house strategy was developed for post-CABG patients presenting to the ED with atrial fibrillation. The newly established protocol allowed patients to be monitored and treated in the cardiac observation unit. In addition, external strategies, including an outpatient furosemide protocol for home health nurses and an outpatient thoracentesis program and order set, were established (eg, for patients with congestive heart failure, shortness of breath).
Methods
Setting
The regional medical center where this project was implemented is the ninth largest hospital in North Carolina and the largest county-owned public hospital in the state. It is a tertiary care center and teaching hospital with 3 hospital campuses and 855 licensed beds. The medical center was included in the 100 Safecare Hospitals list by the Safecare Group; received a grade “A” Hospital Safety Score from the Leapfrog Group; and is 1 of America’s Top 100 Hospitals for Patient Experience.
Real-Time Notification Project
A regional hospital alliance in southeastern North Carolina established a health information exchange (HIE) with its member hospitals and office-based physicians to enable electronic exchange of patient information to improve quality, safety, and efficiency in health care delivery. Our medical center is part of this alliance. The HIE is a digital platform that facilitates the sharing of information between disparate connected EHR systems, and offers a portal for practices and hospitals to access patient information across North Carolina, South Carolina (via SC HIE), and nationwide (select dialysis centers). More specifically, approved providers and team members are able to access, in real time, patient-care encounter documents from other care settings (eg, acute, post-acute, ambulatory) via the HIE. Additionally, approved care entities can query-retrieve web portal information to support patient outcome improvement strategies. A partnership discussion highlighted the opportunity to utilize the HIE’s capabilities, such as real-time notification, to facilitate workflow (eg, when a patient presents to the ED, the HIE can provide access to health information at the point of care). In this capacity, the alert tool notifies care team members about patient encounters to drive timely clinical engagement for care transitions.
In January 2017, we began discussions on using the HIE to facilitate real-time electronic tracking in the Cardiac Surgical Services department at our medical center. Persons involved in these discussions included the cardiovascular (CV) team (comprised of case managers, department managers and coordinators, program coordinators, administrators, and support services [eg, pre-admission testing and home health staff]) and CT surgeons. At that time, CABG readmissions were manually tracked, and the real-time notification tool was being used in other departments (eg, in case management for tracking readmissions). The entire team was part of the initial decision meeting to pursue this possibility. The CV team reached consensus in June 2017 and proposed extending the use of the alert tool to the post-CABG population presenting to the ED (or any ED affiliated with the medical center) or admitted directly to the medical center.
The HIE staff met with the Cardiac Surgical Services team to tailor and develop the logistics of the project, such as who would be notified and how. The goals of the project were to support appropriate care intervention, reduce preventable hospital readmissions, and improve quality of care through enhanced provider communication and engagement. To achieve these goals, on the day of discharge the Cardiac Surgical Services coordinator provided the HIE team with the names of patients who had undergone CABG surgery. This patient list was loaded into the alert tool and continually updated. At 31 days, patient names were removed from the list. When a patient on the list presented to the hospital ED, the alert tool sent 2 real-time electronic notifications, an email and a text message, to the Cardiac Surgical Services coordinator, noting that a patient event occurred. Personal information was not included in the alert in order to protect patient information and comply with Health Insurance Portability and Accountability Act regulations.
The alert prompted the Cardiac Surgical Services coordinator to securely access patient information to identify and, if necessary, visit the patient. Then, based on the information gathered by the Cardiac Surgical Services coordinator, a Situation-Background-Assessment-Recommendation report was relayed to the CT surgeon, who then determined whether intervention by the CT surgical team was warranted. This process, on average, took approximately 30 minutes to complete. This was a key change in processes, one that allowed post-CABG patients to be seen by the CT surgical team while in the ED. If the issue was related to the CABG surgery, the CT surgeons could then determine an appropriate course of action, including admission or implementation of another protocol, such as the home furosemide protocol. For patients directly admitted, the surgeon contacted the admitting provider to discuss the level of care required (ie, observation or inpatient admission and treatment).
Biweekly CV team meetings were conducted during the implementation of the real-time notification alert tool. At each meeting, updates were provided on notifications received, patients who were missed by the notification process, and how well the real-time alerts were working to enhance care and appropriate disposition.
Measurements
Clinical performance data included total notifications, total number of ED visits, ED disposition (inpatient admission, observation, discharge), total number of direct admissions, direct admissions to observation, direct inpatient admissions, and patients missed by the notification process (eg, due to data entry errors, omissions of information [suffix of junior or senior], as well as programming bugs). Finally, the number of observation admissions converted to inpatient admissions was collected and further analyzed to inform needed process changes.
The Cardiac Surgical Services coordinator collected, entered, and maintained data using Excel. Data were obtained from the EHR, recorded in Excel, and analyzed using basic descriptive statistics in an ongoing fashion. Particular attention was focused on problems with the notification process (eg, patients being missed due to errors in data entry) and summarizing information to keep the Cardiac Surgical Services team updated on the progress of the process improvement. This project did not require staff protections or considerations, and because this was not a research study Institutional Review Board approval was not required.
Results
This practice change was implemented in September 2017 and led to improvements in care quality, as evidenced by improved physician communication and collaboration. In the 16-month period from implementation through December 2018, the names of 614 post-CABG patients were input into the HIE for tracking. Of these patients, 47 were treated and discharged from the ED; 31 were admitted for observation; and 44 were readmitted for inpatient care. The remaining 492 patients did not have a qualifying event requiring a notification alert. Clinical performance data from this period included 70 ED visits, 21 direct admissions, 19 direct admissions to observation, 5 patients missed by the notification process, and 4 observation admissions converted to inpatient admissions. A reduction in the CABG readmission rate from 10% in September 2017 to 7.2% in December 2018 was also noted.
Discussion
The aim of this process improvement project was to determine whether a real-time electronic alert that notified the CT surgical team about post-op CABG patients presenting to the ED would result in timely patient engagement, avoidance of readmissions, and an enhanced patient experience. This practice change has been successful, following 16 months of implementation and process refinement. Integrating a real-time electronic alert with a supporting action plan and care protocols resulted in timely patient engagement and avoidance of readmission of post-CABG patients.
Early notification of possible post-CABG readmissions became a standard-of-care process within the Cardiac Surgical Services department, with expansion to all CT post-op patients. Leveraging HIE technology to support quality improvement processes was also viewed by other departments as relevant and beneficial. For example, the hospital stroke and orthopedic-spine teams established their own processes for receiving real-time alerts.
There were several lessons learned during this project. First, gaining 100% physician buy-in to collaborative communication proved to be critical to the project’s success. The CV team was surprised by the length of time (approximately 8-10 months) it took for the practice change to be adopted by the physicians. In part, some of this delay in adoption resulted from medical staff turnover, primarily in the medical resident training rotations. Collaborative communication was key. The CT surgeons spoke with ED leadership and hospitalist services to explain the readmission reduction project and the use of an electronic alert tool. The CT surgeons also communicated to the ED physicians, hospitalists, and cardiologists that the Cardiac Surgical Services coordinator would be involved in the process and discussions regarding patientss care. Additionally, the CT surgeons authored the furosemide protocol and then committed to its use in the home health setting, further highlighting the role of collaborative communication in avoiding readmissions.
Another key step in this quality improvement project was determining who should receive the alert notifications. At the onset of the project, all notifications were sent to 1 person, the Cardiac Surgical Services coordinator. While this seemed logical in the initial stage of the project, it was unsustainable, as the receipt of the alert and the subsequent notification of the CT surgeon depended on 1 person and their availability. Approximately 10 months into the project, the notification process was further refined, with the cardiovascular intensive care unit charge nurse becoming the point of contact for the alerts. The Cardiac Surgical Services coordinator, in collaboration with nursing leaders and CT surgeons, completed a Lean Standard Work template outlining the major steps and the associated responsibilities (for the cardiovascular intensive care unit charge nurse, CT surgeon and on-call surgeon, Cardiac Surgical Services coordinator) in the process of receiving notifications, collecting patient assessment data, and reporting notifications to the CT surgeons.
Establishing adequate support mechanisms during a practice change is also important. For instance, we had to dedicate personnel time for data collection and analysis and involve additional nursing or other qualified personnel in the new process to avoid depending on a single person for the project’s success. Additional considerations were establishing criteria for surgeon notification and defining an appropriate time frame for notification (eg, urgent versus next-day notifications). We accomplished these activities approximately 10 months into the project, after it became apparent at CV team meeting discussions that further clarification of criteria and timelines was needed.
Some aspects of the project unfolded as planned, while others presented opportunities for improvement. For example, the alert notification process worked as envisioned; however, as previously mentioned, the process needed to be more inclusive to ensure there is always a charge nurse on duty to receive the alert notification, rather than just the Cardiac Surgical Services coordinator, who may not always be at the hospital. The outpatient thoracentesis program was well planned and effectively implemented. This program provided an avenue for patients who had symptoms of pleural effusion to be treated in an outpatient setting, rather than requiring an inpatient stay. Opportunities for improvement included addressing the inconsistent use of the home health furosemide protocol (developed in 2016), and the need for continued interprofessional and interdepartmental communication and coordination. For example, we had to inform the ED physicians and staff who rotate or are new to the ED about established processes and protocols in place for managing post-CABG patients who present to the ED.
The primary limitation of this project was the inability to measure the enhanced patient experience, which was 1 of the stated project goals. This goal became secondary because of more pressing issues, specifically, interorganizational collaboration (eg, hospital EHR, HIE, and CT surgical team) and tailoring the functionality of the electronic alert tool to the project. Developing and implementing measures of enhanced patient experience were not feasible during this implementation. Additionally, because this was not a research study, it was not possible to determine cause and effect or to control for confounders, such as a sicker, older cohort with more comorbid conditions, during the comparison period. Finally, although this process improvement project was conducted at a regional medical center that is the only facility performing CABG within the region, patients may have presented to another facility for an event that led to a readmission. Because readmissions to other facilities could not be captured, it is possible that the actual readmission rate was higher than the rate reported here.
Conclusions and Implications
Utilizing a real-time alert from the HIE to the CT surgical team resulted in CT surgeons being immediately made aware when their patients presented to the ED, allowing the CT surgical team the opportunity to intervene, as appropriate, in the care of their patients. Furthermore, this real-time notification and intervention resulted in timely patient engagement and, in some cases, avoidance of readmissions. Currently, patients are monitored for readmission within 30 days of discharge. In the future, the time will expand to 91 days, in preparation for participation in the CMS bundle payment program for CABG surgery.
This practice change can be used in organizations that do not have or participate in a HIE. In fact, these real-time alert applications may be available through an EHR already in use within the organization. The use of the alert requires collaborative communication and having supporting protocols in place to guide decision-making and care of post-CABG patients presenting to the ED.
There appears to be a gap in the literature discussing the use of an electronic alert tool as a real-time patient engagement strategy for post-CABG patients presenting to the ED. As such, this project contributes important results and lessons learned for other hospital service lines/departments that might consider implementing a similar process. Next steps include designing and conducting methodologically rigorous research studies based on this process improvement project to examine mortality rates as an outcome, and designing a more specific measure of patient experience, as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey only provides hospital-level data.
Corresponding author: Stephanie D. Smith, PhD, RN, UNCW School of Nursing, 601 South College Road, Wilmington, NC 28403; [email protected].
Funding disclosures: None.
1. Hannan EL, Zhong Y, Lahey SJ, et al. 30-day readmissions after coronary artery bypass graft surgery in New York State. JACC Cardiovasc Interv. 2011;4:569-576.
2. Feng TR, White R, Gaber-Baylis L, et al. Coronary artery bypass graft readmission rates and risk factors- A retrospective cohort study. Int J Surg. 2018;54 (Part A):7-17.
3. Donndorf P, Kaminski A. “Return to sender” or “consider it done”?! The importance of reducing hospital readmission after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2017;154:1298-1299.
4. Sequist TD, Morong SM, Marston A, et al. Electronic risk alerts to improve primary care management of chest pain: A randomized, controlled trial. J Gen Intern Med. 2012;27:438-444.
5. Engelman D, Benjamin EM. Physician engagement: The “secret sauce” to success in bundled health care. Am J Med Qual. 2018;33:100-102.
1. Hannan EL, Zhong Y, Lahey SJ, et al. 30-day readmissions after coronary artery bypass graft surgery in New York State. JACC Cardiovasc Interv. 2011;4:569-576.
2. Feng TR, White R, Gaber-Baylis L, et al. Coronary artery bypass graft readmission rates and risk factors- A retrospective cohort study. Int J Surg. 2018;54 (Part A):7-17.
3. Donndorf P, Kaminski A. “Return to sender” or “consider it done”?! The importance of reducing hospital readmission after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2017;154:1298-1299.
4. Sequist TD, Morong SM, Marston A, et al. Electronic risk alerts to improve primary care management of chest pain: A randomized, controlled trial. J Gen Intern Med. 2012;27:438-444.
5. Engelman D, Benjamin EM. Physician engagement: The “secret sauce” to success in bundled health care. Am J Med Qual. 2018;33:100-102.
Adenoma detection rate removed from 2020 MIPS, or was it?
Every year, the Centers for Medicare & Medicaid Services (CMS) releases their proposed recommendations for the next performance year and in 2019, the gastroenterology community was surprised that CMS recommended removal of QPP 0343 – Screening Colonoscopy Adenoma Detection Rate from a reportable measure in the Quality Payment Program. So what happened? Why was the measure removed from the QPP? Is there anything that we can do?
Over the next several months we will be publishing a series of articles related to the Adenoma Detection Rate Measure to give every gastroenterologist an inside look at the work that is done on your behalf and steps that you can take in the future to help your fellow gastroenterologists.
This current article explains the joint effort made by all GI societies to try to save the Adenoma Detection Rate measure from removal from the 2020 Quality Payment Program. All societies uniformly submitted a letter to CMS in disapproval of the recommendation and outlined the importance of this measure as follows:
Measure 343: Screening Colonoscopy Adenoma Detection Rate
Our societies are disappointed and disagree with CMS’s decision to remove Measure 343: Screening Colonoscopy Adenoma Detection Rate (ADR) from the Quality Payment Program (QPP) beginning with the 2020 performance year.
The ADR plays a central role in quality improvement and colorectal cancer screening. We urge CMS to reconsider this decision and issue a technical correction to reinstate the measure back into the QPP, as it is the only outcome measure specific to endoscopic skills of gastroenterologists currently available for public reporting.
Studies show that high adenoma detection rates are associated with a significant reduction in colorectal cancer risk.1 Virtually all studies on this subject have demonstrated that there is, in fact, marked variation in adenoma detection rates among physicians. Further, ADR is essential to recommended intervals2 between screening and surveillance examinations.2,3
1. Variables influencing ADR. CMS explained that the measure does not account for variables that may influence the ADR such as geographic location, socioeconomic status of patient population, community compliance of screening, etc. The agency further states that according to the risk factors outlined by the American Cancer Society, African Americans have the highest colorectal cancer incidence and mortality rates of all racial groups in the United States. “In addition, dietary factors, such as consumption of highly processed meats will contribute to an increased risk of colorectal cancer. This diet is more prevalent in lower socioeconomic areas, which could influence the outcome of the measure. There are other patient factors like education, health literacy, etc. that might also affect things like the adequacy of bowel preparation, which in turn could affect performance.”
The societies advised CMS that this rationale reflects a misunderstanding of the definition of ADR, which includes all average-risk patients in whom the physician finds at least one adenoma. Further, ADR only includes colonoscopies with adequate bowel preparation and complete examinations. Studies demonstrate that ADR is not influenced by socioeconomic status and sex mix of the provider’s patient population, or by the rate of screening in the community.
Socioeconomics, ethnicity, and diet are not relevant factors of ADR. That said, our societies welcome the opportunity to work with CMS on creating age and sex standardized ADRs for the U.S. population, if feasible, in order to capture information that CMS deems important.
2. Failure to detect all adenomas. CMS stated that the measure does not account for MIPS eligible clinicians that fail to detect adenomas but may score higher based on the patient population.
The societies pushed back with CMS explaining that this rationale again reflects a misunderstanding of the definition of ADR, which includes average-risk patients for whom the physician finds at least one adenoma. Colonoscopy is heavily operator dependent. In an average-risk, mixed population, the variability in ADR reflects quality of the provider’s endoscopic skills and pathology recognition, rather than the risk of the underlying population.
3. Incidence measure. CMS concluded that Measure 343: Screening Colonoscopy Adenoma Detection Rate is considered an “incidence measure” that does not assess the quality of the care provided. In essence, according to CMS, the measure is based on happenstance rather than the eligible clinician providing a thorough examination.
The societies strongly disagreed with this characterization of ADR. Measure 343: Screening Colonoscopy Adenoma Detection Rate is the only measure that assess the quality of the exam performed by the physician in an average-risk patient with an adequate bowel preparation. Physicians can improve their adenoma detection rate by paying attention to detail, spending more time looking for adenomas, and learning better techniques.
4. Benchmarking. CMS stated that because of the measure construct, benchmarks calculated from this measure are misrepresented and do not align with the MIPS scoring methodology where 100% indicates better clinical care or control. Guidelines and supplemental literature support a performance target for adenoma detection rate of 25% for a mixed sex population (20% in women and 30% in men). CMS determined that Measure 343: Screening Colonoscopy Adenoma Detection Rate may be appropriate for other programs but does not align with the scoring logic within MIPS. When this measure was introduced, according to the agency, it was under the legacy program, Physician Quality Reporting System (PQRS), a pay-for-reporting program that does not have the same scoring implications as MIPS.
The societies reminded CMS that the 25% is the minimum requirement for performance and is not a benchmark. This minimum requirement continues to increase as well. With 25% being the threshold, for every 1% increase in ADR the risk of fatal interval colon cancer decreases by 3%. In one important study by Corley et al, the lowest quintile of ADR was 19% or lower, and was associated with the highest risk of interval colon cancer.4
CMS must begin to move beyond traditional approaches toward benchmarking performance where 100% compliance is expected. It was encouraging to see CMS acknowledge that nuances to evaluating scores are needed based on the ability of a measure to accurately identify and capture performance based on the patient population and measure specifications. For example, these adjustments were finalized for the blood pressure and diabetes HbA1c measures, where the highest number of points will be achieved for anyone scoring 90% or higher. This modification was based on the knowledge that it is not realistic nor in the interest of patients to assume that clinicians will be able to achieve the desired targeted outcome for every patient. The potential for unintended consequences was factored into an assessment of what performance could be considered achievable.
In our view, ADR is a similar example where 100% performance across a clinician’s population of patients is biologically impossible since not every individual who receives a screening colonoscopy will have an adenoma detected. ADR is the best-established colorectal neoplasia-related quality indicator and research demonstrates that high rates are associated with significant reductions in colorectal cancer risk.
CMS must continue to explore alternative strategies toward benchmarking in MIPS to ensure that achievement is fairly assessed, and top performance scores are determined not solely based on peer performance but also based on clinical evidence balanced with minimizing unintended consequences. The MIPS program and its benchmarking and scoring methodologies must continue to innovate to ensure that physicians provide the best possible care to their patients while also accurately and fairly representing and rewarding clinicians’ performance. Continuing to promote a siloed view toward quality will only reduce the relevance of the MIPS program and lead our members to question the integrity and validity of the program.
5. Lack of alignment between cost and quality measures. CMS noted that the agency will consider the relationship between cost and quality, viewing it as an essential component of episode-based measures. Our societies agree that a value-based payment system must balance cost and quality, and as such, members of our societies have been highly engaged in the development of episode-based cost measures as part of episode group prioritization for development, CMS’ measure development contractor asked clinical subcommittee members to consider a measure’s potential for alignment with established quality measures. This includes consideration of whether there is potential for overlap in covering the same patient cohort and the dimensions of care that the quality measure would be capturing in relation to a procedure or condition on which the episode-based cost measure would be focused.
The societies believe that given the well-established role of ADR in gastroenterology practices’ quality improvement programs nationwide, and internationally, the introduction of the Screening/Surveillance Colonoscopy episode-based cost measure beginning in the 2019 performance year, and the proposal from CMS to introduce “MIPS Value Pathways” beginning with the 2021 performance year, the removal of Measure 343: Screening Colonoscopy Adenoma Detection Rate undermines the collective desire of CMS and our organizations to move toward aligned reporting of quality and cost measures relevant to a gastroenterologist’s scope of practice and meaningful to patient care.
6. Development of a new measure. CMS suggested that there is the need for an alternate measure, however, the agency does not agree that Measure 343: Screening Colonoscopy Adenoma Detection Rate should be maintained in the interim.
Our societies welcomed the opportunity to work with CMS on developing a revised version for quality reporting purposes. We also welcomed the opportunity to suggest specific changes with CMS staff to further our shared goal on improving quality reporting and patient care. However, as of now, ADR remains the only validated, relevant, outcome-based measure to evaluate gastroenterologists’ endoscopic quality. It is important that the measure be maintained in the QPP in the interim.
The importance of ADR lies in its association with long-term outcomes. Corley et al. published in the New England Journal of Medicine an examination of the association between adenoma detection rate and risks of subsequent colorectal cancer and death among 264,792 colonoscopies by 136 gastroenterologists. Patients were followed from their baseline examinations for either 10 years or until another colonoscopy with negative results, left the health care system, or were diagnosed with colorectal cancer. There was a 3% reduction in colorectal cancer incidence and a 5% reduction in cancer mortality for each 1% increase in adenoma detection rate. This observation remained for both proximal and distal cancer in both men and women.4 Kaminski et al published a study on the association between adenoma detection rate and interval cancer in Gastroenterology of 294 endoscopists and data on 146,860 colonoscopies that reviewed 895,916 person-years of follow-up evaluation through the National Cancer Registry. The study concluded that there is an association between increased adenoma detection rate and reduced risk of interval cancer and death.5
The focus of any quality improvement program relative to colorectal cancer screening is to reduce colorectal cancer incidence and deaths. As discussed, the literature clearly supports driving improvement in each gastroenterologist’s ADR as the mechanism to achieve these outcomes. Indeed, the first step in any gastroenterology practice’s quality improvement program relative to CRC screening is to measure the endoscopist’s ADR and report to it to the physician, ideally benchmarked against a group or national study. Best practice is to measure and report ADR quarterly. There are a variety of well-established and emerging techniques6-11 technologies,12 and education,13,14 with varying associated cost and effort that can be deployed as systemic interventions aimed at improving adenoma detection rate. The effect of multiple interventions over time aimed at improving ADR has demonstrated increased ADRs with notable increases in the identification of difficult to identify colorectal cancer precursors (i.e., sessile serrated adenomas) and advanced adenomas.15 While the landscape of gastroenterology is changing, the constant is the importance of measuring an endoscopist’s ADR. ADR is fundamental to training and definitions of competency for gastroenterologists.
CMS appears to have listened to the concerns brought to their attention and has been willing to have external discussions with the GI societies in an effort to placate some of these concerns. Over the next several months we will explain the current progress with CMS including reinstating a modified ADR measure as a non-MIPS measure available for reporting in a QCDR. We will also discuss what you can do as a gastroenterologist to help propel some of these efforts forward.
References
1. Kaminski MF, Regula J, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010;362(19):1795-803.
2. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844-57.
3. Rubin CE, Haggitt RC, Burmer GC, et al. DNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis. Gastroenterology. 1992;103:1611-20.
4. Corley D, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370:1298-306.
5. Kaminski MF, et al. Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death. Gastroenterology. 2017 Jul;153[1]:98-105. doi: 10.1053/j.gastro.2017.04.006. Epub 2017 Apr 17.
6. ASGE practice guideline: Measuring the quality of endoscopy. Gastrointest Endosc. 2006;58:S1-S38.
7. Rex DK. Colonoscopic withdrawal technique is associated with adenoma miss rate. Gastrointest Endosc. 2000;51:33-6.
8. Barclay RL, et al. Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. Clin Gastroenterol Hepatol. 2008;6:1091-8.
9. Shaukat A, et al. Longer withdrawal time is associated with a reduced incidence of interval cancer after screening colonoscopy. Gastroenterology. 2015 Oct;149[4]:952-7
10. Lee S, et al. Am J Gastroenterol. 2016 Jan;111(1):63-9.
11. Jia H, et al. Water exchange method significantly improves adenoma detection rate: A multicenter, randomized controlled trial. Am J Gastroenterol. 2017;112(4):568-76.
12. ASGE. Endoscopes and devices to improve colon polyp detection. GIE 2015;81:1122-9.
13. Ussui V, et al. Am J Gastroenterol. 2015;110:489-96.
14. Kaminski MF, et al. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomized trial. Gut 2016;65:616-24.
15. Shaukat A, et al. Rates of detection of adenoma, sessile serrated adenoma, and advanced adenoma are stable over time and modifiable. Gastroenterology 2018(Feb);156:816-7.
Dr. Adams is a gastroenterologist and assistant professor at the University of Michigan, Ann Arbor; Dr. Leiman is a gastroenterologist and assistant professor of medicine at Duke Health, Durham, N.C.; Dr. Mathews is a gastroenterologist and leader of Clinical Innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.
Every year, the Centers for Medicare & Medicaid Services (CMS) releases their proposed recommendations for the next performance year and in 2019, the gastroenterology community was surprised that CMS recommended removal of QPP 0343 – Screening Colonoscopy Adenoma Detection Rate from a reportable measure in the Quality Payment Program. So what happened? Why was the measure removed from the QPP? Is there anything that we can do?
Over the next several months we will be publishing a series of articles related to the Adenoma Detection Rate Measure to give every gastroenterologist an inside look at the work that is done on your behalf and steps that you can take in the future to help your fellow gastroenterologists.
This current article explains the joint effort made by all GI societies to try to save the Adenoma Detection Rate measure from removal from the 2020 Quality Payment Program. All societies uniformly submitted a letter to CMS in disapproval of the recommendation and outlined the importance of this measure as follows:
Measure 343: Screening Colonoscopy Adenoma Detection Rate
Our societies are disappointed and disagree with CMS’s decision to remove Measure 343: Screening Colonoscopy Adenoma Detection Rate (ADR) from the Quality Payment Program (QPP) beginning with the 2020 performance year.
The ADR plays a central role in quality improvement and colorectal cancer screening. We urge CMS to reconsider this decision and issue a technical correction to reinstate the measure back into the QPP, as it is the only outcome measure specific to endoscopic skills of gastroenterologists currently available for public reporting.
Studies show that high adenoma detection rates are associated with a significant reduction in colorectal cancer risk.1 Virtually all studies on this subject have demonstrated that there is, in fact, marked variation in adenoma detection rates among physicians. Further, ADR is essential to recommended intervals2 between screening and surveillance examinations.2,3
1. Variables influencing ADR. CMS explained that the measure does not account for variables that may influence the ADR such as geographic location, socioeconomic status of patient population, community compliance of screening, etc. The agency further states that according to the risk factors outlined by the American Cancer Society, African Americans have the highest colorectal cancer incidence and mortality rates of all racial groups in the United States. “In addition, dietary factors, such as consumption of highly processed meats will contribute to an increased risk of colorectal cancer. This diet is more prevalent in lower socioeconomic areas, which could influence the outcome of the measure. There are other patient factors like education, health literacy, etc. that might also affect things like the adequacy of bowel preparation, which in turn could affect performance.”
The societies advised CMS that this rationale reflects a misunderstanding of the definition of ADR, which includes all average-risk patients in whom the physician finds at least one adenoma. Further, ADR only includes colonoscopies with adequate bowel preparation and complete examinations. Studies demonstrate that ADR is not influenced by socioeconomic status and sex mix of the provider’s patient population, or by the rate of screening in the community.
Socioeconomics, ethnicity, and diet are not relevant factors of ADR. That said, our societies welcome the opportunity to work with CMS on creating age and sex standardized ADRs for the U.S. population, if feasible, in order to capture information that CMS deems important.
2. Failure to detect all adenomas. CMS stated that the measure does not account for MIPS eligible clinicians that fail to detect adenomas but may score higher based on the patient population.
The societies pushed back with CMS explaining that this rationale again reflects a misunderstanding of the definition of ADR, which includes average-risk patients for whom the physician finds at least one adenoma. Colonoscopy is heavily operator dependent. In an average-risk, mixed population, the variability in ADR reflects quality of the provider’s endoscopic skills and pathology recognition, rather than the risk of the underlying population.
3. Incidence measure. CMS concluded that Measure 343: Screening Colonoscopy Adenoma Detection Rate is considered an “incidence measure” that does not assess the quality of the care provided. In essence, according to CMS, the measure is based on happenstance rather than the eligible clinician providing a thorough examination.
The societies strongly disagreed with this characterization of ADR. Measure 343: Screening Colonoscopy Adenoma Detection Rate is the only measure that assess the quality of the exam performed by the physician in an average-risk patient with an adequate bowel preparation. Physicians can improve their adenoma detection rate by paying attention to detail, spending more time looking for adenomas, and learning better techniques.
4. Benchmarking. CMS stated that because of the measure construct, benchmarks calculated from this measure are misrepresented and do not align with the MIPS scoring methodology where 100% indicates better clinical care or control. Guidelines and supplemental literature support a performance target for adenoma detection rate of 25% for a mixed sex population (20% in women and 30% in men). CMS determined that Measure 343: Screening Colonoscopy Adenoma Detection Rate may be appropriate for other programs but does not align with the scoring logic within MIPS. When this measure was introduced, according to the agency, it was under the legacy program, Physician Quality Reporting System (PQRS), a pay-for-reporting program that does not have the same scoring implications as MIPS.
The societies reminded CMS that the 25% is the minimum requirement for performance and is not a benchmark. This minimum requirement continues to increase as well. With 25% being the threshold, for every 1% increase in ADR the risk of fatal interval colon cancer decreases by 3%. In one important study by Corley et al, the lowest quintile of ADR was 19% or lower, and was associated with the highest risk of interval colon cancer.4
CMS must begin to move beyond traditional approaches toward benchmarking performance where 100% compliance is expected. It was encouraging to see CMS acknowledge that nuances to evaluating scores are needed based on the ability of a measure to accurately identify and capture performance based on the patient population and measure specifications. For example, these adjustments were finalized for the blood pressure and diabetes HbA1c measures, where the highest number of points will be achieved for anyone scoring 90% or higher. This modification was based on the knowledge that it is not realistic nor in the interest of patients to assume that clinicians will be able to achieve the desired targeted outcome for every patient. The potential for unintended consequences was factored into an assessment of what performance could be considered achievable.
In our view, ADR is a similar example where 100% performance across a clinician’s population of patients is biologically impossible since not every individual who receives a screening colonoscopy will have an adenoma detected. ADR is the best-established colorectal neoplasia-related quality indicator and research demonstrates that high rates are associated with significant reductions in colorectal cancer risk.
CMS must continue to explore alternative strategies toward benchmarking in MIPS to ensure that achievement is fairly assessed, and top performance scores are determined not solely based on peer performance but also based on clinical evidence balanced with minimizing unintended consequences. The MIPS program and its benchmarking and scoring methodologies must continue to innovate to ensure that physicians provide the best possible care to their patients while also accurately and fairly representing and rewarding clinicians’ performance. Continuing to promote a siloed view toward quality will only reduce the relevance of the MIPS program and lead our members to question the integrity and validity of the program.
5. Lack of alignment between cost and quality measures. CMS noted that the agency will consider the relationship between cost and quality, viewing it as an essential component of episode-based measures. Our societies agree that a value-based payment system must balance cost and quality, and as such, members of our societies have been highly engaged in the development of episode-based cost measures as part of episode group prioritization for development, CMS’ measure development contractor asked clinical subcommittee members to consider a measure’s potential for alignment with established quality measures. This includes consideration of whether there is potential for overlap in covering the same patient cohort and the dimensions of care that the quality measure would be capturing in relation to a procedure or condition on which the episode-based cost measure would be focused.
The societies believe that given the well-established role of ADR in gastroenterology practices’ quality improvement programs nationwide, and internationally, the introduction of the Screening/Surveillance Colonoscopy episode-based cost measure beginning in the 2019 performance year, and the proposal from CMS to introduce “MIPS Value Pathways” beginning with the 2021 performance year, the removal of Measure 343: Screening Colonoscopy Adenoma Detection Rate undermines the collective desire of CMS and our organizations to move toward aligned reporting of quality and cost measures relevant to a gastroenterologist’s scope of practice and meaningful to patient care.
6. Development of a new measure. CMS suggested that there is the need for an alternate measure, however, the agency does not agree that Measure 343: Screening Colonoscopy Adenoma Detection Rate should be maintained in the interim.
Our societies welcomed the opportunity to work with CMS on developing a revised version for quality reporting purposes. We also welcomed the opportunity to suggest specific changes with CMS staff to further our shared goal on improving quality reporting and patient care. However, as of now, ADR remains the only validated, relevant, outcome-based measure to evaluate gastroenterologists’ endoscopic quality. It is important that the measure be maintained in the QPP in the interim.
The importance of ADR lies in its association with long-term outcomes. Corley et al. published in the New England Journal of Medicine an examination of the association between adenoma detection rate and risks of subsequent colorectal cancer and death among 264,792 colonoscopies by 136 gastroenterologists. Patients were followed from their baseline examinations for either 10 years or until another colonoscopy with negative results, left the health care system, or were diagnosed with colorectal cancer. There was a 3% reduction in colorectal cancer incidence and a 5% reduction in cancer mortality for each 1% increase in adenoma detection rate. This observation remained for both proximal and distal cancer in both men and women.4 Kaminski et al published a study on the association between adenoma detection rate and interval cancer in Gastroenterology of 294 endoscopists and data on 146,860 colonoscopies that reviewed 895,916 person-years of follow-up evaluation through the National Cancer Registry. The study concluded that there is an association between increased adenoma detection rate and reduced risk of interval cancer and death.5
The focus of any quality improvement program relative to colorectal cancer screening is to reduce colorectal cancer incidence and deaths. As discussed, the literature clearly supports driving improvement in each gastroenterologist’s ADR as the mechanism to achieve these outcomes. Indeed, the first step in any gastroenterology practice’s quality improvement program relative to CRC screening is to measure the endoscopist’s ADR and report to it to the physician, ideally benchmarked against a group or national study. Best practice is to measure and report ADR quarterly. There are a variety of well-established and emerging techniques6-11 technologies,12 and education,13,14 with varying associated cost and effort that can be deployed as systemic interventions aimed at improving adenoma detection rate. The effect of multiple interventions over time aimed at improving ADR has demonstrated increased ADRs with notable increases in the identification of difficult to identify colorectal cancer precursors (i.e., sessile serrated adenomas) and advanced adenomas.15 While the landscape of gastroenterology is changing, the constant is the importance of measuring an endoscopist’s ADR. ADR is fundamental to training and definitions of competency for gastroenterologists.
CMS appears to have listened to the concerns brought to their attention and has been willing to have external discussions with the GI societies in an effort to placate some of these concerns. Over the next several months we will explain the current progress with CMS including reinstating a modified ADR measure as a non-MIPS measure available for reporting in a QCDR. We will also discuss what you can do as a gastroenterologist to help propel some of these efforts forward.
References
1. Kaminski MF, Regula J, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010;362(19):1795-803.
2. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844-57.
3. Rubin CE, Haggitt RC, Burmer GC, et al. DNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis. Gastroenterology. 1992;103:1611-20.
4. Corley D, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370:1298-306.
5. Kaminski MF, et al. Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death. Gastroenterology. 2017 Jul;153[1]:98-105. doi: 10.1053/j.gastro.2017.04.006. Epub 2017 Apr 17.
6. ASGE practice guideline: Measuring the quality of endoscopy. Gastrointest Endosc. 2006;58:S1-S38.
7. Rex DK. Colonoscopic withdrawal technique is associated with adenoma miss rate. Gastrointest Endosc. 2000;51:33-6.
8. Barclay RL, et al. Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. Clin Gastroenterol Hepatol. 2008;6:1091-8.
9. Shaukat A, et al. Longer withdrawal time is associated with a reduced incidence of interval cancer after screening colonoscopy. Gastroenterology. 2015 Oct;149[4]:952-7
10. Lee S, et al. Am J Gastroenterol. 2016 Jan;111(1):63-9.
11. Jia H, et al. Water exchange method significantly improves adenoma detection rate: A multicenter, randomized controlled trial. Am J Gastroenterol. 2017;112(4):568-76.
12. ASGE. Endoscopes and devices to improve colon polyp detection. GIE 2015;81:1122-9.
13. Ussui V, et al. Am J Gastroenterol. 2015;110:489-96.
14. Kaminski MF, et al. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomized trial. Gut 2016;65:616-24.
15. Shaukat A, et al. Rates of detection of adenoma, sessile serrated adenoma, and advanced adenoma are stable over time and modifiable. Gastroenterology 2018(Feb);156:816-7.
Dr. Adams is a gastroenterologist and assistant professor at the University of Michigan, Ann Arbor; Dr. Leiman is a gastroenterologist and assistant professor of medicine at Duke Health, Durham, N.C.; Dr. Mathews is a gastroenterologist and leader of Clinical Innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.
Every year, the Centers for Medicare & Medicaid Services (CMS) releases their proposed recommendations for the next performance year and in 2019, the gastroenterology community was surprised that CMS recommended removal of QPP 0343 – Screening Colonoscopy Adenoma Detection Rate from a reportable measure in the Quality Payment Program. So what happened? Why was the measure removed from the QPP? Is there anything that we can do?
Over the next several months we will be publishing a series of articles related to the Adenoma Detection Rate Measure to give every gastroenterologist an inside look at the work that is done on your behalf and steps that you can take in the future to help your fellow gastroenterologists.
This current article explains the joint effort made by all GI societies to try to save the Adenoma Detection Rate measure from removal from the 2020 Quality Payment Program. All societies uniformly submitted a letter to CMS in disapproval of the recommendation and outlined the importance of this measure as follows:
Measure 343: Screening Colonoscopy Adenoma Detection Rate
Our societies are disappointed and disagree with CMS’s decision to remove Measure 343: Screening Colonoscopy Adenoma Detection Rate (ADR) from the Quality Payment Program (QPP) beginning with the 2020 performance year.
The ADR plays a central role in quality improvement and colorectal cancer screening. We urge CMS to reconsider this decision and issue a technical correction to reinstate the measure back into the QPP, as it is the only outcome measure specific to endoscopic skills of gastroenterologists currently available for public reporting.
Studies show that high adenoma detection rates are associated with a significant reduction in colorectal cancer risk.1 Virtually all studies on this subject have demonstrated that there is, in fact, marked variation in adenoma detection rates among physicians. Further, ADR is essential to recommended intervals2 between screening and surveillance examinations.2,3
1. Variables influencing ADR. CMS explained that the measure does not account for variables that may influence the ADR such as geographic location, socioeconomic status of patient population, community compliance of screening, etc. The agency further states that according to the risk factors outlined by the American Cancer Society, African Americans have the highest colorectal cancer incidence and mortality rates of all racial groups in the United States. “In addition, dietary factors, such as consumption of highly processed meats will contribute to an increased risk of colorectal cancer. This diet is more prevalent in lower socioeconomic areas, which could influence the outcome of the measure. There are other patient factors like education, health literacy, etc. that might also affect things like the adequacy of bowel preparation, which in turn could affect performance.”
The societies advised CMS that this rationale reflects a misunderstanding of the definition of ADR, which includes all average-risk patients in whom the physician finds at least one adenoma. Further, ADR only includes colonoscopies with adequate bowel preparation and complete examinations. Studies demonstrate that ADR is not influenced by socioeconomic status and sex mix of the provider’s patient population, or by the rate of screening in the community.
Socioeconomics, ethnicity, and diet are not relevant factors of ADR. That said, our societies welcome the opportunity to work with CMS on creating age and sex standardized ADRs for the U.S. population, if feasible, in order to capture information that CMS deems important.
2. Failure to detect all adenomas. CMS stated that the measure does not account for MIPS eligible clinicians that fail to detect adenomas but may score higher based on the patient population.
The societies pushed back with CMS explaining that this rationale again reflects a misunderstanding of the definition of ADR, which includes average-risk patients for whom the physician finds at least one adenoma. Colonoscopy is heavily operator dependent. In an average-risk, mixed population, the variability in ADR reflects quality of the provider’s endoscopic skills and pathology recognition, rather than the risk of the underlying population.
3. Incidence measure. CMS concluded that Measure 343: Screening Colonoscopy Adenoma Detection Rate is considered an “incidence measure” that does not assess the quality of the care provided. In essence, according to CMS, the measure is based on happenstance rather than the eligible clinician providing a thorough examination.
The societies strongly disagreed with this characterization of ADR. Measure 343: Screening Colonoscopy Adenoma Detection Rate is the only measure that assess the quality of the exam performed by the physician in an average-risk patient with an adequate bowel preparation. Physicians can improve their adenoma detection rate by paying attention to detail, spending more time looking for adenomas, and learning better techniques.
4. Benchmarking. CMS stated that because of the measure construct, benchmarks calculated from this measure are misrepresented and do not align with the MIPS scoring methodology where 100% indicates better clinical care or control. Guidelines and supplemental literature support a performance target for adenoma detection rate of 25% for a mixed sex population (20% in women and 30% in men). CMS determined that Measure 343: Screening Colonoscopy Adenoma Detection Rate may be appropriate for other programs but does not align with the scoring logic within MIPS. When this measure was introduced, according to the agency, it was under the legacy program, Physician Quality Reporting System (PQRS), a pay-for-reporting program that does not have the same scoring implications as MIPS.
The societies reminded CMS that the 25% is the minimum requirement for performance and is not a benchmark. This minimum requirement continues to increase as well. With 25% being the threshold, for every 1% increase in ADR the risk of fatal interval colon cancer decreases by 3%. In one important study by Corley et al, the lowest quintile of ADR was 19% or lower, and was associated with the highest risk of interval colon cancer.4
CMS must begin to move beyond traditional approaches toward benchmarking performance where 100% compliance is expected. It was encouraging to see CMS acknowledge that nuances to evaluating scores are needed based on the ability of a measure to accurately identify and capture performance based on the patient population and measure specifications. For example, these adjustments were finalized for the blood pressure and diabetes HbA1c measures, where the highest number of points will be achieved for anyone scoring 90% or higher. This modification was based on the knowledge that it is not realistic nor in the interest of patients to assume that clinicians will be able to achieve the desired targeted outcome for every patient. The potential for unintended consequences was factored into an assessment of what performance could be considered achievable.
In our view, ADR is a similar example where 100% performance across a clinician’s population of patients is biologically impossible since not every individual who receives a screening colonoscopy will have an adenoma detected. ADR is the best-established colorectal neoplasia-related quality indicator and research demonstrates that high rates are associated with significant reductions in colorectal cancer risk.
CMS must continue to explore alternative strategies toward benchmarking in MIPS to ensure that achievement is fairly assessed, and top performance scores are determined not solely based on peer performance but also based on clinical evidence balanced with minimizing unintended consequences. The MIPS program and its benchmarking and scoring methodologies must continue to innovate to ensure that physicians provide the best possible care to their patients while also accurately and fairly representing and rewarding clinicians’ performance. Continuing to promote a siloed view toward quality will only reduce the relevance of the MIPS program and lead our members to question the integrity and validity of the program.
5. Lack of alignment between cost and quality measures. CMS noted that the agency will consider the relationship between cost and quality, viewing it as an essential component of episode-based measures. Our societies agree that a value-based payment system must balance cost and quality, and as such, members of our societies have been highly engaged in the development of episode-based cost measures as part of episode group prioritization for development, CMS’ measure development contractor asked clinical subcommittee members to consider a measure’s potential for alignment with established quality measures. This includes consideration of whether there is potential for overlap in covering the same patient cohort and the dimensions of care that the quality measure would be capturing in relation to a procedure or condition on which the episode-based cost measure would be focused.
The societies believe that given the well-established role of ADR in gastroenterology practices’ quality improvement programs nationwide, and internationally, the introduction of the Screening/Surveillance Colonoscopy episode-based cost measure beginning in the 2019 performance year, and the proposal from CMS to introduce “MIPS Value Pathways” beginning with the 2021 performance year, the removal of Measure 343: Screening Colonoscopy Adenoma Detection Rate undermines the collective desire of CMS and our organizations to move toward aligned reporting of quality and cost measures relevant to a gastroenterologist’s scope of practice and meaningful to patient care.
6. Development of a new measure. CMS suggested that there is the need for an alternate measure, however, the agency does not agree that Measure 343: Screening Colonoscopy Adenoma Detection Rate should be maintained in the interim.
Our societies welcomed the opportunity to work with CMS on developing a revised version for quality reporting purposes. We also welcomed the opportunity to suggest specific changes with CMS staff to further our shared goal on improving quality reporting and patient care. However, as of now, ADR remains the only validated, relevant, outcome-based measure to evaluate gastroenterologists’ endoscopic quality. It is important that the measure be maintained in the QPP in the interim.
The importance of ADR lies in its association with long-term outcomes. Corley et al. published in the New England Journal of Medicine an examination of the association between adenoma detection rate and risks of subsequent colorectal cancer and death among 264,792 colonoscopies by 136 gastroenterologists. Patients were followed from their baseline examinations for either 10 years or until another colonoscopy with negative results, left the health care system, or were diagnosed with colorectal cancer. There was a 3% reduction in colorectal cancer incidence and a 5% reduction in cancer mortality for each 1% increase in adenoma detection rate. This observation remained for both proximal and distal cancer in both men and women.4 Kaminski et al published a study on the association between adenoma detection rate and interval cancer in Gastroenterology of 294 endoscopists and data on 146,860 colonoscopies that reviewed 895,916 person-years of follow-up evaluation through the National Cancer Registry. The study concluded that there is an association between increased adenoma detection rate and reduced risk of interval cancer and death.5
The focus of any quality improvement program relative to colorectal cancer screening is to reduce colorectal cancer incidence and deaths. As discussed, the literature clearly supports driving improvement in each gastroenterologist’s ADR as the mechanism to achieve these outcomes. Indeed, the first step in any gastroenterology practice’s quality improvement program relative to CRC screening is to measure the endoscopist’s ADR and report to it to the physician, ideally benchmarked against a group or national study. Best practice is to measure and report ADR quarterly. There are a variety of well-established and emerging techniques6-11 technologies,12 and education,13,14 with varying associated cost and effort that can be deployed as systemic interventions aimed at improving adenoma detection rate. The effect of multiple interventions over time aimed at improving ADR has demonstrated increased ADRs with notable increases in the identification of difficult to identify colorectal cancer precursors (i.e., sessile serrated adenomas) and advanced adenomas.15 While the landscape of gastroenterology is changing, the constant is the importance of measuring an endoscopist’s ADR. ADR is fundamental to training and definitions of competency for gastroenterologists.
CMS appears to have listened to the concerns brought to their attention and has been willing to have external discussions with the GI societies in an effort to placate some of these concerns. Over the next several months we will explain the current progress with CMS including reinstating a modified ADR measure as a non-MIPS measure available for reporting in a QCDR. We will also discuss what you can do as a gastroenterologist to help propel some of these efforts forward.
References
1. Kaminski MF, Regula J, et al. Quality indicators for colonoscopy and the risk of interval cancer. N Engl J Med. 2010;362(19):1795-803.
2. Lieberman DA, Rex DK, Winawer SJ, et al. Guidelines for colonoscopy surveillance after screening and polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology. 2012;143:844-57.
3. Rubin CE, Haggitt RC, Burmer GC, et al. DNA aneuploidy in colonic biopsies predicts future development of dysplasia in ulcerative colitis. Gastroenterology. 1992;103:1611-20.
4. Corley D, Jensen CD, Marks AR, et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med. 2014;370:1298-306.
5. Kaminski MF, et al. Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death. Gastroenterology. 2017 Jul;153[1]:98-105. doi: 10.1053/j.gastro.2017.04.006. Epub 2017 Apr 17.
6. ASGE practice guideline: Measuring the quality of endoscopy. Gastrointest Endosc. 2006;58:S1-S38.
7. Rex DK. Colonoscopic withdrawal technique is associated with adenoma miss rate. Gastrointest Endosc. 2000;51:33-6.
8. Barclay RL, et al. Effect of a time-dependent colonoscopic withdrawal protocol on adenoma detection during screening colonoscopy. Clin Gastroenterol Hepatol. 2008;6:1091-8.
9. Shaukat A, et al. Longer withdrawal time is associated with a reduced incidence of interval cancer after screening colonoscopy. Gastroenterology. 2015 Oct;149[4]:952-7
10. Lee S, et al. Am J Gastroenterol. 2016 Jan;111(1):63-9.
11. Jia H, et al. Water exchange method significantly improves adenoma detection rate: A multicenter, randomized controlled trial. Am J Gastroenterol. 2017;112(4):568-76.
12. ASGE. Endoscopes and devices to improve colon polyp detection. GIE 2015;81:1122-9.
13. Ussui V, et al. Am J Gastroenterol. 2015;110:489-96.
14. Kaminski MF, et al. Leadership training to improve adenoma detection rate in screening colonoscopy: a randomized trial. Gut 2016;65:616-24.
15. Shaukat A, et al. Rates of detection of adenoma, sessile serrated adenoma, and advanced adenoma are stable over time and modifiable. Gastroenterology 2018(Feb);156:816-7.
Dr. Adams is a gastroenterologist and assistant professor at the University of Michigan, Ann Arbor; Dr. Leiman is a gastroenterologist and assistant professor of medicine at Duke Health, Durham, N.C.; Dr. Mathews is a gastroenterologist and leader of Clinical Innovation at the Johns Hopkins Armstrong Institute for Patient Safety and Quality, Baltimore.
The power and promise of person-generated health data (Part II)
In Part I of our discussion we introduced the concept of person-generated health data (PGHD), defined as wellness and/or health-related data created, recorded, or gathered by individuals.
Such rich, longitudinal information is now being used in combination with traditional clinical information to predict, diagnose, and formulate treatment plans for diseases, as well as understand the safety and effectiveness of medical interventions.
Identifying a disease early
One novel example of digital technologies being used for early identification of disease was a promising 2019 study by Eli Lilly (in collaboration with Apple and Evidation Health) called the Lilly Exploratory Digital Assessment Study.
In this study, the feasibility of using PGHD for identifying physiological and behavioral signatures of cognitive impairment was examined for the purpose of seeking new methods to detect mild cognitive impairment (MCI) in a timely and cost-effective manner. The study enrolled 31 study participants with cognitive impairment and 82 without cognitive impairment. It used consumer-grade sensor technologies (the iPhone, Apple Watch, iPad, and Beddit sleep monitor) to continuously and unobtrusively collect data. Among the information the researchers collected were interaction with the phone keyboard, accelerometer data from the Apple Watch, volume of messages sent/received, and sleep cycles.1
A total of 16 terabytes of data were collected over the course of 12 weeks. Data were organized into a behaviorgram (See Figure 1) that gives a holistic picture of a day in a patient’s life. A machine learning model was used to distinguish between behaviorgrams of symptomatic versus healthy controls, identifying typing speed, circadian rhythm shifts, and reliance on helper apps, among other things, as differentiating cognitively impaired from healthy controls. These behaviorgrams may someday serve as “fingerprints” of different diseases, with specific diseases displaying predictable patterns. In the near future, digital measures like the ones investigated in this study are likely to be used to help clinicians predict and diagnose disease, as well as to better understand disease progression and treatment response.
Leading to better health outcomes
The potential of PGHD to detect diseases early and lead to better health outcomes is being investigated in the Heartline study, a collaboration between Johnson & Johnson and Apple, which is supported by Evidation.2
This study aims to enroll 150,000 adults age 65 years and over to analyze the impact of Apple Watch–based early detection of irregular heart rhythms consistent with atrial fibrillation (AFib). The researchers’ hypothesis is that jointly detecting atrial fibrillation early and providing cardiovascular health programs to new AFib patients, will lead to patients being treated by a medical provider for AFib that otherwise would not have been detected. This, in turn, would lead to these AFib patients decreasing their risks of stroke and other serious cardiovascular events, including death, the study authors speculated.
Presenting new challenges
While PGHD has the potential to help people, it also presents new challenges. It is highly sensitive and personal – it can be as identifying as DNA.3
The vast amount of data that PGHD can collect from interaction with consumer wearable devices poses serious privacy risks if done improperly. To address those risks, companies like Evidation have built in protections. Evidation has an app, Achievement, that has enlisted a connected population of more than 3.5 million members who earn rewards for performing health-related actions, as tracked by wearables devices and apps. Through the Achievement app (See Figure 2.), members are provided opportunities to join research studies. As part of these studies, data collected from sensors and apps is used by permission of the member so that it is clear how their data are contributing to specific research questions or use cases.
This is a collaborative model of data collection built upon trust and permission and is substantially different than the collection of data from electronic health records (EHRs) – which is typically aggregated, deidentified, and commercialized, often without the patients’ knowledge or consent. Stringent protections, explicit permission, and transparency are absolutely imperative until privacy frameworks for data outside of HIPAA regulation catches up and protects patients from discrimination and unintended uses of their data.
Large connected cohorts can help advance our understanding of public health. In one study run on Achievement during the 2017-2018 flu season, a survey was sent to the Achievement population every week asking about symptoms of influenza-like illness and requesting permission to access historical data from their wearable around the influenza-like illness event.4 With the data, it was possible to analyze patterns of activity, sleep, and resting heart rate change around flu events. Resting heart rate, in particular, is shown to increase during fever and at the population level. In fact, through the use of PGHD, it is possible to use the fraction of people with resting heart rate above their usual baseline as a proxy to quantify the number of infected people in a region.5 This resting heart rate–informed flu surveillance method, if refined to increased accuracy, can work in near real time. This means it may be able detect influenza outbreaks days earlier than current epidemiological methods.
Health data generated by connected populations are in the early stages of development. It is clear that it will yield novel insights into health and disease. Only time will tell if it will be able to help clinicians and patients better predict, diagnose, and formulate treatment plans for disease.
Neil Skolnik, M.D. is a professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, and associate director of the Family Medicine Residency Program at Abington Jefferson Health. Luca Foschini PhD, is co-founder & chief data scientist at Evidation Health. Bray Patrick-Lake, MFS, is a patient thought leader and director of strategic partnerships at Evidation Health.
References
1. Chen R et al. Developing measures of cognitive impairment in the real world from consumer-grade multimodal sensor streams. KDD ’19. August 4–8, 2019 Aug 4-8.
2. The Heartline Study. https://www.heartline.com.
3. Foschini L. Privacy of Wearable and Sensors Data (or, the Lack Thereof?). Data Driven Investor, Medium. 2019.
4. Bradshaw B et al. Influenza surveillance using wearable mobile health devices. Online J Public Health Inform. 2019;11(1):e249.
5. Radin JM et al. Harnessing wearable device data to improve state-level real-time surveillance of influenza-like illness in the USA: a population-based study. Lancet Digital Health. 2020. doi: 10.1016/S2589-7500(19)30222-5.
In Part I of our discussion we introduced the concept of person-generated health data (PGHD), defined as wellness and/or health-related data created, recorded, or gathered by individuals.
Such rich, longitudinal information is now being used in combination with traditional clinical information to predict, diagnose, and formulate treatment plans for diseases, as well as understand the safety and effectiveness of medical interventions.
Identifying a disease early
One novel example of digital technologies being used for early identification of disease was a promising 2019 study by Eli Lilly (in collaboration with Apple and Evidation Health) called the Lilly Exploratory Digital Assessment Study.
In this study, the feasibility of using PGHD for identifying physiological and behavioral signatures of cognitive impairment was examined for the purpose of seeking new methods to detect mild cognitive impairment (MCI) in a timely and cost-effective manner. The study enrolled 31 study participants with cognitive impairment and 82 without cognitive impairment. It used consumer-grade sensor technologies (the iPhone, Apple Watch, iPad, and Beddit sleep monitor) to continuously and unobtrusively collect data. Among the information the researchers collected were interaction with the phone keyboard, accelerometer data from the Apple Watch, volume of messages sent/received, and sleep cycles.1
A total of 16 terabytes of data were collected over the course of 12 weeks. Data were organized into a behaviorgram (See Figure 1) that gives a holistic picture of a day in a patient’s life. A machine learning model was used to distinguish between behaviorgrams of symptomatic versus healthy controls, identifying typing speed, circadian rhythm shifts, and reliance on helper apps, among other things, as differentiating cognitively impaired from healthy controls. These behaviorgrams may someday serve as “fingerprints” of different diseases, with specific diseases displaying predictable patterns. In the near future, digital measures like the ones investigated in this study are likely to be used to help clinicians predict and diagnose disease, as well as to better understand disease progression and treatment response.
Leading to better health outcomes
The potential of PGHD to detect diseases early and lead to better health outcomes is being investigated in the Heartline study, a collaboration between Johnson & Johnson and Apple, which is supported by Evidation.2
This study aims to enroll 150,000 adults age 65 years and over to analyze the impact of Apple Watch–based early detection of irregular heart rhythms consistent with atrial fibrillation (AFib). The researchers’ hypothesis is that jointly detecting atrial fibrillation early and providing cardiovascular health programs to new AFib patients, will lead to patients being treated by a medical provider for AFib that otherwise would not have been detected. This, in turn, would lead to these AFib patients decreasing their risks of stroke and other serious cardiovascular events, including death, the study authors speculated.
Presenting new challenges
While PGHD has the potential to help people, it also presents new challenges. It is highly sensitive and personal – it can be as identifying as DNA.3
The vast amount of data that PGHD can collect from interaction with consumer wearable devices poses serious privacy risks if done improperly. To address those risks, companies like Evidation have built in protections. Evidation has an app, Achievement, that has enlisted a connected population of more than 3.5 million members who earn rewards for performing health-related actions, as tracked by wearables devices and apps. Through the Achievement app (See Figure 2.), members are provided opportunities to join research studies. As part of these studies, data collected from sensors and apps is used by permission of the member so that it is clear how their data are contributing to specific research questions or use cases.
This is a collaborative model of data collection built upon trust and permission and is substantially different than the collection of data from electronic health records (EHRs) – which is typically aggregated, deidentified, and commercialized, often without the patients’ knowledge or consent. Stringent protections, explicit permission, and transparency are absolutely imperative until privacy frameworks for data outside of HIPAA regulation catches up and protects patients from discrimination and unintended uses of their data.
Large connected cohorts can help advance our understanding of public health. In one study run on Achievement during the 2017-2018 flu season, a survey was sent to the Achievement population every week asking about symptoms of influenza-like illness and requesting permission to access historical data from their wearable around the influenza-like illness event.4 With the data, it was possible to analyze patterns of activity, sleep, and resting heart rate change around flu events. Resting heart rate, in particular, is shown to increase during fever and at the population level. In fact, through the use of PGHD, it is possible to use the fraction of people with resting heart rate above their usual baseline as a proxy to quantify the number of infected people in a region.5 This resting heart rate–informed flu surveillance method, if refined to increased accuracy, can work in near real time. This means it may be able detect influenza outbreaks days earlier than current epidemiological methods.
Health data generated by connected populations are in the early stages of development. It is clear that it will yield novel insights into health and disease. Only time will tell if it will be able to help clinicians and patients better predict, diagnose, and formulate treatment plans for disease.
Neil Skolnik, M.D. is a professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, and associate director of the Family Medicine Residency Program at Abington Jefferson Health. Luca Foschini PhD, is co-founder & chief data scientist at Evidation Health. Bray Patrick-Lake, MFS, is a patient thought leader and director of strategic partnerships at Evidation Health.
References
1. Chen R et al. Developing measures of cognitive impairment in the real world from consumer-grade multimodal sensor streams. KDD ’19. August 4–8, 2019 Aug 4-8.
2. The Heartline Study. https://www.heartline.com.
3. Foschini L. Privacy of Wearable and Sensors Data (or, the Lack Thereof?). Data Driven Investor, Medium. 2019.
4. Bradshaw B et al. Influenza surveillance using wearable mobile health devices. Online J Public Health Inform. 2019;11(1):e249.
5. Radin JM et al. Harnessing wearable device data to improve state-level real-time surveillance of influenza-like illness in the USA: a population-based study. Lancet Digital Health. 2020. doi: 10.1016/S2589-7500(19)30222-5.
In Part I of our discussion we introduced the concept of person-generated health data (PGHD), defined as wellness and/or health-related data created, recorded, or gathered by individuals.
Such rich, longitudinal information is now being used in combination with traditional clinical information to predict, diagnose, and formulate treatment plans for diseases, as well as understand the safety and effectiveness of medical interventions.
Identifying a disease early
One novel example of digital technologies being used for early identification of disease was a promising 2019 study by Eli Lilly (in collaboration with Apple and Evidation Health) called the Lilly Exploratory Digital Assessment Study.
In this study, the feasibility of using PGHD for identifying physiological and behavioral signatures of cognitive impairment was examined for the purpose of seeking new methods to detect mild cognitive impairment (MCI) in a timely and cost-effective manner. The study enrolled 31 study participants with cognitive impairment and 82 without cognitive impairment. It used consumer-grade sensor technologies (the iPhone, Apple Watch, iPad, and Beddit sleep monitor) to continuously and unobtrusively collect data. Among the information the researchers collected were interaction with the phone keyboard, accelerometer data from the Apple Watch, volume of messages sent/received, and sleep cycles.1
A total of 16 terabytes of data were collected over the course of 12 weeks. Data were organized into a behaviorgram (See Figure 1) that gives a holistic picture of a day in a patient’s life. A machine learning model was used to distinguish between behaviorgrams of symptomatic versus healthy controls, identifying typing speed, circadian rhythm shifts, and reliance on helper apps, among other things, as differentiating cognitively impaired from healthy controls. These behaviorgrams may someday serve as “fingerprints” of different diseases, with specific diseases displaying predictable patterns. In the near future, digital measures like the ones investigated in this study are likely to be used to help clinicians predict and diagnose disease, as well as to better understand disease progression and treatment response.
Leading to better health outcomes
The potential of PGHD to detect diseases early and lead to better health outcomes is being investigated in the Heartline study, a collaboration between Johnson & Johnson and Apple, which is supported by Evidation.2
This study aims to enroll 150,000 adults age 65 years and over to analyze the impact of Apple Watch–based early detection of irregular heart rhythms consistent with atrial fibrillation (AFib). The researchers’ hypothesis is that jointly detecting atrial fibrillation early and providing cardiovascular health programs to new AFib patients, will lead to patients being treated by a medical provider for AFib that otherwise would not have been detected. This, in turn, would lead to these AFib patients decreasing their risks of stroke and other serious cardiovascular events, including death, the study authors speculated.
Presenting new challenges
While PGHD has the potential to help people, it also presents new challenges. It is highly sensitive and personal – it can be as identifying as DNA.3
The vast amount of data that PGHD can collect from interaction with consumer wearable devices poses serious privacy risks if done improperly. To address those risks, companies like Evidation have built in protections. Evidation has an app, Achievement, that has enlisted a connected population of more than 3.5 million members who earn rewards for performing health-related actions, as tracked by wearables devices and apps. Through the Achievement app (See Figure 2.), members are provided opportunities to join research studies. As part of these studies, data collected from sensors and apps is used by permission of the member so that it is clear how their data are contributing to specific research questions or use cases.
This is a collaborative model of data collection built upon trust and permission and is substantially different than the collection of data from electronic health records (EHRs) – which is typically aggregated, deidentified, and commercialized, often without the patients’ knowledge or consent. Stringent protections, explicit permission, and transparency are absolutely imperative until privacy frameworks for data outside of HIPAA regulation catches up and protects patients from discrimination and unintended uses of their data.
Large connected cohorts can help advance our understanding of public health. In one study run on Achievement during the 2017-2018 flu season, a survey was sent to the Achievement population every week asking about symptoms of influenza-like illness and requesting permission to access historical data from their wearable around the influenza-like illness event.4 With the data, it was possible to analyze patterns of activity, sleep, and resting heart rate change around flu events. Resting heart rate, in particular, is shown to increase during fever and at the population level. In fact, through the use of PGHD, it is possible to use the fraction of people with resting heart rate above their usual baseline as a proxy to quantify the number of infected people in a region.5 This resting heart rate–informed flu surveillance method, if refined to increased accuracy, can work in near real time. This means it may be able detect influenza outbreaks days earlier than current epidemiological methods.
Health data generated by connected populations are in the early stages of development. It is clear that it will yield novel insights into health and disease. Only time will tell if it will be able to help clinicians and patients better predict, diagnose, and formulate treatment plans for disease.
Neil Skolnik, M.D. is a professor of family and community medicine at Sidney Kimmel Medical College, Thomas Jefferson University, and associate director of the Family Medicine Residency Program at Abington Jefferson Health. Luca Foschini PhD, is co-founder & chief data scientist at Evidation Health. Bray Patrick-Lake, MFS, is a patient thought leader and director of strategic partnerships at Evidation Health.
References
1. Chen R et al. Developing measures of cognitive impairment in the real world from consumer-grade multimodal sensor streams. KDD ’19. August 4–8, 2019 Aug 4-8.
2. The Heartline Study. https://www.heartline.com.
3. Foschini L. Privacy of Wearable and Sensors Data (or, the Lack Thereof?). Data Driven Investor, Medium. 2019.
4. Bradshaw B et al. Influenza surveillance using wearable mobile health devices. Online J Public Health Inform. 2019;11(1):e249.
5. Radin JM et al. Harnessing wearable device data to improve state-level real-time surveillance of influenza-like illness in the USA: a population-based study. Lancet Digital Health. 2020. doi: 10.1016/S2589-7500(19)30222-5.
Should the practice of counseling patients to present to the office for a string check after IUD insertion be halted?
[polldaddy:10527068]
[polldaddy:10527068]
[polldaddy:10527068]
White House expands seniors’ telehealth for COVID-19
“Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patients’ places of residence, starting March 6, 2020,” the Centers for Medicare & Medicaid Services said in a fact sheet issued March 17.
Some of the existing benefits were previously limited to rural communities.
“These services can also be provided in a variety of settings, including nursing homes, hospital outpatient departments, and more,” said CMS Administrator Seema Verma during a March 17 White House press briefing on administration actions to contain the spread of COVID-19.
That means that seniors can continue to receive their routine care without having to leave the home and risk infection, or they can get medical guidance if they have mild symptoms, which would help mitigate the spread to others.
“This shift is very important for clinicians and providers who, over the coming weeks, will face considerable strain on their time and resources,” Dr. Verma said. “[It] allows the health care system to prioritize care for those who have more needs or who are in dire need, and it also preserves protective equipment.”
A range of providers will be able to deliver telehealth services, including doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers. Visits using telehealth services will be considered the same as in-person visits and will be paid as if the patient were seen in the office.
This expansion of Medicare telehealth services will continue for the duration of the COVID-19 public health emergency.
“In addition, the [Health & Human Services’] office of inspector general is providing flexibility for health care providers to reduce or waive cost-sharing for telehealth visits paid by federal health care programs,” the fact sheet states.Key to the expansion is that it will cover the entire United States and will not be limited to rural areas.
Dr. Verma also noted that the administration “will be temporarily suspending certain HIPAA requirements so that doctors can provide telehealth with their own phones.”
She added that state Medicaid agencies can expand their telehealth services without the approval of CMS during this emergency.
AGA has released a guide to commercial telehealth COVID-19 coding policies (http://ow.ly/8CIH30qsU0B) that supplements their guide to public payors.
“Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patients’ places of residence, starting March 6, 2020,” the Centers for Medicare & Medicaid Services said in a fact sheet issued March 17.
Some of the existing benefits were previously limited to rural communities.
“These services can also be provided in a variety of settings, including nursing homes, hospital outpatient departments, and more,” said CMS Administrator Seema Verma during a March 17 White House press briefing on administration actions to contain the spread of COVID-19.
That means that seniors can continue to receive their routine care without having to leave the home and risk infection, or they can get medical guidance if they have mild symptoms, which would help mitigate the spread to others.
“This shift is very important for clinicians and providers who, over the coming weeks, will face considerable strain on their time and resources,” Dr. Verma said. “[It] allows the health care system to prioritize care for those who have more needs or who are in dire need, and it also preserves protective equipment.”
A range of providers will be able to deliver telehealth services, including doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers. Visits using telehealth services will be considered the same as in-person visits and will be paid as if the patient were seen in the office.
This expansion of Medicare telehealth services will continue for the duration of the COVID-19 public health emergency.
“In addition, the [Health & Human Services’] office of inspector general is providing flexibility for health care providers to reduce or waive cost-sharing for telehealth visits paid by federal health care programs,” the fact sheet states.Key to the expansion is that it will cover the entire United States and will not be limited to rural areas.
Dr. Verma also noted that the administration “will be temporarily suspending certain HIPAA requirements so that doctors can provide telehealth with their own phones.”
She added that state Medicaid agencies can expand their telehealth services without the approval of CMS during this emergency.
AGA has released a guide to commercial telehealth COVID-19 coding policies (http://ow.ly/8CIH30qsU0B) that supplements their guide to public payors.
“Medicare can pay for office, hospital, and other visits furnished via telehealth across the country and including in patients’ places of residence, starting March 6, 2020,” the Centers for Medicare & Medicaid Services said in a fact sheet issued March 17.
Some of the existing benefits were previously limited to rural communities.
“These services can also be provided in a variety of settings, including nursing homes, hospital outpatient departments, and more,” said CMS Administrator Seema Verma during a March 17 White House press briefing on administration actions to contain the spread of COVID-19.
That means that seniors can continue to receive their routine care without having to leave the home and risk infection, or they can get medical guidance if they have mild symptoms, which would help mitigate the spread to others.
“This shift is very important for clinicians and providers who, over the coming weeks, will face considerable strain on their time and resources,” Dr. Verma said. “[It] allows the health care system to prioritize care for those who have more needs or who are in dire need, and it also preserves protective equipment.”
A range of providers will be able to deliver telehealth services, including doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers. Visits using telehealth services will be considered the same as in-person visits and will be paid as if the patient were seen in the office.
This expansion of Medicare telehealth services will continue for the duration of the COVID-19 public health emergency.
“In addition, the [Health & Human Services’] office of inspector general is providing flexibility for health care providers to reduce or waive cost-sharing for telehealth visits paid by federal health care programs,” the fact sheet states.Key to the expansion is that it will cover the entire United States and will not be limited to rural areas.
Dr. Verma also noted that the administration “will be temporarily suspending certain HIPAA requirements so that doctors can provide telehealth with their own phones.”
She added that state Medicaid agencies can expand their telehealth services without the approval of CMS during this emergency.
AGA has released a guide to commercial telehealth COVID-19 coding policies (http://ow.ly/8CIH30qsU0B) that supplements their guide to public payors.
Perspective from the heartland: Cancer care and research during a public health crisis
I have no knowledge of, or experience with, managing a cancer patient during a pandemic. However, from the published and otherwise shared experience of others, we should not allow ourselves to underestimate the voracity of the coronavirus pandemic on our patients, communities, and health care systems.
Data from China suggest cancer patients infected with SARS-CoV-2 face a 3.5 times higher risk of mechanical ventilation, intensive care unit admission, or death, compared with infected patients without cancer (Lancet Oncol 2020;21:335-7).
Health care workers in Seattle have also shared their experiences battling coronavirus infections in cancer patients (J Natl Compr Canc Netw. 2020 Mar 20. doi: 10.6004/jnccn.2020.7560). Masumi Ueda, MD, of Seattle Cancer Care Alliance, and colleagues reviewed their decisions in multiple domains over a 7-week period, during which the state of Washington went from a single case of SARS-CoV-2 infection to nearly 650 cases and 40 deaths.
Making tough treatment decisions
Dr. Ueda and colleagues contrasted their customary resource-rich, innovation-oriented, cancer-combatting environment with their current circumstance, in which they must prioritize treatment for patients for whom the risk-reward balance has tilted substantially toward “risk.”
The authors noted that their most difficult decisions were those regarding delay of cancer treatment. They suggested that plans for potentially curative adjuvant therapy should likely proceed, but, for patients with metastatic disease, the equation is more nuanced.
In some cases, treatment should be delayed or interrupted with recognition of how that could result in worsening performance status and admission for symptom palliation, further stressing inpatient resources.
The authors suggested scenarios for prioritizing cancer surgery. For example, several months of systemic therapy (ideally, low-risk systemic therapy such as hormone therapy for breast or prostate cancer) and surgical delay may be worthwhile, without compromising patient care.
Patients with aggressive hematologic malignancy requiring urgent systemic treatment (potentially stem cell transplantation and cellular immunotherapies) should be treated promptly. However, even in those cases, opportunities should be sought to lessen immunosuppression and transition care as quickly as possible to the outpatient clinic, according to guidelines from the American Society of Transplantation and Cellular Therapy.
See one, do one, teach one
Rendering patient care during a pandemic would be unique for me. However, I, like all physicians, am familiar with feelings of inadequacy at times of professional challenge. On countless occasions, I have started my day or walked into a patient’s room wondering whether I will have the fortitude, knowledge, creativity, or help I need to get through that day or make that patient “better” by any definition of that word.
We all know the formula: “Work hard. Make evidence-based, personalized decisions for those who have entrusted their care to us. Learn from those encounters. Teach from our knowledge and experience – that is, ‘See one, do one, teach one.’ ”
The Seattle oncologists are living the lives of first responders and deserve our admiration for putting pen to paper so we can learn from their considerable, relevant experience.
Similar admiration is due to Giuseppe Curigliano, MD, of the European Institute of Oncology in Milan. In the ASCO Daily News, Dr. Curigliano described an epidemic that, within 3 weeks, overloaded the health care system across northern Italy.
Hospitalization was needed for over 60% of infected patients, and nearly 15% of those patients needed intensive care unit services for respiratory distress. The Italians centralized oncology care in specialized hubs, with spokes of institutions working in parallel to provide cancer-specific care in a COVID-free environment.
To build upon cancer-specific information from Italy and other areas hard-hit by COVID-19, more than 30 cancer centers have joined together to form the COVID-19 and Cancer Consortium. The consortium’s website hosts a survey designed to “capture details related to cancer patients presumed to have COVID-19.”
Calculating deaths and long-term consequences for cancer care delivery
It is proper that the authors from China, Italy, and Seattle did not focus attention on the case fatality rate from the COVID-19 pandemic among cancer patients. To say the least, it would be complicated to tally the direct mortality – either overall or in clinically important subsets of patients, including country-specific cohorts.
What we know from published reports is that, in Italy, cancer patients account for about 20% of deaths from coronavirus. In China, the case-fatality rate for patients with cancer was 5.6% (JAMA. 2020 Feb 24. doi: 10.1001/jama.2020.2648).
However, we know nothing about the indirect death toll from malignancy (without coronavirus infection) that was untreated or managed less than optimally because of personnel and physical resources that were diverted to COVID-19–associated cases.
Similarly, we cannot begin to estimate indirect consequences of the pandemic to oncology practices, such as accelerated burnout and posttraumatic stress disorder, as well as the long-range effects of economic turmoil on patients, health care workers, and provider organizations.
What happens to cancer trials?
From China, Italy, and Seattle, thus far, there is little information about how the pandemic will affect the vital clinical research endeavor. The Seattle physicians did say they plan to enroll patients on clinical trials only when the trial offers a high chance of benefiting the patient over standard therapy alone.
Fortunately, the National Institutes of Health and Food and Drug Administration have released guidance documents related to clinical trials.
The National Cancer Institute (NCI) has also released guidance documents (March 13 guidance; March 23 guidance) for patients on clinical trials supported by the NCI Cancer Therapy Evaluation Program (CTEP) and the NCI Community Oncology Research Program (NCORP).
CTEP and NCORP are making reasonable accommodations to suspend monitoring visits and audits, allow tele–follow-up visits for patients, and permit local physicians to provide care for patients on study. In addition, with appropriate procedural adherence and documentation, CTEP and NCORP will allow oral investigational medicines to be mailed directly to patients’ homes.
Planned NCI National Clinical Trials Network meetings will be conducted via remote access webinars, conference calls, and similar technology. These adjustments – and probably many more to come – are geared toward facilitating ongoing care to proceed safely and with minimal risk for patients currently receiving investigational therapies and for the sites and investigators engaged in those studies.
Each of us has probably faced a personal “defining professional moment,” when we had to utilize every skill in our arsenal and examine the motivations that led us to a career in oncology. However, it is clear from the forgoing clinical and research processes and guidelines that the COVID-19 pandemic is such a defining professional moment for each of us, in every community we serve.
Critical junctures like this cause more rapid behavior change and innovation than the slow-moving pace that characterizes our idealized preferences. As oncologists who embrace new data and behavioral change, we stand to learn processes that will facilitate more perfected systems of care than the one that preceded this unprecedented crisis, promote more efficient sharing of high-quality information, and improve the outcome for our future patients.
Dr. Lyss was an oncologist and researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
I have no knowledge of, or experience with, managing a cancer patient during a pandemic. However, from the published and otherwise shared experience of others, we should not allow ourselves to underestimate the voracity of the coronavirus pandemic on our patients, communities, and health care systems.
Data from China suggest cancer patients infected with SARS-CoV-2 face a 3.5 times higher risk of mechanical ventilation, intensive care unit admission, or death, compared with infected patients without cancer (Lancet Oncol 2020;21:335-7).
Health care workers in Seattle have also shared their experiences battling coronavirus infections in cancer patients (J Natl Compr Canc Netw. 2020 Mar 20. doi: 10.6004/jnccn.2020.7560). Masumi Ueda, MD, of Seattle Cancer Care Alliance, and colleagues reviewed their decisions in multiple domains over a 7-week period, during which the state of Washington went from a single case of SARS-CoV-2 infection to nearly 650 cases and 40 deaths.
Making tough treatment decisions
Dr. Ueda and colleagues contrasted their customary resource-rich, innovation-oriented, cancer-combatting environment with their current circumstance, in which they must prioritize treatment for patients for whom the risk-reward balance has tilted substantially toward “risk.”
The authors noted that their most difficult decisions were those regarding delay of cancer treatment. They suggested that plans for potentially curative adjuvant therapy should likely proceed, but, for patients with metastatic disease, the equation is more nuanced.
In some cases, treatment should be delayed or interrupted with recognition of how that could result in worsening performance status and admission for symptom palliation, further stressing inpatient resources.
The authors suggested scenarios for prioritizing cancer surgery. For example, several months of systemic therapy (ideally, low-risk systemic therapy such as hormone therapy for breast or prostate cancer) and surgical delay may be worthwhile, without compromising patient care.
Patients with aggressive hematologic malignancy requiring urgent systemic treatment (potentially stem cell transplantation and cellular immunotherapies) should be treated promptly. However, even in those cases, opportunities should be sought to lessen immunosuppression and transition care as quickly as possible to the outpatient clinic, according to guidelines from the American Society of Transplantation and Cellular Therapy.
See one, do one, teach one
Rendering patient care during a pandemic would be unique for me. However, I, like all physicians, am familiar with feelings of inadequacy at times of professional challenge. On countless occasions, I have started my day or walked into a patient’s room wondering whether I will have the fortitude, knowledge, creativity, or help I need to get through that day or make that patient “better” by any definition of that word.
We all know the formula: “Work hard. Make evidence-based, personalized decisions for those who have entrusted their care to us. Learn from those encounters. Teach from our knowledge and experience – that is, ‘See one, do one, teach one.’ ”
The Seattle oncologists are living the lives of first responders and deserve our admiration for putting pen to paper so we can learn from their considerable, relevant experience.
Similar admiration is due to Giuseppe Curigliano, MD, of the European Institute of Oncology in Milan. In the ASCO Daily News, Dr. Curigliano described an epidemic that, within 3 weeks, overloaded the health care system across northern Italy.
Hospitalization was needed for over 60% of infected patients, and nearly 15% of those patients needed intensive care unit services for respiratory distress. The Italians centralized oncology care in specialized hubs, with spokes of institutions working in parallel to provide cancer-specific care in a COVID-free environment.
To build upon cancer-specific information from Italy and other areas hard-hit by COVID-19, more than 30 cancer centers have joined together to form the COVID-19 and Cancer Consortium. The consortium’s website hosts a survey designed to “capture details related to cancer patients presumed to have COVID-19.”
Calculating deaths and long-term consequences for cancer care delivery
It is proper that the authors from China, Italy, and Seattle did not focus attention on the case fatality rate from the COVID-19 pandemic among cancer patients. To say the least, it would be complicated to tally the direct mortality – either overall or in clinically important subsets of patients, including country-specific cohorts.
What we know from published reports is that, in Italy, cancer patients account for about 20% of deaths from coronavirus. In China, the case-fatality rate for patients with cancer was 5.6% (JAMA. 2020 Feb 24. doi: 10.1001/jama.2020.2648).
However, we know nothing about the indirect death toll from malignancy (without coronavirus infection) that was untreated or managed less than optimally because of personnel and physical resources that were diverted to COVID-19–associated cases.
Similarly, we cannot begin to estimate indirect consequences of the pandemic to oncology practices, such as accelerated burnout and posttraumatic stress disorder, as well as the long-range effects of economic turmoil on patients, health care workers, and provider organizations.
What happens to cancer trials?
From China, Italy, and Seattle, thus far, there is little information about how the pandemic will affect the vital clinical research endeavor. The Seattle physicians did say they plan to enroll patients on clinical trials only when the trial offers a high chance of benefiting the patient over standard therapy alone.
Fortunately, the National Institutes of Health and Food and Drug Administration have released guidance documents related to clinical trials.
The National Cancer Institute (NCI) has also released guidance documents (March 13 guidance; March 23 guidance) for patients on clinical trials supported by the NCI Cancer Therapy Evaluation Program (CTEP) and the NCI Community Oncology Research Program (NCORP).
CTEP and NCORP are making reasonable accommodations to suspend monitoring visits and audits, allow tele–follow-up visits for patients, and permit local physicians to provide care for patients on study. In addition, with appropriate procedural adherence and documentation, CTEP and NCORP will allow oral investigational medicines to be mailed directly to patients’ homes.
Planned NCI National Clinical Trials Network meetings will be conducted via remote access webinars, conference calls, and similar technology. These adjustments – and probably many more to come – are geared toward facilitating ongoing care to proceed safely and with minimal risk for patients currently receiving investigational therapies and for the sites and investigators engaged in those studies.
Each of us has probably faced a personal “defining professional moment,” when we had to utilize every skill in our arsenal and examine the motivations that led us to a career in oncology. However, it is clear from the forgoing clinical and research processes and guidelines that the COVID-19 pandemic is such a defining professional moment for each of us, in every community we serve.
Critical junctures like this cause more rapid behavior change and innovation than the slow-moving pace that characterizes our idealized preferences. As oncologists who embrace new data and behavioral change, we stand to learn processes that will facilitate more perfected systems of care than the one that preceded this unprecedented crisis, promote more efficient sharing of high-quality information, and improve the outcome for our future patients.
Dr. Lyss was an oncologist and researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
I have no knowledge of, or experience with, managing a cancer patient during a pandemic. However, from the published and otherwise shared experience of others, we should not allow ourselves to underestimate the voracity of the coronavirus pandemic on our patients, communities, and health care systems.
Data from China suggest cancer patients infected with SARS-CoV-2 face a 3.5 times higher risk of mechanical ventilation, intensive care unit admission, or death, compared with infected patients without cancer (Lancet Oncol 2020;21:335-7).
Health care workers in Seattle have also shared their experiences battling coronavirus infections in cancer patients (J Natl Compr Canc Netw. 2020 Mar 20. doi: 10.6004/jnccn.2020.7560). Masumi Ueda, MD, of Seattle Cancer Care Alliance, and colleagues reviewed their decisions in multiple domains over a 7-week period, during which the state of Washington went from a single case of SARS-CoV-2 infection to nearly 650 cases and 40 deaths.
Making tough treatment decisions
Dr. Ueda and colleagues contrasted their customary resource-rich, innovation-oriented, cancer-combatting environment with their current circumstance, in which they must prioritize treatment for patients for whom the risk-reward balance has tilted substantially toward “risk.”
The authors noted that their most difficult decisions were those regarding delay of cancer treatment. They suggested that plans for potentially curative adjuvant therapy should likely proceed, but, for patients with metastatic disease, the equation is more nuanced.
In some cases, treatment should be delayed or interrupted with recognition of how that could result in worsening performance status and admission for symptom palliation, further stressing inpatient resources.
The authors suggested scenarios for prioritizing cancer surgery. For example, several months of systemic therapy (ideally, low-risk systemic therapy such as hormone therapy for breast or prostate cancer) and surgical delay may be worthwhile, without compromising patient care.
Patients with aggressive hematologic malignancy requiring urgent systemic treatment (potentially stem cell transplantation and cellular immunotherapies) should be treated promptly. However, even in those cases, opportunities should be sought to lessen immunosuppression and transition care as quickly as possible to the outpatient clinic, according to guidelines from the American Society of Transplantation and Cellular Therapy.
See one, do one, teach one
Rendering patient care during a pandemic would be unique for me. However, I, like all physicians, am familiar with feelings of inadequacy at times of professional challenge. On countless occasions, I have started my day or walked into a patient’s room wondering whether I will have the fortitude, knowledge, creativity, or help I need to get through that day or make that patient “better” by any definition of that word.
We all know the formula: “Work hard. Make evidence-based, personalized decisions for those who have entrusted their care to us. Learn from those encounters. Teach from our knowledge and experience – that is, ‘See one, do one, teach one.’ ”
The Seattle oncologists are living the lives of first responders and deserve our admiration for putting pen to paper so we can learn from their considerable, relevant experience.
Similar admiration is due to Giuseppe Curigliano, MD, of the European Institute of Oncology in Milan. In the ASCO Daily News, Dr. Curigliano described an epidemic that, within 3 weeks, overloaded the health care system across northern Italy.
Hospitalization was needed for over 60% of infected patients, and nearly 15% of those patients needed intensive care unit services for respiratory distress. The Italians centralized oncology care in specialized hubs, with spokes of institutions working in parallel to provide cancer-specific care in a COVID-free environment.
To build upon cancer-specific information from Italy and other areas hard-hit by COVID-19, more than 30 cancer centers have joined together to form the COVID-19 and Cancer Consortium. The consortium’s website hosts a survey designed to “capture details related to cancer patients presumed to have COVID-19.”
Calculating deaths and long-term consequences for cancer care delivery
It is proper that the authors from China, Italy, and Seattle did not focus attention on the case fatality rate from the COVID-19 pandemic among cancer patients. To say the least, it would be complicated to tally the direct mortality – either overall or in clinically important subsets of patients, including country-specific cohorts.
What we know from published reports is that, in Italy, cancer patients account for about 20% of deaths from coronavirus. In China, the case-fatality rate for patients with cancer was 5.6% (JAMA. 2020 Feb 24. doi: 10.1001/jama.2020.2648).
However, we know nothing about the indirect death toll from malignancy (without coronavirus infection) that was untreated or managed less than optimally because of personnel and physical resources that were diverted to COVID-19–associated cases.
Similarly, we cannot begin to estimate indirect consequences of the pandemic to oncology practices, such as accelerated burnout and posttraumatic stress disorder, as well as the long-range effects of economic turmoil on patients, health care workers, and provider organizations.
What happens to cancer trials?
From China, Italy, and Seattle, thus far, there is little information about how the pandemic will affect the vital clinical research endeavor. The Seattle physicians did say they plan to enroll patients on clinical trials only when the trial offers a high chance of benefiting the patient over standard therapy alone.
Fortunately, the National Institutes of Health and Food and Drug Administration have released guidance documents related to clinical trials.
The National Cancer Institute (NCI) has also released guidance documents (March 13 guidance; March 23 guidance) for patients on clinical trials supported by the NCI Cancer Therapy Evaluation Program (CTEP) and the NCI Community Oncology Research Program (NCORP).
CTEP and NCORP are making reasonable accommodations to suspend monitoring visits and audits, allow tele–follow-up visits for patients, and permit local physicians to provide care for patients on study. In addition, with appropriate procedural adherence and documentation, CTEP and NCORP will allow oral investigational medicines to be mailed directly to patients’ homes.
Planned NCI National Clinical Trials Network meetings will be conducted via remote access webinars, conference calls, and similar technology. These adjustments – and probably many more to come – are geared toward facilitating ongoing care to proceed safely and with minimal risk for patients currently receiving investigational therapies and for the sites and investigators engaged in those studies.
Each of us has probably faced a personal “defining professional moment,” when we had to utilize every skill in our arsenal and examine the motivations that led us to a career in oncology. However, it is clear from the forgoing clinical and research processes and guidelines that the COVID-19 pandemic is such a defining professional moment for each of us, in every community we serve.
Critical junctures like this cause more rapid behavior change and innovation than the slow-moving pace that characterizes our idealized preferences. As oncologists who embrace new data and behavioral change, we stand to learn processes that will facilitate more perfected systems of care than the one that preceded this unprecedented crisis, promote more efficient sharing of high-quality information, and improve the outcome for our future patients.
Dr. Lyss was an oncologist and researcher for more than 35 years before his recent retirement. His clinical and research interests were focused on breast and lung cancers, as well as expanding clinical trial access to medically underserved populations. He is based in St. Louis. He has no conflicts of interest.
Hospitals muzzle doctors and nurses on PPE, COVID-19 cases
Over the past month, an orthopedic surgeon has watched as the crowd of sick patients at his hospital has grown, while the supply of personal protective equipment (PPE) for staff has diminished. As he prepares for another day of staffing testing tents and places his one and only mask across his face, he also receives a daily reminder from hospital management: Don’t talk about it.
“It’s very clear; no one is allowed to speak for the institution or of the institution,” he said in an interview. “We get a daily warning about being very prudent about posts on personal accounts. They’ve talked about this with respect to various issues: case numbers, case severity, testing availability, [and] PPEs.”
The warnings mean staff at the hospital suffer in silence, unable to share the troubling situation with the public or request assistance with supplies.
“I have one mask. We’re expected to reuse them, unless you were exposed or worked with a known COVID victim,” the surgeon said. “However, with the numbers in our region rapidly increasing, you can’t assume that people don’t have it or that you don’t have particles on your mask, even if you’re not in a known quarantine zone within the institution.”
As the COVID-19 health crisis rages on, online platforms have become a common place for health professionals to lament short supplies, share concerns, tell stories, and plead for help. But at the same time, other physicians, nurses, and health care workers are being muzzled by hospital administrators and threatened with discipline for speaking out about coronavirus caseloads and dwindling supplies. Some worry the gag orders are muddying the picture of how hospitals are faring in the pandemic, while placing the safety of frontline workers at risk.
The silencing of physicians by hospitals about PPE shortages and other COVID-19 issues has become widespread, said Nisha Mehta, MD, a physician advocate and community leader who writes about PPE on social media. Physicians are being warned not to speak or post publicly about their COVID-19 experiences, including PPE shortages, case specifics, and the percentage of full hospital beds, Dr. Mehta said in an interview. In some cases, physicians who have posted have been forced to take down the posts or have faced retribution for speaking out, she said.
“There’s definitely a big fear among physicians, particularly employed physicians, in terms of what the consequences may be for telling their stories,” Dr. Mehta said. “I find that counterproductive. I understand not inducing panic, but these are real stories that are important for people to understand so they do stay home and increase the systemic pressure to get sufficient PPE, so that we can preserve our health care workforce for a problem that is going to get worse before it gets better.”
Meanwhile, an Indiana hospitalist who took to social media to ask for masks for hospitals in his area says he was immediately reprimanded by his management after the posts came to light. The hospitalist posted on a social media platform to request donations of N95 masks after hearing members of the public had purchased such masks. He hoped his plea would aid preparation for the pandemic at local hospitals, explained the physician, who spoke on the condition of anonymity.
Shortly afterward, administrators from his hospital contacted the online forum’s moderator and the posts were removed, he said. During a subsequent conversation, administrators warned the doctor not to make such posts about PPE because it made the hospital appear incompetent.
“I was told, ‘we can handle this, we don’t need the public’s help,’” the physician said. “I was hurt and upset. I was trying to help protect my peers.”
After landing on the management’s radar, the hospitalist said he was reprimanded a second time about posts on a separate personal social media account. The second time, the private posts to friends and family were related to COVID-19 and PPE, but did not include any protected health information, he said. However, administrators did not like the content of the posts, and he was told management was monitoring his activity on social media, he said.
“The larger message is that patients are money,” the hospitalist said. “The corporate side of medicine rules out over the medicine side. Image and making sure there is a consistent cash flow trumps all else.”
Another frontline physician who works at a large New York hospital, said staff have been cautioned not to talk with the media and to be careful what they post on social media regarding COVID-19. The general rule is that only information approved by administrators can be shared, said the physician, who spoke on the condition of anonymity.
“[The health system] is very protective of their public image,” he said. “In the past, people that have posted things that they don’t like get spoken to quickly and/or fired depending on what was written. I could only imagine that would be the situation regarding COVID-19. They are very strict.”
The frontline physician, who has close contact with COVID-19 patients, said he has access to N95 masks at the moment, but when he requested higher-level protective gear, hospital management refused the request and denied that such supplies were needed.
“Safety of frontline workers appears to not be taken seriously,” he said of his hospital. “Everyone is stressed, but at the end of the day, the administration is sitting there, while the rest of us are putting ourselves at risk.”
We reached out to one hospital for comment, but messages were not returned. Other hospitals were not contacted because physicians feared they would face retribution. We also contacted the American Hospital Association but they did not immediately respond.
In Chicago, an email by a nurse to her coworkers about the safety of masks has resulted in a lawsuit after the nurse says she was fired for sharing her concerns with staff. The nurse, Lauri Mazurkiewicz, sent an email to staffers at Northwestern Memorial Hospital stating the surgical masks provided by the hospital were less effective against airborne particles than were N95 masks, according to a lawsuit filed March 23 in Cook County Circuit Court. Ms. Mazurkiewicz was terminated the next day in retaliation for her email, the lawsuit alleges.
Ms. Mazurkiewicz could not be reached for comment by press time.
Christopher King, a spokesman for Northwestern Medicine, said the hospital is reviewing the lawsuit.
“As Northwestern Medicine continues to respond to this unprecedented health care pandemic, the health and well-being of our patients, our staff and our employees is our highest priority,” he said in a statement. “We take these matters seriously and we are currently reviewing the complaint. At this time, we will not be commenting further.”
John Mandrola, MD, a Louisville, Ky.–based cardiologist who has written about the recent muzzling of frontline physicians with respect to the coronavirus, said he is not surprised that some hospitals are preventing physicians from sharing their experiences.
“Before C19, in many hospital systems, there was a culture of fear amongst employed clinicians,” he said. “Employed clinicians see other employed physicians being terminated for speaking frankly about problems. It takes scant few of these cases to create a culture of silence.”
Dr. Mandrola, who is a regular Medscape contributor, said that a number of doctors have reached out to him privately about PPE scarcity and shared that they were explicitly warned by administrators not to talk about the shortfalls. Leadership at Dr. Mandrola’s hospital has not issued the same warnings, he said.
“From the hat of total transparency, I think the public is not getting a full view of the impending potential problems that are going to come by doctors not speaking publicly,” he said. “On the other hand, hospital leadership is doing the best they can. It’s not the hospitals’ fault. Hospital administrators can’t manufacture masks.”
From a public health standpoint, Dr. Mehta said that not allowing health professionals to speak publicly about the situations at their hospitals is “irresponsible.” The public deserves to know what is happening, she said, and the health care workforce needs to prepare for what is to come.
“It’s so important that we hear from our colleagues,” she said. “It’s important to hear those accounts so we can prepare for what we’re about to face. Data is crucial. The more you learn from each other, the better shot we have at successfully treating cases and ultimately beating this.”
With the critical shortage of PPE at his hospital and the inability to speak out about the problem, the orthopedic surgeon foresees the dilemma continuing to worsen.
“It’s not only the lives of front-line health care workers that are at risk, but it’s those that they’re going to spread it to and those that are going to be coming to the hospital requiring our care,” he said. “If we don’t have a fully functioning health care force, our capacity is going to be diminished that much further.”
The American Gastroenterological Association, along with 44 other medical specialty societies representing more than 800,000 physicians, signed onto the Council of Medical Specialty Societies letter stating that all frontline health care professionals must have access to PPEs and be able to speak publicly about the lack of PPEs without retribution while pushing for adequate supply and distribution. Review the statement at https://cmss.org/cmss-statement-ppe.
[email protected]
Over the past month, an orthopedic surgeon has watched as the crowd of sick patients at his hospital has grown, while the supply of personal protective equipment (PPE) for staff has diminished. As he prepares for another day of staffing testing tents and places his one and only mask across his face, he also receives a daily reminder from hospital management: Don’t talk about it.
“It’s very clear; no one is allowed to speak for the institution or of the institution,” he said in an interview. “We get a daily warning about being very prudent about posts on personal accounts. They’ve talked about this with respect to various issues: case numbers, case severity, testing availability, [and] PPEs.”
The warnings mean staff at the hospital suffer in silence, unable to share the troubling situation with the public or request assistance with supplies.
“I have one mask. We’re expected to reuse them, unless you were exposed or worked with a known COVID victim,” the surgeon said. “However, with the numbers in our region rapidly increasing, you can’t assume that people don’t have it or that you don’t have particles on your mask, even if you’re not in a known quarantine zone within the institution.”
As the COVID-19 health crisis rages on, online platforms have become a common place for health professionals to lament short supplies, share concerns, tell stories, and plead for help. But at the same time, other physicians, nurses, and health care workers are being muzzled by hospital administrators and threatened with discipline for speaking out about coronavirus caseloads and dwindling supplies. Some worry the gag orders are muddying the picture of how hospitals are faring in the pandemic, while placing the safety of frontline workers at risk.
The silencing of physicians by hospitals about PPE shortages and other COVID-19 issues has become widespread, said Nisha Mehta, MD, a physician advocate and community leader who writes about PPE on social media. Physicians are being warned not to speak or post publicly about their COVID-19 experiences, including PPE shortages, case specifics, and the percentage of full hospital beds, Dr. Mehta said in an interview. In some cases, physicians who have posted have been forced to take down the posts or have faced retribution for speaking out, she said.
“There’s definitely a big fear among physicians, particularly employed physicians, in terms of what the consequences may be for telling their stories,” Dr. Mehta said. “I find that counterproductive. I understand not inducing panic, but these are real stories that are important for people to understand so they do stay home and increase the systemic pressure to get sufficient PPE, so that we can preserve our health care workforce for a problem that is going to get worse before it gets better.”
Meanwhile, an Indiana hospitalist who took to social media to ask for masks for hospitals in his area says he was immediately reprimanded by his management after the posts came to light. The hospitalist posted on a social media platform to request donations of N95 masks after hearing members of the public had purchased such masks. He hoped his plea would aid preparation for the pandemic at local hospitals, explained the physician, who spoke on the condition of anonymity.
Shortly afterward, administrators from his hospital contacted the online forum’s moderator and the posts were removed, he said. During a subsequent conversation, administrators warned the doctor not to make such posts about PPE because it made the hospital appear incompetent.
“I was told, ‘we can handle this, we don’t need the public’s help,’” the physician said. “I was hurt and upset. I was trying to help protect my peers.”
After landing on the management’s radar, the hospitalist said he was reprimanded a second time about posts on a separate personal social media account. The second time, the private posts to friends and family were related to COVID-19 and PPE, but did not include any protected health information, he said. However, administrators did not like the content of the posts, and he was told management was monitoring his activity on social media, he said.
“The larger message is that patients are money,” the hospitalist said. “The corporate side of medicine rules out over the medicine side. Image and making sure there is a consistent cash flow trumps all else.”
Another frontline physician who works at a large New York hospital, said staff have been cautioned not to talk with the media and to be careful what they post on social media regarding COVID-19. The general rule is that only information approved by administrators can be shared, said the physician, who spoke on the condition of anonymity.
“[The health system] is very protective of their public image,” he said. “In the past, people that have posted things that they don’t like get spoken to quickly and/or fired depending on what was written. I could only imagine that would be the situation regarding COVID-19. They are very strict.”
The frontline physician, who has close contact with COVID-19 patients, said he has access to N95 masks at the moment, but when he requested higher-level protective gear, hospital management refused the request and denied that such supplies were needed.
“Safety of frontline workers appears to not be taken seriously,” he said of his hospital. “Everyone is stressed, but at the end of the day, the administration is sitting there, while the rest of us are putting ourselves at risk.”
We reached out to one hospital for comment, but messages were not returned. Other hospitals were not contacted because physicians feared they would face retribution. We also contacted the American Hospital Association but they did not immediately respond.
In Chicago, an email by a nurse to her coworkers about the safety of masks has resulted in a lawsuit after the nurse says she was fired for sharing her concerns with staff. The nurse, Lauri Mazurkiewicz, sent an email to staffers at Northwestern Memorial Hospital stating the surgical masks provided by the hospital were less effective against airborne particles than were N95 masks, according to a lawsuit filed March 23 in Cook County Circuit Court. Ms. Mazurkiewicz was terminated the next day in retaliation for her email, the lawsuit alleges.
Ms. Mazurkiewicz could not be reached for comment by press time.
Christopher King, a spokesman for Northwestern Medicine, said the hospital is reviewing the lawsuit.
“As Northwestern Medicine continues to respond to this unprecedented health care pandemic, the health and well-being of our patients, our staff and our employees is our highest priority,” he said in a statement. “We take these matters seriously and we are currently reviewing the complaint. At this time, we will not be commenting further.”
John Mandrola, MD, a Louisville, Ky.–based cardiologist who has written about the recent muzzling of frontline physicians with respect to the coronavirus, said he is not surprised that some hospitals are preventing physicians from sharing their experiences.
“Before C19, in many hospital systems, there was a culture of fear amongst employed clinicians,” he said. “Employed clinicians see other employed physicians being terminated for speaking frankly about problems. It takes scant few of these cases to create a culture of silence.”
Dr. Mandrola, who is a regular Medscape contributor, said that a number of doctors have reached out to him privately about PPE scarcity and shared that they were explicitly warned by administrators not to talk about the shortfalls. Leadership at Dr. Mandrola’s hospital has not issued the same warnings, he said.
“From the hat of total transparency, I think the public is not getting a full view of the impending potential problems that are going to come by doctors not speaking publicly,” he said. “On the other hand, hospital leadership is doing the best they can. It’s not the hospitals’ fault. Hospital administrators can’t manufacture masks.”
From a public health standpoint, Dr. Mehta said that not allowing health professionals to speak publicly about the situations at their hospitals is “irresponsible.” The public deserves to know what is happening, she said, and the health care workforce needs to prepare for what is to come.
“It’s so important that we hear from our colleagues,” she said. “It’s important to hear those accounts so we can prepare for what we’re about to face. Data is crucial. The more you learn from each other, the better shot we have at successfully treating cases and ultimately beating this.”
With the critical shortage of PPE at his hospital and the inability to speak out about the problem, the orthopedic surgeon foresees the dilemma continuing to worsen.
“It’s not only the lives of front-line health care workers that are at risk, but it’s those that they’re going to spread it to and those that are going to be coming to the hospital requiring our care,” he said. “If we don’t have a fully functioning health care force, our capacity is going to be diminished that much further.”
The American Gastroenterological Association, along with 44 other medical specialty societies representing more than 800,000 physicians, signed onto the Council of Medical Specialty Societies letter stating that all frontline health care professionals must have access to PPEs and be able to speak publicly about the lack of PPEs without retribution while pushing for adequate supply and distribution. Review the statement at https://cmss.org/cmss-statement-ppe.
[email protected]
Over the past month, an orthopedic surgeon has watched as the crowd of sick patients at his hospital has grown, while the supply of personal protective equipment (PPE) for staff has diminished. As he prepares for another day of staffing testing tents and places his one and only mask across his face, he also receives a daily reminder from hospital management: Don’t talk about it.
“It’s very clear; no one is allowed to speak for the institution or of the institution,” he said in an interview. “We get a daily warning about being very prudent about posts on personal accounts. They’ve talked about this with respect to various issues: case numbers, case severity, testing availability, [and] PPEs.”
The warnings mean staff at the hospital suffer in silence, unable to share the troubling situation with the public or request assistance with supplies.
“I have one mask. We’re expected to reuse them, unless you were exposed or worked with a known COVID victim,” the surgeon said. “However, with the numbers in our region rapidly increasing, you can’t assume that people don’t have it or that you don’t have particles on your mask, even if you’re not in a known quarantine zone within the institution.”
As the COVID-19 health crisis rages on, online platforms have become a common place for health professionals to lament short supplies, share concerns, tell stories, and plead for help. But at the same time, other physicians, nurses, and health care workers are being muzzled by hospital administrators and threatened with discipline for speaking out about coronavirus caseloads and dwindling supplies. Some worry the gag orders are muddying the picture of how hospitals are faring in the pandemic, while placing the safety of frontline workers at risk.
The silencing of physicians by hospitals about PPE shortages and other COVID-19 issues has become widespread, said Nisha Mehta, MD, a physician advocate and community leader who writes about PPE on social media. Physicians are being warned not to speak or post publicly about their COVID-19 experiences, including PPE shortages, case specifics, and the percentage of full hospital beds, Dr. Mehta said in an interview. In some cases, physicians who have posted have been forced to take down the posts or have faced retribution for speaking out, she said.
“There’s definitely a big fear among physicians, particularly employed physicians, in terms of what the consequences may be for telling their stories,” Dr. Mehta said. “I find that counterproductive. I understand not inducing panic, but these are real stories that are important for people to understand so they do stay home and increase the systemic pressure to get sufficient PPE, so that we can preserve our health care workforce for a problem that is going to get worse before it gets better.”
Meanwhile, an Indiana hospitalist who took to social media to ask for masks for hospitals in his area says he was immediately reprimanded by his management after the posts came to light. The hospitalist posted on a social media platform to request donations of N95 masks after hearing members of the public had purchased such masks. He hoped his plea would aid preparation for the pandemic at local hospitals, explained the physician, who spoke on the condition of anonymity.
Shortly afterward, administrators from his hospital contacted the online forum’s moderator and the posts were removed, he said. During a subsequent conversation, administrators warned the doctor not to make such posts about PPE because it made the hospital appear incompetent.
“I was told, ‘we can handle this, we don’t need the public’s help,’” the physician said. “I was hurt and upset. I was trying to help protect my peers.”
After landing on the management’s radar, the hospitalist said he was reprimanded a second time about posts on a separate personal social media account. The second time, the private posts to friends and family were related to COVID-19 and PPE, but did not include any protected health information, he said. However, administrators did not like the content of the posts, and he was told management was monitoring his activity on social media, he said.
“The larger message is that patients are money,” the hospitalist said. “The corporate side of medicine rules out over the medicine side. Image and making sure there is a consistent cash flow trumps all else.”
Another frontline physician who works at a large New York hospital, said staff have been cautioned not to talk with the media and to be careful what they post on social media regarding COVID-19. The general rule is that only information approved by administrators can be shared, said the physician, who spoke on the condition of anonymity.
“[The health system] is very protective of their public image,” he said. “In the past, people that have posted things that they don’t like get spoken to quickly and/or fired depending on what was written. I could only imagine that would be the situation regarding COVID-19. They are very strict.”
The frontline physician, who has close contact with COVID-19 patients, said he has access to N95 masks at the moment, but when he requested higher-level protective gear, hospital management refused the request and denied that such supplies were needed.
“Safety of frontline workers appears to not be taken seriously,” he said of his hospital. “Everyone is stressed, but at the end of the day, the administration is sitting there, while the rest of us are putting ourselves at risk.”
We reached out to one hospital for comment, but messages were not returned. Other hospitals were not contacted because physicians feared they would face retribution. We also contacted the American Hospital Association but they did not immediately respond.
In Chicago, an email by a nurse to her coworkers about the safety of masks has resulted in a lawsuit after the nurse says she was fired for sharing her concerns with staff. The nurse, Lauri Mazurkiewicz, sent an email to staffers at Northwestern Memorial Hospital stating the surgical masks provided by the hospital were less effective against airborne particles than were N95 masks, according to a lawsuit filed March 23 in Cook County Circuit Court. Ms. Mazurkiewicz was terminated the next day in retaliation for her email, the lawsuit alleges.
Ms. Mazurkiewicz could not be reached for comment by press time.
Christopher King, a spokesman for Northwestern Medicine, said the hospital is reviewing the lawsuit.
“As Northwestern Medicine continues to respond to this unprecedented health care pandemic, the health and well-being of our patients, our staff and our employees is our highest priority,” he said in a statement. “We take these matters seriously and we are currently reviewing the complaint. At this time, we will not be commenting further.”
John Mandrola, MD, a Louisville, Ky.–based cardiologist who has written about the recent muzzling of frontline physicians with respect to the coronavirus, said he is not surprised that some hospitals are preventing physicians from sharing their experiences.
“Before C19, in many hospital systems, there was a culture of fear amongst employed clinicians,” he said. “Employed clinicians see other employed physicians being terminated for speaking frankly about problems. It takes scant few of these cases to create a culture of silence.”
Dr. Mandrola, who is a regular Medscape contributor, said that a number of doctors have reached out to him privately about PPE scarcity and shared that they were explicitly warned by administrators not to talk about the shortfalls. Leadership at Dr. Mandrola’s hospital has not issued the same warnings, he said.
“From the hat of total transparency, I think the public is not getting a full view of the impending potential problems that are going to come by doctors not speaking publicly,” he said. “On the other hand, hospital leadership is doing the best they can. It’s not the hospitals’ fault. Hospital administrators can’t manufacture masks.”
From a public health standpoint, Dr. Mehta said that not allowing health professionals to speak publicly about the situations at their hospitals is “irresponsible.” The public deserves to know what is happening, she said, and the health care workforce needs to prepare for what is to come.
“It’s so important that we hear from our colleagues,” she said. “It’s important to hear those accounts so we can prepare for what we’re about to face. Data is crucial. The more you learn from each other, the better shot we have at successfully treating cases and ultimately beating this.”
With the critical shortage of PPE at his hospital and the inability to speak out about the problem, the orthopedic surgeon foresees the dilemma continuing to worsen.
“It’s not only the lives of front-line health care workers that are at risk, but it’s those that they’re going to spread it to and those that are going to be coming to the hospital requiring our care,” he said. “If we don’t have a fully functioning health care force, our capacity is going to be diminished that much further.”
The American Gastroenterological Association, along with 44 other medical specialty societies representing more than 800,000 physicians, signed onto the Council of Medical Specialty Societies letter stating that all frontline health care professionals must have access to PPEs and be able to speak publicly about the lack of PPEs without retribution while pushing for adequate supply and distribution. Review the statement at https://cmss.org/cmss-statement-ppe.
[email protected]
AMA offers resources for front-line physicians
.
The literature include news, advocacy, and other information to help front-line physicians provide care to patients and keep themselves safe “in a rapidly changing environment,” the organization said in a statement.
“The AMA continues to forcefully advocate for [personal protective equipment] and critical policy and regulatory changes needed to address our public health and health system needs. Because so many of the challenges of the pandemic are felt at a practice level, we are also providing new tools and information to help physicians respond,” AMA President Patrice A. Harris, MD, said in the statement.
The COVID-19 physician and practice resources released by the AMA include:
- A Physicians Guide to COVID-19 .
- An AMA COVID-19 online resource center and a COVID-19 FAQ.
- A Quick Guide to Telemedicine in Practice.
- Ethical guidance for physicians .
- Evidence-based resources from the The JAMA Network COVID-19 Resource Center.
- CME for physicians through the JAMA Network’s JN Learning website.
.
The literature include news, advocacy, and other information to help front-line physicians provide care to patients and keep themselves safe “in a rapidly changing environment,” the organization said in a statement.
“The AMA continues to forcefully advocate for [personal protective equipment] and critical policy and regulatory changes needed to address our public health and health system needs. Because so many of the challenges of the pandemic are felt at a practice level, we are also providing new tools and information to help physicians respond,” AMA President Patrice A. Harris, MD, said in the statement.
The COVID-19 physician and practice resources released by the AMA include:
- A Physicians Guide to COVID-19 .
- An AMA COVID-19 online resource center and a COVID-19 FAQ.
- A Quick Guide to Telemedicine in Practice.
- Ethical guidance for physicians .
- Evidence-based resources from the The JAMA Network COVID-19 Resource Center.
- CME for physicians through the JAMA Network’s JN Learning website.
.
The literature include news, advocacy, and other information to help front-line physicians provide care to patients and keep themselves safe “in a rapidly changing environment,” the organization said in a statement.
“The AMA continues to forcefully advocate for [personal protective equipment] and critical policy and regulatory changes needed to address our public health and health system needs. Because so many of the challenges of the pandemic are felt at a practice level, we are also providing new tools and information to help physicians respond,” AMA President Patrice A. Harris, MD, said in the statement.
The COVID-19 physician and practice resources released by the AMA include:
- A Physicians Guide to COVID-19 .
- An AMA COVID-19 online resource center and a COVID-19 FAQ.
- A Quick Guide to Telemedicine in Practice.
- Ethical guidance for physicians .
- Evidence-based resources from the The JAMA Network COVID-19 Resource Center.
- CME for physicians through the JAMA Network’s JN Learning website.
Cancer care and COVID-19 in Seattle, the first U.S. epicenter
Two months after the first patient with COVID-19 was identified in China, the first case was reported in the United States in the Seattle, Washington, metropolitan area.
Seattle rapidly became the first US epicenter for COVID-19, and local experts are now offering their expertise and advice on how to provide optimal cancer care during the pandemic in a special feature published online March 20 in the Journal of the National Comprehensive Cancer Network.
“We began implementing measures in early March, including infection control and screening of visitors, staff, and patients at the door,” said lead author Masumi Ueda, MD, who holds positions at the Seattle Cancer Care Alliance, the University of Washington, and the Fred Hutchinson Research Center.
“A lot of changes have been implemented, and it changes on a daily basis. We are responding to the growing rate of COVID-19 infection in the community,” she told Medscape Medical News.
Ueda notes that as a result of the quick implementation of new procedures, so far, very few cancer patients at their facilities have been infected by the virus. “It has not hit our cancer population hard, which is a good thing,” she said.
Create “Incident Command Structure”
In sharing their experience, the authors emphasize the importance of keeping channels of communication open between all stakeholders ― administrators and staff, patients, caregivers, and the general public. They also recommend that each facility create an “incident command structure” that can provide early coordination of institution-wide efforts and that can rapidly respond to changing information.
Ueda noted that their command structure was set up very early on, “so we could get communication set up and start building an infrastructure for response.”
Several areas of care that required new strategies were addressed, both to protect patients and to work around staff shortages caused by possible exposure and/or school closings, as well as projected shortages of supplies and hospital resources.
First and foremost was to identify patients and visitors who had respiratory symptoms and to provide them with masks. Although this is always routine practice during the respiratory virus season, screening has now been initiated at entry points throughout the system.
“We were lucky in Seattle and Washington state in that the University of Washington virology lab developed PCR [polymerase chain reaction] testing early on for COVID-19, which subsequently got FDA approval,” said Ueda. “So we were able to have local testing and didn’t have to rely on the state lab. Testing has also been rapidly scaled up.”
Initiating a comprehensive policy for testing staff, tracking results and exposures for persons under investigation, and defining when it is possible to return to work are essential elements for maintaining a stable workforce. In addition, reinforcing a strict “stay at home when ill” policy and providing access to testing for symptomatic staff have been key to limiting exposures.
“What is unique to our region is that we had testing early on, and we are turning it around in 24 hours,” she pointed out. “This is important for staff to be able to return to work.” Currently, staff, patients, and visitors are being tested only if they show the cardinal symptoms associated with COVID-19: fever, shortness of breath, and cough, although muscle aches have recently been added to their testing protocol.
“I think if we had unlimited capacity, we might consider testing people who are asymptomatic,” Ueda noted, “although if you don’t have symptoms, you may not have the viral load needed for an accurate test.”
Educational materials explaining infection control were also needed for patients and families, along with signs and a website to provide COVID-19 education. These were quickly developed.
In addition, a telephone triage line was established for patients with mild symptoms in order to minimize exposures in clinics and to lessen the number of patients presenting at emergency departments.
Outpatient Care
Because theirs is a referral center, many cancer patients come from out of town, and so there is concern about exposing nonlocal patients to COVID-19 as the virus spreads in the Seattle area. In addition, staffing shortages due to factors such as illness, exposure, and school closures are anticipated.
To address these problems, an initial priority was to establish a “multilayer” coverage system for the clinics in the event that practitioners had to be quarantined on short notice, the authors explain.
One decision was to reschedule all wellness visits for current patients or to use telemedicine. Capacity for that option expanded quickly, which was greatly helped by the recent decision by the Centers for Medicare & Medicaid Services to lift Medicare restrictions on the use of certain telemedicine services.
Another approach is to defer all consultations for second opinions for patients who were already undergoing treatment and to increase clinic hours of operations and capabilities for acute evaluations. This helps reserve emergency departments and hospital resources for patients who require higher-level care, the authors comment.
Treatment Decisions
Treatment decisions were more challenging to make, the authors note. One decision was that, despite the risk for COVID-19 for patients with solid tumors, adjuvant therapy with curative intent should proceed, they note. Similarly, patients with metastatic disease might lose the window of opportunity for treatment if it is delayed.
Treatment for aggressive hematologic malignancies is usually urgent, and stem cell transplant and cellular immunotherapies that provide curative treatments cannot be delayed in many cases.
Enrollment in clinical trials will most likely be limited to those trials that are most likely to benefit the patient.
Ueda noted that, because their patients come from all over the country, they are now conducting consultations for stem cell transplant by telephone so that nonlocal patients do not have to travel to Seattle. “If there is some way we can delay the treatment, we have taken that approach,” Ueda told Medscape Medical News. “If we can divert a patient to an area that is not as heavily affected, that’s another option we are taking.”
Although cancer surgery is not considered elective, surgical intervention needs to be prioritized, the authors comment. In the Seattle system, there is currently a 2-week ban on elective surgery in the healthcare system, owing to limited availability of personal protective equipment (PPE), staffing, and beds.
The oncology teams are currently reviewing treatment regimens to determine which treatments might lessen immunosuppression and which treatment options can be moved from the inpatient to the outpatient setting or can be delayed.
Inpatient Care
For hospitalized patients, several issues are being addressed. The priority is to prepare for an upcoming shortage of beds and resources because of the surge of patients with COVID-19 that is predicted. For both clinic and hospitalized patients, shortages of blood products have necessitated stricter adherence to thresholds for transfusion, and consideration is being given to lowering those thresholds.
Another important problem is the need to conserve PPE, which includes masks, gowns, gloves, and other products. The Seattle teams have implemented solutions such as favoring handwashing with soap and water over the use of hand gel for standard-precaution rooms, limiting the number of personnel entering patient rooms (so as to use less PPE), and reducing nursing procedures that require PPE, such as measuring urine output, unless they are necessary.
In addition, a no-visitor policy has been adopted in inpatient units to conserve PPE, with the exception of end-of-life situations.
The Future
The future trajectory of the COVID-19 pandemic is uncertain, Ueda commented. She emphasized that “we must continue to prepare for its widespread impact. The unknown is what we are looking at. We are expecting it to evolve, and the number of infections cannot go down.”
Ueda and coauthors end their article on a positive note. “To many of us, this has become the health care challenge of our generation, one that modern cancer therapy has never had to face. We will prevail, and when the pandemic ends, we will all be proud of what we did for our patients and each other in this critical moment for humanity.”
Two months after the first patient with COVID-19 was identified in China, the first case was reported in the United States in the Seattle, Washington, metropolitan area.
Seattle rapidly became the first US epicenter for COVID-19, and local experts are now offering their expertise and advice on how to provide optimal cancer care during the pandemic in a special feature published online March 20 in the Journal of the National Comprehensive Cancer Network.
“We began implementing measures in early March, including infection control and screening of visitors, staff, and patients at the door,” said lead author Masumi Ueda, MD, who holds positions at the Seattle Cancer Care Alliance, the University of Washington, and the Fred Hutchinson Research Center.
“A lot of changes have been implemented, and it changes on a daily basis. We are responding to the growing rate of COVID-19 infection in the community,” she told Medscape Medical News.
Ueda notes that as a result of the quick implementation of new procedures, so far, very few cancer patients at their facilities have been infected by the virus. “It has not hit our cancer population hard, which is a good thing,” she said.
Create “Incident Command Structure”
In sharing their experience, the authors emphasize the importance of keeping channels of communication open between all stakeholders ― administrators and staff, patients, caregivers, and the general public. They also recommend that each facility create an “incident command structure” that can provide early coordination of institution-wide efforts and that can rapidly respond to changing information.
Ueda noted that their command structure was set up very early on, “so we could get communication set up and start building an infrastructure for response.”
Several areas of care that required new strategies were addressed, both to protect patients and to work around staff shortages caused by possible exposure and/or school closings, as well as projected shortages of supplies and hospital resources.
First and foremost was to identify patients and visitors who had respiratory symptoms and to provide them with masks. Although this is always routine practice during the respiratory virus season, screening has now been initiated at entry points throughout the system.
“We were lucky in Seattle and Washington state in that the University of Washington virology lab developed PCR [polymerase chain reaction] testing early on for COVID-19, which subsequently got FDA approval,” said Ueda. “So we were able to have local testing and didn’t have to rely on the state lab. Testing has also been rapidly scaled up.”
Initiating a comprehensive policy for testing staff, tracking results and exposures for persons under investigation, and defining when it is possible to return to work are essential elements for maintaining a stable workforce. In addition, reinforcing a strict “stay at home when ill” policy and providing access to testing for symptomatic staff have been key to limiting exposures.
“What is unique to our region is that we had testing early on, and we are turning it around in 24 hours,” she pointed out. “This is important for staff to be able to return to work.” Currently, staff, patients, and visitors are being tested only if they show the cardinal symptoms associated with COVID-19: fever, shortness of breath, and cough, although muscle aches have recently been added to their testing protocol.
“I think if we had unlimited capacity, we might consider testing people who are asymptomatic,” Ueda noted, “although if you don’t have symptoms, you may not have the viral load needed for an accurate test.”
Educational materials explaining infection control were also needed for patients and families, along with signs and a website to provide COVID-19 education. These were quickly developed.
In addition, a telephone triage line was established for patients with mild symptoms in order to minimize exposures in clinics and to lessen the number of patients presenting at emergency departments.
Outpatient Care
Because theirs is a referral center, many cancer patients come from out of town, and so there is concern about exposing nonlocal patients to COVID-19 as the virus spreads in the Seattle area. In addition, staffing shortages due to factors such as illness, exposure, and school closures are anticipated.
To address these problems, an initial priority was to establish a “multilayer” coverage system for the clinics in the event that practitioners had to be quarantined on short notice, the authors explain.
One decision was to reschedule all wellness visits for current patients or to use telemedicine. Capacity for that option expanded quickly, which was greatly helped by the recent decision by the Centers for Medicare & Medicaid Services to lift Medicare restrictions on the use of certain telemedicine services.
Another approach is to defer all consultations for second opinions for patients who were already undergoing treatment and to increase clinic hours of operations and capabilities for acute evaluations. This helps reserve emergency departments and hospital resources for patients who require higher-level care, the authors comment.
Treatment Decisions
Treatment decisions were more challenging to make, the authors note. One decision was that, despite the risk for COVID-19 for patients with solid tumors, adjuvant therapy with curative intent should proceed, they note. Similarly, patients with metastatic disease might lose the window of opportunity for treatment if it is delayed.
Treatment for aggressive hematologic malignancies is usually urgent, and stem cell transplant and cellular immunotherapies that provide curative treatments cannot be delayed in many cases.
Enrollment in clinical trials will most likely be limited to those trials that are most likely to benefit the patient.
Ueda noted that, because their patients come from all over the country, they are now conducting consultations for stem cell transplant by telephone so that nonlocal patients do not have to travel to Seattle. “If there is some way we can delay the treatment, we have taken that approach,” Ueda told Medscape Medical News. “If we can divert a patient to an area that is not as heavily affected, that’s another option we are taking.”
Although cancer surgery is not considered elective, surgical intervention needs to be prioritized, the authors comment. In the Seattle system, there is currently a 2-week ban on elective surgery in the healthcare system, owing to limited availability of personal protective equipment (PPE), staffing, and beds.
The oncology teams are currently reviewing treatment regimens to determine which treatments might lessen immunosuppression and which treatment options can be moved from the inpatient to the outpatient setting or can be delayed.
Inpatient Care
For hospitalized patients, several issues are being addressed. The priority is to prepare for an upcoming shortage of beds and resources because of the surge of patients with COVID-19 that is predicted. For both clinic and hospitalized patients, shortages of blood products have necessitated stricter adherence to thresholds for transfusion, and consideration is being given to lowering those thresholds.
Another important problem is the need to conserve PPE, which includes masks, gowns, gloves, and other products. The Seattle teams have implemented solutions such as favoring handwashing with soap and water over the use of hand gel for standard-precaution rooms, limiting the number of personnel entering patient rooms (so as to use less PPE), and reducing nursing procedures that require PPE, such as measuring urine output, unless they are necessary.
In addition, a no-visitor policy has been adopted in inpatient units to conserve PPE, with the exception of end-of-life situations.
The Future
The future trajectory of the COVID-19 pandemic is uncertain, Ueda commented. She emphasized that “we must continue to prepare for its widespread impact. The unknown is what we are looking at. We are expecting it to evolve, and the number of infections cannot go down.”
Ueda and coauthors end their article on a positive note. “To many of us, this has become the health care challenge of our generation, one that modern cancer therapy has never had to face. We will prevail, and when the pandemic ends, we will all be proud of what we did for our patients and each other in this critical moment for humanity.”
Two months after the first patient with COVID-19 was identified in China, the first case was reported in the United States in the Seattle, Washington, metropolitan area.
Seattle rapidly became the first US epicenter for COVID-19, and local experts are now offering their expertise and advice on how to provide optimal cancer care during the pandemic in a special feature published online March 20 in the Journal of the National Comprehensive Cancer Network.
“We began implementing measures in early March, including infection control and screening of visitors, staff, and patients at the door,” said lead author Masumi Ueda, MD, who holds positions at the Seattle Cancer Care Alliance, the University of Washington, and the Fred Hutchinson Research Center.
“A lot of changes have been implemented, and it changes on a daily basis. We are responding to the growing rate of COVID-19 infection in the community,” she told Medscape Medical News.
Ueda notes that as a result of the quick implementation of new procedures, so far, very few cancer patients at their facilities have been infected by the virus. “It has not hit our cancer population hard, which is a good thing,” she said.
Create “Incident Command Structure”
In sharing their experience, the authors emphasize the importance of keeping channels of communication open between all stakeholders ― administrators and staff, patients, caregivers, and the general public. They also recommend that each facility create an “incident command structure” that can provide early coordination of institution-wide efforts and that can rapidly respond to changing information.
Ueda noted that their command structure was set up very early on, “so we could get communication set up and start building an infrastructure for response.”
Several areas of care that required new strategies were addressed, both to protect patients and to work around staff shortages caused by possible exposure and/or school closings, as well as projected shortages of supplies and hospital resources.
First and foremost was to identify patients and visitors who had respiratory symptoms and to provide them with masks. Although this is always routine practice during the respiratory virus season, screening has now been initiated at entry points throughout the system.
“We were lucky in Seattle and Washington state in that the University of Washington virology lab developed PCR [polymerase chain reaction] testing early on for COVID-19, which subsequently got FDA approval,” said Ueda. “So we were able to have local testing and didn’t have to rely on the state lab. Testing has also been rapidly scaled up.”
Initiating a comprehensive policy for testing staff, tracking results and exposures for persons under investigation, and defining when it is possible to return to work are essential elements for maintaining a stable workforce. In addition, reinforcing a strict “stay at home when ill” policy and providing access to testing for symptomatic staff have been key to limiting exposures.
“What is unique to our region is that we had testing early on, and we are turning it around in 24 hours,” she pointed out. “This is important for staff to be able to return to work.” Currently, staff, patients, and visitors are being tested only if they show the cardinal symptoms associated with COVID-19: fever, shortness of breath, and cough, although muscle aches have recently been added to their testing protocol.
“I think if we had unlimited capacity, we might consider testing people who are asymptomatic,” Ueda noted, “although if you don’t have symptoms, you may not have the viral load needed for an accurate test.”
Educational materials explaining infection control were also needed for patients and families, along with signs and a website to provide COVID-19 education. These were quickly developed.
In addition, a telephone triage line was established for patients with mild symptoms in order to minimize exposures in clinics and to lessen the number of patients presenting at emergency departments.
Outpatient Care
Because theirs is a referral center, many cancer patients come from out of town, and so there is concern about exposing nonlocal patients to COVID-19 as the virus spreads in the Seattle area. In addition, staffing shortages due to factors such as illness, exposure, and school closures are anticipated.
To address these problems, an initial priority was to establish a “multilayer” coverage system for the clinics in the event that practitioners had to be quarantined on short notice, the authors explain.
One decision was to reschedule all wellness visits for current patients or to use telemedicine. Capacity for that option expanded quickly, which was greatly helped by the recent decision by the Centers for Medicare & Medicaid Services to lift Medicare restrictions on the use of certain telemedicine services.
Another approach is to defer all consultations for second opinions for patients who were already undergoing treatment and to increase clinic hours of operations and capabilities for acute evaluations. This helps reserve emergency departments and hospital resources for patients who require higher-level care, the authors comment.
Treatment Decisions
Treatment decisions were more challenging to make, the authors note. One decision was that, despite the risk for COVID-19 for patients with solid tumors, adjuvant therapy with curative intent should proceed, they note. Similarly, patients with metastatic disease might lose the window of opportunity for treatment if it is delayed.
Treatment for aggressive hematologic malignancies is usually urgent, and stem cell transplant and cellular immunotherapies that provide curative treatments cannot be delayed in many cases.
Enrollment in clinical trials will most likely be limited to those trials that are most likely to benefit the patient.
Ueda noted that, because their patients come from all over the country, they are now conducting consultations for stem cell transplant by telephone so that nonlocal patients do not have to travel to Seattle. “If there is some way we can delay the treatment, we have taken that approach,” Ueda told Medscape Medical News. “If we can divert a patient to an area that is not as heavily affected, that’s another option we are taking.”
Although cancer surgery is not considered elective, surgical intervention needs to be prioritized, the authors comment. In the Seattle system, there is currently a 2-week ban on elective surgery in the healthcare system, owing to limited availability of personal protective equipment (PPE), staffing, and beds.
The oncology teams are currently reviewing treatment regimens to determine which treatments might lessen immunosuppression and which treatment options can be moved from the inpatient to the outpatient setting or can be delayed.
Inpatient Care
For hospitalized patients, several issues are being addressed. The priority is to prepare for an upcoming shortage of beds and resources because of the surge of patients with COVID-19 that is predicted. For both clinic and hospitalized patients, shortages of blood products have necessitated stricter adherence to thresholds for transfusion, and consideration is being given to lowering those thresholds.
Another important problem is the need to conserve PPE, which includes masks, gowns, gloves, and other products. The Seattle teams have implemented solutions such as favoring handwashing with soap and water over the use of hand gel for standard-precaution rooms, limiting the number of personnel entering patient rooms (so as to use less PPE), and reducing nursing procedures that require PPE, such as measuring urine output, unless they are necessary.
In addition, a no-visitor policy has been adopted in inpatient units to conserve PPE, with the exception of end-of-life situations.
The Future
The future trajectory of the COVID-19 pandemic is uncertain, Ueda commented. She emphasized that “we must continue to prepare for its widespread impact. The unknown is what we are looking at. We are expecting it to evolve, and the number of infections cannot go down.”
Ueda and coauthors end their article on a positive note. “To many of us, this has become the health care challenge of our generation, one that modern cancer therapy has never had to face. We will prevail, and when the pandemic ends, we will all be proud of what we did for our patients and each other in this critical moment for humanity.”