Community-Based Hospitals Benefit From Restrictive Transfusion Practices.

ABSTRACT: Blood availability was uncertain during the COVID-19 pandemic, yet transfusion remained a common and sometimes necessary procedure. Substantial work on optimizing transfusion practices is centered in tertiary hospitals as high utilizers of blood while the care delivered in smaller community hospitals comprises more than half the nation's transfusions. Improving transfusion practices in community hospitals represents a substantial opportunity to enhance patient safety and the availability of blood resources. Clinical specialists developed a dashboard to retrospectively examine transfusion events including an evidence-based analysis of the patient's clinical situation at the time of transfusion to more accurately identify how appropriately blood was used. The compiled data were discussed and shared with transfusing providers. It was hypothesized that the data provided and communication strategies used would educate providers to current evidence-based practice, leading to more appropriate transfusion with an overall reduction in packed red blood cell utilization. There was an 11% increase in transfusion appropriateness (p = <.001) and a 14% decrease in the units transfused (p = .004). Improvement in transfusion practices demonstrates a significant impact on patient safety and the availability of blood resources. Although absolute opportunity may be less in a community hospital, fewer resources are needed to achieve meaningful change.

A Cost-Utility Analysis of Remote Pulse-Oximetry Monitoring of Patients With COVID-19.

OBJECTIVES: Since 2020, COVID-19 has infected tens of millions and caused hundreds of thousands of fatalities in the United States. Infection waves lead to increased emergency department utilization and critical care admission for patients with respiratory distress. Although many individuals develop symptoms necessitating a ventilator, some patients with COVID-19 can remain at home to mitigate hospital overcrowding. Remote pulse-oximetry (pulse-ox) monitoring of moderately ill patients with COVID-19 can be used to monitor symptom escalation and trigger hospital visits, as needed. METHODS: We analyzed the cost-utility of remote pulse-ox monitoring using a Markov model with a 3-week time horizon and daily cycles from a US health sector perspective. Costs (US dollar 2020) and outcomes were derived from the University Hospitals' real-world evidence and published literature. Costs and quality-adjusted life-years (QALYs) were used to determine the incremental cost-effectiveness ratio at a cost-effectiveness threshold of $100 000 per QALY. We assessed model uncertainty using univariate and probabilistic sensitivity analyses. RESULTS: Model results demonstrated that remote monitoring dominates current standard care, by reducing costs ($11 472 saved) and improving outcomes (0.013 QALYs gained). There were 87% fewer hospitalizations and 77% fewer deaths among patients with access to remote pulse-ox monitoring. The incremental cost-effectiveness ratio was not sensitive to uncertainty ranges in the model. CONCLUSIONS: Patient with COVID-19 remote pulse-ox monitoring increases the specificity of those requiring follow-up care for escalating symptoms. We recommend remote monitoring adoption across health systems to economically manage COVID-19 volume surges, maintain patients' comfort, reduce community infection spread, and carefully monitor needs of multiple individuals from one location by trained experts.

The Unrecognized Impact of Anxiety in Complex and Costly Patients.

Strategies to reduce suffering and expense for complex and costly patients have met with limited success. This may be due to both the ongoing dependence on transactional relationships and the failure to recognize anxiety spectrum disorders as a primary driver of medical complexity. The authors describe an emerging current of thought regarding a universal approach to the conceptualization of anxiety disorders and extend it for application to medical complexity. Using 4 cases, they illustrate distinct anxiety-complexity patterns and describe how a relational intervention untangled and identified treatment targets within that process, with excellent results for patients, providers, and payors. They go on to propose future directions and implications of this intervention.

Remote Patient Monitoring During COVID-19: An Unexpected Patient Safety Benefit.

This Viewpoint explains how some hospitals used home monitoring of pulse oximetry during the COVID-19 pandemic to avoid patient overcrowding and control high patient to staff ratios and how increased use of home monitoring for other vital signs could potentially improve patient safety and decrease costs.

Digital Health: Unlocking Value in a Post-Pandemic World.

The COVID-19 pandemic has forever changed health care, spurring a revolution in digital health technologies. Across the world, hundreds of thousands of health care systems are considering a central question: how do we connect with our patients? Digital health has been used as a stopgap in many cases to continue the essential functions of health systems. As the post-pandemic world and our "new normal" come into focus, further needs will have to be met with a digital patient interaction, with an eye toward value transformation. One barrier to fully leveraging digital tools is the lack of a framework for classifying the type of digital health care. This can limit our ability to design, deploy, evaluate, and communicate through digital means. This article presents 3 categories of digital health and their relationships to value metrics: (1) telehealth or direct care delivery, (2) digital access tools, and (3) digital monitoring. An evidence-based discussion reveals past successes, current promises, and future challenges in reducing defects in value through digital care. In the coming years, value transformation will become more crucial to the success of health care systems. By using the taxonomy in this article, health systems can better implement digital tools with a value-driven purpose. Defining the role of digital health in the post-pandemic world is needed to assist health systems and practices to build a bridge to value-based care.

Achieving Large-Scale Quality Improvement in Primary Care Annual Wellness Visits and Hierarchical Condition Coding.

BACKGROUND: Completion of Medicare Annual Wellness Visits (AWV) and documentation of Hierarchical Condition Categories (HCC) are important metrics in accountable care organizations (ACO) with quality and financial implications. To improve performance in large healthcare organizations, quality improvement (QI) efforts need to be scaled up in a way that is feasible within available system-wide resources. OBJECTIVE: We describe a 3-year effort using a multifaceted QI framework called the fractal management system for AWV and HCC performance. DESIGN: Pre-post evaluation of a multi-level, health system-wide QI management system intervention between 2018 and 2020. The system provided project management, coaching, communications, feedback of performance, and health informatics. PARTICIPANTS: The intervention was delivered to all 97 primary care practices within an Ohio-based accountable care organization, comprising 72,603 attributed Medicare and Medicare Advantage patients as of 2018. Eighty-nine of these practices were included in the analysis. APPROACH: AWV completion was defined as percent of eligible patients with a documented AWV during the calendar year. HCC completion was defined as documented reassessment of all prior-year HCC conditions. KEY RESULTS: AWV completion at the practice level increased from 23.7% (SD .14) in 2018 to 34.9% (SD .18) in 2019, and 59.8% (SD .17) in 2020. This was a statistically significant effect of time on AWV completion rates overall (F[2, 87] = 164.43, p < .000). More than half (56.2%) of practices met or exceeded the 60% goal in 2020. Practice-level HCC completion tracking started in 2019 (M = 75.9%, SD 7.4%) and increased in 2020 (M = 79.7%, SD 7.1%); t(172) = 2.0, p < .001. CONCLUSIONS: AWV and HCC performance goals were met in 2020, despite service disruptions due to COVID-19. The QI approach we used is applicable to other problems and other large healthcare systems.

Mitigating the July effect

An editorial is presented on the mitigating the July effect. Topics include the arrival of a crop of newly graduated medical students beginning their internships, the influx of so many freshly trained physicians arriving at the same time always triggers concern, and the belief in a July effect with presumed adverse consequences for patient safety and quality of care.