Pivoting to the QUAD AIM-Lessons Learned From the Central Texas Market.

INTRODUCTION: Since 2009, the Military Health System (MHS) has represented its mission as that of attaining the Quadruple Aim (QUAD AIM): increased readiness, better health, better care, and low per capita costs. The journey to reach the four goals is challenging and ongoing. Leaders in the MHS's Central Texas Market (CTM) sought to understand and overcome the root-cause obstacles that interfered with achieving the QUAD AIM. This process required a self-critical and thoroughly objective review of the behavioral economics of the system. We hypothesized that two corporate behaviors fed upon each other to create a vicious downward spiral. First, as a socialized (salary-based) system, the enterprise has a built-in incentive that covertly competes with the attainment of the QUAD AIM. Because additional work does not result in any material gain for its workers, the system regulates to a comfortable flow. Second, centralized leaders defer important management controls to tactical teammates due to their special medical expertise. This corporate behavior makes overcoming the first one challenging-keeping realization of the QUAD AIM elusive. METHODS: Beginning in July of 2019, CTM leaders strove to replace the two identified corporate behaviors with more productive ones. First, in place of regulating to comfort, we directed teammates to focus wholly on achieving the QUAD AIM. Second, we exerted leadership from the top down to attain the QUAD AIM's four goals. Because the vicious cycle manifested itself differently in the realms of primary, inpatient, and specialty care, we adapted the application of our virtuous behaviors to match the problem set in each realm. In primary care, we replaced fee-for-service incentives with value-based ones. In inpatient care, we eliminated hidden incentives that resulted in inappropriate and unnecessary transfers. In specialty care, we consolidated the management of referrals, templating, and scheduling-taking central control of system productivity. The interventions in each realm required the introduction of new workflows, policies, and dashboards to ensure change. RESULTS: Over a 2-year period, the CTM made a quantum to leap toward attaining the QUAD AIM. In our community based primary care homes, we significantly improved our operations as quantified by the value-based metrics of patient satisfaction, Healthcare Effectiveness Data and Information Set (HEDIS) quality metrics, access to care, and leakage. In the inpatient realm, we decreased monthly transfers by 73% (110 s to 30 s) resulting in higher bed censuses and multiple downstream positive impacts. In specialty care, we demonstrated our ability to return our specialty service lines quickly to high levels of production in the coronavirus disease-2019 crisis. Each of these interventions demonstrated large-scale movement toward the QUAD AIM. CONCLUSIONS: The CTM's actions demonstrate that the QUAD AIM can be attained in military medicine. Doing so requires the recognition of two destructive corporate behaviors. Through decades of hardening, these corporate behaviors have been imprinted upon the MHS, making them practically invisible as guiding currents in economic behavior. Counteracting them with persistent regulation to the QUAD AIM facilitated by proactive top-down leadership offers a solution.

Patients with previous immediate hypersensitivity reactions to polyethylene glycol can safely receive the BNT162b2 mRNA COVID-19 vaccine.

Previous anaphylaxis or immediate allergic reaction to polyethylene glycol (PEG; also known as macrogol) is considered a contraindication to the BNT162b2 mRNA COVID-19 vaccine, which contains 50 ug of PEG at a molecular weight of 2000, and this component is thought to account for the higher rate of anaphylaxis seen with this vaccine (4.7 per million doses) than with other non-mRNA vaccines. However, there is evidence that both anaphylaxis to PEG and anaphylaxis to the Pfizer COVID-19 reaction may not be IgE-mediated, with patients with anaphylaxis to first dose of the Pfizer COVID-19 vaccine receiving their second dose of vaccine without no or milder reactions in a high-risk clinic setting. In New Zealand, non-PEG-containing COVID-19 vaccines were not available until late 2021. Therefore, we offered patients with known or suspected PEG anaphylaxis their first dose of Pfizer COVID-19 vaccine in a high-risk hospital clinic. Eleven patients with previous hypersensitivity to PEG (including eight with anaphylaxis) successfully received their first dose with mild or no reactions; all have now had their second doses in the community without significant reaction. Record review also showed that most patients with previous hypersensitivity reactions to pegylated asparaginase have also been successfully vaccinated. This demonstrates that previous PEG hypersensitivity, including anaphylaxis, does not exclude immunisation with the Pfizer COVID-19 vaccine.

Oversight May Reduce Military Health System Leakage: Preventing Inappropriate Interhospital Transfers.

INTRODUCTION: The Military Health System (MHS) offers an example of a socialized healthcare model, operating within a larger "purchased care" civilian healthcare market. This arrangement has facilitated a trend wherein MHS clinicians often transfer moderate-to-complex patients to surrounding civilian hospitals, despite having the capability to care for such patients in-house. In an effort to stem this behavior, two initiatives were introduced at Carl R Darnall Army Medical Center (CRDAMC): A Transfer Policy Statement and Transfer Rounds. The Transfer Policy Statement emphasized that patients ought to be transferred only for capability gaps within the hospital. Transfer Rounds were then used to review the care received by each transferred patient and assess if that care could have been delivered internally. The purpose of this study is to assess the effect of these initiatives on reducing transfers from our hospital. MATERIALS AND METHODS: We performed a retrospective chart review from July 2019 through June 2020 to identify the number of total emergency department (ED) transfers, subcategorized as either transfers we had the capability to care for or transfers we did not have the capability to care for. The Transfer Policy Statement was published in August 2019, and Transfer Rounds were instituted in November 2019. We hypothesized that the two interventions would decrease the number of monthly inappropriate transfers. This was assessed by analyzing the proportion of inappropriate to appropriate patient transfers via Cochran and Armitage using SAS 9.4 (SAS Institute, Cary, NC). The projected received an Exemption Determination from the CRDAMC's Human Research Protections Office. The Defense Health Agency approved the data-sharing agreement. RESULTS: Over the study period, a total of 706 transfers met the criteria for analysis. The monthly median for total ED transfers was 64.5 (Interquartile Range (IQR) 45-74); appropriate transfers averaged 29.5 (median, IQR 24.5-36) and inappropriate 25.5 (median, IQR 9-41.5). A statistically significant downward trend in the fraction of inappropriate transfers was demonstrated by Cochran and Armitage (P < .0001). CONCLUSION: Our analysis supports the hypothesis that implementing a Transfer Policy and Transfer Rounds can significantly reduce the amount of MHS Leakage-that is the number of transferred patients that the MHS could have equally cared for. The effects of reduced patient transfers have many implications for the MHS: patients experience improved continuity of care by remaining in the same hospital system; clinicians maintain and extend their scope of practice by treating more complex patients; and patient flow and ED wait times are reduced by eliminating the transfer process. The financial implications of reduced MHS Leakage were not directly evaluated by our study, however may be assessed in future study.

Increased uptake of cervical screening by women with HIV infection in Auckland regardless of ethnicity, requirement for an interpreter or level of education.

BACKGROUND: Current guidelines recommend that women with HIV infection receive annual cervical smears. METHODS: We evaluated the uptake of annual cervical smears by women with HIV infection under the care of the Infectious Disease Service at Auckland City Hospital. In an attempt to identify potential barriers to regularly receiving an annual cervical smear, we invited the women to complete a questionnaire. The responses from women who had regularly received an annual cervical smear were compared with those who had not. RESULTS: The proportion of women who had received a cervical smear increased from 44% in 2001, to 73% in 2010 (p=0.001). Ninety-three women (76%) completed the study questionnaire. No statistically significant differences were found in the questionnaire responses between the women who had regularly received an annual cervical smear and those who had not. CONCLUSION: The proportion of women in this cohort who received a cervical smear in 2010 is comparable with other studies of women with HIV infection in New Zealand and overseas. We have not been able to identify barriers that prevent women with HIV infection in Auckland regularly receiving an annual cervical smear. We plan to encourage women who have not received a cervical smear in the previous 2-year period to have a cervical smear performed when they attend the Infectious Disease Clinic, and will continue to notify the National Cervical Screening Programme that all women who are newly diagnosed with HIV infection should have an annual recall code attached to future cervical smear reports. We expect that these interventions will further increase the proportion of women with HIV infection in Auckland who receive an annual cervical smear.

Uptake, yield and resource requirements of screening for asymptomatic sexually transmissible infections among HIV-positive people attending a hospital outpatient clinic.

UNLABELLED: Background We performed a prospective audit of screening for asymptomatic sexually transmissible infections (STIs), during an intensive effort to screen all patients at our hospital-based HIV clinic. We aimed to measure the effectiveness and resource implications of our screening program. METHODS: All outpatients who attended during an 8-month period were invited to take part in opt-out screening for chlamydia (Chlamydia trachomatis), gonorrhoea (Neisseria gonorrhoeae) and syphilis. Participants completed a brief questionnaire, were asked about current symptoms of STIs and self-collected specimens for laboratory testing. RESULTS: The majority (535 out of 673, 80%) of the patients who were asked to participate provided specimens for screening. No chlamydia, gonorrhoea or syphilis infections were identified in women (n=91) or in heterosexual men (n=76). In contrast, 34 out of 368 (10%) of men who have sex with men tested positive (chlamydia, 25; gonorrhoea, 2; chlamydia and gonorrhoea, 2; syphilis, 5). The laboratory cost of diagnosing each case of rectal chlamydia or gonorrhoea (NZ$664) was substantially lower than the cost of diagnosing each case of urethral infection (NZ$5309). CONCLUSIONS: There was high uptake of screening among our clinic population, who preferred screening to be performed at the hospital clinic. The yield of screening men who have sex with men warrants continued annual screening for rectal gonorrhoea and chlamydia and for syphilis.