Entries in Clinical & Quality (39)

Friday
Feb122016

What Is the Difference Between Population Health, Community Health and Public Health?

by Clive Riddle, February 12, 2016

What Is the Difference Between Population Health, Community Health and Public Health? That is the question asked in the ThoughtLeaders Corner in this month’s issue of Population Health News. Here’s what some population health experts had to share:

Garth Graham, M.D., MPH, President of Aetna Foundation says “throughout medical school and residency, I paid close attention to my mentors in their efforts to make an impact both on the individual patient and on the broader public health level to influence health outcomes in entire communities. Today, as a cardiologist and president of the Aetna Foundation, I work every day to follow in their footsteps by looking at three distinct areas: population health, community health and public health.  When talking about population health, we are describing health and healthcare outcomes that impact a specific group of people being tracked and managed for specified health conditions. For example, at the Aetna Foundation, we’re working to bridge the health divide by paying close attention to chronic diseases, such as heart disease and diabetes, that disproportionately affect African Americans.”

Graham continues: “Community health broadens the scope, going beyond traditional health and healthcare needs to factor in the social determinants of health, such as education, employment, public safety and more. In our work with communities, we know factors such as access to information and services can have a direct impact on community health. As we look at the broader tapestry of national and state indicators, we see public health unfold beyond a specific community or group. It is the 10,000-foot view that helps us define the health of an entire nation. At the Aetna Foundation, we know that where you live can make a dramatic impact on your health. According to data from the Centers for Disease Control and Prevention (CDC), your zip code is a greater indicator of your health than your genetic code. As we work to improve health outcomes and close health divides for underserved communities in our nation, we can all contribute by sparking change—community by community, city block by city block. “ 

Alexis Pezzullo, Chief Growth Officer for DST Health Solutions offers this take: “One of the favorable consequences of the ACA’s passage has been the re-ignition of discussion around ways to enhance and sustain health in individuals, groups and populations. Stakeholders are thinking about and collaborating in various ways to improve health outcomes and address value-based utilization of healthcare resources. Not too surprisingly, the importance of public and community health efforts is becoming increasingly clear. Public health by definition is the science of protecting and improving health of entire populations, from neighborhoods to countries, through promotion of healthy lifestyles, research for disease and injury prevention and detection and control of infectious diseases.”

Pezzullo contrasts that “community health, on the other hand, is a field of public health centered on the study and enhancement of the health characteristics of biological communities. While the term can be broadly defined, community health tends to focus services, education and research on geographical areas with shared characteristics. Population health, meanwhile, is concerned with the distribution of health outcomes across a group of individuals. This field includes health outcomes, patterns of health determinants and policies and interventions that link the two. Improving ‘total’ population health requires partners across public health, healthcare organizations, community organizations and businesses. Today’s population health management necessitates innovative approaches that address the complexity involved in analyzing data, evaluating patient risk and effectively managing care. The cumulative value of these efforts has never been fully realized. As the healthcare industry seeks to optimize outcomes, changing strategies, capabilities and actions to leverage synergies across these health ecosystems is essential.            

Deborah Dorman-Rodriguez, Leader, Healthcare Practice Group, Freeborn & Peters LLP offers that “the terms population health, community health and public health are often used interchangeably even though they are somewhat distinct. Population health is now commonly used in the post-ACA environment in association with the Triple Aim of improving the quality of care, improving the health of populations and reducing the per capita cost of healthcare. David Kindig and Greg Stoddart first defined population health in 2003 as: ‘health outcomes of a group of individuals, including the distribution of such outcomes within the group.’ (Kindig D, Stoddart G. “What Is Population Health?” Am J Public Health. March 2003;93(3):380-383.)”

Dorman-Rodriguez goes on to say that “the definition did not include the cost or provider intervention aspects of healthcare. The evolution of the term over the last 10 to 12 years indicates there is not one specific definition that is universally recognized. It appears, however, that the concept of investment/cost and provider intervention/influence is likely to be included. In contrast, the terms public health and community health have traditionally meant a focus on the improved health of a population. The WHO defines public health broadly as ‘all organized measures (whether public or private) to prevent disease, promote health and prolong life among the population as a whole.’ The CDC Foundation defines public health as being ‘concerned with protecting the health of entire populations.’ Community health is often seen as a field within public health, focusing on the health of a particular population group that has common characteristics, such as culture, work, physical traits, geography or other demographics. All three terms are likely to evolve in their respective meanings given the current emphasis on improving healthcare outcomes.”  

Finally, Neil Smiley, CEO/Founder of Loopback Analytics has this to say: “Population health is a health improvement strategy for risk-based entities, such as managed care plans, self-insured employers and accountable care organizations that are financially responsible for clinical and economic outcomes of beneficiaries under their care. Population health competencies include analytics to proactively identify individuals with shared characteristics, such as chronic conditions, payer classifications, patient demographics and other risk factors. Once a population of interest has been identified, individuals are matched with interventions to manage health risk, with a feedback loop to measure clinical and economic efficacy. “

Smiley states that “community health is defined by local geography, such as a town, city or county. Communities typically include many risk-based entities, each operating their respective population health strategies. Whereas population health is often focused on clinical interventions, community health addresses non-clinical interventions, such as social services, transportation, housing and education provided by non-profits and community-based organizations. Public health spans both risk-based entities and communities with a focus on clinical research, health policy, regulations and quality and safety standards. Public health encompasses environmental factors that can impact the health of a population, such as infectious disease control (Centers for Disease Control and Prevention), air and water quality (Environmental Protection Agency) and safety of the food supply (U.S. Food & Drug Administration). Ideally, population, community and public health initiatives work together to continuously improve healthcare delivery and outcomes. “

More information about Population Health News is available at www.PopulationHealthNews.com

Thursday
Jan282016

Doing Different Differently

By Kim Bellard, January 28, 2016

I was all set to write about bacteriophages, then I realized that what appealed to me about them was as an example of attacking mainstream problems with non-mainstream solutions. So I decided to write more generally about how organizations are trying to encourage that.

Let's start with IBM. Big Blue is trying to reinvent itself as a company that uses "design thinking" to develop products and services.

Their design principles emphasize "making users your North Star," using collaborative multidisciplinary teams, "restless reinvention," and a continuous loop of "observe/reflect/make."

So far, about 10,000 employees have gone through the design bootcamp, and around 100 products have been developed using design thinking. Those are drops in the bucket for IBM, but the approach is an audacious and long overdue attempt for IBM to stay relevant in a millennium in which Apple has reminded companies about the importance of design.

Or take Microsoft. If there is any doubt that Microsoft is well on its way to doing things differently, look at the Surface Book or Surface Pro, each of which has won rave reviews. CEO Satya Nadella has been shaking things up ever since he took over two years ago.

One of Mr. Nadella's actions was to break up Microsoft's Research group, which had been kept separate from the day-to-day action. Bloomberg reports that Mr. Nadella has insisted that the research teams work hand-in-hand with the product teams to get new ideas into actual products quicker.

Mr. Nadella has emphasized, "we need to be open to new ideas, and Microsoft Research is where they will come from." This attitude led to Skype Translator becoming an actual product within three months of Mr. Nadella learning about the underlying research.

Venture capitalist Anshu Storm has a theory -- "stack fallacy" -- that he believes explains why so many big companies fail to innovate. The theory posits that many companies suffer from the "mistaken belief that it is trivial to build the layer above yours." 

He cites how Apple has built great devices but also has missed on simple apps, or IBM's classic blindspot about letting Microsoft own the OS layer that ran their PCs.

In his view, "Product management is the art of knowing what to build." The trouble is that too many companies focus on the how and not enough on the "why."

For example, think about hospitals. They're trying hard to position themselves as patient-centered health systems, but no one who has been in a hospital can believe that hospitals see patients as the customer. Hospital gowns? Waking patients up in the middle of the night to take vitals? Corridors upon winding corridors?

We need the health care experience to be less like health care and more like things we actually like. Nick de la Mare suggests that hospitals (and schools) "should be more like theme parks," and that designers should be aiming for "magical experiences."

That's the attitude we need to be taking as we try to innovate; it's not just doing more, but really rethinking the overall consumer experience. I was particularly struck by Mr. de la Mare's caution: 

The trick is to deploy technology strategically and sparingly, since new tools tend to introduce unintended complexities....A hospital patient may feel similarly overwhelmed by impersonal and bureaucratic processes that seem to serve the health care provider at their expense. Just because we have the technology to do something, doesn’t mean we should.

There is cool innovation going on within health care. David Chase, for example, raves about how Zoom+ (which I've written about before) has revamped the ER experience, and there is no shortage of other health care companies hoping to be disruptive (e.g., Becker's list of 30).

There is plenty of incremental innovation going on, and health care sure can use it, but I continue to be on the lookout for breath-taking innovation -- innovations that surprise, excite, and delight.

This post is an abridged version of the posting in Kim Bellard’s blogsite. Click here to read the full posting

Friday
May152015

Patient Reported Outcomes

By Clive Riddle, May 15, 2015

The National Quality Forum defines Patient-Reported Outcomes (PROs) as "any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else." They elaborate that “in other words, PRO tools measure what patients are able to do and how they feel by asking questions. These tools enable assessment of patient–reported health status for physical, mental, and social well–being.”

The concept is obviously not new, but has certainly been overlooked at times. In an era with tremendous advances and emphasis in patient engagement, mobile health technologies, patient-centered care, we need to continue to see application of PROs receive the attention they deserve.

Dr. Bruce Feinberg, vice president and chief medical officer of Cardinal Health Specialty Solutions, tells us "As our healthcare system moves toward a value-based care model, the role of the patient is becoming increasingly important. We need to reframe the way we think about care to include not only the cost and clinical effectiveness of the treatment, but also the burden of disease and therapy on the patient's perceived sense of well-being. Patient-reported outcomes (PRO) are key to this equation, particularly for patients being treated for high-cost, complex diseases such as cancer or rheumatoid arthritis (RA)."

Dr. Feinberg’s organization is presenting a series of new clinical studies demonstrating the potential role of PRO research in improving the quality and reduce the costs of treatment provided to patients with complex diseases, at the International Society of Pharmacoeconomic and Outcomes Research (ISPOR) annual meeting.

Here's an overview of some of the key findings they will be presenting:

  • One study used PRO to demonstrate that rheumatologists significantly underestimated the negative impact of RA disease burden and treatment on their patients' sense of well-being. Understanding this disparity in perceptions can help physicians make effective treatment decisions that lessen the burden on patients – and can sometimes also reduce the costs of their care.
  • Another study showed that PRO can be critical to identifying and managing medication access and adherence challenges for high-cost specialty drugs.
  • Of a total of 239 oncology and rheumatology patients who were contacted at the time of their initial prescription to provide patient reported outcomes, 28% were identified as having problems that either restricted access or adherence to the drug.
  • Armed with this information, interventions and support services were provided to address those challenges. With the support of these interventions, a medication possession ration exceeding 95% was achieved – enabling nearly all patients to initiate or continue treatment.
  • A third study  proved the feasibility of collecting PRO at the point of care. In the clinical study involving 3,185 RA patients, PRO data was captured during 90% of physician visits. The participating physicians were then able to utilize the data to inform real-time treatment decisions at the point of care.
Friday
Oct312014

Top Ten Medical Innovations for 2015

By Clive Riddle, October 31st, 2014

The Cleveland Clinic annually announces their take on the Top Ten Medical Innovations that are likely to have major impact on improving patient care in the coming year. They have just released their ninth annual version of this list, selected by a panel of 110 Cleveland Clinic physicians and scientists. With no further adieu, here – verbatim – is their narrative on their compilation of the Top 10 Medical Innovations for 2015:

  1. Mobile Stroke Unit
    Time lost is brain lost. High-tech ambulances bring the emergency department straight to the patient with stroke symptoms. Using telemedicine, in-hospital stroke neurologists interpret symptoms via broadband video link, while an onboard paramedic, critical care nurse and CT technologist perform neurological evaluation and administer t-PA after stroke detection, providing faster, effective treatment for the affected patient.
  2. Dengue Fever Vaccine
    One mosquito bite is all it takes. More than 50 to 100 million people in more than 100 countries contract the dengue virus each year. The world's first vaccine has been developed and tested, and is expected to be submitted to regulatory groups in 2015, with commercialization expected later that year.
  3. Cost-effective, Fast, Painless Blood-Testing
    Have the days of needles and vials come to an end? The new art of blood collection uses a drop of blood drawn from the fingertip in a virtually painless procedure. Test results are available within hours of the original draw and are estimated to cost as little as 10% of the traditional Medicare reimbursement.
  4. PCSK9 Inhibitors for Cholesterol Reduction
    Effective statin medications have been used to reduce cholesterol in heart disease patients for over two decades, but some people are intolerant and cannot benefit from them. Several PCSK9 inhibitors, or injectable cholesterol lowering drugs, are in development for those who don't benefit from statins. The FDA is expected to approve the first PCSK9 in 2015 for its ability to significantly lower LDL cholesterol to levels never seen before.
  5. Antibody-Drug Conjugates
    Chemotherapy, the only form of treatment available for treating some cancers, destroys cancer cells and harms healthy cells at the same time. A promising new approach for advanced cancer selectively delivers cytotoxic agents to tumor cells while avoiding normal, healthy tissue.
  6. Checkpoint Inhibitors
    Cancer kills approximately 8 million people annually and is difficult to treat, let alone cure. Immune checkpoint inhibitors have allowed physicians to make significantly more progress against advanced cancer than they've achieved in decades. Combined with traditional chemotherapy and radiation treatment, the novel drugs boost the immune system and offer significant, long-term cancer remissions for patients with metastatic melanoma, and there is increasing evidence that they can work on other types of malignancies.
  7. Leadless Cardiac Pacemaker
    Since 1958, the technology involved in cardiac pacemakers hasn't changed much. A silver-dollar-sized pulse generator and a thin wire, or lead, inserted through the vein kept the heart beating at a steady pace. Leads, though, can break and crack, and become infection sites in 2 percent of cases. Vitamin-sized wireless cardiac pacemakers can be implanted directly in the heart without surgery and eliminate malfunction complications and restriction on daily physical activities.
  8. New Drugs for Idiopathic Pulmonary Fibrosis
    Nearly 80,000 American adults with idiopathic pulmonary fibrosis may breathe easier in 2015 with the recent FDA-approval of two new experimental drugs. Pirfenidone and nintedanib slow the disease progress of the lethal lung disease, which causes scarring of the air sacs. Prior to these developments, there was no known treatment for IPF, in which life expectancy after diagnosis is just three to five years.
  9. Single-Dose Intra-Operative Radiation Therapy for Breast Cancer
    Finding and treating breast cancer in its earliest stages can oftentimes lead to a cure. For most women with early-stage breast cancer, a lumpectomy is performed, followed by weeks of radiation therapy to reduce the likelihood of recurrence. Intra-operative radiation therapy, or IORT, focuses the radiation on the tumor during surgery as a single-dose, and has proven effective as whole breast radiation.
  10. New Drug for Heart Failure
    Angiotensin-receptor neprilysin inhibitor, or ARNI, has been granted "fast-track status" by the FDA because of its impressive survival advantage over the ACE inhibitor enalapril, the current "gold standard" for treating patients with heart failure. The unique drug compound represents a paradigm shift in heart failure therapy.

Wondering what Cleveland Clinic proclaimed a year ago would be the top innovations for this year? Here was their top ten list from last year:

  1. Retinal Prosthesis System – Early Stage Bionic Eye
  2. Genome-Guided Solid Tumor Diagnostics
  3. Responsive Neurostimulator For Intractable Epilepsy
  4. Direct-Acting Antiviral Oral Hepatitis C Drugs
  5. Perioperative Decision Support System
  6. Fecal Microbiota Transplantation

  7. Relaxin For Acute Heart Failure
  8. Computer-Assisted Personalized Sedation System
  9. TMAO: A Novel Biomarker For Heart Attack, Stroke Risk
  10. B-Cell Receptor Pathway To Treat Blood Cancers
Friday
Aug152014

Ten Things to Know About Ebola Today:

Clive Riddle, August 15, 2014

While Ebola is only rampant in Africa, cases are now out-migrating, and Ebola is finally starting to get the increased  attention of the world it needs.  For those of us half a world away, we typically want to condense this information down to how it might ultimately indirectly or directly affect us. Unfortunately, some of that attention is overly shaped by fear, misinformation or even political agendas.

The CDC is a great resource site on Ebola Hemorrhagic Fever ,  including Ebola Virus Disease Information for Clinicians in U.S. Healthcare Settings.  NPR has a post today interviewing Jeanine Thomas, on why the Ebola decision has relevance for the U.S. health care system.  Much of the dilemma in West Africa is due to their lack of healthcare resources compared to more industrialized nations, as discussed in a Science Daily article posted yesterday, Ebola outbreak highlights global disparities in health-care resources, which pulls from NIH and New England Journal of Medicine content.

Perhaps a best first step for non-clinicians in the business of healthcare, is to become more conversant in the current state of affairs for Ebloa. As Lee Norman, MD, chief medical officer for The University of Kansas Hospital, reminds us, “the current Ebola Virus Disease is the deadliest on record but it is important to understand key elements of this virus. He and the University of Kansas Hospital have just released an excellent summary in the regard: 10 things to know about Ebola, we’ll repeat in its entirety:

  1. Cases Are Out-Migrating From Africa: This is happening due to the fact that infected or ill people are traveling out of those countries in Africa with Ebola outbreaks. Cases found outside of Africa may likely go up as the number of people leaving outbreak areas increases when aid-workers and others return to their home countries.
  2. No Cases of Human-to-Human Transmission Outside of Africa: There has been no human-to-human or other transmission to humans outside of Africa.
  3. Ebola Is Not Transmitted By Air, Only Via Bodily Secretions: Ebola is not respiratory, so it is not transmitted through coughing or breathing. These infections are occurring because of people who are exposed to bodily fluids of infected individuals.
  4. Ebola Is Not The Most Infectious Disease: As infectious diseases go, Ebola virus isn't inherently the most infectious nor is it the least infective from person-to-person. Measles and chickenpox, for example, are easier to spread. So are influenza and MERS.
  5. High Mortality Rates Due to Geography: The mortality rate is quite high in Africa Ebola cases, partly because of the chaos, instability, and unrest of the governments there, and very directly related to the fact that their access to standard treatment supplies (IV solution, tubing, syringes, and protective equipment) is not universally available. Ebola cases identified and treated in westernized nations, and those with modern infection control practices, will have a much lower rate than those seen in most African regions.
  6. Likelihood of Breakouts In Areas Outside of Africa: Meticulous infection control practices in modern hospitals will make it more unlikely that human-to-human transmission will occur in these settings. While expensive and advanced bio-containment units provide the highest level of infection control, it is unlikely that these units will be widespread throughout the world.
  7. No Approved Immunizations and Treatments: There are no approved immunizations to prevent Ebola virus infection. There are no approved treatments for Ebola virus infection. There are experimental antibody treatments, as well as an antiviral medication not approved for Ebola. But whether either or both are safe or effective for widespread use is not known. "Compassionate use" or "experimental use" of the above treatments is tempting, because no targeted, specific "conventional treatment" exists. But widely adopting experimental, unproven medications as "the new conventional therapy" has its own difficulties: Is it safe? Is it effective? Is it costly? Are there unanticipated "down-sides" to using them? A WHO ethics panel has given the go-ahead for this, something it has never done before.
  8. How Animals Play a Role: The non-human vectors that can harbor Ebola virus (fruit bats, non-human primates) are widespread in areas far removed from Africa. As such, it bears watching whether those vectors begin to harbor the virus. The WHO has an excellent map showing the parts of the world with these vectors.
  9. Alert Levels: The WHO and CDC both recently increased their respective alert levels. State and local health departments throughout the U.S. and world will certainly seek guidance as to the adoption of best "local practices" to guide hospital and care providers. The guidance by the CDC as to how to manage exposed individuals and those who might be incubating the infection are quite specific and helpful. They will certainly change as time goes on.
  10. What We Don't Know About Ebola: There are things unknown about Ebola. For example:
  1. Can a person have had a low-level infection and not know they ever had it? Probably, based on serum testing.
  2. Does a person who has had it and survived develop lifelong immunity? That is unknown at this point. The various strains of Ebola are enough different antigenically that there may not be cross-immunity.
  3. Is there such a thing as a "chronic carrier state" in humans where a person can shed the virus and be infectious for a long period of time, even when they themselves have no illness or symptoms? That is also unknown at this point.