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US Responses to Coronavirus Outbreak Expose Many Flaws in Our Medical System

Curator: Stephen J. Williams, Ph.D.

The  coronavirus pandemic has affected almost every country in every continent however, after months of the novel advent of novel COVID-19 cases, it has become apparent that the varied clinical responses in this epidemic (and outcomes) have laid bare some of the strong and weak aspects in, both our worldwide capabilities to respond to infectious outbreaks in a global coordinated response and in individual countries’ response to their localized epidemics.

 

Some nations, like Israel, have initiated a coordinated government-private-health system wide action plan and have shown success in limiting both new cases and COVID-19 related deaths.  After the initial Wuhan China outbreak, China closed borders and the government initiated health related procedures including the building of new hospitals. As of writing today, Wuhan has experienced no new cases of COVID-19 for two straight days.

 

However, the response in the US has been perplexing and has highlighted some glaring problems that have been augmented in this crisis, in the view of this writer.    In my view, which has been formulated after social discussion with members in the field ,these issues can be centered on three major areas of deficiencies in the United States that have hindered a rapid and successful response to this current crisis and potential future crises of this nature.

 

 

  1. The mistrust or misunderstanding of science in the United States
  2. Lack of communication and connection between patients and those involved in the healthcare industry
  3. Socio-geographical inequalities within the US healthcare system

 

1. The mistrust or misunderstanding of science in the United States

 

For the past decade, anyone involved in science, whether directly as active bench scientists, regulatory scientists, scientists involved in science and health policy, or environmental scientists can attest to the constant pressure to not only defend their profession but also to defend the entire scientific process and community from an onslaught of misinformation, mistrust and anxiety toward the field of science.  This can be seen in many of the editorials in scientific publications including the journal Science and Scientific American (as shown below)

 

Stepping Away from Microscopes, Thousands Protest War on Science

Boston rally coincides with annual American Association for the Advancement of Science (AAAS) conference and is a precursor to the March for Science in Washington, D.C.

byLauren McCauley, staff writer

Responding to the troubling suppression of science under the Trump administration, thousands of scientists, allies, and frontline communities are holding a rally in Boston’s Copley Square on Sunday.

#standupforscience Tweets

 

“Science serves the common good,” reads the call to action. “It protects the health of our communities, the safety of our families, the education of our children, the foundation of our economy and jobs, and the future we all want to live in and preserve for coming generations.”

It continues: 

But it’s under attack—both science itself, and the unalienable rights that scientists help uphold and protect. 

From the muzzling of scientists and government agencies, to the immigration ban, the deletion of scientific data, and the de-funding of public science, the erosion of our institutions of science is a dangerous direction for our country. Real people and communities bear the brunt of these actions.

The rally was planned to coincide with the annual American Association for the Advancement of Science (AAAS) conference, which draws thousands of science professionals, and is a precursor to the March for Science in Washington, D.C. and in cities around the world on April 22.

 

Source: https://www.commondreams.org/news/2017/02/19/stepping-away-microscopes-thousands-protest-war-science

https://images.app.goo.gl/UXizCsX4g5wZjVtz9

 

https://www.washingtonpost.com/video/c/embed/85438fbe-278d-11e7-928e-3624539060e8

 

 

The American Association for Cancer Research (AACR) also had marches for public awareness of science and meaningful science policy at their annual conference in Washington, D.C. in 2017 (see here for free recordings of some talks including Joe Biden’s announcement of the Cancer Moonshot program) and also sponsored events such as the Rally for Medical Research.  This patient advocacy effort is led by the cancer clinicians and scientific researchers to rally public support for cancer research for the benefit of those affected by the disease.

Source: https://leadingdiscoveries.aacr.org/cancer-patients-front-and-center/

 

 

     However, some feel that scientists are being too sensitive and that science policy and science-based decision making may not be under that much of a threat in this country. Yet even as some people think that there is no actual war on science and on scientists they realize that the public is not engaged in science and may not be sympathetic to the scientific process or trust scientists’ opinions. 

 

   

From Scientific American: Is There Really a War on Science? People who oppose vaccines, GMOs and climate change evidence may be more anxious than antagonistic

 

Certainly, opponents of genetically modified crops, vaccinations that are required for children and climate science have become louder and more organized in recent times. But opponents typically live in separate camps and protest single issues, not science as a whole, said science historian and philosopher Roberta Millstein of the University of California, Davis. She spoke at a standing-room only panel session at the American Association for the Advancement of Science’s annual meeting, held in Washington, D.C. All the speakers advocated for a scientifically informed citizenry and public policy, and most discouraged broadly applied battle-themed rhetoric.

 

Source: https://www.scientificamerican.com/article/is-there-really-a-war-on-science/

 

      In general, it appears to be a major misunderstanding by the public of the scientific process, and principles of scientific discovery, which may be the fault of miscommunication by scientists or agendas which have the goals of subverting or misdirecting public policy decisions from scientific discourse and investigation.

 

This can lead to an information vacuum, which, in this age of rapid social media communication,

can quickly perpetuate misinformation.

 

This perpetuation of misinformation was very evident in a Twitter feed discussion with Dr. Eric Topol, M.D. (cardiologist and Founder and Director of the Scripps Research Translational  Institute) on the US President’s tweet on the use of the antimalarial drug hydroxychloroquine based on President Trump referencing a single study in the International Journal of Antimicrobial Agents.  The Twitter thread became a sort of “scientific journal club” with input from international scientists discussing and critiquing the results in the paper.  

 

Please note that when we scientists CRITIQUE a paper it does not mean CRITICIZE it.  A critique is merely an in depth analysis of the results and conclusions with an open discussion on the paper.  This is part of the normal peer review process.

 

Below is the original Tweet by Dr. Eric Topol as well as the ensuing tweet thread

 

https://twitter.com/EricTopol/status/1241442247133900801?s=20

 

Within the tweet thread it was discussed some of the limitations or study design flaws of the referenced paper leading the scientists in this impromptu discussion that the study could not reasonably conclude that hydroxychloroquine was not a reliable therapeutic for this coronavirus strain.

 

The lesson: The public has to realize CRITIQUE does not mean CRITICISM.

 

Scientific discourse has to occur to allow for the proper critique of results.  When this is allowed science becomes better, more robust, and we protect ourselves from maybe heading down an incorrect path, which may have major impacts on a clinical outcome, in this case.

 

 

2.  Lack of communication and connection between patients and those involved in the healthcare industry

 

In normal times, it is imperative for the patient-physician relationship to be intact in order for the physician to be able to communicate proper information to their patient during and after therapy/care.  In these critical times, this relationship and good communication skills becomes even more important.

 

Recently, I have had multiple communications, either through Twitter, Facebook, and other social media outlets with cancer patients, cancer advocacy groups, and cancer survivorship forums concerning their risks of getting infected with the coronavirus and how they should handle various aspects of their therapy, whether they were currently undergoing therapy or just about to start chemotherapy.  This made me realize that there were a huge subset of patients who were not receiving all the information and support they needed; namely patients who are immunocompromised.

 

These are patients represent

  1. cancer patient undergoing/or about to start chemotherapy
  2. Patients taking immunosuppressive drugs: organ transplant recipients, patients with autoimmune diseases, multiple sclerosis patients
  3. Patients with immunodeficiency disorders

 

These concerns prompted me to write a posting curating the guidance from National Cancer Institute (NCI) designated cancer centers to cancer patients concerning their risk to COVID19 (which can be found here).

 

Surprisingly, there were only 14 of the 51 US NCI Cancer Centers which had posted guidance (either there own or from organizations like NCI or the National Cancer Coalition Network (NCCN).  Most of the guidance to patients had stemmed from a paper written by Dr. Markham of the Fred Hutchinson Cancer Center in Seattle Washington, the first major US city which was impacted by COVID19.

 

Also I was surprised at the reactions to this posting, with patients and oncologists enthusiastic to discuss concerns around the coronavirus problem.  This led to having additional contact with patients and oncologists who, as I was surprised, are not having these conversations with each other or are totally confused on courses of action during this pandemic.  There was a true need for each party, both patients/caregivers and physicians/oncologists to be able to communicate with each other and disseminate good information.

 

Last night there was a Tweet conversation on Twitter #OTChat sponsored by @OncologyTimes.  A few tweets are included below

https://twitter.com/OncologyTimes/status/1242611841613864960?s=20

https://twitter.com/OncologyTimes/status/1242616756658753538?s=20

https://twitter.com/OncologyTimes/status/1242615906846547978?s=20

 

The Lesson:  Rapid Communication of Vital Information in times of stress is crucial in maintaining a good patient/physician relationship and preventing Misinformation.

 

3.  Socio-geographical Inequalities in the US Healthcare System

It has become very clear that the US healthcare system is fractioned and multiple inequalities (based on race, sex, geography, socio-economic status, age) exist across the whole healthcare system.  These inequalities are exacerbated in times of stress, especially when access to care is limited.

 

An example:

 

On May 12, 2015, an Amtrak Northeast Regional train from Washington, D.C. bound for New York City derailed and wrecked on the Northeast Corridor in the Port Richmond neighborhood of Philadelphia, Pennsylvania. Of 238 passengers and 5 crew on board, 8 were killed and over 200 injured, 11 critically. The train was traveling at 102 mph (164 km/h) in a 50 mph (80 km/h) zone of curved tracks when it derailed.[3]

Some of the passengers had to be extricated from the wrecked cars. Many of the passengers and local residents helped first responders during the rescue operation. Five local hospitals treated the injured. The derailment disrupted train service for several days. 

(Source Wikipedia https://en.wikipedia.org/wiki/2015_Philadelphia_train_derailment)

What was not reported was the difficulties that first responders, namely paramedics had in finding an emergency room capable of taking on the massive load of patients.  In the years prior to this accident, several hospitals, due to monetary reasons, had to close their emergency rooms or reduce them in size. In addition only two in Philadelphia were capable of accepting gun shot victims (Temple University Hospital was the closest to the derailment but one of the emergency rooms which would accept gun shot victims. This was important as Temple University ER, being in North Philadelphia, is usually very busy on any given night.  The stress to the local health system revealed how one disaster could easily overburden many hospitals.

 

Over the past decade many hospitals, especially rural hospitals, have been shuttered or consolidated into bigger health systems.  The graphic below shows this

From Bloomberg: US Hospital Closings Leave Patients with Nowhere to go

 

 

https://images.app.goo.gl/JdZ6UtaG3Ra3EA3J8

 

Note the huge swath of hospital closures in the midwest, especially in rural areas.  This has become an ongoing problem as the health care system deals with rising costs.

 

Lesson:  Epidemic Stresses an already stressed out US healthcare system

 

Please see our Coronavirus Portal at

https://pharmaceuticalintelligence.com/coronavirus-portal/

 

for more up-to-date scientific, clinical information as well as persona stories, videos, interviews and economic impact analyses

and @pharma_BI

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HUBweek 2018, October 8-14, 2018, Greater Boston – “We The Future” – coming together, of breaking down barriers, of convening across disciplinary lines to shape our future

Reporter: Aviva Lev-Ari, PhD, RN

 

HUBweek 2018

Hi Aviva,

 

At HUBweek and in this community, we believe a brighter future is built together. In these times of division, particularly when many are feeling excluded from the benefits brought forth by rapid technological development, there is critical importance in the act of coming together, of breaking down barriers, of convening across disciplinary lines to shape our future.

That’s why this year’s theme for HUBweek is We the Future. It is a call to action and an invitation. Throughout the week, we’ll bring together innovators, artists, and curious minds to explore the ways in which we can shape a more inclusive and equitable future for all.

Today, HUBweek kicks off with dozens of events taking place across the city–from public art tours, a drone zoo, and discussions on nuclear weapons and the impact of emerging technologies on people with disabilities, to a policy hackathon hosted by MIT and the first ever Change Maker Conference.

There are 225+ more experiences to take part in throughout HUBweek–a three-day Forum and a documentary film festival; open dialogues with leading thinkers; a robot block party; and collaborative and participatory art. And we’ve got a little fun in store for you, too–make sure you sign up and stop by The HUB later this week to check it all out.

At its core, HUBweek is a collaboration. If not for our partners and the unwavering support of this community, this would not be a reality. A big thank you to our presenting partners Blue Cross Blue Shield of Massachusetts, Liberty Mutual Insurance, and Merck KGaA, to our sponsors, and to the hundreds of collaborating organizations, speakers, artists, and creative minds that are behind this year’s festival.

On behalf of the HUBweek team and our founders The Boston Globe, Harvard University, Mass. General Hospital, and MIT, we’re thrilled to invite you to join us at HUBweek 2018.

 

Linda Pizzuti Henry

SOURCE

 

From: Linda Pizzuti Henry <hello@hubweek.org>

Reply-To: <hello@hubweek.org>

Date: Monday, October 8, 2018 at 9:38 AM

To: Aviva Lev-Ari <AvivaLev-Ari@alum.berkeley.edu>

Subject: Welcome to HUBweek

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PCI, CABG, CHF, AMI – Two Payment Methods: Bundled payments (hospitalization costs, up to 90 days of post-acute care, nursing home care, complications, and rehospitalizations) vs Diagnosis-related groupings cover only what happens in the hospital.

Reporter: Aviva Lev-Ari, PhD, RN

 

UPDATED on 8/17/2018

Certain risk factors make survivors of an acute MI more likely to suffer major cardiovascular events within a year, researchers said.

A model with 19 factors (comprising 15 unique variables) was created for the identification of high-risk patients; the strongest factors in the training sample (n=2,113) were found to be:

  • Age 85 years and older: HR 6.73 (95% CI 2.83-15.96)

  • Prior angina: HR 2.05 (95% CI 1.17-3.58)

  • Prior ventricular tachycardia or fibrillation: HR 2.15 (95% CI 0.99-4.70)

  • Ejection fraction under 40%: HR 2.86 (95% CI 1.89-4.34)

  • White blood cell count greater than 12,000 per μL: HR 2.65 (95% CI 1.53-4.61)

  • Heart rate faster than 90 beats per minute: HR 2.02 (95% CI 1.43-2.84)

With the tool, 11.3%, 81.0%, and 7.7% of patients were stratified to high-, average-, and low-risk groups, with respective probabilities of 0.32, 0.06, and 0.01 for 1-year events. Moreover, the model showed predictive ranges of 1.2%-33.9%, 1.2%-37.9%, and 1.3%-34.3% in these groups.

“This may aid clinicians in identifying high-risk patients who would benefit most from intensive follow-up and aggressive risk factor reduction,” the researchers wrote, noting that past efforts to identify risk factors have focused on the period immediately after initial hospitalization for acute MI.

SOURCE

https://www.medpagetoday.com/cardiology/myocardialinfarction/74528?xid=nl_mpt_cardiodaily_2018-08-17&eun=g99985d0r&utm_source=Sailthru&utm_medium=email&utm_campaign=AHAWeekly_081718&utm_term=AHA%20Cardiovascular%20Daily%20-%20Active%20Users%20180%20days

PCI, CABG, CHF, AMI – Two Payment Methods: Bundled payments (hospitalization costs, up to 90 days of post-acute care, nursing home care, complications, and rehospitalizations) vs Diagnosis-related groupings cover only what happens in the hospital.

Bundled payments (hospitalization costs, up to 90 days of post-acute care, nursing home care, complications, and rehospitalizations) vs Diagnosis-related groupings cover only what happens in the hospital.

A retrospective, cross-sectional comparison of the BPCI model 2 bundles for percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), congestive heart failure (CHF), and acute myocardial infarction (AMI).

The bundled payments covered hospitalization costs and, in most cases, up to 90 days of post-acute care, including nursing home care, complications, and rehospitalizations. Diagnosis-related groupings cover only what happens in the hospital, while bundled payments cover the entire 90-day episode in most cases.

A Good, Not Simple Idea

Blumenthal and Joynt Maddox agree that the idea of using financial incentives to drive quality improvement is a good one, but one that requires careful consideration and input from clinicians.

“I think policymakers think that it’s easier than it really is and, to be fair, why would a lawyer in DC understand how to make good health policy? I think we really need more clinicians and people with clinical knowledge involved in policymaking,” Joynt Maddox said.

“The idea is to build the bridge between inpatient and outpatient care, by coordinating care better, coordinating transitions better, reducing unnecessary care, and avoiding complications and readmissions,” she added.

An example might be to switch from automatically sending certain patients from the hospital to a nursing home for 30 days. “Maybe they only need 10 days or 1 week, or maybe they can just go home,” she said, but to allow better transitions and lower costs, there needs to be “someone to strategically approach the issue, and a lot of hospitals don’t have that ability.”

“You could argue that all hospitals should have the ability, and I totally agree that we should be doing a better job of organizing across settings, but the problem is that realistically these voluntary programs aren’t going to attract under-resourced hospitals, so this pilot will tell us what is possible in a well-resourced hospital but not much more,” said Joynt Maddox.

To date, the only outcomes reported on the new payment models have been a few evaluations from the federal government. Joynt Maddox recently reported some preliminary outcomes showing a lack of “clinically meaningful changes in access, utilization, or clinical outcomes” with episode-based payment for AMI, CHF, and pneumonia. Her final findings will be published soon.

SOURCE

https://www.medscape.com/viewarticle/899026?nlid=123768_3866&src=WNL_mdplsfeat_180710_mscpedit_card&uac=93761AJ&spon=2&impID=1680511&faf=1#vp_2

Brief Report
June 27, 2018

Factors Associated With Participation in Cardiac Episode Payments Included in Medicare’s Bundled Payments for Care Improvement Initiative

JAMA Cardiol. Published online June 27, 2018. doi:10.1001/jamacardio.2018.1736
Key Points

Question  Are hospitals participating in Medicare’s Bundled Payments for Care Improvement initiative for cardiac bundles different from nonparticipating hospitals in ways that could limit the generalizability of program outcomes to all US acute care hospitals?

Findings  In this cross-sectional study, participation in Bundled Payments for Care Improvement model 2 bundled payments for acute myocardial infarction, congestive heart failure, coronary artery bypass graft surgery, and percutaneous coronary intervention was associated with larger hospital size, non–safety net hospital status, and access to cardiac catheterization laboratories.

Meaning  Outcomes of cardiac bundled payments included in Bundled Payments for Care Improvement may have limited external validity, particularly among small and safety net hospitals with more limited cardiac capabilities.

Abstract

Importance  Medicare’s Bundled Payments for Care Improvement (BPCI) is a voluntary pilot program evaluating bundled payments for several common cardiovascular conditions. Evaluating the external validity of this program is important for understanding the effects of bundled payments on cardiovascular care.

Objective  To determine whether participants in BPCI cardiovascular bundles are representative of US acute care hospitals and identify factors associated with participation.

Design, Setting, and Participants  Retrospective cross-sectional study of hospitals participating in BPCI model 2 bundles for acute myocardial infarction (AMI), congestive heart failure (CHF), coronary artery bypass graft, and percutaneous coronary intervention and nonparticipating control hospitals (October 2013 to January 2017). The BPCI participants were identified using data from the Centers for Medicare and Medicaid Services, and controls were identified using the 2013 American Hospital Association’s Survey of US Hospitals. Hospital structural characteristics and clinical performance data were obtained from the American Heart Association survey and Centers for Medicare and Medicaid Services. One hundred fifty-nine hospitals participating in BPCI model 2 cardiac bundles and 1240 nonparticipating control hospitals were compared, and a multivariable logistic regression was estimated to identify predictors of BPCI participation.

Exposures  Bundled payments.

Main Outcomes and Measures  Hospital-level structural characteristics and 30-day risk-adjusted readmission and mortality rates for AMI and CHF.

Results  Compared with nonparticipants, BPCI participants were larger, more likely to be privately owned or teaching hospitals, had lower Medicaid bed day ratios (ratio of Medicaid inpatient days to total inpatient days: 17.0 vs 19.3; P < .001), and were less likely to be safety net hospitals (2.5% vs 12.3%; P < .001). The BPCI participants had higher AMI and CHF discharge volumes, were more likely to have cardiac intensive care units and catheterization laboratories, and had lower risk-standardized 30-day mortality rates for AMI (13.7% vs 16.6%; P = .001) and CHF (11.3 vs 12.4; P = .005). In multivariable analysis, larger hospital size and access to a cardiac catheterization laboratory were positively associated with participation. Being a safety net hospital was negatively associated with participation (odds ratio, 0.3; 95% CI, 0.1-0.7; P = .001).

Conclusions and Relevance  Hospitals participating in BPCI model 2 cardiac bundles differed in significant ways from nonparticipating hospitals. The BPCI outcomes may therefore have limited external validity, particularly among small and safety net hospitals with limited clinical cardiac services.

SOURCE

https://jamanetwork.com/journals/jamacardiology/article-abstract/2686124

Invited Commentary
June 27, 2018

What Can We Learn From Voluntary Bundled Payment Programs?

JAMA Cardiol. Published online June 27, 2018. doi:10.1001/jamacardio.2018.1734

SOURCE

https://jamanetwork.com/journals/jamacardiology/article-abstract/2686128

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Top 10 Medical Innovations for 2018 by Cleveland Clinic

Reporter: Aviva Lev-Ari, PhD, RN

 

Top 10 for 2018

#1 Hybrid Closed-Loop Insulin Delivery System

#1 Hybrid Closed-Loop Insulin Delivery System

This approach has not just made T1D management easier than ever, it is also getting praise for stabilizing blood glucose at an unprecedented level.


#2 Neuromodulation to Treat Obstructive Sleep Apnea

#2 Neuromodulation to Treat Obstructive Sleep Apnea

While C.P.A.P. is the gold standard treatment for OSA, the risk of misuse or discontinued use has created an opportunity for innovators to search for a less intrusive way to treat it. The result is ne


#3 Gene Therapy for Inherited Retinal Diseases

#3 Gene Therapy for Inherited Retinal Diseases

In 2018 gene therapy is expected to make its comeback with expected FDA approvals for a variety of inherited retinal diseases (“IRDs”).


#4 The Unprecedented Reduction of LDL Cholesterol

#4 The Unprecedented Reduction of LDL Cholesterol

These new drugs are taking cholesterol to low levels never seen before.


#5 The Emergence of Distance Health

#5 The Emergence of Distance Health

In 2018, the prevalence of connectivity enables distance health.


#6 Next Generation Vaccine Platforms

#6 Next Generation Vaccine Platforms

In 2018, innovators will be upgrading the entire vaccine infrastructure to support the rapid development of new vaccines (a concept that was #1 on the Top 10 Medical Innovations for 2015).


#7 Arsenal of Targeted Breast Cancer Therapies

#7 Arsenal of Targeted Breast Cancer Therapies

For breast cancer patients that are BRCA1 or BRCA2 positive, there is new hope for a targeted therapy that is already seeing success in the ovarian cancer market.


#8 Enhanced Recovery After Surgery

#8 Enhanced Recovery After Surgery

After seeing substantial growth in hospital readmissions and an opioid epidemic spiraling out of control, it is clear that physicians need to overhaul the post-surgery strategies currently in use.


#9 Centralized Monitoring of Hospital Patients

#9 Centralized Monitoring of Hospital Patients

Centralized monitoring has emerged as the answer, as part of a “mission control” operation in which off-site personnel use advanced equipment monitor patients.


#10 Scalp Cooling for Reducing Chemotherapy Induced Hair Loss

#10 Scalp Cooling for Reducing Chemotherapy Induced Hair Loss

The practice of “Scalp Cooling” has been shown to be highly effective for preserving hair in women receiving neoadjuvant or adjuvant chemotherapy for early-stage breast cancer.

SOURCE

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