Mobilize medical specialists as part of the campaign to improve the health of the population
In many countries, when patients see specialists such as surgeons, the doctor focuses on the primary health problem and does not screen the patient for chronic diseases or unhealthy behaviors. It’s a missed opportunity. The programs that have been started in Michigan, North Carolina and England to address this issue can serve as a model for other regions and health systems.
Today, a patient in the United States and other developed countries may see an array of specialists, undergo various procedures, but never talk to a doctor about basic health behaviors such as smoking, diet, smoking, and smoking. exercise or chronic diseases such as diabetes, obesity and stress.
Consider a hypothetical patient seen in the emergency department for abdominal pain and referred to a surgeon for symptomatic cholelithiasis. She is a 54-year-old woman with obesity, poorly controlled diabetes, active smoking and, unbeknownst to the surgeon, difficulty paying for her prescription drugs. Since neither of these conditions is a contraindication to surgery, she underwent an uncomplicated outpatient operation to remove her gallbladder. Two weeks later, during a follow-up visit, the surgeon finds that her incisions have healed, that she feels well and that she has no complaints. By all current quality measures, her episode of care was a complete success. She had no complications, did not require hospitalization and was completely satisfied with her care. However, she emerged from this high-intensity encounter without anyone addressing her chronic illnesses, which could significantly shorten her life.
It’s a common story. Millions of patients in the United States and other countries are going through a similar experience. How can we leverage these episodes of discreet care with specialists to move the needle on our country’s most pressing population health needs?
One way is to integrate existing resources that address fundamental health issues like health behaviors and chronic disease – which explain majority of premature deaths — in specialized care pathways. Hospitals already have tools to manage chronic conditions, but patients are rarely connected to these resources during an operation. Screening and referral to treatment for chronic diseases not only improves immediate postoperative results they also allow patients to engage with the healthcare system in a close and specialized way to establish meaningful, long-term health maintenance. There are already innovative models that do just that.
the Michigan Surgical Home and Optimization Program (MSHOP) at Michigan Medicine and at Preoperative anesthesia and surgical screening (PASS) The Duke Health program are interdisciplinary programs that address longitudinal health at the time of surgery. Patients who pursue any type of operation are screened for chronic conditions such as diabetes, obesity, smoking, malnutrition, physical inactivity, frailty and stress. Patients who present with any of these interveneable conditions are then referred to appropriate providers to establish longitudinal care for them.
In the UK, the National Health Service England is taking a similar approach with its Making Every Touch Count (MECC) effort to help patients change their health behavior, such as quitting smoking and increasing physical activity. Patients who undergo anything from a routine eye exam to a minor operation are screened for chronic conditions and offered brief interventions and referral for treatment. Additionally, MECC trains caregivers at all levels (e.g., waiting room staff, physician assistants, physicians) to identify and engage patients in these brief interventions around behavior change in health.
These programs reduce the cost of care, improve chronic medical conditionsand help patients make crucial lifestyle changes, such as stop smoking. Considering that 50 million surgical procedures are performed each year in the United States, such an approach is a powerful way to improve population health within current care delivery pathways.
There is long-established evidence that this pragmatic way of addressing core health issues within the existing US healthcare system is effective. Research published over the past 20 years shows that major life events such as having surgery, visiting an emergency department, or receiving a new diagnosis serve as “teachable moments.” These are events that motivate individuals to make changes to their health that they had not considered or been able to make before. For example, while less than 10% of smokers successfully quit each year, more than 50% of smokers undergoing surgery for smoking-related illnesses successfully quit after surgery. Even patients undergoing operations unrelated to smoking, such as elective joint replacement, become more likely to quit smoking.
As surgeons, we see this phenomenon time and time again: patients who are told they need surgery speak of a new motivation to do everything in their power to ensure the best possible outcome. . Currently, however, few health systems have processes in place to translate this motivation into action across the lifespan.
lead the charge
You can’t improve what you don’t measure. A critical way clinical leaders can help integrate population health needs into specialty care pathways is to create quality measures that explicitly recognize these efforts. In surgical care, quality of care is traditionally measured by whether a patient has a postoperative complication or is readmitted to hospital. Expanding quality measures to include such things as orientation to longitudinal health management at the time of surgery – an equally important element of high-quality care – is a critical step in the evolution of clinical practice.
In Michigan, we started doing this for one of the most common surgeries: hernia repair. Recognizing the particularly high prevalence unmanaged health issues in patients undergoing hernia repair, hospitals are now capturing and reporting the number of patients who are referred for smoking cessation counseling, diabetes management, and weight loss management at the time of surgery. Michigan Medicine has even created a dedicated multidisciplinary clinic to track the progress of surgical patients as they log into treatment for their chronic health conditions. Already, the simple measurement of these processes has led to a multiply by eight in references for long-term health management at the time of surgery and helped patients achieve remarkable improvements in health that last a long time after undergoing their operation.
Other efforts are underway in Michigan with similar goals. Two statewide initiatives have recently been launched specifically to help hospitals measure and improve health behaviors and social determinants of health as part of routine specialist care.
Insurers can also help direct this burden through financial incentives. Two programs recently implemented by Michigan’s Blue Cross Blue Shield are examples. One, part of the initiative for patients undergoing hernia repair, pays hospitals extra to report their screenings and referrals for chronic conditions at the time of surgery. The other provides hospitals with an end-of-year bonus for referral to smoking cessation counseling as part of the surgical episode.
The system we have against the system we want
It is said that every system is perfectly designed to achieve the results it achieves. If a hospital needs to recover nearly $1 million in reimbursement of a complex surgical procedure such as an organ transplant, but only $25 for smoking cessation advice, it’s easy to see which efforts he will prioritize. Although the adoption of value-based or capitation health care, which links payments to outcomes and patient satisfaction, could alter these priorities, the examples above demonstrate that even within the fee-for-service still dominant in the United States, there are ways to align the delivery of specialty care with efforts to meet the most salient health needs of the population.
Returning to our patient example above, we could now envision a scenario where her surgical care involves automatic screening that leads the surgeon to refer her to the hospital’s existing smoking cessation program, an endocrinologist who would assess her and would help her optimize medications and diet to better manage her diabetes, a structured exercise program, and social work services to obtain financial assistance for her prescriptions. These simple steps could profoundly alter his health trajectory long after his surgical care is complete. Success in just one of these areas would likely have a far greater impact on his longevity than his surgical care.
Health care reform in the United States is expected to continue to be a slow process. In the meantime, creatively integrating the kinds of efforts we’ve described into the health care system we have — rather than waiting for the health care system we want — may be our best bet for improving the health of our people.