State-Level Support for Tobacco 21 Laws: Results of a Five-State Survey.

Introduction: Legal strategies to raise the minimum age of purchase for tobacco from 18 to 21, known as "Tobacco 21 laws" are a promising means to reduce adolescent tobacco initiation and use. Tobacco 21 laws are enacted at the local and state level, yet prior studies have examined national support. To address this gap, we assessed attitudes of residents in five states toward Tobacco 21 laws, and how attitudes varied by demographic, political, and health status characteristics. Methods: The data are derived from the 2016 Texas Medical Center (TMC) Consumer Health Report, a survey of 5007 adults from five states: California, Florida, Ohio, New York, and Texas. Bivariate and multivariate logistic regression analyses were used to assess differences in support. Results: Eight in 10 respondents supported Tobacco 21. Support was high across all five states, ranging from 78% in Texas to 85% in New York. Tobacco 21 was supported by a majority of respondents in all racial, educational, age, and income groups assessed. While support was generally strong, chi-square analyses revealed differences across states in support by demographic and health status characteristics. Support was generally higher among older individuals, whites, and those with more education, although the size and even direction of the relationship by population subgroup varied across states. Conclusion: Tobacco 21 laws enjoy overwhelming majority support in all five states and across all sociodemographic subgroups assessed. However, the strength of support by population subgroup varies across states. Implications: While earlier studies had found strong support for Tobacco 21 laws at the national level, little data were available about attitudes at the state level, where current Tobacco 21 policymaking efforts are concentrated. Our data indicate that legislators from both liberal and conservative states should feel confident in advancing Tobacco 21 laws to protect the current and future health of adolescents. However, patterns of support vary by population subgroup across states. Understanding variations in support by population subgroup at the state level can guide policymakers in targeted efforts to advance public health laws aimed at reducing adolescent tobacco initiation and use.

Patient Use of Cardiovascular Devices and Apps: Are We Getting Our Money's Worth?

The evolution of technology makes it likely that a large number of people will invest in and use health-related mobile applications and wearable devices. Yet the question remains: Do these technology-based interventions modify health behavior and improve health…and are we getting our money's worth? The vast majority of studies concerning health-related apps and wearable devices have small sample sizes and short time spans of 6 months or less, so it is not clear if these durations were determined by lack of consistent use over time. Furthermore, many of the most popular applications have not been subjected to randomized trials. Overall, the small demonstrated improvements in outcomes are often associated with professional involvement from clinicians, coaches, or diabetes educators provided in conjunction with use of mobile health (mHealth) platforms. This paper explores the use of mHealth technologies that address cardiovascular disease/prevention (eg, diabetes, diet, physical activity, and associated weight loss) and discusses the lack of adequate evidence to support even minimal patient investment in mobile applications or wearable devices at this time.

Reducing the Cost of Medicaid: A Multistate Simulation.

According to some estimates, the United States wastes as much as 30% of health care dollars. Some of that waste can be mitigated by reducing certain costs associated with Medicaid. We chose 5 areas of savings applicable to Medicaid: (1) modification of physician payment models to reduce unnecessary care, (2) development of a medication adherence program for patients dually eligible for Medicaid and Medicare support ("dual eligibles"), (3) improvement in unnecessary admissions and readmissions for dual eligibles, (4) reduction in emergency department visits among children in Medicaid and dual-eligible beneficiaries, and (5) improvement in adoption of end-of-life advance directives. We chose the states from both ends of the spending spectrum: the 5 with the lowest annual Medicaid expenditures: Wyoming, South Dakota, Montana, Vermont, and Alaska, and those with the highest: California, New York, Texas, Pennsylvania, and Florida. This spectrum demonstrates the range of potential cost-saving measures, from US $23.6 million in Wyoming to US $3.4 billion in California. We conclude that there are a number of ways to reduce Medicaid spending and improve quality. To the extent that states have already adopted programs addressing the same problems, our approach may be supplementary but the total savings may be achieved with a combination of current initiative and those described here. As Medicaid creates savings, physician payment could be increased to attract more physicians into caring for Medicaid patients.

Effect of Grand-Aides Nurse Extenders on Readmissions and Emergency Department Visits in Medicare Patients With Heart Failure.

Numerous procedures have been tested to reduce hospital readmissions with varying success. The objective of this study was to evaluate all-cause readmissions and emergency department (ED) visits 30 days and 6 months after discharge with Grand-Aides (GAs): nurse extenders making frequent home visits under video direction by a nurse supervisor. Medicare patients with primary diagnosis of heart failure at the University of Virginia discharged January 1, 2013 to January 1, 2015 were included. A GA visited the patient's home within 24 to 48 hours with supervisor on video for medication reconciliation. Every visit, a GA completed a questionnaire for a supervisor who then had brief video conversation with the patient, reinforced adherence with medical regimen and danger signs, making 3 visits in the first week, 2 visits each in weeks 2 and 3, 1 visit in week 4, then a monthly visit supplemented by telephone. Outcomes were recorded for 108 GA and 854 controls. Statistical adjustment was performed through inverse probability of treatment weighting, with the distribution of covariates resembling a propensity score-matched cohort. Patients with GA had 2.8% 30-day all-cause readmissions versus 15.8% controls-82% reduction-(adjusted odds ratio [aOR] = 0.17; p = 0.0060); 6-month all-cause readmissions 13.0% versus 44.7% (aOR = 0.19; p <0.0001); ED 30-days 2.8% versus 45.1% (aOR = 0.03; p <0.0001); ED 6-months 12.0% versus 51.5% (aOR = 0.09; p <0.0001); and 6-month mortality 6.5% versus 8.8% (aOR = 0.73; p = 0.4698). At 30 days, 92% had "substantial medication adherence." Savings per $562,097, 7× return on investment. In conclusion, the GA approach to population health compares favorably in outcomes and expense 30 days and 6 months after discharge.

Tailored Educational Approaches for Consumer Health: A Model to Address Health Promotion in an Era of Personalized Medicine.

PURPOSE: To develop a model, based on market segmentation, to improve the quality and efficiency of health promotion materials and programs. DESIGN: Market segmentation to create segments (groups) based on a cross-sectional questionnaire measuring individual characteristics and preferences for health information. Educational and delivery recommendations developed for each group. SETTING: General population of adults in Virginia. PARTICIPANTS: Random sample of 1201 Virginia residents. Respondents are representative of the general population with the exception of older age. MEASURES: Multiple factors known to impact health promotion including health status, health system utilization, health literacy, Internet use, learning styles, and preferences. ANALYSIS: Cluster analysis and discriminate analysis to create and validate segments. Common sized means to compare factors across segments. RESULTS: Developed educational and delivery recommendations matched to the 8 distinct segments. For example, the "health challenged and hard to reach" are older, lower literacy, and not likely to seek out health information. Their educational and delivery recommendations include a sixth-grade reading level, delivery through a provider, and using a "push" strategy. CONCLUSION: This model addresses a need to improve the efficiency and quality of health promotion efforts in an era of personalized medicine. It demonstrates that there are distinct groups with clearly defined educational and delivery recommendations. Health promotion professionals can consider Tailored Educational Approaches for Consumer Health to develop and deliver tailored materials to encourage behavior change.

Operating room efficiency and hospital capacity: factors affecting operating room use during maximum hospital census.

BACKGROUND: Academic medical centers are faced with increasing volumes, higher acuity, and, as a consequence, capacity issues. These affect operating room (OR) use and patient throughput, with negative impact on finances and patient and physician satisfaction. We evaluated our experiences in dealing with OR efficiency at a time of maximum hospital capacity and occupancy. STUDY DESIGN: Using a multidisciplinary approach, we put in place seven agreed-upon strategies: daily communication, improved bed planning, discharge by noon program, internal staffing pool, special assignments for a patient transition unit, incentives, and stepped up environmental services. RESULTS: After institution of these strategies, we were able to realize a gain in OR patient volume of 8% and a decrease in OR holds of 37%. This resulted in a decrease in canceled OR cases from 4.3% to 3.1%. CONCLUSIONS: Academic medical centers face occupancy issues that are not likely to go away and will have an impact on OR volume and productivity. To improve the situation in a short-term fashion, a multidisciplinary approach involving several strategies will be needed.

International differences in patient and physician perceptions of "high quality" healthcare: a model from pediatric cardiology.

Although the quality of health care would logically seem to be a universal concept, this study hypothesized that physicians and their patients could differ in their perceptions of "high-quality care" and that those beliefs might vary by country. Such a mismatch in beliefs may be especially important as clinical practice guidelines developed in the United States are globalized. A survey of 20 statements describing various components of health care delivery and quality was sent to pediatric cardiologists in 33 countries, who ranked the statements in order of priority for ideal health care. Each participating physician administered the questionnaire to the parents of children with congenital heart disease; 554 questionnaires were received and analyzed. A subanalysis of 9 countries with the largest number of responses was done (Canada, the Czech Republic, France, Germany, Italy, The Netherlands, Sweden, the United Kingdom, and the United States). Doctors and parents rated the same 4 statements among the top 5: "the doctor is skillful and knowledgeable"; "the doctor explains health problems, tests, and treatments in a way the patient can understand"; "a basic level of healthcare is available to all citizens regardless of their ability to pay"; and "treatment causes the patient to feel physically well." Overall, parents' responses differed more among countries than those of physicians; the magnitude of the difference between parents and physicians varied by country. This discrepancy highlights a potential mismatch between patients' and physicians' views about the desired components of health care delivery, in particular the application of American quality standards for health care to systems in other countries.

The uninsured: problems, solutions, and the role of academic medicine.

The number of uninsured persons in the United States--46 million--is more than the number covered by Medicare. The author discusses why there are so many uninsured, the health effects of being uninsured, and strategies to help the uninsured, with an emphasis on changing the safety net and employer-based insurance for smaller businesses. He then asks "What can academic medicine (AM) do now?" and proposes that (1) AM can help eliminate waste in health care. For example, AM can research areas of potential waste such as how often patients with chronic disease need to be seen and what tests they need (not to restrict care, but to determine what is appropriate). AM can also continue to develop electronic medical records that eliminate unnecessary repetition of work and can have embedded national practice guidelines with reminders. (2) AM can act as a large employer and develop novel benefit plans that provide various important choices and develop ways to educate employees to choose the appropriate health plan. The University of Virginia has established the Consumer Health Education Institute, which is researching ways to educate consumers in the format most accessible for them as individuals (i.e., tailored to their health literacy). (3) AM can work with state governments to develop innovative coverage models. Because it appears that innovation in health care may be at the state level at least for the next few years, individuals in AM can be extremely helpful in making suggestions to formulate policy and implement programs. The current estimate is for the United States to have 56 million uninsured by 2013--an increase to 19.4% of the population. Academic medicine can help slow this increase.

U.S. healthcare: the intertwined caduceus of physicians, coverage, quality, and cost.

As cardiologists, we should increase our efforts to improve coverage, quality, and cost, both by caring for individual patients and by improving our systems. How? Coverage: by promoting a coordinated approach, beginning with state demonstrations of new safety net and individual and private insurance approaches. Quality: by adopting evidence-based practice and adapting practice guidelines for payment, beginning with non-payment for class III; by setting standards of practice below which we may not fall and paying for quality and service above this level; by involving patients as partners in their care and providing them with incentives. Cost: by challenging routine practices (why return in one year?); by beginning to address the widening gap between what is possible and what is affordable, taking part in broader discussions on what is worth the cost, supporting tort reform, and proposing alternatives; by improving our systems to reduce medical errors and addressing future physician shortages by working in teams with primary care physicians and nurses. Let's work with our patients to improve their health. Together we can make real progress.

Integrating quality into the cycle of therapeutic development.

The quality of healthcare, particularly as reflected in current practice versus the available evidence, has become a major focus of national health policy discussions. Key components needed to provide quality care include: 1) development of quality indicators and performance measures from specific practice guidelines, 2) better ways to disseminate such guidelines and measures, and 3) development of support tools to promote standardized practice. Although rational decision-making and development of practice guidelines have relied upon results of randomized trials and outcomes studies, not all questions can be answered by randomized trials, and many treatment decisions necessarily reflect physiology, intuition, and experience when treating individuals. Debate about the role of "evidence-based medicine" also has raised questions about the value of applying trial results in practice, and some skepticism has arisen about whether advocated measures of clinical effectiveness, the basic definition of quality, truly reflect a worthwhile approach to improving medical practice. We provide a perspective on this issue by describing a model that integrates quantitative measurements of quality and performance into the development cycle of existing and future therapeutics. Such a model would serve as a basic approach to cardiovascular medicine that is necessary, but not sufficient, to those wishing to provide the best care for their patients.

2015 ACC Health Policy Statement on Cardiovascular Team-Based Care and the Role of Advanced Practice Providers.

The mission of the American College of Cardiology is "to transform cardiovascular care and improve heart health." Cardiovascular team-based care is a paradigm for practice that can transform care, improve heart health, and help meet the demands of the future. One strategic goal of the College is to help members successfully transition their clinical practices to the future, with all its complexity, challenges, and opportunities. The ACC's strategic plan is aligned with the triple aim of improved care, improved population health, and lower costs per capita. The traditional understanding of quality, access, and cost is that you cannot improve one component without diminishing the others. With cardiovascular team-based care, it is possible to achieve the triple aim of improving quality, access, and cost simultaneously to also improve cardiovascular health. Striving to serve the best interests of patients is the true north of our guiding principles. Cardiovascular team-based care is a model that can improve care coordination and communication and allow each team member to focus more on the quality of care. In addition, the cardiovascular team-based care model increases access to cardiovascular care and allows expansion of services to populations and geographic areas that are currently underserved. This document will increase awareness of the important components of cardiovascular team-based care and create an opportunity for more discussion about the most creative and effective means of implementing it. We hope that this document will stimulate further discussions and activities within the ACC and beyond about team-based care. We have identified areas that need improvement, specifically in APP education and state regulation. The document encourages the exploration of collaborative care models that should enable team members to optimize their education, training, experience, and talent. Improved team leadership, coordination, collaboration, engagement, and efficiency will enable the delivery of higher-value care to the betterment of our patients and society.

Closing the gap between science and practice: the need for professional leadership.

Major opportunity exists to better align clinical science and clinical practice. To do so will require efforts not only to develop clinical practice guidelines, but to facilitate their application in practice. The American College of Cardiology operates a program to develop and assess the effectiveness of tools that facilitate the application of guidelines in practice. Here we review what we have learned about the process of guideline implementation, lay out the major research questions that need to be addressed, and argue that professional societies play a critical role in moving from guideline development to application.

New systems of care can leverage the health care workforce: how many doctors do we really need?

Improving access to appropriate health care, currently inadequate for many Americans, is more complex than merely increasing the projected number of physicians and nurses. Any attainable increase in their numbers will not solve the problem. To bring supply and demand closer, new systems of care are required, leveraging every member of the health care workforce, permitting professionals to provide their unique contributions.To increase supply: Redefine the roles of physicians and nurse practitioners (NPs), assess how much primary care must be delivered by a physician, and provide support from other team members to let the physician deal with complex patients. NPs can deliver much primary care and some specialty care. Care must be delivered in integrated systems permitting new payment models (e.g., salary with bonus) and team-based care as well as maximum use of electronic health records. Teams must make better use of nonprofessionals, such as Grand-Aides, using telephone protocols and portable telemedicine with home visits and online direct reporting of every encounter. The goals are to improve health and reduce unnecessary clinic and emergency department visits, admissions, and readmissions.To decrease demand: Physician payment must foster quality and appropriate patient volume (if accompanied by high patient satisfaction). Patients must be part of the team, work to remain healthy, and reduce inappropriate demand.The nation may not need as many physicians and nurses if the systems can be changed to promote integration, leveraging every member of the workforce to perform at his or her maximum competency.

A new corps of trained Grand-Aides has the potential to extend reach of primary care workforce and save money.

Because the Affordable Care Act will expand health insurance to cover an estimated thirty-two million additional people, new approaches are needed to expand the primary care workforce. One possible solution is Grand-Aides®, who are health care professionals operating under the direct supervision of nurses, and who are trained and equipped to conduct telephone consultations or make primary care home visits to patients who might otherwise be seen in emergency departments and clinics. We conducted pilot tests with Grand-Aides in two pediatric Medicaid settings: an urban federally qualified health center in Houston, Texas, and a semi-rural emergency department in Harrisonburg, Virginia. We estimated that Grand-Aides and their supervisors averted 62 percent of drop-in visits at the Houston clinic and would have eliminated 74 percent of emergency department visits at the Virginia test site. We calculated the cost of the Grand-Aides program to be $16.88 per encounter. That compares with current Medicaid payments of $200 per clinic visit in Houston and $175 per emergency department visit in Harrisonburg. In addition to reducing health care costs, Grand-Aides have the potential to make a substantial impact in reducing congestion in primary care practices and emergency departments.

Perspective: Leveraging the health care workforce: what do we need and what educational system will get us there?

Shortages of 100,000 physicians and up to one million nurses are projected in the next 10 years. If these statistics are close to true, medical schools would need a 100% increase in graduates over the next 4 years, and nursing schools a 100% increase over the next 13 years. These calculations are instructive in that they demonstrate the absurdity of expecting schools to provide these sorts of increases in that time frame. Other solutions must be considered. For instance, do doctors and nurses need to do everything they are currently called on to do? Could not other members of the health care workforce, such as well-trained lay workers, be leveraged to do some of the more routine work, freeing medical professionals to perform their unique roles? How is such a workforce built, and how shall learners be educated to fill those needs? This article presents a hypothetical model that could be implemented based on carefully researched pilots to meet health care education needs. The model features three essential components: (1) a school for the public in which lay teachers develop curricula with members of the public, for example, about how to incentivize healthy behavior, (2) a college for health as part of a university with interdisciplinary teaching, where patients, faculty members, and students interact in each of the schools and learn together, and (3) the most effective and efficient nursing and medical school curricula, developed together based on evidence of what the student needs to know.