Frontiers of Upstream Stroke Prevention and Reduced Stroke Inequity Through Predicting, Preventing, and Managing Hypertension and Atrial Fibrillation: A Call to Action From the Value in Healthcare Initiative's Predict & Prevent Learning Collaborative.

Stroke is one of the leading causes of morbidity and mortality in the United States. While age-adjusted stroke mortality was falling, it has leveled off in recent years due in part to advances in medical technology, health care options, and population health interventions. In addition to adverse trends in stroke-related morbidity and mortality across the broader population, there are sociodemographic inequities in stroke risk. These challenges can be addressed by focusing on predicting and preventing modifiable upstream risk factors associated with stroke, but there is a need to develop a practical framework that health care organizations can use to accomplish this task across diverse settings. Accordingly, this article describes the efforts and vision of the multi-stakeholder Predict & Prevent Learning Collaborative of the Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. This article presents a framework of a potential upstream stroke prevention program with evidence-based implementation strategies for predicting, preventing, and managing stroke risk factors. It is meant to complement existing primary stroke prevention guidelines by identifying frontier strategies that can address gaps in knowledge or implementation. After considering a variety of upstream medical or behavioral risk factors, the group identified 2 risk factors with substantial direct links to stroke for focusing the framework: hypertension and atrial fibrillation. This article also highlights barriers to implementing program components into clinical practice and presents implementation strategies to overcome those barriers. A particular focus was identifying those strategies that could be implemented across many settings, especially lower-resource practices and community-based enterprises representing broad social, economic, and geographic diversity. The practical framework is designed to provide clinicians and health systems with effective upstream stroke prevention strategies that encourage scalability while allowing customization for their local context.

Streamlining and Reimagining Prior Authorization Under Value-Based Contracts: A Call to Action From the Value in Healthcare Initiative's Prior Authorization Learning Collaborative.

Utilization management strategies, including prior authorization, are commonly used to facilitate safe and guideline-adherent provision of new, individualized, and potentially costly cardiovascular therapies. However, as currently deployed, these approaches encumber multiple stakeholders. Patients are discouraged by barriers to appropriate access; clinicians are frustrated by the time, money, and resources required for prior authorizations, the frequent rejections, and the perception of being excluded from the decision-making process; and payers are weary of the intensive effort to design and administer increasingly complex prior authorization systems to balance value and appropriate use of these treatments. These issues highlight an opportunity to collectively reimagine utilization management as a transparent and collaborative system. This would benefit the entire healthcare ecosystem, especially in light of the shift to value-based payment. This article describes the efforts and vision of the multistakeholder Prior Authorization Learning Collaborative of the Value in Healthcare Initiative, a partnership between the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. We outline how healthcare organizations can take greater utilization management responsibility under value-based contracting, especially under different state policies and local contexts. Even with reduced payer-mandated prior authorization in these arrangements, payers and healthcare organizations will have a continued shared need for utilization management. We present options for streamlining these programs, such as gold carding and electronic and automated prior authorization processes. Throughout the article, we weave in examples from cardiovascular care when possible. Although reimagining prior authorization requires collective action by all stakeholders, it may significantly reduce administrative burden for clinicians and payers while improving outcomes for patients.

Advancing Value-Based Models for Heart Failure: A Call to Action From the Value in Healthcare Initiative's Value-Based Models Learning Collaborative.

Heart failure (HF) is a leading cause of hospitalizations and readmissions in the United States. Particularly among the elderly, its prevalence and costs continue to rise, making it a significant population health issue. Despite tremendous progress in improving HF care and examples of innovation in care redesign, the quality of HF care varies greatly across the country. One major challenge underpinning these issues is the current payment system, which is largely based on fee-for-service reimbursement, leads to uncoordinated, fragmented, and low-quality HF care. While the payment landscape is changing, with an increasing proportion of all healthcare dollars flowing through value-based payment models, no longitudinal models currently focus on chronic HF care. Episode-based payment models for HF hospitalization have yielded limited success and have little ability to prevent early chronic disease from progressing to later stages. The available literature suggests that primary care-based longitudinal payment models have indirectly improved HF care quality and cardiovascular care costs, but these models are not focused on addressing patients' longitudinal chronic disease needs. This article describes the efforts and vision of the multi-stakeholder Value-Based Models Learning Collaborative of The Value in Healthcare Initiative, a collaboration of the American Heart Association and the Robert J. Margolis, MD, Center for Health Policy at Duke University. The Learning Collaborative developed a framework for a HF value-based payment model with a longitudinal focus on disease management (to reduce adverse clinical outcomes and disease progression among patients with stage C HF) and prevention (an optional track to prevent high-risk stage B pre-HF from progressing to stage C). The model is designed to be compatible with prevalent payment models and reforms being implemented today. Barriers to success and strategies for implementation to aid payers, regulators, clinicians, and others in developing a pilot are discussed.

Transformation to Academic Leadership: The Role of Mentorship and Executive Coaching.

The transition to academic leadership entails learning to utilize an enormous new collection of skills. Executive leadership coaching is a personalized training approach that is being increasingly used to accelerate the onboarding of effective leaders. Vanderbilt University Medical Center has invested in a robust coaching strategy that is offered broadly to institutional leaders. This case study details the early transformational learning of leadership skills by one new institutional leader in the first two years in an academic leadership role, telling the first-person account of the experience of being coached while independently leading a division of hematology and oncology at a highly ranked medical center. Over two years' time, assessed in 6-month intervals, the academician transitions into the role, and using scenarios from regular practice in this position, learns to incorporate core leadership principles into the daily activities of running a division. The transition to academic leadership involves a transformation; a conversion that can be accelerated, guided, and applied with a greater deal of sophistication through intentional coaching, and the application of principles of behavioral science and psychology. Much like the process of coaching a high performing athlete, an elite academician can be trained in skills that enhance their game and succeed in creating a winning team. The academic medical center (AMC) is an interesting social organization, made up of highly accomplished and well-educated people, brought together around a variety of missions and motivations: education, patient service, research, community building, financial margins, and citizenship to name a few. Moreover, the leadership of AMCs almost entirely comes from within this community, drawing people with talents in science, teaching, clinical research, and service into roles that industries reserve usually for MBAs, lawyers, and other professionals who undergo rigorous guided training. Fortunately, academics are well-equipped with skills in lifelong learning, focused curiosity, and tend to be ambitious to a fault. Thus, there is a steady pipeline of budding leaders in AMC's eager to tackle new challenges that will further their missions. Like major industries in the public and private sectors, the demands of leadership are significant. How to navigate the transitions from physician, teacher, or scientist to academic leader is not covered easily in any text. Vanderbilt University Medical Center has adopted a model of Leadership Coaching, akin to the Trusted Leadership Advisor model (Wasylyshyn, 2017). This case study details the experience of one new leader (first author), freshly plucked from the medical science proving ground. Accounts and description of the experiences and intentions of the leadership coach, Dick Kilburg, provide insight into the processes applied in facilitating this transition. Finally, observations of the transition from the vantage point of the primary supervisor (Department Chair, Nancy Brown) provide a further description of the coaching effect on the early development of an AMC leader. The experience of the client, Kimryn Rathmell (Kim), is told in first person narrative format-fitting for the intense and personal experience that accompanies the transition to a leadership role.

Call to Action: Urgent Challenges in Cardiovascular Disease: A Presidential Advisory From the American Heart Association.

Although advances in care have spurred improvements in cardiovascular outcomes, cardiovascular disease remains the leading cause of death in the United States and around the world. Previous declines in cardiovascular disease mortality have slowed and even reversed for certain demographics. Further concerns exist with regard to cardiovascular drug innovation, quality of care, and healthcare costs. The Value in Healthcare Initiative-Transforming Cardiovascular Care, a collaboration of the American Heart Association and Duke University, Robert J. Margolis, MD, Center for Health Policy, aims to increase access to and affordability of cardiovascular treatment and to decrease barriers to care. The following Call to Action describes trends in cardiovascular care, identifies gaps in areas of cardiovascular disease prevention and treatment, highlights challenges with medical product innovation, and finally, outlines a series of learning collaboratives that will aid in the development of road maps for transforming cardiovascular care.

Systolic Blood Pressure and Biochemical Assessment of Adherence: A Cross-Sectional Analysis in the Emergency Department.

Elevated blood pressure (BP) is common in the emergency department (ED), but the relationship between antihypertensive medication adherence and BP in the ED is unclear. This cross-sectional study tested the hypothesis that higher antihypertensive adherence is associated with lower systolic BP (SBP) in the ED among adults with hypertension who sought ED care at an academic hospital from July 2012 to April 2013. Biochemical assessment of antihypertensive adherence was performed using a mass spectrometry blood assay, and the primary outcome was average ED SBP. Analyses were stratified by number of prescribed antihypertensives (<3, ≥3) and adjusted for age, sex, race, insurance, literacy, numeracy, education, body mass index, and comorbidities. Among 85 patients prescribed ≥3 antihypertensives, mean SBP for adherent patients was 134.4 mm Hg (±26.1 mm Hg), and in adjusted analysis was -20.8 mm Hg (95% confidence interval, -34.2 to -7.4 mm Hg; P=0.003) different from nonadherent patients. Among 176 patients prescribed <3 antihypertensives, mean SBP was 135.5 mm Hg (±20.6 mm Hg) for adherent patients, with no difference by adherence in adjusted analysis (+2.9 mm Hg; 95% confidence interval, -4.7 to 10.5 mm Hg; P=0.45). Antihypertensive nonadherence identified by biochemical assessment was common and associated with higher SBP in the ED among patients who had a primary care provider and health insurance and who were prescribed ≥3 antihypertensives. Biochemical assessment of antihypertensives could help distinguish medication nonadherence from other contributors to elevated BP and identify target populations for intervention.

Combined Angiotensin Receptor Antagonism and Neprilysin Inhibition.

Heart failure affects ≈5.7 million people in the United States alone. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, ß-blockers, and aldosterone antagonists have improved mortality in patients with heart failure and reduced ejection fraction, but mortality remains high. In July 2015, the US Food and Drug Administration approved the first of a new class of drugs for the treatment of heart failure: Valsartan/sacubitril (formerly known as LCZ696 and currently marketed by Novartis as Entresto) combines the angiotensin receptor blocker valsartan and the neprilysin inhibitor prodrug sacubitril in a 1:1 ratio in a sodium supramolecular complex. Sacubitril is converted by esterases to LBQ657, which inhibits neprilysin, the enzyme responsible for the degradation of the natriuretic peptides and many other vasoactive peptides. Thus, this combined angiotensin receptor antagonist and neprilysin inhibitor addresses 2 of the pathophysiological mechanisms of heart failure: activation of the renin-angiotensin-aldosterone system and decreased sensitivity to natriuretic peptides. In the Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial, valsartan/sacubitril significantly reduced mortality and hospitalization for heart failure, as well as blood pressure, compared with enalapril in patients with heart failure, reduced ejection fraction, and an elevated circulating level of brain natriuretic peptide or N-terminal pro-brain natriuretic peptide. Ongoing clinical trials are evaluating the role of valsartan/sacubitril in the treatment of heart failure with preserved ejection fraction and hypertension. We review here the mechanisms of action of valsartan/sacubitril, the pharmacological properties of the drug, and its efficacy and safety in the treatment of heart failure and hypertension.

RN Diabetes Virtual Case Management: A New Model for Providing Chronic Care Management.

The U.S. chronic disease health care system has substantial gaps in delivery of services. New models of care change traditional delivery of care and explore new settings for care. This article describes a new model of diabetes chronic care delivery: nurse-delivered care that includes protocol-based insulin titration and patient education delivered solely in a virtual environment. In phase 1, the clinical outcome of time to achievement of glycated hemoglobin (A(1C)) goals (P < .001; 95% confidence interval, 1.68-2.24) was significantly improved by registered nurse (RN) standing order intervention (n = 24) as compared with historical controls (n = 28). In phase 2, patients who were referred to an RN-managed insulin titration protocol with individualized A(1C) goals had a significant (P < .001; 95% confidence interval, 1.680-2.242) reduction in results from a mean of 9.6% at baseline to 7.7% at completion. Average patient age was 66 years, with a mean duration of 11 years diagnosed with diabetes. Safety was demonstrated by the absence of hypoglycemia related to RN protocol adjustment. There were no admissions or emergency room (ER) visits for hypoglycemia. This study demonstrates safety and efficacy of RN virtual chronic disease management for an older population of patients with long-standing diabetes.

Part-time physician faculty in a pediatrics department: a study of equity in compensation and academic advancement.

PURPOSE: To assess equity in compensation and academic advancement in an academic pediatrics department in which a large proportion of the physician faculty hold part-time appointments. METHOD: The authors analyzed anonymized data from Vanderbilt University School of Medicine Department of Pediatrics databases for physician faculty (faculty with MD or MD/PhD degrees) employed during July 1, 2007 to June 30, 2008. The primary outcomes were total compensation and years at assistant professor rank. They compared compensation and years at junior rank by part-time versus full-time status, controlling for gender, rank, track, years since first appointment as an assistant professor, and clinical productivity. RESULTS: Of the 119 physician faculty in the department, 112 met inclusion criteria. Among those 112 faculty, 23 (21%) were part-time and 89 (79%) were full-time faculty. Part-time faculty were more likely than full-time faculty to be women (74% versus 28%, P < .001) and married (100% versus 84%, P = .042). Analyses accounting for gender, years since first appointment, rank, clinical productivity, and track did not demonstrate significant differences in compensation by part-time versus full-time status. In other adjusted analyses, faculty with part-time appointments spent an average of 2.48 more years as an assistant professor than did faculty with full-time appointments. CONCLUSIONS: Overall group differences in total compensation were not apparent in this department, but physician faculty with part-time appointments spent more time at the rank of assistant professor. This study provides a model for determining and analyzing compensation and effort to ensure equity and transparency across faculty.

Centralized oversight of physician-scientist faculty development at Vanderbilt: early outcomes.

PURPOSE: In 2000, faced with a national concern over the decreasing number of physician-scientists, Vanderbilt School of Medicine established the institutionally funded Vanderbilt Physician-Scientist Development (VPSD) program to provide centralized oversight and financial support for physician-scientist career development. In 2002, Vanderbilt developed the National Institutes of Health (NIH)-funded Vanderbilt Clinical Research Scholars (VCRS) program using a similar model of centralized oversight. The authors evaluate the impact of the VPSD and VCRS programs on early career outcomes of physician-scientists. METHOD: Physician-scientists who entered the VPSD or VCRS programs from 2000 through 2006 were compared with Vanderbilt physician-scientists who received NIH career development funding during the same period without participating in the VPSD or VCRS programs. RESULTS: Seventy-five percent of VPSD and 60% of VCRS participants achieved individual career award funding at a younger age than the comparison cohort. This shift to career development award funding at a younger age among VPSD and VCRS scholars was accompanied by a 2.6-fold increase in the number of new K awards funded and a rate of growth in K-award dollars at Vanderbilt that outpaced the national rate of growth in K-award funding. CONCLUSIONS: Analysis of the early outcomes of the VPSD and VCRS programs suggests that centralized oversight can catalyze growth in the number of funded physician-scientists at an institution. Investment in this model of career development for physician-scientists may have had an additive effect on the recruitment and retention of talented trainees and junior faculty.

State Medicaid and private payer reimbursement for telemedicine: An overview.

Individual states in the USA were given the option of paying for telemedicine services with Medicaid (i.e. federal health-care funds administered by the state) in 1998, when the Health Care Financing Administration (HCFA) published final rules for Medicare payment for teleconsultations in health professional shortage areas (HPSAs). It was left to telemedicine practitioners in each state to negotiate the scope of the services covered with the state Medicaid office. Three reports of data gathered by 2002-03 surveys on state reimbursement policies have been reviewed, with additional information from a brief informal 2005 survey conducted by the author. In the seven years since 1998, 34 states have added coverage of telemedicine services to their Medicaid programmes, although there are wide variations in service coverage, payment policies, and geographical and other restrictions. There is less published information on private payer reimbursement. One survey performed by AMD Telemedicine (AMD) and the American Telemedicine Association (ATA) showed that over half of the 72 telemedicine programmes in 25 states delivering billable services were being reimbursed by private payers. In 1999, 43% of responding telemedicine networks saw reimbursement as a barrier to long-term sustainability, while in 2004 only 22% did so. It appears that some progress has been made in Medicaid and private payer reimbursement for telemedicine.

Healthcare utilization by women in a comprehensive managed care population subsequent to diagnosis of a sexually transmitted disease.

BACKGROUND: Healthcare utilization (HCU) following a sexually transmitted disease (STD) diagnosis is poorly characterized. GOAL: The goal was to quantify HCU for new/recurrent STDs and other relevant Ob-Gyn and mental health problems in the 18 months subsequent to an STD diagnosis. STUDY DESIGN: We compared HCU between a group of females aged 18 to 45 years who were Kaiser Permanente Medical Program members with a diagnosed STD (n = 1,205) and a medical center- and age group-matched sample of women seen for a non-STD diagnosis in the same time period (n = 4820), with controlling where appropriate for age, medical center, and chronic disease status. RESULTS: An STD diagnosis was associated with significantly greater likelihood of subsequent visits for STDs (relative risk [RR] = 3.8), pelvic inflammatory disease/endometritis (RR = 2.9), candidiasis (RR = 2.0), vaginitis (RR = 2.4), cervical dysplasia (RR = 1.7), menstrual disorders/abnormal bleeding (RR = 1.3), high risk/complicated/ectopic pregnancy (RR = 1.5), and behavioral/mental health problems (RR = 1.3) than for women seen for a non-STD diagnosis. CONCLUSION: Detrimental sequelae of STDs are reflected in substantially elevated near-term HCU following an STD diagnosis.

Assessment of community contamination: a critical approach.

The purpose of this paper is to review data from two Superfund sites and describe the latitude of interpretation of "environmental risk" by residents living in the area, governmental agencies, and the media. The first community was located within a 5-mi perimeter of the Rocky Flats Environmental Technology Site (RFETS) outside Denver, Colorado. The second community was located on the south side of Tucson, Arizona, adjacent to the Tucson International Airport area (TIAA) Superfund site. Critical theory was the perspective used in this analysis and proposal of public health actions to attain social justice. Differences between the two populations' experiences with risk and contamination coincided with divergent levels of trust in government. RFETS residents demanded monitoring, whereas the minority residents at TIAA were ambivalent about their trust in government cleanup activities. Unraveling the purpose of "facts" and the social force of "truth" can direct nurses to address environmental justice issues. By policing governmental and business activities in halting or cleaning up environmental contamination, nurses may become mouthpieces for the concerns underlying the fragile surface of "virtual trust" in contaminated communities. Cutting through competing rhetoric to police environmental safety, the core function of assurance becomes what nurses do, not what they say.