Mobile health clinic model in the COVID-19 pandemic: lessons learned and opportunities for policy changes and innovation.

BACKGROUND: Mobile Clinics represent an untapped resource for our healthcare system. The COVID-19 pandemic has exacerbated its limitations. Mobile health clinic programs in the US already play important, albeit under-appreciated roles in the healthcare system. They provide access to healthcare especially for displaced or isolated individuals; they offer versatility in the setting of a damaged or inadequate healthcare infrastructure; and, as a longstanding community-based service delivery model, they fill gaps in the healthcare safety-net, reaching social-economically underserved populations in both urban and rural areas. Despite an increasing body of evidence of the unique value of this highly adaptable model of care, mobile clinics are not widely supported. This has resulted in a missed opportunity to deploy mobile clinics during national emergencies such as the COVID-19 pandemic, as well as using these already existing, and trusted programs to overcome barriers to access that are experienced by under-resourced communities. MAIN TEXT: In March, the Mobile Healthcare Association and Mobile Health Map, a program of Harvard Medical School's Family Van, hosted a webinar of over 300 mobile health providers, sharing their experiences, challenges and best practices of responding to COVID 19. They demonstrated the untapped potential of this sector of the healthcare system in responding to healthcare crises. A Call to Action: The flexibility and adaptability of mobile clinics make them ideal partners in responding to pandemics, such as COVID-19. In this commentary we propose three approaches to support further expansion and integration of mobile health clinics into the healthcare system: First, demonstrate the economic contribution of mobile clinics to the healthcare system. Second, expand the number of mobile clinic programs and integrate them into the healthcare infrastructure and emergency preparedness. Third, expand their use of technology to facilitate this integration. CONCLUSIONS: Understanding the economic and social impact that mobile clinics are having in our communities should provide the evidence to justify policies that will enable expansion and optimal integration of mobile clinics into our healthcare delivery system, and help us address current and future health crises.

Factors Associated With Childhood Vaccination Adherence in Kindergartens of the Houston Independent School District.

OBJECTIVE: Adequate childhood vaccination rates are crucial for successful control of infectious diseases. Nevertheless, exemption requests, lack of health care access and information and other barriers can reduce vaccination adherence rates, and increase the risk of epidemics. This study aimed to identify factors associated with kindergarten vaccination adherence in the Houston Independent School District (HISD). DESIGN AND SETTING: This study was a retrospective observational data analysis. The study used data from 155 elementary schools of the HISD. The data sets included were (1) Elementary School Profile Reports (2015-2016) and (2) Annual Report of Immunization Status (2016-2017). Logistic regression was used to examine the association between vaccination adherence in schools and the school's student demographic and economic profile, student behavior indicators, teacher profile, and school rank. MAIN OUTCOME MEASURE: A binary variable measuring adequate vaccination adherence rates in schools is the main outcome variable. RESULTS: Lower vaccination adherence among the kindergarten students was associated with higher enrollment, a higher percentage of African American students and students with English as second language, and a lower percentage of gifted/talented students in the schools. CONCLUSIONS: The school characteristics that were found to be significantly associated with kindergarten student vaccination adherence in this study are the ones that have historically been associated with socioeconomic determinants of health and socioeconomic privilege. Hence, the findings of this study suggest the need for development of policies and interventions that can help overcome the barriers associated with low socioeconomic status, language, and marginalization in order to improve vaccination rates in school districts. These include culturally appropriate polices and health promotion, patient navigation, and educational interventions that can overcome the challenges faced by socially and economically vulnerable minorities and immigrant communities in order to improve vaccination rates.

Resource Utilization for Patients with Intracerebral Hemorrhage Transferred to a Comprehensive Stroke Center.

BACKGROUND: As a comprehensive stroke center (CSC), we accept transfer patients with intracerebral hemorrhage (ICH) in our region. CSC guidelines mandate receipt of patients with ICH for higher level of care. We determined resource utilization of patients accepted from outside hospitals compared with patients directly arriving to our center. METHODS: From our stroke registry, we compared patients with primary ICH transferred to those directly arriving to our CSC from March 2011-March 2012. We compared the proportion of patients who utilized at least one of these resources: neurointensive care unit (NICU), neurosurgical intervention, or clinical trial enrollment. RESULTS: Among the 362 patients, 210 (58%) were transfers. Transferred patients were older, had higher median Glasgow Coma Scale scores, and lower National Institutes of Health Stroke Scale scores than directly admitted patients. Transfers had smaller median ICH volumes (20.5 cc versus 15.2 cc; P = .04) and lower ICH scores (2.1 ± 1.4 versus 1.6 ± 1.3; P < .01). A smaller proportion of transfers utilized CSC-specific resources compared with direct admits (P = .02). Fewer transferred patients required neurosurgical intervention or were enrolled in trials. No significant difference was found in the proportion of patients who used NICU resources, although transferred patients had a significantly lower length of stay in the NICU. Average hospital stay costs were less for transferred patients than for direct admits. CONCLUSIONS: Patients with ICH transferred to our CSC underwent fewer neurosurgical procedures and had a shorter stay in the NICU. These results were reflected in the lower per-patient costs in the transferred group. Our results raise the need to analyze cost-benefits and resource utilization of transferring patients with milder ICH.

Healthcare Utilization Disparities Among Lung Cancer Patients in US Hospitals During 2010-2014: Evidence from the US Hispanic Population's Hospital Charges and Length of Stay.

PURPOSE: There is a lack of research focused on understanding the differences in the healthcare utilization of lung cancer patients between ethnic groups. This study aims to characterize disparities in healthcare utilization for Hispanic lung cancer patients compared to non-Hispanic patients. METHODS: National Inpatient Sample was used to identify nationwide lung cancer patients (n=141,675, weighted n=702,878) from 2010 to 2014. We examined the characteristics of the study sample by race (Hispanic vs non-Hispanic) and its association with healthcare utilization, measured by discounted hospital charges and length of stay. Multivariate survey regression models were used to identify predictors by racial groups. RESULTS: Among 702,878 lung cancer patients, 5.1% were Hispanic. Descriptive statistics showed that Hispanics have higher hospital charges and length of stay. Survey regression results also suggested that Hispanic lung cancer patients were associated with higher hospital charges (26.6%) and length of stay (3.5%) than non-Hispanic lung cancer patients. Subgroup analysis displayed a similar trend to the full model. CONCLUSION: Healthcare utilization disparities may exist for lung cancer Hispanic patients due to insurance status and early detection. Thus, our findings support providing financial assistance and targeted programs for minority patients. Future health policy consideration should be given to those vulnerable populations where limited healthcare resources are available.

Cost of care for asylum seekers and refugees entering the United States: The case of volunteer medical providers in El Paso, Texas.

BACKGROUND: Between October 2018, and February 2020, the United States saw an unprecedented increase in the number of asylum seekers and refugees arriving unexpectedly at international crossings along the US-Mexico Border. Many of these migrants needed proper medical attention, and consequently created significant pressure on local health systems. In El Paso, Texas, volunteer clinicians, collaborating closely with religious organizations and non-governmental organizations, provided outpatient medical care for the new arrivals; the county hospital provided in-patient care at local tax payers' expense. The objective of this study was to estimate costs of healthcare services offered by these volunteers in order to formulate sustainable and appropriate healthcare policies to address the needs of refugees and asylum seekers in the United States. METHODS: A mixed methods approach was used including personal interviews with stakeholders, and follow up surveys with volunteer clinicians. The cost analysis was done from the payer perspective using Medicaid reimbursement rates. RESULTS: Total costs of care provided to asylum seekers and refugees varied between $1.9MM to $4.4MM during the study period. The number of patient visits was estimated at 15,736 to 19,236, and cost per patient ranged between $99 and $281. Most common conditions treated by volunteer providers were abdominal pain, dermatological conditions, headaches, dehydration and hypertension. CONCLUSIONS: This is the first study looking at the cost of healthcare for refugees and asylum seekers provided by volunteer clinicians, in a binational context. The resources invested by volunteer providers were significant, and essential to meet medical needs of migrant populations. Without appropriate financial support, a strategy relying on volunteer and local community resources will prove unsustainable in the long term. Findings from this study will help formulate federal and local policies to support local health systems along the US-Mexico Border in providing care to future migrations into the United States.

Analysis of Annual Costs of Mobile Clinics in the Southern United States.

INTRODUCTION: Mobile clinics provide an efficient manner for delivering healthcare services to at-risk populations, and there is a need to understand their economics. This study analyzes the costs of operating selected mobile clinic programs representing service categories in dental, dental/preventive, preventive care, primary care/preventive, and mammography/primary care/preventive. METHODS: The methodology included a self-reported survey of 96 mobile clinic programs operating in Texas, North Carolina, Georgia, and Florida; these states did not expand Medicaid and have a large proportion of uninsured individuals. Data were collected over an 8-month period from November 2016 to July 2017. The cost analyses were conducted in 2018, and were analyzed from the provider perspective. The average annual estimated costs; as well the costs per patient in each mobile clinic program within different service delivery types were assessed. Costs reported in the study survey were classified into recurrent direct costs and capital costs. RESULTS: Results indicate that mean operating costs range from about $300 000 to $2.5 million with costs increasing from mammography/primary care/preventive delivery to dental/preventive. The majority of mobile clinics provided dental care followed by dental/preventive. The cost per patient visit for all mobile clinic service types ranged from $65 to $529, and appears to be considerably less than those reported in the literature for fixed clinic services. CONCLUSION: The overall costs of all delivery types in mobile clinics were lower than the costs of providing care to Medicare beneficiaries in federally funded health centers, making mobile clinics a sound economic complement to stationary healthcare facilities.

Strategic performance evaluation in cancer centers.

Most research in healthcare strategy has focused on formulating or implementing organizational plans and strategies, and little attention has been dedicated to the post-implementation control and evaluation of strategy, which we contend is the most critical aspect of achieving organizational goals. The objective of this study was to identify strategic control approaches used by major cancer centers in the country and to relate these practices to financial performance. Our intent was to expand the theory and practice of healthcare strategy to focused services, such as oncology. We designed a 17-question survey to capture elements of strategy and performance from our study sample, which comprised major cancer hospitals in the United States and shared similar mandates and resource constraints. The results suggest that high-performing cancer centers use more sophisticated analytical approaches, invest greater financial resources in performance analysis, and conduct more frequent performance reviews than do low-performing organizations. Our conclusions point to the need for a more robust approach to strategic assessment. In this article, we offer a number of recommendations for management to achieve strategic plans and goals on the basis of our research. To our knowledge, this study is one of the first to concentrate on the area of strategic control.

A Microcosting Study of Establishing a Baby Café® in Texas.

BACKGROUND: This article focuses on the costs of opening and running a Baby Café. A Baby Café is an intervention that focuses on providing peer-to-peer support for breastfeeding mothers. Research aim: This study aimed to estimate the costs of establishing and running a Baby Café. METHODS: The authors used a microcosting approach to identifying costs using the case of a Baby Café located in San Antonio, Texas, and modeled after other existing cafés in the United States. They also used extensive literature review and conducted an informal interview with a manager of an existing Baby Café in the United States to validate our cost data. The cost analysis was done from the provider perspective. RESULTS: Costs of starting a Baby Café were $36,000, whereas annual operating costs totaled $47,000. Total discounted costs for a 5-year period amounted to $250,000, resulting in a cost per Baby Café session of $521 and cost per mother of $104. Varying the number of sessions per week and number of mothers attending each session, the discounted cost per Baby Café session ranged between $460 and $740 and the cost per mother varied between $65 and $246. CONCLUSION: These findings can be used by policy makers and organizations to evaluate local resource requirements for starting a Baby Café. Further research is needed to evaluate the effectiveness of this intervention against other breastfeeding promoting initiatives.

Technology governance strategies for maximizing healthcare economic value. Developing management systems for IT.

Based on industry averages, healthcare providers spend from 1.5 percent to 3 percent of their revenues on information technology. That can equate to a million dollars a year for even the smallest hospitals and as much as $50 million or $60 million a year for large health systems. That significant amount of capital must be wisely managed because these investments are long-term assets that can help transform the enterprise and contribute to the organization's strategic goals. Unfortunately, in many hospitals these investments are often made without regard for the actual return on investment that the systems will generate. ROI, or economic value, is difficult to quantify in healthcare because of the complex multi-dimensional processes and perspectives that exist. Administrators and providers often question how a clinical system can be quantified and compared with an ERP, research technology or any other information system. When value can be defined in so many ways - such as improvements in clinical outcomes, improvements in system uptime or reliability, or enhancements in productivity and operational business processes-quantification of economic value becomes much more ambiguous and therefore easy to neglect. However, business value can be created by any combination of shifts in performance. Reductions in waiting lines, improvements in imaging capabilities, increased procedures per labor hour, extensions of system life and higher transaction processing all have potential value. However, ROI cannot be calculated or maximized if underlying key performance indicators are not defined and measured, both pre- and post-implementation. This article will build on solid governance strategies for IT that will help to ensure positive economics and improved productivity in healthcare. It also will discuss specific strategies and methods for extracting the most value out of IT in healthcare.

Methodological issues for designing and conducting a multicenter, international clinical trial in Acute Stroke: Experience from ARTSS-2 trial.

BACKGROUND: We describe innovations in the study design and the efficient data coordination of a randomized multicenter trial of Argatroban in Combination with Recombinant Tissue Plasminogen Activator for Acute Stroke (ARTSS-2). METHODS: ARTSS-2 is a 3-arm, multisite/multiregional randomized controlled trials (RCTs) of two doses of Argatroban injection (low, high) in combination with recombinant tissue plasminogen activator (rt-PA) in acute ischemic stroke patients and rt-PA alone. We developed a covariate adaptive randomization program that balanced the study arms with respect to study site as well as hemorrhage after thrombolysis (HAT) score and presence of distal internal carotid artery occlusion (DICAO). We used simulation studies to validate performance of the randomization program before making any adaptations during the trial. For the first 90 patients enrolled in ARTSS-2, we evaluated performance of our randomization program using chi-square tests of homogeneity or extended Fisher's exact test. We also designed a four-step partly Bayesian safety stopping rule for low and high dose Argatroban arms. RESULTS: Homogeneity of the study arms was confirmed with respect to distribution of study site (UK sites vs. US sites, P=0.98), HAT score (0-2 vs. 3-5, P=1.0), and DICAO (N/A vs. No vs. Yes, P=0.97). Our stopping thresholds for safety of low and high dose Argatroban were not crossed. Despite challenges, data quality was assured. CONCLUSIONS: We recommend adaptive designs for randomization and Bayesian safety stopping rules for multisite Phase I/II RCTs for maintaining additional flexibility. Efficient data coordination could lead to improved data quality.

Cost analysis of PET and comprehensive lifestyle modification for the reversal of atherosclerosis.

UNLABELLED: We present a preliminary cost analysis of a combination intervention using PET and comprehensive lifestyle modification to reverse atherosclerosis. With a sensitivity of 92%-95% and specificity of 85%-95%, PET is an essential tool for high-precision diagnosis of coronary artery disease, accurately guiding optimal treatment for both symptomatic and asymptomatic patients. PET imaging provides a powerful visual and educational aid for helping patients identify and adopt appropriate treatments. However, little is known about the operational cost of using the technology for this purpose. METHODS: The analysis was done in the context of the Century Health Study for Cardiovascular Medicine (Century Trial), a 1,300-patient, randomized study combining PET imaging with lifestyle changes. Our methodology included a microcosting and time study focusing on estimating average direct and indirect costs. RESULTS: The total cost of the Century Trial in present-value terms is $9.2 million, which is equal to $7,058 per patient. Sensitivity analysis indicates that the present value of total costs is likely to range between $8.8 and $9.7 million, which is equivalent to $6,655-$7,606 per patient. CONCLUSION: The clinical relevance of the Century Trial is significant since it is, to our knowledge, the first randomized controlled trial to combine high-precision imaging with lifestyle strategies. The Century Trial is in its second year of a 5-y protocol, and we present preliminary findings. The results of this cost study, however, provide policy makers with an early estimate of the costs of implementing, at large scale, a combined intervention such as the Century Trial. Further, we believe that imaging-guided lifestyle management may have considerable potential for improving outcomes and reducing health-care costs by eliminating unnecessary invasive procedures.

A transition strategy for becoming a baby-friendly hospital: exploring the costs, benefits, and challenges.

The objectives of this study were to provide an economic assessment as well as a calculated projection of the costs that typical U.S. tertiary-care hospitals would incur through policy reconfiguration and implementation to achieve the UNICEF/World Health Organization Baby-Friendly® Hospital designation and to examine the associated challenges and benefits of becoming a Baby-Friendly Hospital. We analyzed hospital resource utilization, focusing on formula use and staffing profiles at one U.S. urban tertiary-care teaching hospital, as well as conducted an online survey and telephone interviews with a selection of Baby-Friendly Hospitals to obtain their perspective on costs, challenges, and benefits. Findings indicate that added costs for a new Baby-Friendly Hospital will approximate $148 per birth, but these costs sharply decrease over time as breastfeeding rates increase in a Baby-Friendly environment.

Economic methods in the century trial--a comprehensive lifestyle modification study for managing coronary artery disease.

While most studies assess the cost-effectiveness of treating acute coronary conditions, the Century Health Study for Cardiovascular Medicine (Century Trial) focuses on ameliorating coronary artery disease (CAD) through a comprehensive lifestyle modification program. This 1,300-patient phase III randomized study uses positron emission tomography for risk stratification, complemented with comprehensive educational and motivational therapy for patients with preclinical or established CAD. The Century Trial is in its second year of a five-year follow-up protocol, and it is one of the first to combine imaging technology and lifestyle modification as a way to improve patient behavior and health. In this article, we present the economic study design used in the Century Trial and provide considerable methodological detail to serve as reference for other researchers. We describe the cost and effect estimation methods as well as our analysis and uncertainty modeling plans. The study will incorporate quality-adjusted life years and use a societal perspective to measure both in-trial and lifetime costs through incremental cost-effectiveness ratios. The approach we follow should provide further evidence on the cost-effectiveness of comprehensive lifestyle modification programs in regressing coronary artery disease.

Cost comparison of baby friendly and non-baby friendly hospitals in the United States.

OBJECTIVES: The objectives of this study were to provide an economic assessment of the incremental costs associated with obtaining the World Health Organization and United Nations International Children's Emergency Fund designation as a Infant-Friendly hospital. We hypothesized that baby-friendly hospitals will have higher costs than similar non-baby-friendly hospitals. METHODS: Data from the 2007 American Hospital Association and the 2007 Centers for Medicare and Medicaid Cost Reports were used to compare labor and delivery costs in baby-friendly and non-baby-friendly hospitals. Operational costs per delivery were calculated using a matched-pairs analysis of a sample of baby-friendly and non-baby-friendly hospitals in the United States. Costs associated with labor-and-delivery diagnosis-related codes were analyzed for each baby-friendly hospital and compared with the mean and median costs incurred by non-baby-friendly hospitals. RESULTS: Nursery plus labor-and-delivery costs for the baby-friendly sites were $2205 per delivery, compared with $2170 for the non-baby-friendly matched pair. Baby-friendly facilities have slightly higher costs than non-baby-friendly facilities, ranging from 1.6% to 5%, but these costs were not statistically significant (P > .05). CONCLUSIONS: These results suggest that becoming baby-friendly is relatively cost-neutral for a typical acute care hospital. Although the overall expense of providing baby-friendly hospital nursery services is greater than nursery service costs of non-baby-friendly hospitals, the cost difference was not statistically significant. Additional research is needed to compare the economic impact of maternal and infant health benefits from breastfeeding versus the incremental expenses of becoming a baby-friendly hospital.