Surveillance and Security in US Medicine and Equipment Supply Chains.

The COVID-19 pandemic exposed vulnerabilities of the United States' routine and emergency supply chains of medicines and critical equipment. These vulnerabilities underscore an urgent need to prevent routine and emergency shortages by making drug manufacturing more transparent and by tracking how key supplies get to end users. Near real-time surveillance systems must be developed to monitor fluctuations in supplies of medicines and equipment. Implementation of such systems will require getting key stakeholders (clinicians, administrators, community members, manufacturers, and policy makers) to collaborate.

Identifying Strategies for Strengthening the Health Care Workforce in the Commonwealth of Virginia.

Like the United States as a whole, Virginia faces a significant shortage of health care workers in nursing, primary care, and behavioral health. If current trends persist, these shortages will increase across Virginia. The authors of this study identify interventions that can help the Virginia Health Workforce Development Authority (VHWDA) address these health care workforce shortages. To accomplish this goal, they applied an analytic framework to existing or potential interventions for retaining, recruiting, and improving the structural efficiency of the nursing, primary care, and behavioral health workforces in Virginia. In this study, they highlight which interventions VHWDA should prioritize based on its desired outcomes and policy goals.

Conceptualizing lifer versus destination patients for optimized care delivery.

BACKGROUND: Patients presenting to academic medical centers (AMC) typically receive primary care, specialty care, or both. Resources needed for each type of care vary, requiring different levels of care coordination. We propose a novel method to determine whether a patient primarily receives primary or specialty care to allow for optimization of care coordination. OBJECTIVES: We aimed to define the concepts of a Lifer Patient and Destination Patient and analyze the current state of care utilization in those groups to inform opportunities for improving care coordination. METHODS: Using AMC data for a 36-month study period (FY17-19), we evaluated the number of unique patients by residence zip code. Patients with at least one primary care visit and patients without a primary care visit were classified as Lifer and Destination patients, respectively. Cohen's effect sizes were used to evaluate differences in mean utilization of different care delivery settings. RESULTS: The AMC saw 35,909 Lifer patients and 744,037 Destination patients during the study period. Most patients were white, non-Hispanic females; however, the average age of a Lifer was seventy-two years whereas that of a Destination patient was thirty-eight. On average, a Lifer had three times more ambulatory care visits than a Destination patient. The proportion of Inpatient encounters is similar between the groups. Mean Inpatient length of stay (LOS) is similar between the groups, but Destination patients have more variance in LOS. The rate of admission from the emergency department (ED) for Destination patients is nearly double Lifers'. CONCLUSION: There were differences in ED, ambulatory care, and inpatient utilization between the Lifer and Destination patients. Furthermore, there were incongruities between rate of hospital admissions and LOS between two groups. The Lifer and Destination patient definitions allow for identification of opportunities to tailor care coordination to these unique groups and to allocate resources more efficiently.

A cross-stakeholder approach to improving out-of-hospital cardiac arrest survival.

BACKGROUND: Out-of-hospital cardiac arrest (OHCA) affects over 300,000 individuals per year in the United States with poor survival rates overall. A remarkable 5-fold difference in survival-to-hospital discharge rates exist across United States communities. METHODS: We conducted a study using qualitative research methods comparing the system of care across sites in Michigan communities with varying OHCA survival outcomes, as measured by return to spontaneous circulation with pulse upon emergency department arrival. RESULTS: Major themes distinguishing higher performing sites were (1) working as a team, (2) devoting resources to coordination across agencies, and (3) developing a continuous quality improvement culture. These themes spanned the chain of survival framework for OHCA. By examining the unique processes, procedures, and characteristics of higher- relative to lower-performing sites, we gleaned lessons learned that appear to distinguish higher performers. The higher performing sites reported being the most collaborative, due in part to facilitation of system integration by progressive leadership that is willing to build bridges among stakeholders. CONCLUSIONS: Based on the distinguishing features of higher performing sites, we provide recommendations for toolkit development to improve survival in prehospital systems of care for OHCA.

Evaluating the pediatric mental health care continuum at an American health system.

Objective: To describe trends in the pediatric mental health care continuum and identify potential gaps in care coordination. Methods: We used electronic medical record data from October 2016 to September 2019 to characterize the prevalence of mental health issues in the pediatric population at a large American health system. This was a single institution case study. From the electronic medical record data, primary mental health discharge and readmission diagnoses were identified using International Classification of Diseases (ICD-9-CM, ICD-10-CM) codes. The electronic medical record was queried for mental health-specific diagnoses as defined by International Classification of Diseases classification, analysis of which was facilitated by the fact that only 176 mental health codes were billed for. Additionally, prevalence of care navigation encounters was assessed through electronic medical record query, as care navigation encounters are specifically coded. These encounter data was then segmented by care delivery setting. Results: Major depressive disorder and other mood disorders comprised 49.6% and 89.4% of diagnoses in the emergency department and inpatient settings respectively compared to 9.0% of ambulatory care diagnoses and were among top reasons for readmission. Additionally, only 1% of all ambulatory care encounters had a care navigation component, whereas 86% of care navigation encounters were for mental health-associated reasons. Conclusions: Major depressive disorder and other mood disorders were more common diagnoses in the emergency department and inpatient settings, which could signal gaps in care coordination. Bridging potential gaps in care coordination could reduce emergency department and inpatient utilization through increasing ambulatory care navigation resources, improving training, and restructuring financial incentives to facilitate ambulatory care diagnosis and management of major depressive disorder and mood disorders. Furthermore, health systems can use our descriptive analytic approach to serve as a reasonable measure of the current state of pediatric mental health care in their own patient population.

Strategies for Enhancing Prehospital Outcomes for Cardiac Arrest (EPOC).

Out-of-hospital cardiac arrest (OHCA) is a common, life-threatening event that is a leading cause of death in the United States. However, it is unclear how to design strategies that can be successfully implemented in emergency medical services (EMS) agencies and broader emergency response systems (such as fire, police, dispatch, and bystanders to OHCA events) in different communities to help improve daily care processes and outcomes in OHCA. The National Heart, Lung, and Blood Institute-funded Enhancing Prehospital Outcomes for Cardiac Arrest (EPOC) study lays the foundation for future quality improvement efforts in OHCA by identifying, understanding, and validating the best practices adopted within emergency response systems to address these life-threatening events and by addressing potential barriers to implementation of these practices. RAND researchers developed recommendations covering all levels of the prehospital OHCA incident response and the principles of change management necessary to implement those recommendations.

How health systems facilitate patient-centered care and care coordination: a case series analysis to identify best practices.

Large- and small-scale transformation of healthcare delivery toward improved patient experience through promotion of patient-centered and coordinated care continues to be at the forefront of health system efforts in the United States. As part of a Quality Improvement (QI) project at a large, midwestern health system, a case series of high-performing organizations was explored with the goal of identifying best practices in patient-centered care and/or care coordination (PCC/CC). Identification of best practices was done through rapid realist review of peer-reviewed literature supporting three PCC/CC interventions per case. Mechanisms responsible for successful intervention outcomes and associated institutional-level facilitators were evaluated, and cross-case analysis produced high-level focus items for health system leadership, including (1) institutional values surrounding PCC/CC, (2) optimization of IT infrastructure to enhance performance and communication, (3) pay structures and employment models that enhance accountability, and (4) organizing bodies to support implementation efforts. Health systems may use this review to gain insight into how institutional-level factors may facilitate small-scale PCC/CC behaviors, or to conduct similar assessments in their own QI projects. Based on our analysis, we recommend health systems seeking to improve PCC/CC at any level or scale to evaluate how IT infrastructure affects provider-provider and provider-patient communication, and the extent to which institutional prioritization of PCC/CC is manifest and held accountable in performance feedback, incentivization, and values shared among departments and settings. Ideally, this evaluation work should be performed and/or supported by cross-department organizing bodies specifically devoted to PCC/CC implementation work.

Identifying Strategies to Boost COVID-19 Vaccine Acceptance in the United States.

This study presents the results of an evaluation of the root causes of COVID-19 vaccine hesitancy to inform strategies to boost vaccine acceptance among vaccine-hesitant populations in the United States. The authors conducted a literature review of the causes of vaccine hesitancy and vaccine acceptance; focus groups with patients, pre-hospital first responders, and hospital-based health care providers; a social media platform sentiment analysis to review attitudes regarding the COVID-19 vaccine; and a roundtable discussion with experts on vaccine hesitancy. Drawing on this mixed-methods analysis, the authors recommend strategies to help boost COVID-19 vaccine acceptance in the United States, grouping them according to three overall goals: boosting confidence in the safety and effectiveness of the COVID-19 vaccines, combating complacency about the pandemic, and increasing the convenience of getting vaccinated. The authors emphasize that combating misinformation about the COVID-19 vaccine is key to achieving these goals. These recommendations can inform the development of a toolkit of strategies to reach herd immunity and end the pandemic.

Assessment of telecommunicator cardiopulmonary resuscitation performance during out-of-hospital cardiac arrest using a standardized tool for audio review.

OBJECTIVE: Telecommunicator cardiopulmonary resuscitation (T-CPR) is a critical component of optimized out-of-hospital cardiac arrest (OHCA) care. We assessed a pilot tool to capture American Heart Association (AHA) T-CPR measures and T-CPR coaching by telecommunicators using audio review. METHODS: Using a pilot tool, we conducted a retrospective review of 911 call audio from 65 emergency medical services-treated out-of-hospital cardiac arrest (OHCA) patients. Data collection included events (e.g., OHCA recognition), time intervals, and coaching quality measures. We calculated summary statistics for all performance and quality measures. RESULTS: Among 65 cases, the patients' mean age was 64.7 years (SD: 14.6) and 17 (26.2%) were women. Telecommunicator recognition occurred in 72% of cases (47/65). Among 18 non-recognized cases, reviewers determined 12 (66%) were not recognizable based on characteristics of the call. Median time-to-recognition was 76 seconds (n = 40; IQR:39-138), while median time-to-first-instructed-compression was 198 seconds (n = 26; IQR:149-233). In 36 cases where coaching was needed, coaching on compression-depth occurred in 27 (75%); -rate in 28 (78%); and chest recoil in 10 (28%) instances. In 30 cases where repositioning was needed, instruction to position the patient's body flat occurred in 18 (60%) instances, on-back in 22 (73%) instances, and on-ground in 22 (73%) instances. CONCLUSIONS: Successful collection of data to calculate AHA T-CPR measures using a pilot tool for audio review revealed performance near AHA benchmarks, although coaching instructions did not occur in many instances. Application of this standardized tool may aid in T-CPR quality review.

The association of fire or police first responder initiated interventions with out of hospital cardiac arrest survival.

OBJECTIVE: Fire and police first responders are often the first to arrive in medical emergencies and provide basic life support services until specialized personnel arrive. This study aims to evaluate rates of fire or police first responder-initiated cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) use, as well as their associated impact on out-of-hospital cardiac arrest (OHCA) outcomes. METHODS: We completed a secondary data analysis of the MI-CARES registry from 2014 to 2019. We reported rates of CPR initiation and AED use by fire or police first responders. Multilevel modeling was utilized to evaluate the relationship between fire/police first responder-initiated interventions and outcomes of interest: ROSC upon emergency department arrival, survival to hospital discharge, and good neurologic outcome. RESULTS: Our cohort included 25,067 OHCA incidents. We found fire or police first responders initiated CPR in 31.8% of OHCA events and AED use in 6.1% of OHCA events. Likelihood of sustained ROSC on ED arrival after CPR initiated by a fire/police first responder was not statistically different as compared to EMS initiated CPR (aOR 1.01, CI 0.93-1.11). However, fire/police first responder interventions were associated with significantly higher odds of survival to hospital discharge and survival with good neurologic outcome (aOR 1.25, 95% CI 1.08-1.45 and aOR 1.40, 95% CI 1.18-1.65, respectively). Similar associations were see when examining fire or police initiated AED use. CONCLUSIONS: Fire or police first responders may be an underutilized, potentially powerful mechanism for improving OHCA survival. Future studies should investigate barriers and opportunities for increasing first responder interventions by these groups in OHCA.

Quantifying Ambulatory Care Use Preceding Emergency Department Visits and Hospitalizations for Ambulatory Care Sensitive Conditions.

Ambulatory Care Sensitive Conditions (ACSC) represent a significant source of health care spending in the United States. Existing literature is largely descriptive and there is limited information about how an emergency department (ED) visit or hospitalization for ACSCs is related to prior ambulatory care visits. A retrospective, observational study was conducted using health records from a large midwestern health system during a 20-month period between 2012 and 2014. Our primary variables were (1) type of care setting (i.e., ED visit or hospitalization) and (2) whether the patient received ambulatory care services in the 14, 30, and 60 days before the ED visit or hospital admission. Of patients seen in the ED for ACSCs, 11.9%, 16.3%, and 21.67% were seen in ambulatory care in the 14, 30, and 60 days prior, respectively. Of those hospitalized for ACSCs, 29.1%, 39.9%, and 53% were seen in ambulatory care in the 14, 30, and 60 days prior, respectively. These results highlight a potential lost opportunity to address ACSCs in the ambulatory care setting. Such knowledge can inform interventions to reduce avoidable ACSC-related acute care use and health care costs, and improve patient outcomes.

Health and Social Services in Puerto Rico Before and After Hurricane Maria: Predisaster Conditions, Hurricane Damage, and Themes for Recovery.

"In September 2017, Puerto Rico was struck by two major hurricanes-Irma and Maria-that intensified existing challenges in Puerto Rico's health and social services infrastructure. In the aftermath, the government of Puerto Rico created a long-term recovery plan built on an evidence-based assessment of the damage from the hurricanes and the ongoing needs across Puerto Rico. Development of the recovery plan was supported by the Federal Emergency Management Agency, other federal agencies, local stakeholders, and analysis from the Homeland Security Operational Analysis Center (HSOAC), operated by RAND Corporation under contract with the U.S. Department of Homeland Security. HSOAC research provided the foundation for the 31 courses of action in the recovery plan addressing the health and social services sector. These actions are a mix of social, governmental, fiscal, and economic policies and reforms. This collection of actions presents an opportunity to build a more resilient health and social services infrastructure and regional health care networks to ensure reliable access to services, promote health and well-being, and more efficiently and effectively respond to public health crises and future disasters. The actions span the areas of health care, public health and emergency preparedness, environmental health, mental and behavioral health, and social services. The damage and needs assessment and courses of actions cover four major themes: building system capacity to respond both during disasters and routine times; strengthening the health and social services workforce; strengthening support services for at-need populations; and creating health-promoting communities.

Data missingness in the Michigan NEMSIS (MI-EMSIS) dataset: a mixed-methods study.

OBJECTIVE: The study was done to evaluate levels of missing and invalid values in the Michigan (MI) National Emergency Medical Services Information System (NEMSIS) (MI-EMSIS) and explore possible causes to inform improvement in data reporting and prehospital care quality. METHODS: We used a mixed-methods approach to study trends in data reporting. The proportion of missing or invalid values for 18 key reported variables in the MI-EMSIS (2010-2015) dataset was assessed overall, then stratified by EMS agency, software platform, and Medical Control Authorities (MCA)-regional EMS oversight entities in MI. We also conducted 4 focus groups and 10 key-informant interviews with EMS participants to understand the root causes of data missingness in MI-EMSIS. RESULTS: Only five variables of the 18 studied exhibited less than 10% missingness, and there was apparent variation in the rate of missingness across all stratifying variables under study. No consistent trends over time regarding the levels of missing or invalid values from 2010 to 2015 were identified. Qualitative findings indicated possible causes for this missingness including data-mapping issues, unclear variable definitions, and lack of infrastructure or training for data collection. CONCLUSIONS: The adoption of electronic data collection in the prehospital setting can only support quality improvement if its entry is complete. The data suggest that there are many EMS agencies and MCAs with very high levels of missingness, and they do not appear to be improving over time, demonstrating a need for investment in efforts in improving data collection and reporting.

Optimizing Routine and Disaster Prehospital Care Through Improved Emergency Medical Services Oversight.

OBJECTIVE: To identify modifiers of emergency medical services (EMS) oversight quality, including facilitators and barriers, and inform best practices and policy related to EMS oversight and system performance. METHODS: We used a qualitative design, including 4 focus groups and 10 in-depth, 1-on-1 interviews. Primary data were collected from EMS stakeholders in Michigan from June to July 2016. Qualitative data were analyzed using the rapid assessment technique. RESULTS: Emergent themes included organizational structure, oversight and stakeholder leadership, interorganizational communication and relationships, competition or collaboration among MCA stakeholders, quality improvement practices, resources, and needs specific to rural communities. CONCLUSIONS: EMS is a critical component of disaster response. This study revealed salient themes and modifiers, including facilitators and barriers, of EMS oversight quality. These findings were evaluated in the context of current evidence and informed state policy to improve the quality of EMS oversight and prehospital care for both routine and disaster settings. Some were particular to geographic regions and communities, whereas others were generalizable.

Social network theory-an underutilized opportunity to align innovative methods with the demands of the opioid epidemic.

It has been almost 3 years since the opioid epidemic was declared a national public health emergency under federal law. Solutions have focused on supply-reduction strategies. These approaches, however, have failed to significantly curtail opioid overdose and related death. Demand for opioid use arising from social networks and environment is an important contributing factor to the current opioid epidemic. Adoption of existing underused methods is needed to drive further progress. This Perspective proposes the social contagion model as a promising framework through which to operationalize evaluation of the influence of social networks and environment in the opioid epidemic and argues for its greater application. Comparing the current epidemic with previous opioid epidemics reiterates the utility of the social contagion model. This model acknowledges social network influence on individual behavior. It leverages tools from epidemiology, permits evaluation of interpersonal influence, facilitates consideration of disproportionate and collateral effects, and overcomes limitations of traditional models and geographic assumptions inherent to many approaches surrounding the current opioid epidemic. Analyzing the opioid epidemic within a social contagion framework will enhance evaluation methods and enable the design of interventions to reflect the actual demands of the current crisis. If the influence of social networks and environment is not considered, the devastating toll of the opioid epidemic could grow.

Variation in pre-hospital outcomes after out-of-hospital cardiac arrest in Michigan.

AIM: Care by emergency medical service (EMS) agencies is critical for optimizing prehospital outcomes following out-of-hospital cardiac arrest (OHCA). We explored whether substantial differences exist in prehospital outcomes across EMS agencies in Michigan-specifically focusing on rates of sustained return of spontaneous circulation (ROSC) upon emergency department (ED) arrival. METHODS: Using data from Michigan Cardiac Arrest Registry to Enhance Survival (MI-CARES) for years 2014-2017, we calculated rates of sustained ROSC upon ED arrival across EMS agencies in Michigan. We used hierarchical logistic regression models that accounted for patient, arrest-, community-, and response-level characteristics to determine adjusted rates of sustained ROSC among EMS agencies. RESULTS: A total of 103 EMS agencies and 20,897 OHCA cases were included. Average age of the cohort was 62.5 years (SD = 19.6), 39.7% were female, and 17.9% had an initial shockable rhythm due to ventricular fibrillation or pulseless ventricular tachycardia. The adjusted rate of sustained ROSC upon ED arrival across all EMS agencies was 23.8% with notable variation across EMS agencies (interquartile range [IQR], 20.5-29.2%). The top five EMS agencies had mean adjusted rates of sustained ROSC upon ED arrival of 42.7% (95% CI: 34.6-51.1%) while the bottom five had mean adjusted rates of 9.8% (95% CI: 7.6-12.7%). CONCLUSIONS: Substantial variation in sustained ROSC upon ED arrival exists across EMS agencies in Michigan after adjusting for patient-, arrest, community-, and response-level features. Such differences suggest opportunities to identify and improve best practices in EMS agencies to advance OHCA care.

Enhancing Prehospital Outcomes for Cardiac Arrest (EPOC) study: sequential mixed-methods study protocol in Michigan, USA.

INTRODUCTION: Out-of-hospital cardiac arrest (OHCA) is a common, life-threatening event encountered routinely by first responders, including police, fire and emergency medical services (EMS). Current literature suggests that there is significant regional variation in outcomes, some of which may be related to modifiable factors. Yet, there is a persistent knowledge gap regarding strategies to guide quality improvement efforts in OHCA care and, by extension, survival. The Enhancing Prehospital Outcomes for Cardiac Arrest (EPOC) study aims to fill these gaps and to improve outcomes. METHODS AND ANALYSIS: This mixed-methods study includes three aims. In aim I, we will define variation in OHCA survival to the emergency department (ED) among EMS agencies that participate in the Michigan Cardiac Arrest Registry to Enhance Survival (CARES) in order to sample EMS agencies with high-survival and low-survival outcomes. In aim II, we will conduct site visits to emergency medical systems-including 911/dispatch, police, non-transport fire, and EMS agencies-in approximately eight high-survival and low-survival communities identified in aim I. At each site, key informant interviews and a multidisciplinary focus group will identify themes associated with high OHCA survival. Transcripts will be coded using a structured codebook and analysed through thematic analysis. Results from aims I and II will inform the development of a survey instrument in aim III that will be administered to all EMS agencies in Michigan. This survey will test the generalisability of factors associated with increased OHCA survival in the qualitative work to ultimately build an EPOC Toolkit which will be distributed to a broad range of stakeholders as a practical 'how-to' guide to improve outcomes. ETHICS AND DISSEMINATION: The EPOC study was deemed exempt by the University of Michigan Institutional Review Board. Findings will be compiled in an 'EPOC Toolkit' and disseminated in the USA through partnerships including, but not limited to, policymakers, EMS leadership and health departments.

The Association Between Hospital Occupancy and Mortality Among Medicare Patients.

BACKGROUND: Hospital crowding is a major challenge facing US health care systems, but few studies have evaluated the association between inpatient occupancy and patient mortality. The objective of this study was to determine how increasing hospital occupancy is associated with the likelihood of inpatient and 30-day out-of-hospital mortality using a novel measure of inpatient occupancy. METHODS: The researchers conducted a retrospective, observational study using secondary data from the California Office of Statewide Health Planning and Development, including nonfederal, acute care facilities from 1998 to 2012. Using measures of relative hospital occupancy, the researchers ran logistic regressions to assess the relationship between increasing hospital occupancy and inpatient mortality and 30-day out-of-hospital mortality among Medicare patients age 65 years and older with myocardial infarction, heart failure, or pneumonia. RESULTS: Higher admission day occupancy (odds ratio [OR] = 0.96, 95% confidence interval [CI]: 0.94-0.99) and higher discharge day occupancy (OR = 0.62, 95% CI: 0.60-0.64) were associated with decreased inpatient mortality. Thirty-day out-of-hospital mortality increased with higher discharge day occupancy (OR=1.28, 95% CI: 1.24-1.32) but was unrelated to admission day occupancy. CONCLUSION: This study found a counterintuitive relationship between admission and discharge day occupancy and inpatient mortality. Higher discharge day occupancy appears to displace deaths into the outpatient setting. Understanding why higher inpatient occupancy is associated with lower overall mortality merits investigation to inform best practices for inpatient care in busy hospitals.

Location of Violent Crime Relative to Trauma Resources in Detroit: Implications for Community Interventions.

INTRODUCTION: Detroit, Michigan, is among the leading United States cities for per-capita homicide and violent crime. Hospital- and community-based intervention programs could decrease the rate of violent-crime related injury but require a detailed understanding of the locations of violence in the community to be most effective. METHODS: We performed a retrospective geospatial analysis of all violent crimes reported within the city of Detroit from 2009-2015 comparing locations of crimes to locations of major hospitals. We calculated distances between violent crimes and trauma centers, and applied summary spatial statistics. RESULTS: Approximately 1.1 million crimes occurred in Detroit during the study period, including approximately 200,000 violent crimes. The distance between the majority of violent crimes and hospitals was less than five kilometers (3.1 miles). Among violent crimes, the closest hospital was an outlying Level II trauma center 60% of the time. CONCLUSION: Violent crimes in Detroit occur throughout the city, often closest to a Level II trauma center. Understanding geospatial components of violence relative to trauma center resources is important for effective implementation of hospital- and community-based interventions and targeted allocation of resources.