Care In America Research Articles

EHR Solutions for Information Transfer Deficits During Transitions in Care for Sepsis Survivors.

In a previous study, sepsis was noted as a diagnosis on the home health record only 4% of the time for 165,000 sepsis survivors transitioning from hospital to home health care in America. If sepsis and other conditions are not clearly documented in the transitional care record this can lead to unpreparedness, missed, care, and poor patient outcomes. Our implementation science study discovered a source of this problem regarding the sepsis documentation in 16 hospitals referring to five home care agencies. Together, researchers, hospital, and home care personnel developed and implemented two information technology solutions to address this deficit in seven hospitals. The automated method was more readily adopted and effective in improving information transfer between hospital and home health care.

The Vexing Problem of Access to Health Care in America: Is Employer-Based Health Insurance the Real Culprit?

The Vexing Problem of Access to Health Care in America: Is Employer-Based Health Insurance the Real Culprit?

Some Reflections on the 50th Anniversary of Hospice Care in America.

This article celebrates the 50th anniversary of hospice care in America. It also offers a brief recounting of one person's reflections on some aspects of the history, achievements, and current status of American hospice care.

Dead Ringers and the Horror of Childbirth on the Small Screen

The streaming series Dead Ringers (Amazon), loosely adapted from David Cronenberg’s 1988 body horror film about twin male gynecologists, viscerally represents the too-often-violent act of childbirth in order to address the crisis of maternal health care in America. As a series for the small screen, it exploits television’s capacities to show and tell as a form of public education, directing our attention to social issues, including the maternal mortality crisis and the racist history of gynecology and obstetrics. FQ contributing editor Laurie Ouellette argues that the series is “uncomfortable television” by feminist design, in that it deploys corporeal aesthetics and social criticism to unsettle audiences.

Alfred Washington Adson: Perspectives on Intracranial Neurosurgery and the Responsibilities of the Neurosurgeon.

In a period when the budding field of neurosurgery was believed to have little promise, Dr Alfred Washington Adson founded and led the first neurosurgical department at Mayo Clinic. He was not without reservations-surgical intervention for neurological conditions was rarely pursued because of poor outcomes and high complication rates, and Dr Adson acknowledged his early concerns about the future of neurosurgery in his memoirs. However, his education, mentorship, his training, and his first neurosurgical cases helped to shape the impact he ultimately had on the field and his legacy as a neurosurgeon. Dr Adson trained with several renowned Mayo general surgeons, notably his mentor Dr Emil Beckman, whose desire for operative precision shaped Dr Adson's drive to develop his own skills as a surgeon. Two years into his residency, he became the youngest staff surgeon and was tasked with managing the neurosurgical cases at Mayo. The five neurosurgical cases overseen by Dr Adson in the next year illuminated the opportunity for neurosurgery to drastically improve the lives of patients. Dr Adson, given the option of continuing as either a general surgeon or a neurosurgeon, ultimately chose to pursue neurosurgery. This article seeks to provide a historical perspective on the neurosurgeon Dr Alfred Washington Adson using primary and secondary accounts from the Mayo archives, highlighting his contributions to the early understanding of intracranial pathology and how his early experiences as a trainee developed into a personal passion for self-improvement, education, and advocacy for health care in America.

Clinician burnout (CBO) research trends from 2013-2022: Results from the State of Cancer Care in America (SOCCA) ASCO Annual Meeting abstract analysis.

41 Background: Interest in CBO and wellness has increased due to concern about the impact of workforce wellness on the quality of care. Oncology CBO accelerated during the COVID-19 pandemic and affected the entire health care system and workforce. We analyzed whether increased interest in CBO is reflected in research on the oncology workforce by reviewing abstracts submitted to the ASCO Annual Meeting between 2013-2022. Methods: We reviewed abstracts from the 2013-2022 ASCO Annual Meetings available from the ASCO Data Library. We limited our analysis to abstracts accepted to the Care Delivery and Regulatory Policy, Health Services Research, and the Professional Development & Education Advances tracks. Abstract titles and body text were searched for keywords related to CBO, and a manual review was conducted to ensure match validity. A Poisson regression was used to estimate the annual rate of change. Results: Of the 48,761 abstracts submitted to the ASCO Annual Meeting between 2013-2022, 4,843 abstracts were submitted to the tracks of interest. The keyword search and subsequent manual review identified 53 abstracts related to CBO (1.1% of relevant track submissions, and 0.1% of all abstract submissions). 4 (8%) abstracts flagged for CBO terms were submitted in the first 5 years of the time-period (2013-2017), while 49 (92%) abstracts were submitted in the last 5 years of the time-period (2018-2022). From 2013-2022 there was a 34.1% annual increase (95% confidence interval: 18.1%, 54.1%) in CBO related abstracts submitted to the tracks of interest. Of those submitted between 2021-2022, 30% (n=8) were related to the impact of COVID-19 on CBO. Between 2013-2022, 53% of all abstracts and 72% of health service track abstracts submitted to the ASCO Annual Meeting were submitted by US-based authors. Of the 53 CBO abstracts identified between 2013-2022, 72% (n=38) were written by US-based authors. Conclusions: CBO-related research submitted to the ASCO Annual Meeting increased between 2013-2022 with a predominant share originating from US-based researchers. This reflects the growing concern in the U.S. health care system around workforce wellness and the potential negative impact of CBO on the quality of patient care. Importantly, the factors contributing to CBO existed prior to the COVID-19 pandemic, including institutional and system-level burdens. The COVID-19 pandemic likely accelerated this existing trend as demonstrated by the increase in abstract submissions on CBO in recent years. [Table: see text]

Multilevel factors impacting clinical trial participation: An ASCO State of Cancer Care in America (SOCCA) analysis of oncology fellows’ perceptions of preparedness to conduct clinical research in practice and importance of clinical trial participation.

110 Background: Despite cancer treatment advances from clinical trials, the proportion of those with cancer enrolling on oncology studies remains low, due to system-, patient-, and physician-level facilitators and barriers to participation. To better understand the upstream context impacting oncologists’ consideration of trials, we studied oncology fellows’ perceptions of trial participation and preparedness for clinical research. Methods: All year 1 (Y1), Y2, & Y3 fellows taking the 2023 ASCO Medical Oncology In-Training Exam (ITE) were invited to take a post-ITE optional survey. After consent, fellows answered whether they agree, disagree or are unsure of their preparedness by their fellowship program to address key elements of practice and research and their perceived importance of trial participation after training, ranging from Very Important, Important, Moderately, Slightly, or Not Important, the latter 3 ratings aggregated and labeled as ‘less important.’ Descriptive statistics and Chi-squared tests comparing responses by fellowship year are presented. Results: Overall, 97% of fellows (2184/2231) taking the 2023 ITE participated in this study and are included in this analysis; 32% were in Y1, 37% Y2, 30% Y3. When asked ‘my fellowship training program is adequately preparing me to address the following in my future,’ nearly one in four fellows felt unsure or disagreed that their program prepared them for (a) treating patients outside of an academic medical center (Y1 24%, Y2 24%, Y3 23%) or (b) conducting clinical research (Y1 26%, Y2 26%, Y3 28%). When asked ‘how important is it to you to have the opportunity to participate in clinical trials following completion of your training,’ nearly half of oncology fellows (Y1 49%, Y2 46%, Y3 40%, p.038) felt trial participation was ‘less important.’ When considering future practice setting, two out of 3 fellows (66%) planning a non-academic practice and one of 3 fellows (33%) planning an academic practice rated trial participation as ‘less important’ (p<.0001). When compared to fellows who reporting being unsure or unprepared by their programs to conduct clinical research, those who felt adequately prepared were more likely to rate trial participation as important/very important (57% vs 49%, p=.005). Conclusions: Our findings show that value of clinical trial participation is assigned early in oncologists’ careers during fellowship training. Addressing barriers to clinical trial participation calls for multilevel interventions that include efforts to identify and augment clinical research learning needs of oncology fellows and ensuring broad exposure during fellowship to successful and efficient conduct of cancer clinical trials.

Wellbeing and burnout among oncology fellows compared to prior fellows and current practicing oncologists: An ASCO State of Cancer Care in America (SOCCA) trend analysis.

47 Background: Burnout impacts oncology clinicians across their professional lifecycle. To better understand clinician wellbeing and the role of fellowship training, we characterized trends in oncology fellows’ burnout and perception of preparedness during training. Methods: As an ASCO SOCCA initiative, all medical oncology fellows taking the 2023 ASCO Medical Oncology In-Training Exam (ITE) were invited to complete an optional post-ITE professional wellbeing survey. Fellows were asked 1 item on fatigue (on a 0-10 Likert scale, 10 = “as bad as can be”), 1 item on satisfaction with work-life integration (WLI) and 2 Maslach Burnout Inventory (MBI) items on emotional exhaustion (EE) and depersonalization (DP), each scored on a 1-7 scale, >5 being high. Per convention, respondents with a high EE and/or DP were categorized as having burnout. 2023 ITE responses were compared to (1) 2013 ASCO Fellows Post-ITE survey (n=1345),1 (2) 2012-13 ASCO survey of practicing oncologists (n=1117),2 and (3) 2023 ASCO survey of practicing oncologists (n=328; 26% tagged as early career, using age <40 as proxy; 64% in academia). Results: 2231 fellows who took the ITE in 2023. Responses from 1568 first (33%), second (36%) and third year (31%) fellows who responded to at least one wellbeing item are included in this analysis. Compared to 10 years prior, oncology fellows in 2023 reported less burnout (20% in 2023 vs 34% in 2013, p<.001) and higher satisfaction with WLI (50% in 2023 vs 34% in 2013; p<.001). Fellows across both 2013 and 2023 studies reported higher satisfaction with WLI with advancing fellowship year (1-3). The 2013 analyses found no statistically significant difference in EE, DP or overall burnout between fellows and practicing oncologists. However, in 2023, the prevalence of high EE, DP and burnout was significantly lower in fellows vs both all and early career practicing oncologists (all p<.005, Table). Most (72%) fellows in 2023 felt their training is adequately preparing them to manage burnout in future practice. Conclusions: Oncology fellows in 2023 reported significantly less burnout and higher WLI satisfaction than fellows in 2013 and current practicing oncologists. Most fellows felt prepared to manage burnout in future practice. The higher prevalence of burnout in early career oncologists vs fellows suggests a gap between expectations of practice during training and the actual experience of oncology practice. (1) Shanafelt et al: JCO 32(27), 2014. (2) Shanafelt et al: JCO 32(11), 2014. [Table: see text]

Integrating the business of oncology during oncology fellowship: An ASCO State of Cancer Care in America (SOCCA) study of professional preparedness and practice expectations among medical oncology fellow physicians in training between 2013 and 2023.

48 Background: The current healthcare climate calls for a deep understanding among physicians on the business side of medicine. Oncology fellows entering clinical practice face key issues related to the business of cancer care, prompting us to explore the preparation from fellowship training for those financial competencies that factor into day-to-day practice. Methods: All fellows taking the 2023 ASCO Medical Oncology In-Training Exam (ITE) were invited to participate in a post-exam survey which included items on perception of preparedness for future practice and expected practice setting. Respondents answering one or more survey items are included in this analysis. Practice setting expectations were compared to findings from the 2013 post-ITE survey (n=1536). Descriptive statistics and Chi-squared tests comparing responses by fellowship year and exam years are presented. Results: Overall, 2184 (97%) of 2231 fellows taking the 2023 ITE participated in this post-ITE survey study, including 704 in their first, 807 in their second, and 673 in their third year of fellowship. Overall, in areas of communication, most felt adequately prepared by their program: communicating with patients about treatment options (98%), multidisciplinary care coordination (97%), electronic records or other healthcare tech use (95%), staying up to date on changes in oncology (95%), and practicing cultural humility (92%). However, in areas on business of oncology, a greater proportion felt under- or unprepared; specifically, 30% of fellows felt unprepared or unsure about discussing the cost of medical care with patients, 35% on obtaining prior authorization, and 45% on participating in alternative payment models. Compared to 2013, the expected practice setting of the 2023 fellows remained unchanged with subsets anticipating an academic practice (62% in 2023 vs 61% in 2013), non-academic practice (hospital/health system or physician/independently owned; 32% in 2023 vs 34% in 2013), government/regulatory (2%), industry (<1%), or other setting (3%). Conclusions: While nearly all oncology fellows reported high levels of preparedness for certain essential components of patient-centered multidisciplinary practice, over a third felt unprepared or underprepared to navigate domains under the business of oncology. These findings highlight the opportunity to augment oncology fellowship training to include financial competencies of clinical practice and care, which collectively form the foundation of cancer care.

State of Cancer Care in America: Achieving Cancer Health Equity Among Sexual and Gender Minority Communities.

In 2017, ASCO issued the position statement, Strategies for Reducing Cancer Health Disparities Among Sexual and Gender Minority Populations, outlining five areas of recommendations to address the needs of both sexual and gender minority (SGM, eg, LGBTQ+) populations affected by cancer and members of the oncology workforce who identify as SGM: (1) patient education and support; (2) workforce development and diversity; (3) quality improvement strategies; (4) policy solutions; and (5) research strategies. In 2019, ASCO convened the SGM Task Force to help actualize the recommendations of the 2017 position statement. The percentage of the US population who publicly identify as SGM has increased dramatically over the past few years. Although increased national interest in SGM health equity has accompanied a general interest in research, policy change, and education around diversity, equity, and inclusion, resulting from public concern over discrimination in health care against Black, Indigenous, and People of Color, this has been accompanied by a surge in discriminatory legislation directly impacting the SGM community. Although much progress has been made in advancing SGM cancer health equity since 2017, more progress is needed to reduce disparities and advance equity. The five focus areas outlined in the 2017 ASCO position statement remain relevant, as we must continue to promote and advance equity in quality improvement, workforce development, patient care, research, and SGM-affirming policies. This article reports on the progress toward reducing SGM cancer disparities and achieving equity across these five areas and identifies future directions for the work that still remains.

Lack of evidence for telehealth fraud.

Despite evidence to the contrary, U.S. policy makers, payers, and the public continue to express apprehension that the use of telehealth is associated with increased risk of fraud and abuse. The fraudulent use of telehealth is multifaceted and complex, ranging from potentially false claims to miscoding, inaccurate billing, and kickbacks. For the past 6 years, the U.S. Federal Government has undertaken research studies to examine potential fraud issues related to the use of telehealth, including up-coding time spent with the patient, misrepresentation of the service provided, and billing for services that were not rendered. This article reviews previous efforts to assess the risk of fraud associated with the delivery of virtual care in America, concluding that there is little evidence for higher levels of fraud and abuse related to the use of telehealth.

NCCN Virtual Policy Summit: Defining the "New Normal" - 2021 and the State of Cancer Care in America Following 2020.

US healthcare systems have been deeply impacted by significant societal shifts over the past several years. The COVID-19 pandemic has changed the way we interact with healthcare, political narratives have impacted how healthcare is perceived and engaged with by the public, and the United States has become increasingly aware of historic and ongoing racial injustices across all health and social systems. The watershed events experienced during the last several years play a critical role in shaping the future of cancer care for payers, providers, manufacturers, and, most importantly, patients and survivors. To explore these issues, in June 2021 NCCN convened a virtual policy summit: Defining the "New Normal" - 2021 and the State of Cancer Care in America Following 2020. This summit offered the opportunity for a varied group of stakeholders to begin to explore the impact of recent events on the current and future state of oncology in the United States. Topics included the impact of COVID-19 on cancer detection and treatment, the role of innovation in ensuring continuity of care, and efforts to create more equitable systems of care.

Collaboration Key to Psychiatry’s Future and a Mentally Healthy Nation, Levin Says

Back to table of contents Next article Annual MeetingFull AccessCollaboration Key to Psychiatry’s Future and a Mentally Healthy Nation, Levin SaysMark MoranMark MoranSearch for more papers by this authorPublished Online:8 Jun 2023https://doi.org/10.1176/appi.pn.2023.07.7.15AbstractLevin introduced a major APA Foundation campaign titled “Mental Health Care Works,” dedicated to encouraging Americans to seek treatment for mental and substance use disorders when they need it.“Collaboration, innovation, and leadership are key components of progress for psychiatry and for the future of mental health care in America,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A., citing the theme of this year’s APA Annual Meeting, at the Annual Meeting’s Opening Session.“It seems like just yesterday that we were here in San Francisco celebrating the 175th anniversary of our Association back in 2019, where we celebrated our past,” Levin recalled. “The events of the past few years have underscored the importance of innovation, collaboration, and of claiming our future as experts in the connection between mind, body, and brain.”“Integrated health systems that emphasize the total health of a patient are the way forward.,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A.Levin said this year’s presidential theme is a timely one. “In order to chart the best course for our future, we must collaborate with other medical specialties and outside groups; pursue and embrace innovative treatments, technologies, and solutions to persistent problems; and motivate our members and psychiatrists everywhere in the world to take a leadership role in affecting positive change in our profession,” he said.Collaboration is especially important, he said, noting that most patients who need care for mental or substance use disorders first find care in an emergency department or primary care setting. “For years we have espoused the benefits of the collaborative care model and the potential they have for addressing the immense demand of mental health care, reducing costs, and improving outcomes for our patients,” Levin said. “Integrated health systems that emphasize the total health of a patient are the way forward.”Levin used the occasion to introduce a major APA Foundation campaign titled “Mental Health Care Works,” dedicated to encouraging Americans to seek treatment for mental and substance use disorders when they need it.“Our goal for this campaign is to reinforce the idea that the work that psychiatrists do every day is essential to the health and well-being of our nation … and that it is courageous and life-affirming to seek it out.” He added that achieving a mentally healthy nation is well worth the investment of whatever time and money are necessary.“We must emphasize that no one is immune from mental health challenges, nor is anyone beyond help,” he said. “By embracing our humanity and promoting community, we can socialize the idea that mental illness and addiction are not moral failings, but are treatable illnesses like any other physical ailment.”Levin reminded attendees of several positive trends for APA—membership numbers are trending upward, with more than 38,000 psychiatrists, and the association is more diverse in race, gender, and geography.“We are embracing and supporting this change, as it is a reflection of the ever-diversifying patient population in our country,” Levin said. He hailed especially the place of international medical graduates (IMGs) in American psychiatry. “I myself am an IMG and am heartened to see how invested our members are in ensuring that their colleagues who are IMGs feel supported and are able to integrate into our system successfully,” he said.He emphasized that principles of diversity, equity, inclusion, and belonging are inseparable from APA’s mission as a medical association.“Equality and health equity cannot truly happen unless we address the social determinants of health and mental health that cause and worsen barriers and gaps in care,” he said. “These principles are our guiding light as we work to support and facilitate diversity in our profession and improve access to high-quality mental health care for minority and underrepresented groups, including women and the LGBTQ+ community.” ■ResourcesMental Health Care Works campaign site ISSUES NewArchived

Home Care in America: The Urgent Challenge of Putting Ethical Care into Practice.

Home care is one of the fastest-growing industries in the United States, providing valuable opportunities for millions of older adults and people with disabilities to live at home rather than in institutional settings. Home care workers assist clients with essential activities of daily living, but their wages and working conditions generally fail to reflect the importance of their work. Drawing on the work of Eva Feder Kittay and other care ethicists, we argue that good care involves attending to the needs of another out of a concern for their well-being. Such care should be standard in the home care system. Yet, because of the pervasive racial, gender, and economic inequalities that the home care industry perpetuates, home care workers and their clients cannot reasonably be expected to care about each other. We endorse reforms aimed at enabling home care workers and their clients to form and maintain professional relationships that cultivate care..

Centering Home Care in Bioethics Scholarship, Education, and Practice.

This commentary responds to "Home Care in America: The Urgent Challenge of Putting Ethical Care into Practice," by Coleman Solis and colleagues, in the May-June 2023 issue of the Hastings Center Report. More specifically, we respond to the authors' call for "inquiry into the nature, value, and practice" of home care. We argue that the most urgently needed normative reset for thinking about care work is the replacement of dominant individualistic thinking with systemic thinking. Deepening a focus on the social, economic, and historical forces that shape the state of contemporary care work will help bioethicists to argue more effectively for improvements to working conditions. In turn, better working conditions will ease the oppositional stance between caregivers and receivers that has been set up by the current system, enabling all parties involved to better pursue the feminist ethical ideal of care.

Special Report: Measurement-Based Care—Using Data to Augment Psychotherapy

Special Report: Measurement-Based Care—Using Data to Augment Psychotherapy

Disparities and Inequities in US Health Care: Alive and Sick.

Disparities and inequities based on ethnic and racial differences have been a part of health care in America from the time of its founding. These disparities have persisted through recurrent efforts to reform our health care system. This article brings historical perspective to what has become a systemic part of US health care; examines the extent of disparities today as they impact access, quality, and outcomes of care; and considers what can be done within our polarized political environment to eliminate them. It is hoped that this can help to spark dialogue within our discipline on these matters of critical importance. A single-payer national health insurance program, whereby all Americans can access affordable care based on medical need instead of ability to pay, can help to move our current nonsystem toward health equity. This change can bring improved health care to all Americans with simplified administration, cost containment, and less bureaucracy. It can be financed through a progressive tax system whereby 95% of Americans pay less than they do now and receive more in return. The past is never dead. It's not even past.1-William Faulkner.

Abortion Care in America.

Patchy, unequal, and, above all, contentious.

A Digitally Capable Mobile Health Clinic to Improve Rural Health Care in America: A Pilot Quality Improvement Study

ObjectiveTo address the problem of limited health care access for patients in rural southern Minnesota, a digitally capable mobile health clinic (MHC) quality improvement initiative was launched in a rural community-based health system. MethodsThis project was designed and implemented according to our institutional strategic plan, guiding principles for virtual community care, and existing approved standards of care. A quality improvement development and pilot implementation framework was rapidly developed using Agile methodology. ResultsThe resulting technology and equipment selection, overall clinic design, vehicle vendor selection, clinical schedule and workflows, staffing model, equipment and technology selection, and testing were achieved in 12 months. The pilot site communities were chosen on the basis of size, interest, and lack of existing access. Four underserved rural communities now have access to telehealth consultations, laboratory testing, and in-person primary care examinations. By April 30, 2022, the MHC had provided 1498 patient appointments while maintaining our standards of care. Newly established broadband internet access for these communities and their residents was a valuable secondary outcome. ConclusionBy designing and implementing an MHC quality improvement intervention that provides both in-person and advanced telehealth options for patients in rural communities, our institution rapidly provided a potential solution for the rural health care crisis. The MHC not only replaces traditional brick-and-mortar facilities but also expands service offerings and access to technology for rural communities and the people who live and work in them.

Book Review: Big Med: Megaproviders and the High Cost of Health Care in America

By Dale Steinreich. Dale Steinreich reviews Dranove and Burns's analysis of health economics and policy, finding an interesting history of hospitals, but falling short of identifying the true causes of medical care dysfunction.