UW Health Research Articles

AJHP names Cesarz contributing editor.

AJHP welcomes Joe Cesarz, M.S., Pharm.D., director of ambulatory pharmacy services at UW Health in Madison, Wisconsin, as the journal’s first-ever contributing editor for specialty pharmacy. “I am honored and excited to serve the profession in this role,” Cesarz said. “Given the continued importance of specialty pharmacy to health systems, there is a need for resources and increased dialogue to support initiatives related to this area of practice.” Under Cesarz’s direction, UW Health’s specialty pharmacy team supports inpatient and ambulatory care throughout the integrated health system, including its community pharmacies, ambulatory care clinics, mail-order pharmacy, and infusion service. Cesarz led the establishment of UW Health’s postgraduate year 2 specialty pharmacy residency training program. He said creating the residency, achieving ASHP accreditation, and watching the program and its graduates develop has been highly rewarding personally and professionally. AJHP Editor in Chief Daniel J. Cobaugh said Cesarz’s appointment to the editorial board “is critical to the journal’s ongoing efforts to publish cutting-edge specialty pharmacy content, which supports ASHP members as they provide high quality care to their patients.”

Implementing value assessment in oncology practice: A single-center experience.

Cancer treatment costs in the United States are rising. Evidence suggests that increased costs do not always correlate with improved outcomes. Several organizations have developed tools and frameworks to assess cancer treatment value; however, many centers have reported difficulty in implementing these tools and effectively incorporating value-based decision making into clinical practice. After evaluating existing frameworks, the Carbone Cancer Center at UW Health set out to create a value-based tool that could be used to inform the decisions of clinicians and patients. This tool was piloted in metastatic or advanced non-small cell lung cancer, specifically in the second-line setting to assess the value of immune checkpoint inhibitors nivolumab, atezolizumab, and pembrolizumab. The results of the pilot suggest that atezolizumab is the best value of the three agents in this patient population. Challenges and opportunities for improvement that were identified during the pilot process have helped refine the tool for use in a variety of disease states within oncology.

Inpatient pharmacists’ patient referrals to a transitions-of-care pharmacist: Evaluation of an automated referral process

ObjectivesTo evaluate the impact of a pharmacist screening and automated referral process that identifies patients at risk for readmission due to medication-related problems (MRPs). SettingUniversity of Wisconsin (UW) Hospital is 505-bed flagship hospital that is part of UW Health, an academic health system. Practice descriptionThe integrated pharmacy practice model at UW Health has inpatient pharmacists who perform discharge medication reconciliation. Before enhancing the screening and referral process, a transitions-of-care (TOC) pharmacist identified patients with the use of a low yield report and performed a second postdischarge medication reconciliation on selected patients. Practice innovationA screening process was developed to identify patients at risk for readmission due to MRPs and allow for direct referral from inpatient pharmacists to a TOC pharmacist for postdischarge follow-up. EvaluationPatient characteristics, readmission risk, and readmission rate were compared between inpatient only (before referral) and inpatient plus second medication reconciliation (after referral). MRPs identified during medication reconciliation were quantified and categorized as provider or patient-associated. ResultsBefore process improvement, 9 patients (5%) received a second medication reconciliation out of 175 patients who received standard-of-care inpatient medication reconcilation. After implementation, 45 patients (24%) received a second medication reconcilation out of 188 referrals. Patients referred for postdischarge follow-up with the TOC pharmacist had an average of 3.2 more medications and 2.7 more chronic conditions than before process implementation (P < 0.01). Both inpatient and TOC pharmacists identified at least 1 MRP in about two-thirds of patients (P = 0.60). Provider-associated MRPs were more commonly identified in both inpatient and postdischarge settings. ConclusionInpatient pharmacist screening is an effective method for identifying patients for referral to a TOC pharmacist to receive postdischarge follow-up. Despite the robustness of the inpatient medication reconciliation process in identifying provider-associated MRPs, patient-associated MRPs still emerged after discharge that warranted additional pharmacist intervention.

Granulocyte colony-stimulating factor utilization postautologous hematopoietic stem cell transplant in multiple myeloma patients: Does one size fit all?

To evaluate a single institution's experience with granulocyte colony-stimulating factor after autologous hematopoietic stem cell transplant in myeloma patients to identify populations that benefit most from granulocyte colony-stimulating factor administration. Retrospective chart reviews were conducted on patients 18+ years with multiple myeloma that underwent autologous hematopoietic stem cell transplant at UW Health from January 2012 to May 2016. Data collection included demographics, length of stay, time to engraftment, Eastern Cooperative Oncology Group performance status score, and hematopoietic cell transplantation-comorbidity index. The primary outcome was days from transplant to engraftment, defined as absolute neutrophil count > 500/mm3 for two consecutive days or absolute neutrophil count > 1000/mm3 once. A subset analysis was performed on patients whose date of engraftment was known. In total, 216 individual patients were included in the full cohort and 122 patients included in the subset analysis. Median time to engraftment between patients administered granulocyte colony-stimulating factor and the nongranulocyte colony-stimulating factor group was 12 versus 19 days (P < 0.001) in the full cohort and 12 versus 14 days (P < 0.001) in the subset analysis. The average length of stay posthematopoietic stem cell transplant in the granulocyte colony-stimulating factor group was 15 days versus 17 days in the nongranulocyte colony-stimulating factor group (P = 0.026) in the subset analysis. Additionally, no difference in time to engraftment was seen when stratified by age, Eastern Cooperative Oncology Group performance status score, or hematopoietic cell transplantation-comorbidity index. Our study supports use of granulocyte colony-stimulating factor posthematopoietic stem cell transplant in myeloma patients to decrease time to engraftment and length of stay. Consideration should be given to utilization in all patients in this population posthematopoietic stem cell transplant. Further research is needed to identify the populations that benefit most from granulocyte colony-stimulating factor administration.

Using Quality Improvement Tools to Redefine a Clinical Librarianship Program: A Case Study

ABSTRACTUniversity of Washington (UW) Medicine is a large hospital system in Seattle, Washington. Historically, the UW Health Sciences Library (HSL) has had one clinical librarian to support the organization. However, after the clinical librarian retired in 2015, 1.5 FTE clinical librarians were hired to support UW Medicine. This article details process improvement strategies being implemented at UWHSL to align and modernize the library’s clinical librarianship program given the significant changes occurring in healthcare. This case study will examine the use of qualitative research techniques for gathering information and the use of Value Engineering tools to analyze results.

Interprofessional development and implementation of a pharmacist professional advancement and recognition program.

The interprofessional development, implementation, and outcomes of a pharmacist professional advancement and recognition program (PARP) at an academic medical center are described. Limitations of the legacy advancement program, in combination with low rates of employee engagement in peer recognition and professional development, at the UW Health department of pharmacy led to the creation of a task force comprising pharmacists from all practice areas to develop a new pharmacist PARP. Senior leadership within the organization expanded the scope of the project to include an interprofessional work group tasked to develop guidelines and core principles that other professional staff could use to reduce variation across advancement and recognition programs. Key program design elements included a triennial review of performance against advancement standards and the use of peer review to supplement advancement decisions. The primary objective was to meaningfully improve pharmacists' engagement as measured through employee engagement surveys. Secondary outcomes of interest included the results of pharmacist and management satisfaction surveys and the program's impact on the volume and mix of pharmacist professional development activities. Of the 126 eligible pharmacists, 93 participated in the new program. The majority of pharmacists was satisfied with the program. For pharmacists who were advanced as part of the program, meaningful increases in employee engagement scores were observed, and a mean of 95 hours of professional development and quality-improvement activities was documented. Implementation of a PARP helped increase pharmacist engagement through participation in quality-improvement and professional development activities. The program also led to the creation of organizationwide interprofessional guidelines for advancement programs within various healthcare disciplines.

Creation of a certification requirement for pharmacists in direct patient care roles.

Steps taken by a large health system to require certification for all pharmacists in direct patient care roles are detailed. Major supply chain changes and rising payer expectations are reshaping pharmacy practice, resulting in expanded responsibilities for pharmacists and a heightened need for certification in specialized practice areas. In response, the pharmacy leadership team at UW Health, the integrated health system of the University of Wisconsin-Madison, used an iterative process and a "rolling" FAQ format to develop and implement a certification requirement. Key decisions during the process included decisions to accept only rigorous certifications (mainly those offered by the Board of Pharmacy Specialties), to provide institutional support for continuing education-based recertification, and to use an accepted definition of direct patient care in determining which pharmacists need to be certified. The team obtained the support of the UW Health human relations department by drafting a policy and rewriting all pharmacist position descriptions to incorporate the certification requirement. An all-pharmacist forum was held to build staff commitment. As a result of the requirement, 73 pharmacists were required to obtain certification by 2018 at a total cost to UW Health of $44,000; ongoing support of certification maintenance will cost an estimated $40,000 per year. Health systems can be successful in establishing uniform certification expectations for pharmacists in direct patient care roles, even across diverse practice settings, by aligning expectations with organizational goals.

An Epic Viewpoint: An Interview with Judy Faulkner, CEO of Epic Systems

An Epic Viewpoint: An Interview with Judy Faulkner, CEO of Epic Systems

Scope of practice in Wisconsin expands to drug product administration.

A recently enacted law in Wisconsin will allow pharmacists to administer injectable medications—including products other than vaccines and in situations other than teaching patients how to inject themselves. “We would be another available resource for patients,” UW Health’s Joe Cesarz said he told two legislative committees when they held hearings on the legislation. UW Health, whose pharmacists at 14 dispensing pharmacies in Madison can administer vaccines, has not fully determined how the new law will affect patient care, said Cesarz, manager of ambulatory care pharmacy services. But one of the goals, he affirmed, will be to improve medication adherence among patients who are prescribed a weekly or monthly injection and have “needle phobia” or inadequate manual dexterity. By being able to administer medications, Cesarz said, community-based pharmacists can help those patients, who otherwise would have to find a willing friend or family member or schedule an appointment at their prescriber’s office.

The Scale Imperative for Academic Medical Centers: Part 2—Case Study

In our previous column in this series (see the Operations and Strategy column in the January/February 2015 issue of JHM), we describe the scale imperative for academic medical centers (AMCs) if they wish to remain viable in a healthcare landscape characterized by consolidation, increasingly closed systems, new reimbursement models, decreased funding, and other challenges. In addition, we describe AMCs' approaches to achieving adequate scale in terms of our five-category framework. The framework, with additional examples, is revisited in the sidebar on page 87 of this issue.Here, we discuss the case of one AMC-UW Health-that has embarked on the journey to developing scale. It hopes to leverage scale in shoring up its ability to support its missions of research and education.ABOUT UW HEALTHUW Health is the umbrella organization for the clinical operations of the various University of Wisconsin-Madison entities-UW School of Medicine and Public Health, UW Medical Foundation (the academic group practice), and UW Hospital and Clinics (the academic teaching hospital). Located in Madison, Wisconsin, a relatively small market in south central Wisconsin, UW Health's clinical mission involves providing service locally, regionally, statewide, and across state lines into the adjacent states of Illinois and Iowa. UW Health has had excellent financial performance for the past 15 years and remains strong today. UW School of Medicine and Public Health's academic performance and reputation also have been consistently strong throughout this period.THE DECISION TO SCALE UPIn addition to the national trends affecting all AMCs, UW Health faced a number of external conditions that influenced its decision to scale up:* It is surrounded by five large regional/national systems-Mayo Clinic, Ministry Health Care/Ascension Health, Aurora Health Care, Advocate Health Care, and UnityPoint Health-that have been growing rapidly and moving towardMadison from all directions. In early 2014, UnityPoint Health completed its acquisition of Meriter Health in Madison and established a local presence, while the formerly independent Dean Clinic sold itself to SSM Health Care, based in St. Louis, Missouri.* The relatively high cost of healthcare in the Madison region is not likely to be sustainable.* About 60% of the quaternary referrals to UW Health, which yield very high contribution margins, are outside its control and at risk as surrounding systems grow and become increasingly self-contained.As UW Health looks into the future, it expects to encounter daunting clinical challenges, as noted in Figure 1. Although its market in 2014 was moderately integrated both horizontally and vertically (including physician alignment), payers are still many, and diverse, and competition on value is modest. Over the next 5 years, the market is expected to evolve across all five of these factors. The result is that UW Health faces a transforming market that is likely to move quickly toward highly organized and increasingly closed systems of care, thus placing at risk the tertiary and quaternary referrals from throughout the state that have been the lifeblood of its clinical growth and academic support.UW HEALTH'S APPROACHIn response to these challenges, UW Health set about creating a culture that will support the scale imperative by identifying the leadership commitment and degree of scale required.Leadership CommitmentsTo advance a new organizational culture, a different set of leadership capabilities and commitments is required. These competencies are quite different from the leadership expectations in most AMCs. If leadership is not fully committed to cohesion, collaboration, and building scale, including tackling the often difficult intraorganizational issues, internal forces will block growth. Scaling up requires support staff to fuel inorganic growth and then a new support structure to manage a larger, more diverse, and geographically dispersed organization. …

Engaging Patients at the Front Lines of Primary Care Redesign: Operational Lessons for an Effective Program

Article-at-a-Glance Background: The lack of patient engagement in quality improvement is concerning. As part of an enterprisewide initiative to redesign primary care at UW Health, interdisciplinary primary care teams received training in patient engagement. Organizational stakeholders held a structured discussion and used nominal group technique to identify the key components critical to fostering a culture of patient engagement and critical lessons learned. These findings were augmented and illustrated by review of transcripts of two focus groups held with clinic managers and 69 interviews with individual microsystem team members. From late 2009 to 2014, 47 (81%) of 58 teams have engaged patients in various stages of practice improvement projects. Organizational components identified as critical to fostering a culture of patient engagement were alignment of the organization's vision that guided the redesign with national priorities, readily available external experts, involvement of all care team members in patient engagement, integration within an existing continuous improvement team development program, and an intervention deliberately matched to organizational readiness. Critical lessons learned were the need to embed patient engagement into current improvement activities, designate a neutral point person(s) or group to navigate organizational complexities, commit resources to support patient engagement activities, and plan for sustained team-patient interactions. Current national health care policy and local market pressures are compelling partnering with patients in efforts to improve the value of the health care delivery system. The UW Health experience may be useful for organizations seeking to introduce or strengthen the patient role in designing delivery system improvements.

Abstract A52: A phase III skin cancer chemoprevention study of DFMO in subjects with a history of non-melanoma skin cancer (NMSC): Follow-up of NMSC events greater than 5 years post-study participation

Abstract The most commonly diagnosed malignancy in the United States is non-melanoma skin cancer (NMSC) with &amp;gt; 2 million new cases of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) predicted for 2010. The economic burden and increasing incidence in younger populations, especially women, reinforces the value of skin cancer prevention. Health education and prior attempts at skin cancer chemoprevention have had limited success. A strong link between epithelial carcinogenesis and elevated polyamines, together with a series of phase I and II trials, led to a NCI-sponsored phase III double-blind, placebo-controlled skin cancer chemoprevention trial of α-difluoromethylornithine (DFMO) (500 mg/m2/day) for 4–5 years in 291 subjects with a history of NMSC. Subjects receiving DFMO developed significantly fewer BCC s than placebo subjects with an event rate of 0.28 BCC/person/year versus 0.40 BCC/person/year, (P = 0.03; Total BCCs: DFMO 163, placebo 243). DFMO appeared to have minimal effects on SCC incidence (DFMO 0.15 SCC/person/year, placebo 0.19, p=0.56; Total SCCs: DFMO 95, placebo 115). Subjects tolerated DFMO well, and the only significant observed toxicity was increased audiometric hearing loss. A key issue in the clinical viability of a chemoprevention agent after acute effectiveness and/or tolerance is the latent effectiveness and/or toxicity of the agent. Such effects attributable to DFMO have not been assessed. Earlier chemoprevention research has observed positive and negative latent effects with chemopreventive agents. Use of tamoxifen (5 years) for breast cancer prevention provided continued or greater protection for up to 10 years after drug stoppage. On the contrary, early work with retinoids in oral cancer prevention implied a rebound effect with subjects developing more neoplasms upon discontinuation. Also, the recent linkage between isotretinoin and inflammatory bowel disease is a concerning example of toxicity experienced years after use of a chronically administered agent. The continued interest in DFMO as a chemopreventive agent provided cause to update the clinical data and overall health status of the 291 subjects from the phase III skin cancer prevention study of DFMO to understand the sustainability of the observed DFMO effects. After institutional review board approval, we reviewed medical records of 243 subjects who received care at UW Health. Individual records were manually reviewed, and a pending comparative review of data mining by Natural Language Processing will also be completed. Both reviews focused on the skin cancer events by histology, other neoplasia (invasive and non-invasive), significant other diagnoses, and survival. The rate of skin cancer recurrence from end of study drug to the time of last medical contact (the primary endpoint) was compared between subjects randomized to DFMO or placebo using a two-sample test for primary analysis. As a secondary analysis, the rate of skin cancer recurrence from randomization to the time of last medical contact was also compared. In an exploratory analysis, the primary endpoint was analyzed using Poisson regression models to account for the baseline patient/disease characteristics at the time of randomization such as sex and age of patients and pre-study skin cancer history. Data from the 243 subjects totaling over 2,300 person years is undergoing further validation and preliminary data analysis, and will be available shortly. Citation Information: Cancer Prev Res 2011;4(10 Suppl):A52.

Athletic Trainers in an Orthopedic Practice

ATHLETIC TRAINERS at the University of Wisconsin Hospital have assisted orthopedic and primary-care sports-medicine physicians in the clinic since 1981. At the core of our success is the long-standing relationship of the certified athletic trainer and the team physician. We have extended the traditional on-the-field athletic training room model to the sports-medicine orthopedic clinic. This model has produced excellent clinic efficiency and flow and increased revenue for our hospital and physicians. Presently, the UW Health Sports Medicine Clinic has eight sportsmedicine-fellowship-trained physicians. Four of these have specialties in orthopedics, two in family medicine, and two in pediatrics. They are also the team physicians for the University of Wisconsin Athletic Department. A total of a 4.0 FTE equivalent of athletic trainers staff these clinics along with nurses, physician assistants, medical assistant, residents, and fellows. The athletic trainers are all hospital employees and are not employed by the physician group. The responsibilities of the various support staff are described in the sidebar.

University of Wisconsin Medical School.

University of Wisconsin Medical School.