Value Institute Wins National Library of Medicine Grant to Create Alert System to Detect, Treat Sepsis before it becomes Deadly

Sepsis, a life-threatening organ dysfunction, causes nearly half of all U.S. hospital deaths, accruing $20 billion in treatment costs each year.

A team from the Value Institute is determined to change that landscape. It is pioneering an innovative approach to detect and treat the insidious disease, which affects about 1 million people annually, killing a quarter of them.

Their research project, “Signaling Sepsis: Developing a Framework to Optimize Alert Design,” recently won a highly competitive, four-year grant from the National Library of Medicine funded through the U.S. National Institutes of Health. The study is a collaboration with University of Pennsylvania, University of Michigan, and the Medical University of South Carolina and demonstrates a partnership between the Value Institute and Christiana Care information technology and clinician stakeholders.

It is the first such grant to originate with Christiana Care as the leading research entity, said the project’s primary investigator, Kristen Miller, DrPH, MSPH and the Value Institute’s associate director of Clinical Human Factors. 

“Clinicians and nurses on the general medical-surgical units are not as oriented or experienced in recognizing and diagnosing septic patients,” said Eric V. Jackson Jr., M.D., MBA, director of Health Care Delivery Science and associate director of the Value Institute.  

Sepsis occurs when the body exhibits a severe response to bacterial, fungal, viral or yeast infection. The release of chemicals into the bloodstream causes widespread inflammation that can eventually reduce blood flow and damage organs. 

The tricky part is that sepsis often hides behind other diagnoses, escaping detection. 

“It’s not as clear-cut as, say, a heart attack,” said Vinay Maheshwari, M.D., MHCDS, FCCP, vice chair of the Department of Medicine. “Sepsis has such a broad presentation. It can creep up on providers, who don’t necessarily connect the dots.”

The CLIK project involved a time-and-motion study that ascertained how interpreters spend each hour of their day.

Value Institute Partners with Language Services to Solve Tricky Interpreter Staffing Issues to Better Serve Diverse Patients

Research recently conducted at Christiana Care could help health systems around the country in their struggle to provide skilled language interpretation services to an increasingly diverse patient population.

The Communication/Language is Key (CLIK) project analyzed various factors surrounding difficult-to-predict medical interpretation needs, culminating in the development of a staffing optimization model that will improve service provided to patients with Limited English Proficiency while simultaneously reducing costs. CLIK is a research-oriented collaboration between the Value Institute and Department of Cultural Competence and Language Services.

To find the sweet spot between providing exceptional patient service while reducing overall cost, CLIK researchers took a multi-faceted approach to designing the staffing optimization model. This included quantifying the benefits of providing interpreters to Limited English Proficiency patients; analyzing current and projected demand for interpreters in various languages; and studying how staff interpreters’ time is used.

One of the most challenging areas of the study was determining ideal interpreter staffing levels. Unlike nurse-to-patient ratios, there are no national guidelines and little research on optimal interpreter staffing levels or workflow. In addition, the number of Limited English Proficiency patients is under-reported.

Value Institute researchers bridged this gap by conducting a time-and-motion study to learn how interpreters actually spend each hour of their day (time spent interpreting versus time spent waiting for patients or clinicians, for example) and a four-week pilot prevalence study to determine the true number of Limited English Proficiency patients in Christiana Care’s inpatient units.  

They then used a simulation-optimization approach (consisting of Discrete-Event Simulation and Integer Programming) to determine optimal staffing levels for Spanish and Mandarin since these two languages comprise 85 percent of Christiana Care’s total medical interpretation requests. 

The study determined optimal full-time equivalent staffing positions at Christiana Care to be 10.5 for Spanish interpreters, and 1 for Mandarin – positions currently staffed at only 6.8 and 0.2 FTEs respectively. The study showed that the optimized staffing level for Spanish and Mandarin interpreters will decrease the reliance on agency interpreters. This will provide further opportunities to ensure exceptional experience and quality service to patients and providers. It is also projected to contribute to organizational vitality through an annual 11 percent cost savings.

“This research is on the cutting edge nationally as far as analyzing language services and is of critical importance to understanding the complex needs of those we serve in our community, to eliminating disparities and to ensuring we are well positioned to provide excellent care to all our patients” said Bettina Tweardy Riveros, chief health equity officer and senior vice president of government affairs and community engagement.

Aggregated Pharmacy Claims Data used to Study Rate at which Patients leave Prescriptions Unfilled

Whether patients fill their prescriptions and use medications as advised by their doctors has a profound effect on their health and the health care system overall. Poor medication adherence leads to increases in costs, hospitalization rates, and mortality rates. It is estimated that 33 percent to 69 percent of hospital admissions in the United States are medication-related and that the total potential savings from proper adherence and related disease management could be $290 billion annually, or 13 percent of health care spending.

The retrospective study by the Value Institute and Pharmacy Services targeted claims data, an objective but indirect measure of medication adherence.

A recent study conducted by Value Institute researchers, in collaboration with Thomas Jefferson University, used aggregated pharmacy claims data available within electronic health records to identify patients who do and do not fill prescriptions for an antihypertensive medication in real time. The combined pharmacy and electronic health record data have tremendous clinical power and utility, providing an opportunity to understand “primary nonadherence,” those patients who fail to fill their initial prescriptions. The study results demonstrated that this approach could enhance the monitoring of medication usage and improve adherence among patients treated in a large, nonintegrated primary care network.

The retrospective study of available pharmacy claims data identified 791 patients who were prescribed initial regimens of antihypertensive medications at 14 primary care sites. According to the study, 66 percent of the patients filled their prescriptions within 30 days, with the majority doing so on the day the script was received. Patients with lower diastolic blood pressure and those on Medicare were less likely to fill prescriptions within 30 days. The association of primary nonadherence to lower diastolic blood pressure was a key finding, which may have been caused by a lack of urgency from patients to fill their medications because hypertension is asymptomatic. This project demonstrated a unique and forward-thinking approach to use pharmacy-based solutions in order to have a more complete view of a patient’s care.

The Value Institute is building on the project through a CTR Pilot Program grant looking at discharge medications for Christiana Care’s ischemic heart disease population. By identifying predictors for and frequency of nonadherence, researchers are more able to create targeted interventions to prevent nonadherence.

Team-Based Care: Optimizing Primary Care for Patients and Providers

Creating a robust primary care presence in the communities we serve is a strategic priority for Christiana Care as we evolve into a population health-based care system. Re-imagining the way we deliver that care, a group of providers and researchers is working on a novel, redesigned care delivery model meant to improve outcomes and satisfaction for both patients and providers.

With support from the Value Institute, the Primary Care and Community Medicine Service Line is piloting an innovative model of team-based primary care called Patient-Anchored Care Teams (PACT). Under this model, caregivers work in teams to care for a specific group of patients. Each care team includes providers, nurses and dedicated medical assistants and is supported by behavioral health consultants and employees of Christiana Care’s Care Link, a robust information technology-enabled network of care coordination support services that works with providers and patients to optimize outcomes.

The team-based approach allows patients to get to know their assigned teams, and allows each member of the team to practice at the top of their license in daily clinical care. Team members also assume specific oversight roles, such as preventative care or chronic disease management, to improve outcomes for their entire patient panel.

The approach, which is being piloted at four geographically and demographically distinct primary care practices around Delaware, is intended to improve outcomes and lower costs while addressing patient concerns about fragmented, anonymous primary care and provider concerns about low morale and burnout. The Value Institute is helping with program evaluation of the pilot by assessing specific quality metrics and running focus groups to gauge the program’s impact on work satisfaction among PACT members. The focus groups will help provide recommendations for implementation and possible changes to the PACT model.

Kert Anzilotti, M.D., MBA, physician leader in the Neurosciences Service Line, chair of Radiology, and interim president and CEO and chair of the Board of the eBrightHealth ACO and Christiana Care Quality Partners, is an author of a study published in the Journal of the American College of Radiology that reviews the appropriateness of clinicians' orders for high-end imaging.

Radiologist Consultation in High-End Imaging Orders Benefits Patient Safety, Collaboration and Bottom Line

Turning to its own radiologists to review the appropriateness of clinicians’ orders for high-end imaging, Christiana Care is increasing patient safety, fostering new collaboration among its medical teams, and cutting costs at a crucial time in which health care is swiftly moving toward a value-based model.

The results of a year-long study were so notable that the Journal of the American College of Radiology showcased them as its featured article in June.

The idea for the in-house collaboration grew from a review of Christiana Care’s own health care expenses for its employees and dependents. Historically, clinicians’ imaging orders have been reviewed by a contracted radiology benefits manager, said Kert Anzilotti, M.D., MBA, physician leader in the Neurosciences Service Line, chair of Radiology, and interim president and CEO and chair of the Board of the eBrightHealth ACO and Christiana Care Quality Partners.

“We built a homegrown Radiology Department workflow by which we reviewed all CTs, MRIs, and PET scans on outpatients and approved, declined, or recommended an alternate test,” he said.

Data from the 2014-15 fiscal year show that the in-house collaboration resulted in improved measures of patient safety, cost savings and resource use.

The Value Institute partnered with the Radiology Department in the study, evaluating the data and disseminating it in a meaningful way that looked at patient experience, best practices, organizational vitality and appropriate imaging, said Kristen Miller, DrPH, MSPH, associate director of Clinical Human Factors.

“We’re harnessing the power of radiologists not just as people who read the images, but in determining what to image and how,” Miller said.

In the study, 2,177 imaging orders were reviewed by about two dozen radiologists. In 1,887 cases (86.7 percent), the radiologist agreed with the clinician. In 203 orders (9.3 percent), an alternate test was recommended.

In 87 cases (4 percent), the radiologists declined the test. In 20 of those, the clinician either insisted the study be performed or agreed to an alternative. 

In the end, the study found only five cases in which a clinically significant outcome was noted that may not otherwise have been detected by the preliminary studies proposed by the in-house radiologist.

CALL FOR APPLICATIONS
Student applicants encouraged to apply for Value Institute mentored research internships

The Value Institute is accepting applications for two of the newest additions to its student internship program: the Seema S. Sonnad Memorial Fund for Young Investigators Student Internship and the Value Institute Harrington Fund Student Research Scholarship.

The Seema S. Sonnad Memorial Fund for Young Investigators was established in 2015, in memory of the Value Institute’s former director of health services research, to foster future Innovatives and scientific discoveries through the development of young researchers interested in health services and clinical research. The internship is open to recent graduates from a bachelor’s or master’s degree program who intend to pursue a career in health services research. The selected intern will be expected to dedicate 30 hours per week for a full six months on a mentored research project at the Value Institute. At the end of the internship, the intern will be expected to present their work at a Value Institute-sponsored venue. 

The Harrington Fund Student Research Scholarship was established in 2015 to encourage under-represented minority undergraduates to pursue clinical and translational research. Applicants must be Delaware residents or attend a Delaware college or university. Selected students will work with researchers at the Value Institute, supported by physicians and staff at the main Christiana Care campus, to conduct clinical research. They will be expected to dedicate 20 to 30 hours per week on a mentored research project. A yearlong commitment is desirable but not required. At the end of the internship, the awardees will be expected to present their work at a Value Institute-sponsored venue. 

The application deadline for both programs is March 15, 2017, and the internships begin in June 2017. For more information or to apply for the Seema S. Sonnad student internship, email Kim Williams. For more information or to apply for the Harrington Fund student research scholarship, email Kristen Miller.

New Scholars

		Michelle L. Collins MSN, APRN, CNS, RN-BC, ACNS-BC, LSSBB Director, Magnet Recognition Program®
		Vinay Maheshwari, M.D., MHCDS, FCCP Vice Chair, Department of Medicine Associate Physician Operations Lead, Acute Medicine Service Line
		Megan Lane-Fall, M.D., MSHP Assistant Professor of Anesthesiology and Critical Care at the Perelman School of Medicine Senior Fellow, Leonard Davis Institute of Health Economics, University of Pennsylvania
		Megan Wenner, Ph.D. Assistant Professor, Kinesiology & Applied Physiology, College of Health Sciences, University of Delaware

Getting Involved

The Value Institute is built on a model of high-level collaboration. The Value Institute partners with academic institutions, corporations, health care professionals, and thought leaders who share our commitment to improving health care value and delivery by turning evidence into reality. We cultivate relationships with patients, clinicians, sponsors, and professional colleagues who recognize the importance of improving health care delivery and health outcomes, organizational excellence, and quality and safety. 

You can partner with the Value Institute on collaborative research, including clinical trials, database studies, and demonstration projects. Christiana Care providers can connect with the Value Institute by submitting a Consultation Request. One of our team members will then contact you to discuss your research plans. Value Institute staff members are actively involved in 108 research projects in a variety of disciplines.


Contact: Email Lisa Marie Maturo or call 302-733-2071.

Awards

Dominique Comer, Pharm.D, M.S. senior clinical researcher at the Value Institute; Mitch Fawcett, MBA, senior systems engineer at the Value Institute; Pan Wu, Ph.D., senior biostatistician at the Value Institute; and Dani Mosby, MPH, research associate at the Value Institute received a Delaware CTR Pilot Program Grant for the project “Utilizing Linked Pharmacy Claims to Understand Primary and Secondary Nonadherence." The team will be mentored by Dan Elliott, M.D., MSCE, FACP, medical director of Quality Partners and the Quality Partners Accountable Care Organization and a Value Institute Scholar and William Weintraub, M.D., MACC, FAHA, FESC, Christiana Care Principal Investigator of the Delaware CTR.

Kristen Miller, DrPH, associate director of Clinical Human Factors at the Value Institute; Ryan Arnold, M.D., Emergency Medicine and clinical investigator at the Value Institute; and Muge Capan, Ph.D., associate director of Health Systems Optimization at the Value Institute received a Delaware CTR Shovel Ready Pilot Program Grant for the project “Sepsis Shadowboxing: Teaching through Insights." The team will be mentored by J. Sanford (Sandy) Schwartz, M.D., Leon Hess Professor in Internal Medicine at the Perelman School of Medicine and Professor of Health Care Management at The Wharton School of the University of Pennsylvania.

Tze Chiam, Ph.D., associate director of Research Informatics at the Value Institute, partnered with a multidisciplinary team including clinical staff, medication history technicians, clinical pharmacists, and the Virtual Education and Simulation Training Center on the project “Medication History Technicians Invade ED”, receiving the Christiana Care Way Learning Award (Silver).

Selected Publications

Manta CJ, Caplan R, Goldsack J, Smith S, Robinson E. The impact of health information technologies on patient satisfaction. American Journal of Accountable Care. 2016 Dec 4(4)9-15.

Gajdosik DA, Rosini JM. The use of desmopressin (DDAVPO) after a nontraumatic intracerebral hemorrhage. Journal of Emergency Nursing. 2016 Nov 42(6):541-543. PMID: 27912810.

Drees M, Gerber JS, Morgan DJ, Lee GM. Research methods in healthcare epidemiology and antimicrobial stewardship – use of administrative and surveillance database. Infection Control & Hospital Epidemiology. 2016 Nov 37(11):1278-1287. PMID: 27572516.

Goldstein N, Burstyn I, Welles SL. Bayesian approaches to racial disparities in HIV risk estimation among men who have sex with men. Epidemiology. 2016 Oct 21. PMID: 27779498.

Selected Presentations

Ivy J, Nataraj N, Capan M, Arnold R.Wilson J. Intervention Strategies for Complex Patients with Sepsis. Presented at: INFORMS Computing Society Conference. 2017 January 15-17. Austin, TX.

Jurkovitz C, Caplan R, Heckler S, Laughery JT, Ewen E. Trends in the Timing of a Second GFR after a First GFR Lower than 60 in a Primary Care Setting. Poster presented at: American Society of Nephrology: Kidney Week Annual Meeting. 2016 November 15-20. Chicago, IL.

Capan M, Hoover S, Glasgow JM, Mascioli S, Jackson. Validation and Implementation of Early Warning System to Synthesize Acuity Clinical Judgement, and Workload. Presented at INFORMS 2016 Annual Meeting. 2016 November 13-16. Nashville, TN.

Howard Smola, S & Miller K. Integrating Mobile Technology into Health Care. Presented at: 9th Annual Regional Conference, Delaware Valley and New Jersey Chapters of HIMSS. 2016 October 19-21. Atlantic City, NJ.

Washio Y, PHumphreys M, Colchado E, Ortiz M, Young R, Kilby LM, Zhang Z, Collins B, Kirby KC. Incentive-based Intervention to Increase Breastfeeding Duration Among Puerto Rican Mothers. Poster presented at: 4th Annual Vermont Center on Behavior and Health Conference. 2016 October 6-7. Burlington, VT.