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New Study Finds Improved Outcomes in NICU with Longer Lengths of Stay

September 1, 2016
by Rajiv Leventhal
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Simulation analytics in study debunks myth that shorter NICU stays lower costs

A new study led by Duke University Health System and SAS, a Cary. N.C.-based analytics vendor, has found that for newborns in the neonatal intensive care unit (NICU), longer hospital length of stays are correlated with lower costs and more positive outcomes.

The common belief regarding healthcare spending and health outcomes in the U.S. has been that shorter hospital stays equate to cost savings. But for this study, just published in the Journal of Perinatology, researchers applied a discrete event simulation model of the Duke NICU to predict outcomes and costs using pre-existing study data from the National Institutes of Health Neonatal Research Network (NRN). “Using this model, we debunked what has been a pervasive tenet in healthcare—the belief that if you relentlessly drive down length of stay, you will universally decrease costs,” said one of the study’s lead authors, Chris DeRienzo, M.D., a neonatologist and chief quality officer at Mission Health System, in Asheville, N.C.

“Our evidence shows that’s just not true,” he added. “We found that in a composite NICU with the best possible outcomes, the length of stay actually averages three days longer than in a unit with poor outcomes. However, comparable annual costs are actually $3 million less.”

David Tanaka, M.D., a neonatologist at Duke Children’s Hospital, and study co-lead author, first approached SAS about his interest in simulation modeling in 2012. SAS’ Emily Lada, a principal operations research specialist, later built the model as part of a research project using SAS Simulation Studio 14.1. The model was validated earlier this year in a study published by the Health Informatics Journal. That study used the simulation tool to predict and plan for NICU staffing needs. For the current study, researchers replaced the model’s standard probability distributions with composite distributions representing the best and worst neonatal outcomes published by the NRN.

Discrete event simulation modeling with advanced analytics aims to give organizations a fast, effective and non-intrusive means to perform “what-if” experiments without disrupting their real-world systems, according to SAS officials. Workflow-oriented industries like manufacturing, retail and finance have used discrete event modeling for decades to gauge how different scenarios might affect business operations. Now, a growing number of health systems are adopting the technology, which DeRienzo called “the Rosetta stone” for performance and quality improvement in healthcare settings.

“I think healthcare in 10 years will necessarily look very different from healthcare now, and we’re right in the middle of that transition,” said DeRienzo. “This project is just one example of how we can use innovative analytics tools to improve not only the ways we provide care but the actual care we provide. Analytics has a tremendous role to play in facilitating that transformation—not just in the NICU but across the clinical spectrum.”

Key findings of this study show that, in the composite best virtual NICU:

  • Overall average length of stay (ALOS) was three days longer (27 days versus 24 days). ALOS was 20 days longer (86 days versus 66 days) for infants of 28 weeks or less gestational age.
  • Average cost per patient was actually lower ($16,400 versus $19,700 overall and $56,800 versus $76,700 for infants of 28 weeks or less gestational age).
  • Mortality was more than 75 percent less.
  • Related disorders of prematurity were dramatically lower:
  • Incidence of necrotizing enterocolitis (a rare but devastating intestinal disease among premature babies) were 91 percent lower.
  • Cases of sepsis (a life-threatening bloodstream infection) were nearly 97 percent fewer.
  • Incidence of intraventricular hemorrhage (a bleed inside the brain) were 59 percent lower, hinting at even greater lifetime cost savings for this patient population based on known long-term neurodevelopmental impacts of even low-grade IVH.

“The findings suggest that, being single-mindedly focused on this one measure [average length of stay], executives might actually be missing the boat in reducing costs and improving outcomes,” said Tanaka. “It’s more critically important to focus on quality outcomes—not just because it’s the right thing to do, but also because this is tangible evidence to the CFO that it’s financially the right thing to do.”

Duke’s current NICU simulation tool requires a data scientist to run the models. However, a general user interface currently under development at SAS will make the tool independently accessible to everyday users like medical directors, nurse managers, and hospital administrators. Future iterations of the study’s discrete event simulation model will also be applicable to any NICU in the U.S., officials said.

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/article/analytics/how-data-driven-approach-can-bolster-fight-against-opioid-abuse

How a Data-Driven Approach Can Bolster the Fight Against Opioid Abuse

October 12, 2018
by Steve Bennett, Ph.D., Industry Voice
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I want to tell you about Andy. Andy’s mom, Pam, is a colleague of mine. Growing up an only child, Andy was a happy kid. He was a straight-A student, loved to play the violin, and spent a year as an exchange student in Europe. Andy had two loving parents. But Andy suffered an injury in college, and needed to have some minor surgery performed to repair his sinuses. Following that surgery, his doctor prescribed opioid pain medication for him, to which he became addicted. Despite several years of effort, Andy was unable to shake the addiction, and tragically lost his life to a heroin overdose two years after his surgery. This was a normal kid with a normal family, like mine, and like yours.

Andy’s story is an important story. The opioid epidemic has led to the deadliest drug overdose crisis in the history of the United States, killing more than 64,000 people in 2016 alone – the last year numbers were available. This is a true national epidemic, and one that continues to get worse. For the first time in nearly 60 years, life expectancy for Americans has dropped for two years in a row due to the opioid epidemic.

The opioid crisis has been so difficult to curtail, in part, because of the inability to integrate data from various stakeholders and systems. With so many players and data sources, today’s information is partial, fragmented, and often not actionable.

While this disconnect applies directly to the opioid epidemic it is a systematic problem that affects the healthcare community at large. Better data and analytics can help develop better treatment protocols for a wide array of medical and public health challenges that affect the general public. For opioids, that could be to develop better pain management programs or for better, more-targeted remediation and rehabilitation for those that become dependent on drugs.

A Data-Driven Healthcare Approach: Making Information Real

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Ample data has been collected on the opioid epidemic, but disparate sources are not communicating with one another. Addressing this disconnect and lack of communication is something that can provide researchers, lawmakers and the public with improved insights.

Data-driven healthcare can help provide this guidance by using available data and analytics to help create programs that can make a tangible difference on population areas that need the most help. By looking at the data, lawmakers, hospital administrators and doctors can begin to make impactful changes throughout the system.

While much can be learned from this data, most of it is not being analyzed in a way that brings true benefits. It has been put in a silo and/or it is not organized in a way that is interoperable with other data systems.

The 21st Century Cures Act, which established the Health Information Technology Advisory Committee, shows the commitment of national leaders to improving healthcare information sharing. Analytics can take this data and turn it into something real. Subsequent visualization of this analyzed data presents the information in a way that can truly tell a story, making sense of data that analysts sometimes miss. Analytics can arrange and organize data in different ways and pick up previously undetected trends or anomalies. This information can be turned into real programs that produce real outcomes for those affected.

The data management and integration process can also help us understand where our knowledge gaps are, revealing flaws in data quality and availability. Organizations may learn that they lack sufficient data in a certain area where they want to learn more, but are currently limited. They can then make changes to data collection efforts or seek out different sources to fill these larger gaps. They can resolve data quality issues across systems and arrive at a consistent, reliable version of the truth.

As organizations get better at assembling and managing the data, automating processes to generate standard reports and file exchanges can ease the burden on analysts. Streamlining the user interfaces for prescription drug monitoring programs and other systems allows analysts and medical informatics staff to spend less time working on the data itself and more time enabling and encouraging the use of predictive modeling and “what-if” scenario capabilities.

Helping to Solve a Problem

The national opioid epidemic is a terrible and complex issue. It is not something that can be solved with just one action, approach or program. It is a layered issue that will require systematic changes to how patients are treated and how the healthcare system operates. Some of the nation’s best continue to work on providing operational solutions to these problems, but as the statistics show, they need more help.

A data-driven approach can be that help. Using data analytics to find better and deeper insights into the root problems of this epidemic can help decision-makers make real change. While opioids are the focus now, there will come a day when a new problem emerges. Having data and analytic solutions in place can prepare these organizations to tackle these future challenges as well.

64,000 people died in 2016 as a result of opioid abuse. But 64,000 is more than a large number – it’s also Andy and his family. With analytics and a data-driven approach, government and healthcare leaders can make better decisions that can help people in need.

Steve Bennett, Ph.D., is the director of SAS' global government practice. He is the former director of the National Biosurveillance Integration Center within the Department of Homeland Security


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DOJ Approves CVS-Aetna $69B Merger, On Condition Aetna Divest Part D Business

October 10, 2018
by Heather Landi, Associate Editor
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The Department of Justice (DOJ) has approved a $69 billion merger between mega-pharmacy retailer CVS Health and health insurer Aetna, after Aetna entered into an agreement with the DOJ to divest is Medicare Part D prescription drug plan business.

According to a statement released by the DOJ on Wednesday, the settlement, in which Aetna will sell off its Part D business, was a condition of the merger’s approval and resolves the DOJ’s “competition concerns.”

The deal is the latest in a wave of combinations among healthcare companies, including many pharmacy benefit manager (PBM) and insurer integrations. Last month, the Justice Department approved Cigna’s $67 billion takeover of Express Scripts.

CVS Health announced in early December 2017 its intention to acquire Aetna in a $69 billion-dollar merger, marking the largest ever in the health insurance industry. Woonsocket, R.I.-based CVS operates the nation’s largest retail pharmacy chain, owns a large pharmacy benefit manager called Caremark, and is the nation’s second-largest provider of individual prescription drug plans, with approximately 4.8 million members. CVS earned revenues of approximately $185 billion in 2017. Aetna, headquartered in Hartford, Connecticut, is the nation’s third-largest health-insurance company and fourth-largest individual prescription drug plan insurer, with over two million prescription drug plan members. Aetna earned revenues of approximately $60 billion in 2017.

Following news of the deal back in December, there was speculation that antitrust regulators might not approve the deal. Back in January 2017, a federal judge blocked a merger that would have resulted in Aetna acquiring Louisville, Ky.-based insurer Humana, which at the time was the largest acquisition of its type in the history of health insurance in the U.S., reported at $37 billion. At the time, U.S. District Judge John D. Bates in Washington said that proposed deal would “violate antitrust laws by reducing competition among insurers.” Similarly, a proposed combination of two other health insurers, Anthem and Cigna, was also shot down last year.

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According to the DOJ’s statement issued today on the CVS-Aetna deal, the Justice Department’s Antitrust Division had significant concerns about the anticompetitive effects of the merger with regards to the Medicare Part D businesses. CVS and Aetna are significant competitors in the sale of Medicare Part D prescription drug plans to individuals, together serving 6.8 million members nationwide, according to the DOJ.

In a press release issued today, CVS Health said, “DOJ clearance is a key milestone toward finalizing the transaction, which is also subject to state regulatory approvals, many of which have been granted.” CVS Health's acquisition of Aetna remains on track to close in the early part of Q4 2018, the company said.

“DOJ clearance is an important step toward bringing together the strengths and capabilities of our two companies to improve the consumer health care experience,” CVS Health president and CEO Larry J. Merlo, said in a statement. “We are pleased to have reached an agreement with the DOJ that maintains the strategic benefits and value creation potential of our combination with Aetna. We are now working to complete the remaining state reviews.”

Merlo also said, “CVS Health and Aetna have the opportunity to combine capabilities in technology, data and analytics to develop new ways to engage patients in their total health and wellness. Our focus will be at the local and community level, taking advantage of our thousands of locations and touchpoints throughout the country to intervene with consumers to help predict and prevent potential health problems before they occur. Together, we will help address the challenges our health care system is facing, and we'll be able to offer better care and convenience at a lower cost for patients and payors.”

Following the close of the transaction, Aetna will operate as a standalone business within the CVS Health enterprise and will be led by members of its current management team.

The American Medical Association (AMA), an industry group that has been opposed to the merger, issued a statement saying the agreement that Aetna divest its Part D business doesn't go far enough to protect patients.

"While the AMA welcomes the U.S. Department of Justice (DOJ) requiring Aetna to divest its Medicare Part D drug plan business, we are disappointed that the DOJ did not go further by blocking the CVS-Aetna merger," Barbara L. McAneny, M.D., president, American Medical Association, said in a statement. "The AMA worked tirelessly to oppose this merger and presented a wealth of expert empirical evidence to convince regulators that the merger would harm patients. We now urge the DOJ and state antitrust enforcers to monitor the post-merger effects of the Aetna acquisition by CVS Health on highly concentrated markets in pharmaceutical benefit management services, health insurance, retail pharmacy, and specialty pharmacy."

Agreement with DOJ Resolves “Competition Concerns”

Late last month, Aetna agreed to sell its Part D business to WellCare. According to a Securities and Exchange Commission (SEC) filing from WellCare Health Plans last month, WellCare entered into an asset purchase agreement with Aetna to acquire the company’s entire standalone Medicare Part D prescription drug plan business, which has 2.2 million members. According to the agreement, Aetna will provide administrative services to and retain the financial risk of the Part D business through 2019. In that filing, it states that Aetna is divesting its Part D business as part of CVS Health’s proposed acquisition of Aetna.

“Today’s settlement resolves competition concerns posed by this transaction and preserves competition in the sale of Medicare Part D prescription drug plans for individuals,” Assistant Attorney General Makan Delrahim of the Justice Department’s Antitrust Division, said in a statement. “The divestitures required here allow for the creation of an integrated pharmacy and health benefits company that has the potential to generate benefits by improving the quality and lowering the costs of the healthcare services that American consumers can obtain.”

In its statement, the DOJ referred to WellCare as “an experienced health insurer focused on government-sponsored health plans, including Medicare Part D individual prescription drug plans.”

The Department’s Antitrust Division, along with the offices of five state attorneys general, today filed a civil antitrust lawsuit in the U.S. District Court for the District of Columbia to enjoin the proposed transaction, along with a proposed settlement that, if approved by the court, would fully resolve the Department’s competitive concerns. The participating state attorneys general offices represent California, Florida, Hawaii, Mississippi, and Washington.

In a complaint filed to the U.S. District Court, DOJ attorneys argued that without the divestiture, the combination of CVS, which markets its Medicare Part D individual prescription drug plans under the “SilverScript” brand, and Aetna would cause “anticompetitive effects, including increased prices, inferior customer service, and decreased innovation in sixteen Medicare Part D regions covering twenty-two states.” DOJ attorneys also argued that the loss of competition between CVS and Aetna would result in “lower-quality services and increased costs for consumers, the federal government, and ultimately, taxpayers.”

Under the terms of the proposed settlement, Aetna must divest its individual prescription drug plan business to WellCare and allow WellCare the opportunity to hire key employees who currently operate the business.  Aetna must also assist WellCare in operating the business during the transition and in transferring the affected customers through a process regulated by the Centers for Medicare and Medicaid Services (CMS).

 


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A Data-Driven Effort to Tackle Indiana’s COPD Problem

October 9, 2018
by Rajiv Leventhal, Managing Editor
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One patient care organization in Indiana has leveraged a robust data analytics platform to reduce avoidable COPD readmissions and improve the overall health of the community

Although reduction in avoidable readmissions after chronic obstructive pulmonary disease (COPD)-related hospitalizations is a national objective, in one Indiana community it’s moved its way up to the very top of the healthcare priority list.

In Jackson County, Indiana, the COPD population is roughly two times the national average. And considering that COPD is the third-leading cause of death in the U.S., working to fix the problem has taken precedence at local hospitals—including Schneck Medical Center, a community hospital in Seymour. Says Susan Zabor, vice president of clinical services at the medical center, “We have a high obesity population and a high smoking population, so in Jackson County, COPD is very prevalent. When we looked at our 2014 data, we knew it was an issue and we knew that it was a high-volume diagnosis for us, ranking second in our [hospital] readmissions.”

Indeed, at the time, Schneck Medical Center had a raw readmissions rate of nearly 14 percent for the specific COPD patient population, and these re-hospitalizations were leading to substantial added readmissions costs—upwards of $300,000 per year, according to Zabor. “We needed to put a focused intervention in place,” she attests.

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Susan Zabor

The fines for failure to meet the Centers for Medicare & Medicaid Services’ (CMS’) avoidable readmissions reduction criteria, as part of the government’s Hospital Readmission Reduction Program (HRRP), focus on six conditions: heart attack, congestive heart failure, pneumonia, COPD, elective hip and knee replacements, and for the first time starting in 2016—coronary artery bypass graft surgery. The current focus in the HRRP is on readmissions occurring after initial hospitalizations for these selected conditions, and hospitals with 30-day readmission rates that exceed the national average are penalized by a reduction in payments across all of their Medicare admissions.

As such, it’s clear that in healthcare’s future of value-based care, treating patients outside of an organization’s four walls will be critical to an organization’s success. What’s more, drilling down into the data and being able to specifically predict and target patients who are at high risk for readmissions has become a key point of emphasis for many hospitals.

At Schneck Medical Center, clinical IT leaders launched a data analytics initiative with IBM Watson Health, whereby they were able to analyze treatment patterns, costs, and outcomes data for their own hospital and compare those with peer group hospitals around the country. It was this analysis which showed that Schneck was experiencing much higher than average numbers of complications, readmissions, and patient deaths related to COPD.

Zabor notes that the hospital was “doing well on process measures and publicly-reported measures, but we weren’t doing so well on some bigger issues like complications, mortality and length-of-stay, and we leaned on CareDiscovery [a Watson Health solution] to give us actionable data that was as close to real time as possible to help us improve.”

Using this data, hospital leadership was able to pull together teams focused on closing those gaps. Schneck’s organizational efforts for COPD patients included developing a long-term care practice, which currently includes a physician medical director, a full-time physician, three nurse practitioners and two medical assistants, as well as the hospital’s respiratory care department. This team makes weekly respiratory care visits, incorporates sleep studies into its observations and conducts patient discharge planning. In addition, the hospital put in place new protocols that included the installation of a transition team to help with patient discharge, follow-ups with recently discharged patients, and annual facility education regarding COPD.

Indeed, the data available in the Watson Health’s CareDiscovery solution helped the hospital focus efforts to improve care for COPD patients, eventually resulting in an 80-percent reduction in its unplanned COPD readmission rate and hundreds of thousands of dollars in savings—representing a 99-percent decrease in costs related to readmissions.

“We started doing a better job of managing patients’ chronic illness in whatever setting they were in— be it long-term care, home care, or primary care. Before long, they didn’t need to come into the hospital,” Zabor says. To this end, the hospital also witnessed a 55-percent decrease in patients admitted with a COPD diagnosis from 2014 to 2017. Zabor notes that reducing primary admissions actually was an unplanned result of the organization’s efforts, but one they were happy with nonetheless.

As many hospitals and health systems remain in a position today in which they are straddling two payment worlds—fee-for-service and pay-for-performance—one might ponder if it’s truly in the organization’s best interest to keep patients away. But Zabor says that for Schneck Medical Center’s executive leadership, it was never a question. “For our patients and our community, keeping them out of the hospital is the best thing to do, whether you are making money or not,” she says.

“Zabor adds, “We [do have] one foot in value and one in volume, which is difficult, but we have a patient-first culture here. Yes, have a finance pillar, but it does not overpower our quality of care or customer experience pillars, which all support that patient-first culture.”

 

 


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