Category Archives: Uncategorized

Communicating with Patients with Hearing Loss

Provider Efficiency, Uncategorized

Poor compliance with healthcare provider advice for health and wellness actions is a growing issue. For older patients, hearing loss may contribute to lack of adherence with provider guidance.

BACKGROUND

The U.S. Census Bureau projects that by 2035, there will be 78 million people who are age 65 and older[i]. Research[ii] shows that nearly half of those 65 years of age and over have hearing loss, with age as the greatest predictor of hearing loss for adults between 20 and 69 years of age[iii]. Of these, about a third have significant hearing loss. However, most people over age 60 do not receive testing for hearing loss[iv].

Hearing loss negatively impacts multiple aspects of patients’ lives by creating communication barriers. A University of Manchester study[v] showed that people with hearing loss understand about 21 percent of speech. Use of either a hearing aid or speechreading[1] results in comprehension increasing to 64 percent. If both of these aids are used, comprehension increases to 90 percent; however, less than 30 percent of those 70 and older who could benefit from a hearing aid use them.[vi] Given the significant increase in understanding by use of hearing aids, why do people avoid the use of this readily accessible tool?

Aging is often stigmatized in U.S. culture, which can contribute to avoidance of addressing common physical deficits of aging, including hearing loss.  Hearing aids can be perceived as an outward, visible sign of aging and impairment. Johns Hopkins research shows the average adult waits 15 years to address hearing loss[vii]. Additionally, assistive devices are expensive, not covered by most insurances, and can be seen as a low priority expense for those on a fixed income. These factors contribute to patients not using hearing aids and thereby not understanding what their provider is communicating in the office visit.  Other negative impacts to health include a link between hearing loss and increased falls, physical and cognitive decline, brain shrinkage, and increased risk of dementia[viii].

APPROACHES

Once impaired hearing has been identified and where providers are part of a larger integrated health system or practice, a patient Electronic Medical Record or database and tools may be available to provide reporting that identifies patients with hearing loss or risk factors for impaired hearing. Desktop applications or manual processes are alternative options, although less efficient. Examples of data that can be informative include patient age, history of environmental exposure to loud noise, or existing sensory deficits. Once identified, this information can generate alerts for regular hearing screening.

Alerting practice staff with a chart or system flag for patients with a hearing deficit or risk factors can provide the opportunity for advanced planning for office visits. For example, preparing written materials for those with hearing loss with a larger font can be useful for those with hearing loss and vision deficits as well. Content might include topics such as:

  • May I see your insurance information and picture identification?
  • Do you need a sign language interpreter?
  • Please have a seat and we will let you know when your provider is ready to see you.

Training staff on effective communication techniques for those with sensory deficits can be very helpful for both patient and staff. Approaches include directly facing the person, speaking clearly and a bit more slowly than usual, minimizing background noise, and providing written materials, such as a summary of the treatment plan written at a literacy level appropriate for broad comprehension. Small whiteboards can be helpful to augment communication for both the provider and the hard-of-hearing patient.

By using patient data for proactive identification, the patient visit can result in comprehension of the recommended plan of care and actions by use of planned techniques to address hearing communication barriers.

[1] Speechreading is defined as the act or process of determining the intended meaning of a speaker by utilizing all visual clues accompanying speech attempts, as lip movements, facial expressions, and bodily gestures, used especially by people with impaired hearing. Source: https:// dictionary.com. Accessed 10/17/2018.

[i]United States Census Bureau. (March 13, 2018). Older People Projected to Outnumber Children for the First Time in U.S. History. Retrieved on 5/28/2018 from https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html.

[ii]StratisHealth. (September 2011). Deaf and Hard-of-Hearing Minnesotans. Retrieved on 5/9/2018 from http://culturecareconnection.org/documents/InformationSheet_Deaf.pdf.

[iii]National Institutes of Health, National Institute on Deafness and other Communication Disorders. (December 15, 2016). Quick Statistics About Hearing. Retrieved on 5/25/2018 from https://www.nidcd.nih.gov/health/statistics/quick-statistics-hearing.

[iv]StratisHealth. Ibid.

[v]StratisHealth. Ibid.

[vi]National Institutes of Health, National Institute on Deafness and other Communication Disorders. Ibid.

[vii] Minnesota Commission of Deaf, Deafblind and Hard of Hearing Minnesotans. (December 14, 2017). First-of-its-Kind Pilot Program Aims to Increase Awareness of Hearing Loss Among Older Minnesotans. Retrieved on 5/9/2018 from https://mn.gov/deaf-commission/news/?id=1063-320251.

[viii]Johns Hopkins Medicine. (January 22, 2014). Hearing Loss Linked to Accelerated Brain Tissue Loss. Retrieved on 5/25/2018 from https://www.hopkinsmedicine.org/news/media/releases/hearing_loss_linked_to_accelerated_brain_tissue_loss_.

 

Wasteful Pre-Operative Cardiac Testing Prior to Low-Risk Surgery

, Evidence Based Decision Making, Health Waste Calculator, Medical Management, Uncategorized, Value-Based Care

Anesthesiologists perform pre-operative assessment on all patients undergoing surgery in order to identify any disease or risks to the surgery and to plan perioperative anesthetic care to mitigate surgical risk. In patients with known cardiac disease, diagnostic cardiac tests such as stress tests and echocardiograms are sometimes recommended as part of this assessment.

A recommendation from the American Society of Anesthesiologists notes that pre-operative cardiac stress testing is only appropriate for identifying extremely high-risk patients, in whom the results would change management prior to surgery, change the decision of the patient to undergo surgery, or change the type of procedure that the surgeon will perform. 1 The American College of Cardiology and American Heart Association recommends that there is no benefit for routine pre-operative cardiac testing in low risk surgery for patients with no cardiac disease. 2

For this reason, Milliman MedInsight’s Health Waste Calculator identifies pre-operative cardiac testing for patients undergoing low- or moderate-risk non-cardiac procedures (e.g., surgery cataract, laparoscopic cholecystectomy, corneal transplant, and removal of tonsils) as wasteful. We applied the Health Wast Calculator pre-operative testing measure for one of our clients, a commercial health plan with approximately 850,000 members, using claims data from calendar year 2012. As shown in Figure 1, 2.2% of the 5,120 pre-operative cardiac testing services were wasteful, at a cost of $88,000. Hence, it is recommended that clinicians perform pre-operative evaluation appropriately and reduce distress among patients.

Service TypeNumber of ServicesPercentage of ServicesAggregate Allowed AmountPercentage of Allowed Amount
Total Preoperative Cardiac Testing5,120100%$2,513,987100%
Wasteful Preoperative Cardiac Testing1122.19%$88,0413.50%

It is important to note that claims data alone allows only an approximate identification of wasteful pre-operative cardiac testing. Even so, we were able to confirm instances of pre-operative testing for our client that could help it potentially avoid healthcare costs in the absence of benefit.

For more information on how to identify wasteful services, visit the MedInsight Health Waste Calculator web page.

What a (Low Back) Pain

, Avoidable Admissions, Avoidable Events, Uncategorized, Value-Based Care

Low back pain is a common problem: more than one in four adults surveyed report having had low back pain during the past three months.[1] Though most low back pain resolves on its own, without medical intervention, it remains one of the most common reasons for physician visits.[2]

Imaging tests of the low back, such as plain X-rays, CT scans, or MRIs, commonly show abnormalities—even in asymptomatic people. Evidence of disk abnormalities, such as degeneration, bulging, protrusion, and annular fissure, is present in over 50% of asymptomatic people in their 30s, and in nearly 90% of people aged 60 or older.[3]

This combination creates a situation where people who undergo imaging tests for low back pain may have abnormalities identified that are unrelated to the pain. Additional tests, consultations, drugs, therapies, and procedures—sometimes even major surgery—may cascade from the initial decision to perform imaging. All this for low back pain that may resolve on its own: what a waste!

Milliman’s MedInsight® Health Waste Calculator can identify wasteful imaging practices for low back pain, using an evidence-based algorithm to analyze claims data in order to classify imaging services as “necessary,” “likely wasteful,” or “wasteful.” For one of our clients, a large commercial health plan, we looked at services performed in 2012. Forty-six percent of services were wasteful; 45% were likely wasteful; and only 9% were necessary. The total aggregate allowed cost for low back pain imaging was $3.3 million, of which wasteful imaging accounted for $2.0 million.

With an evidence-based and conservative approach to measuring the cost of wasteful imaging services—one that does not include the costs of the cascade of additional services—the MedInsight Health Waste Calculator identified an important opportunity to address cost and care for low back pain for our client.

For more information on how the MedInsight Health Waste Calculator can identify wasteful services, click here.

[1] Centers for Disease Control and Prevention (2015). Health, United States, 2015: Table 41: Severe Headache or Migraine, Low Back Pain, and Neck Pain Among Adults Aged 18 and Over, by Selected Characteristics: United States, Selected Years 1997-2014. Retrieved December 2, 2016, from http://www.cdc.gov/nchs/data/hus/2015/041.pdf.

[2] Centers for Disease Control and Prevention. National Ambulatory Medical Care Survey: 2012 State and National Summary Tables: Table 11: Twenty Leading Principal Reasons for Office Visits, by Patient’s Sex: United States, 2012. Retrieved December 2, 2016, from http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2012_namcs_web_tables.pdf.

[3] Brinjikji, W., Luetmer, P.H., Comstock, B., Bresnahan, B.W., Chen, L.E., Deyo, R.A., et al. (April 2015). Systematic literature review of imaging features of spinal degeneration in asymptomatic populations. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173. Epub 2014 Nov 27. AJNR Am J Neuroradiol. 2015 Apr;36(4):811-6. doi: 10.3174/ajnr.A4173.