Practically Speaking
December 2021

At the end of 2021, Donaghue announced its five most recent awards in the Greater Value Portfolio grant program, with a total investment of over $2.1 million for this year’s cycle. This program funds research projects for two years with a maximum amount of $400,000 per award (plus a 10% indirect) for the purpose of advancing promising approaches to achieve a higher value healthcare system. The goal of this program is to test approaches and tools that organizations can readily use to improve the value of the healthcare they provide to patients and communities. In addition, applicants must partner with an organization that delivers healthcare services or be a researcher based in a research unit embedded in a healthcare organization.

William Dale, MD, PhD
City of Hope
“Geriatric Assessment-Drive Supportive Care Interventions to Reduce Low-value Care in Older Adults with Cancer in the Community”
Partnering organization: City of Hope (multiple campuses)

The majority of cancer patients and survivors are older than 65. The validated Geriatric Assessment (GA), developed largely at the City of Hope (COH) in conjunction with the Cancer and Aging Research Group (CARG), per ASCO, has become the standard of care (SOC) for older patients with cancer. Two recent large studies have shown the value of GA-guided interventions on important outcomes in older adults with cancer. The goal of this project is to assess the value of our proven GA-directed multidisciplinary intervention for older adults (65+), called the Geriatric Assessment-Driven Intervention (GAIN), adapted to a community oncology setting, including early supportive care, and delivered via telemedicine, called GAIN-S. They propose to test the impact of GAIN-S on advanced directives and costs, as well as determine outcomes of the earlier implementation of the GAIN-S versus SOC and delayed implementation. The partnering organizations are the COH’s main academic campus and two oncology community practices within the COH network in Southern California. Building upon their preliminary data, which has shown that their telemedicine-based intervention GAIN-S is feasible, that it can significantly improve advanced directive completion, and that earlier implementation of supportive care reduces the length of hospitalizations and costs in an academic setting, they will test the value of the intervention (including costs) when implemented in a community setting. If it proves to be valuable, they will implement it widely across the full COH community network, which currently constitutes 31 different sites. In addition, they will disseminate the findings across our CARG (inter)national network.

Rachel L. Epstein, MD, MSc
Boston Medical Center
“Cost-effectiveness and Clinical Outcomes of Liver Disease Staging Evaluations in Chronic Hepatitis C Virus (HCV) Infection: Strategies to Increase Hepatitis C Treatment Access and Achieve HCV Elimination”
Partnering organization(s): National Viral Hepatitis Roundtable, Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV, and the Rhode Island Department of Health

Safe, effective medications to cure hepatitis C virus (HCV) exist, but with their high price tag and limited resources, US insurers erect significant barriers to limit their use. Liver disease (fibrosis) staging required by many insurers, depending on the test chosen, may cause unnecessary short-term costs and may increase long-term costs for individuals lost to follow-up before completing an off-site test. This project seeks to 1) determine current fibrosis staging requirements across representative state Medicaid and commercial payers, 2) measure real-world costs of HCV staging and treatment, plus clinical outcomes from staging misclassification, and 3) compare the clinical- and cost-effectiveness of staging strategies employed to determine which yield the best value for each payer. For Aim 1, they will partner with the National Viral Hepatitis Roundtable (NVHR), an organization experienced in surveying Medicaid programs to determine HCV treatment restrictions. In Aim 2, they will partner with the Center for Health Economics of Treatment Interventions for Substance Use Disorder, HCV, and HIV (CHERISH) and the Rhode Island Department of Health (RIDOH) to obtain Medicaid costing data. In Aim 3, all partner organizations will help them to disseminate findings to engage local and national stakeholders, and RIDOH will integrate findings into their HCV Elimination Strategy, which includes initiatives to support policy to improve HCV care access, educate providers, and increase low-threshold HCV testing and treatment services. Implementation of the most cost-effective strategies for fibrosis staging will improve value in healthcare and reduce barriers to care to eliminate HCV in the United States.

Mark D. Neuman, MD, MSc
University of Pennsylvania
“Accelerating de-adoption of low-value care for older surgical patients through behavioral economics and patient empowerment”
Partnering organization: US Anesthesia Partners

Over 21 million surgical procedures take place among adults aged 65 and older in the US each year, and many older surgical patients in the US now receive benzodiazepines (e.g., midazolam, lorazepam) during anesthesia care. This occurs despite recommendations from the American Geriatrics Society to avoid these medications in older surgical patients due to associated medical risks and lack of demonstrated benefit in high-quality studies. In other words, much current benzodiazepine administration to older surgical patients is likely to represent low-value care that is a suitable target for de-adoption. They propose to test 3 low-cost interventions to support the de-adoption of this practice: (1) smartphone-delivered clinician “nudges” incorporating peer comparisons; (2) education-based patient empowerment; and (3) both interventions combined. They hypothesize that these interventions will reduce rates of benzodiazepine administration compared to usual care while improving patient satisfaction, reducing rates of adverse events, and decreasing preventable care utilization after surgery. The interventions will be tested in a 2×2 factorial stepped-wedge cluster randomized trial enrolling 300,000 patients aged 65 and older across 394 hospitals and ambulatory surgery centers in 8 US states served by the Partner Organization, US Anesthesia Partners (USAP, Dallas TX), a large national private medical group. This project will produce definitive and immediately actionable information that will accelerate the de-adoption of a widespread, low-value practice. It will provide a model for future studies by employing innovative mobile technologies and patient-empowerment strategies and by leveraging a novel academic-private partnership to establish a new practice-based research network.

Anna Sick-Samuels, MD, MPH
Johns Hopkins University
“Reducing overuse of respiratory cultures and antibiotic use in mechanically ventilated children across a national pediatric critical care collaborative”
Partnering organization(s): Children’s Hospital of Philadelphia and Boston Children’s Hospital

The number of children living with mechanical ventilation who are at risk for developing ventilator-associated infections (VAIs) is rising. Frequently, clinicians use respiratory cultures to help diagnose VAIs, however, the respiratory tract is not sterile and the growth of bacteria in these cultures is often misinterpreted as evidence of infection requiring antibiotic treatment. Thus, over-testing leads to over-treatment, compounding patient morbidity by promoting antibiotic resistance, antibiotic-associated adverse events, and increasing healthcare costs in chronically and critically ill children. In a pilot program at the Johns Hopkins Hospital pediatric intensive care unit (PICU), they demonstrated that clinical decision support tools successfully reduced respiratory culture use, antibiotic treatment for VAI and led to cost savings without negative impacts on clinical outcomes. Partnering with investigators at Children’s Hospital of Philadelphia and Boston Children’s Hospital, they will guide 15 PICUs to implement tools improving respiratory culture practices. These hospitals are part of the Johns Hopkins-led Bright STAR collaborative, a national quality improvement collaborative that includes over 15 diverse PICUs who have previously worked together to reduce blood culture overuse in critically ill children. The goal of this study is to assess the impact of clinical decision support tools to improve the evaluation of VAIs and reduce testing and treatment overuse among critically ill children across a national PICU collaborative and inform reproducible implementation strategies. Using a mixed-methods approach, they will assess the impact on respiratory culture use, antibiotic use, and clinical outcomes, and identify facilitators and barriers of successful implementation to inform tools for broader dissemination.

Cassandra Thiel, PhD
NYU Grossman School of Medicine
“Increasing Value through Optimized Cataract Surgical Care Pathways and Supply”
Partnering organization: NYU Langone Eye Center

Cataract surgery is one of the most commonly performed procedures in the world. Yet in the US, extraneous steps and wasted surgical supplies add unnecessarily to provider and patient costs. While ophthalmologists recognize these challenges, little research has been conducted to identify and establish best practices to improve the value of cataract surgery and other surgeries. This study seeks to test value-improvement interventions in cataract surgery, analyzing the clinical, financial, and environmental impacts of various interventions. Using both qualitative and quantitative methods, they will track the reception towards and impact of various value improvement interventions to establish best practices to control expenses and decrease waste. Their project partner is the NYU Langone Eye Center, a state-of-the-art eye care treatment facility that performs over 5,000 procedures annually. Researchers will observe Eye Center administrative and clinical activities; identify and pilot supply and pathway optimization strategies; interview Eye Center leaders, clinicians, and staff; analyze qualitative data for common themes indicating barriers or facilitators to implementing specific strategies; and measure and analyze costs, waste, environmental emissions, and clinical outcomes before and during pilot testing. By documenting the drivers and barriers to successful implementation, they hope to elucidate clearer pathways towards sustainability for surgeons and surgical facilities across the US. This research will be disseminated within the NYU Langone Health system and through national ophthalmic organizations to promote and aid in the adoption of emerging best practices.