Enhancing Prehospital Outcomes for Cardiac Arrest (EPOC)
PIs: Mahshid Abir, MD, MSc and Brahmajee Nallamothu, MD
In collaboration with the RAND Corporation, ACRU will be conducting a 4-year study on out-of-hospital cardiac arrest (OHCA), which is a common, life-threatening event that is associated with poor patient outcomes. Only ~30% of patients survive to hospital admission and less than 10% are ultimately discharged alive. Yet as a recent Institute of Medicine (IOM) report highlighted, some communities have been consistently more successful in responding to and treating OHCA than others. While this is largely believed to be due to the adoption of key care processes by emergency medical services (EMS) agencies in the pre-hospital setting, how these processes are actually utilized in routine practice and the underlying factors contributing to their successful implementation is largely unknown. Further, an integrative systems approach that examines the interaction of EMS agencies with other important stakeholders who provide care before and after EMS arrives – such as first-responders (e.g., police, fire) and hospitals – has not been undertaken.
A better understanding and dissemination of strategies to improve care processes employed by high-performing EMS agencies across the continuum of OHCA care is a critical yet unfulfilled step for improving outcomes. Accordingly, the Enhancing Pre-Hospital Outcomes for Cardiac Arrest (EPOC) study will lay the foundation for future quality improvement efforts in OHCA through the following three aims:
- Identify variations in OHCA survival among EMS agencies and communities
- Define system of care ‘best practices’ for OHCA survival
- Validate system of care factors associated with OHCA survival
We will use a sequential mixed methods approach to accomplish these aims. We build on extensive prior work by our investigative team to systematically understand factors associated with delivering optimal care in other emergency settings (mass casualty incidents, heart attacks, in- hospital cardiac arrest) and leverage our team’s multidisciplinary expertise in emergency care, cardiology, clinical epidemiology, and mixed methods research. Findings from this study will be used to construct a toolkit of ‘best practices’ – the EPOC Toolkit – that may be implemented by EMS agencies both within and beyond CARES through key state and national partners to improve OHCA outcomes in communities across the U.S.
Exploring the Impact of Rapid Telehealth Uptake: New Implications of the Digital Divide
PIs: Rama Salhi, MD, MS and Mahshid Abir, MD, MSc
Team members: Neil Kamdar, MS, and Michael O’Leary
The objective of this study is to examine differentials in telehealth uptake related to individual and community characteristics, including the Digital Divide Index (DDI). We will reach this objective through the following aims:
Aim 1. Describe rates of telehealth utilization among safety net patients during the COVID-19 pandemic. We hypothesize that patients will have disparate rates of telehealth utilization based on both individual and structural social determinants of health. Studies published to-date show disparate telehealth utilization based on income, race, and age. We anticipate extension of similar trends along the additional social determinants of heath (SDoH) variables available in OCHIN-ADVANCE and will seek to understand how they may mediate and moderate one another.
Aim 2. Identify geographic patterns of telehealth uptake. We hypothesize that there will be wide geographic variation in telehealth uptake at the zip code level. Further, we anticipate that a significant portion of the variability seen utilizing the SDoH outlined in aim 1 will be mediated by structural factors.
To complete this aim we will use multilevel regression to examine variation in telehealth uptake by neighborhood by assessing zip code level information on income, race, education, and unemployment.
Understanding Patient and Physician Perspectives on Virtual Care During COVID-19
PIs: Timothy C. Guetterman, PhD, and Laurie Buis, PhD, U-M Department of Family Medicine
During the COVID-19 pandemic, virtual care expanded rapidly at Michigan Medicine due to the Centers for Medicare and Medicaid Services reimbursing for telehealth at a larger scale and an effort to keep patients out of ambulatory care settings to prevent further spread of COVID-19. Of particular concern is whether the shift toward virtual care had an effect on healthcare disparities among subgroups of patients. It is well established that some groups (e.g., racial and ethnic minorities, older adults 65+ years of age, individuals with less education, and lower income households) have lower rates of home broadband, smartphone ownership, and patient portal adoption, which directly impact access to virtual care.
The goal of this research is to gain insight into whether the expansion of virtual care at Michigan Medicine created new, or alleviated or exacerbated existing healthcare disparities. This study is aimed at understanding perceptions of different types of virtual care, as well as barriers and facilitators to access, during the COVID-19 pandemic. We propose a mixed methods analysis of reported experiences of Michigan Medicine patients and primary care providers. Although the immediate threat of COVID-19 may have abated in Michigan, virtual care is likely to remain widely available and there is a need to uncover unanticipated healthcare disparities. Evaluating how the expansion of virtual care during COVID-19 impacted subgroups, presents an opportunity for Michigan Medicine to shape future virtual care, develop best practices, and identify new supports to minimize potential disparities in access to and quality of care received.
Identifying Strategies to Boost COVID-19 Vaccine Acceptance in the United States
Project leads: Florian Schmitzberger, MD, MS and Kirstin Scott, MD, PhD
Michigan Medicine: Care Continuum Healthcare Delivery Redesign
Project leads: Mahshid Abir, MD, MSc and Margaret Greenwood-Ericksen, MD, MPH
2020 Migrant and Refugee Child Health Conference
Exploring the Creation of a Sustainable Statewide Network to Address the Acute and Long-Term Health and Social Needs of Immigrant Children in Michigan
- Increase awareness of these children and their unique health, social, educational, and legal needs.
- Explore the building blocks, needed partnerships, and potential funding sources for a sustainable statewide network to address the children’s unmet needs.
1. Welcome and Introduction
2. Human Rights at the Mexican Border
3. Perspectives from Bethany Christian Services and Samaritas
4. Understanding the Legal Status and Legal Needs of Children in Immigration Detention
5. Discussion Panel: Identifying the Acute and Long-Term Unmet Health, Social, Educational, and Legal Needs of Migrant Children in Michigan
6. Immigrant Child Health: Can Academic Pediatrics Optimize Care for a Vulnerable Population
7. Then and Now: History and Policies Around Child Detention Centers in the U.S.
8. Small Group Discussions
MidMichigan Medical Center – Alpena: Rural Healthcare Delivery Redesign
Project leads: Margaret Greenwood-Ericksen, MD, MPH and Mahshid Abir, MD, MSc
In 2008, the concept of the Triple Aim was born – focused on improving the US health care system through simultaneous pursuit of three aims: making care more patient-centered, more cost effective, and improving overall population health. However, many community and rural hospitals have expressed concerns that care delivery innovations will be a significant challenge due to resource limitations, economies of scale and provider shortages.
MidMichigan Health is one of Michigan Medicine’s key affiliations. This strategic partnership expands access to specialty care for patients. MidMichigan Medical Center – Alpena has identified a new area for collaboration with interest in employing innovative, evidence-based approaches to their emergency department (ED) and primary care (PC) settings. The goal is to improve care coordination and promote patient-centered care based on population health management principals. Disease specific focus areas are improvements in chronic disease management and substance abuse.
Researchers and content experts at the University of Michigan Acute Care Research Unit (ACRU) have the expertise to translate scientific evidence to care delivery reform. Through the evaluation of key service lines and the specific break-points and barriers to care coordination and patient-centered care, MidMichigan Medical Center – Alpena’s healthcare delivery redesign aims to improve population health and patient satisfaction.
Michigan Department of Health and Human Services Opioid Overdose Validation
PI: Mahshid Abir, MD, MSc
Everyday, a record number of Americans die of an opioid-involved overdose, bringing devastation to families and communities across the U.S. Lack of appropriate surveillance indicators limit the ability to accurately quantify the opioid epidemic’s scope and severity. Naloxone administration has been proposed as a measure for opioid-related overdose counts due to its application in prehospital and hospital settings to treat overdose (OD).
In collaboration with the U-M Injury Prevention Center and funded by the Michigan Department of Health and Human Services (MDHHS), this project validates naloxone administration by ambulances and emergency opioid overdose-related emergency department (ED) chief complaints as predictors of opioid overdose for the purposes of fatal and non-fatal opioid overdose surveillance. We used emergency medical services (EMS) data and ED data from Washtenaw County, MI, between January 1, 2017 and December 31, 2017 to perform the following two validation steps:
Step 1—Measure the positive predictive value (PPV) and sensitivity of naloxone administration ascertained via data from Washtenaw county’s single paramedic EMS agency as a predictor of opioid overdose.
Step 2—Measure the PPV and sensitivity of ED chief complaints as a predictor of opioid overdose.
Findings from this study will be used to inform opioid overdose surveillance efforts.
Identifying, Comparing, and Disseminating Best Practices to Address the Needs of “Super-Utilizer” Patients
Co-PIs: Paula Lantz, PhD; Peter D. Jacobson, JD, MPH
A subset of people with serious health care and social needs—referred to as “super-utilizers”— account for the majority of public health care expenditures in the United States. Although there recently has been increased attention to this subpopulation of patients, the existing evidence regarding the impact of interventions on health care intentions by this group is limited.
This project investigates Medicaid super-utilizers of health care in Michigan. The research approach includes:
- A statewide survey of strategies currently employed by Michigan acute-care hospitals and Medicaid managed care plans to target the medical and social needs of super-utilizer patients.
- Medicaid claims data analysis to examine patterns of super-utilizer health care experiences for enrollees of all ages.
- Quasi-experimental analysis of the associations between the super-utilizer interventions/strategies in effect at acute-care hospitals, Medicaid managed care plans and the super-utilizer health care experiences for Medicaid beneficiaries.
This is part of a joint effort, funded by the Robert Wood Johnson Foundation (RWJF) as part of the Policies for Action Research Hub at the University of Michigan, which includes the following projects:
- The Role of Pay for Success in Building a Culture of Health, Lead Faculty: Paula Lantz, PhD.
- Building the Evidence for Health in All Policies, Lead Faculty: Peter D. Jacobson, JD, MPH.
- Best Practices for Addressing the Medical and Social Needs of “Super-Utilizer” Patients, Lead Faculty: Mahshid Abir, MD, MSc.
- Advancing the Utility of Policy Simulation Models, Lead Faculty: David Mendez, PhD.
System for Opioid Overdose Surveillance (S.O.S.)
PI: Mahshid Abir, MD, MSc
“The increasing number of deaths from opioid overdose is alarming. The opioid epidemic is devastating American families and communities.” Centers for Disease Control and Prevention Director Tom Frieden, MD, MPH.
In 2015, a record number of Americans died of an opioid-involved overdose, bringing devastation to families and communities in urban and rural communities alike. Now more people in America die from drug overdoses than car accidents.
In response to this alarming public health crisis, the Office of National Drug Control Policy is supporting the development of opioid overdose monitoring systems in High Intensity Drug Trafficking Areas (HIDTA).
In collaboration, the University of Michigan Injury Center and the Acute Care Research Unit are developing and piloting a real-time System for Opioid Overdose Surveillance (S.O.S.) in the Michigan HIDTA counties.
Through connecting overdose and mortality data from regional emergency departments, the Medical Examiner, and Emergency Medical Services (EMS) agencies, the S.O.S. project aims to increase the timeliness and quality of overdose reporting so that regional strategies to reduce fatal and non-fatal overdoses may be developed. The certificate of confidentiality for this project can be found here.
Medical Control Authority (MCA) Assessment Project
PI: Mahshid Abir, MD, MSc
A mixed method study funded by the Michigan Department of Health and Human Services (MDHHS), this project seeks to determine the characteristics of successful MCAs, the oversight entities for emergency medical services in Michigan.
The specific objectives of the project are to:
- Evaluate the quality of MI-EMSIS data, the quality reporting database for pre-hospital EMS care in the state.
- Identify MCA structure, processes, and resources that correlate with successful MCAs.
- Identify community-specific quality measures across Michigan based on regional/local needs and challenges.
- Provide policy recommendations to the MDHHS regarding MCA structure and performance measures.
Investigating Patient-Centered Interventions to Reduce Asthma-Related Pediatric Hospitalizations
PI: Mahshid Abir, MD, MSc
A mixed method study funded by the Emergency Medicine Foundation (EMF), this community-based participatory research (CBPR) project was initiated by community stake-holders in Camden, New Jersey, who recognized that lack of access to timely, effective ambulatory care is contributing to poor care management for asthmatic children and increasing pediatric asthma-related hospitalizations.
In response to this community need, the Camden Coalition of Health Care Providers (CCHP)—an organization dedicated to improving the health of the residents of Camden by increasing the capacity, quality, and accessibility of care—is partnering with the University of Michigan and the RAND Corporation to investigate evidence-based interventions to reduce potentially avoidable asthma-related pediatric hospitalizations by improving the quality of and access to ambulatory pediatric care.
The objective of this project is to support parents and other caregivers of children in obtaining healthcare in ways that work for them and that improve outcomes they care about.
The specific objectives of this project are to:
- Identify geographic clusters of children with distinct patterns of asthma-related emergency department visits and hospitalizations.
- Identify promising interventions thought to be effective in reducing potentially avoidable pediatric asthma-related hospitalizations through eliciting the views of patients, parents, and other caregivers of children about the perceived effectiveness and acceptability of candidate interventions.
- Arrive at a consensus set of patient-centered interventions to reduce potentially avoidable pediatric asthma-related emergency department visits and hospitalizations.
The Effect of Inpatient Occupancy on Outcomes for Elderly Medicare Patients
PI: Mahshid Abir, MD, MSc
This project is funded by the National Institute on Aging (R21) and includes researchers from the University of Michigan and RAND Corporation. Hospital crowding is a fundamental challenge confronting the U.S. healthcare systems. Most studies on crowding focus on the emergency department (ED), showing increased mortality, reduced care quality, and impaired access to care during periods of crowding. Few studies have examined the effect of a surge in admissions, high inpatient occupancy, and increased demand for resources on outcomes in the inpatient setting, and these showed mixed results.
To fill this knowledge gap this ongoing project evaluates the impact of increasing inpatient occupancy on outcomes for older Medicare patients discharged from acute care facilities in California (CA) with a primary diagnosis of myocardial infarction, congestive heart failure, and pneumonia over the years 1998-2012. Past research has shown that annual bed reports, which do not account for day-to-day variation in patient volume and within-year changes in bed supply, are not a reliable measure of hospital capacity. Therefore, we constructed a novel measure of hospital occupancy to evaluate the impact of inpatient occupancy on outcomes.
We found that increasing hospital occupancy is associated with decreased in-hospital mortality, increased 30-day out-of-hospital mortality, and decreased 30-day readmissions and ED visits. Furthermore, we found significant variation in the occupancy-outcome relationship at the hospital level.
The long-term goal of this work is to inform hospital administrators and policymakers about the potential adverse effects of hospitals operating at high occupancy levels and the need to identify areas where interventions may be implemented to promote safer clinical practice, improved quality of care, and better patient outcomes.
National Health Security Strategy Development Implementation, and Evaluation Support Services
PIs: Jeffrey Wasserman, Ph.D.; and Jeanne Ringel, Ph.D.
Dr. Abir has been an integral part of teams of RAND researchers who developed the hospital and healthcare coalition surge tools, tools that measure hospital and healthcare coalition capabilities to surge in response to large mass casualty incidents (MCIs) and disasters. She also contributed to the development of the Peer Assessment of Preparedness Activities (PAPA) Tool – a tool that evaluates the responses to MCIs as a way to identify those preparedness activities that are most effective to a successful community response to inform federal preparedness policy and investments.