Game changer: Patients of doctors who played online game had better control of blood pressure

Boston, MA – Primary care providers who engaged in an online game to solve clinical cases about hypertension management improved blood pressure control of their patients in a shorter amount of time compared to non-gamers, according to a new study by researchers at Brigham and Women's Hospital (BWH) and the Veterans Affairs Boston Healthcare System.

The study was published May 20, 2014 in Circulation: Cardiovascular Quality and Outcomes.

"This study is the first to show that an online educational game among medical professionals can improve the health measures of their patients," said Alexander Turchin, MD, MS, director of Informatics Research, BWH Division of Endocrinology, co-lead study author.

Leveraging spaced education, a learning concept in which students may significantly increase knowledge retention if information is presented and reinforced over spaced intervals of time, researchers found that primary care clinicians who participated in an online spaced-education game developed by B. Price Kerfoot, MD, EdM, staff surgeon, Veterans Affairs Boston Healthcare System, lead study author, improved their knowledge of managing high blood pressure and generated a modest but significant decrease in the time it took for their patients with high blood pressure to reach their blood pressure target.

A two-arm, randomized trial was conducted during the course of a little over a year among primary care clinicians at eight Veterans Affairs hospitals in the Northeast United States. Clinicians were randomized to either a group that received educational content about lowering blood pressure in the form of an online game vs. a group who received identical content via a static online posting. One hundred eleven clinicians enrolled in the study. Of those enrolled, 48 completed the trivia game while 47 completed the readings of the online posting.

Educational content consisted of 32 validated clinical cases followed by multiple-choice questions with explanations on hypertension management. Those in the online game group were e-mailed one question every three days. Questions were re-sent in 12 or 24 days if answered incorrectly or correctly, respectively. A question was retired when clinicians answered it correctly twice consecutively. The game would post clinician scores to foster competition.

Primary outcome measured was time to reach blood pressure target (less than 140/90 mm Hg). In multivariable analysis of 17,866 hypertensive periods among 14,336 patients, the researchers observed a modest decrease in the time to achieve target blood pressure values in patients treated by clinicians in the online game group.

Researchers found that patients of clinicians playing the game lowered their blood pressure to their target level in 142 days compared to 148 days for those whose clinicians read an online posting.

The number of clinicians who had to participate in the game to achieve target blood pressure in one more patient was 0.43 (i.e., for every four clinicians who participated in the game, approximately 10 more patients achieved target blood pressure).

According to the researchers, anyone can enroll in the spaced-education game for free at Qstream (http://qstream.com/vabpgame), a start-up company launched by Harvard to develop and disseminate the spaced-education methodology outside of its firewalls.

"Based on our findings, educational games may be effective tools to engage health professionals, boost learning, optimize practice patterns, and improve patient outcomes," said Turchin. "We hope that future studies continue to focus on figuring out how to most effectively integrate games into the education of health professionals for the benefit of their patients."

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This research was supported by the Research Career Development Award Program and research grant from the Veterans Affairs Health Services Research and Development Service, the American Urologic Association Foundation, Astellas Pharma US Inc., Wyeth Inc., and the National Institutes of Health (K24 DK63214, R01 HL77234).

Brigham and Women's Hospital (BWH) is a 793-bed nonprofit teaching affiliate of Harvard Medical School and a founding member of Partners HealthCare. BWH has more than 3.5 million annual patient visits, is the largest birthing center in Massachusetts and employs nearly 15,000 people. The Brigham's medical preeminence dates back to 1832, and today that rich history in clinical care is coupled with its national leadership in patient care, quality improvement and patient safety initiatives, and its dedication to research, innovation, community engagement and educating and training the next generation of health care professionals. Through investigation and discovery conducted at its Brigham Research Institute (BRI), BWH is an international leader in basic, clinical and translational research on human diseases, more than 1,000 physician-investigators and renowned biomedical scientists and faculty supported by nearly $650 million in funding. For the last 25 years, BWH ranked second in research funding from the National Institutes of Health (NIH) among independent hospitals. BWH continually pushes the boundaries of medicine, including building on its legacy in transplantation by performing a partial face transplant in 2009 and the nation's first full face transplant in 2011. BWH is also home to major landmark epidemiologic population studies, including the Nurses' and Physicians' Health Studies and the Women's Health Initiative. For more information, resources and to follow us on social media, please visit BWH's online newsroom.

Redefining the language of health care

THE PODIUM

By Wayne Lowell

JUNE 10, 2013

Providing health care to the poor increasingly means providing health care to non-English speakers, and that’s a challenge that is about to get more challenging.

According to the US Census, more than 55 million people speak a language other than English at home. In Massachusetts, the number is 1.2 million. In the City of Boston, one in three residents speak another language.

At Cambridge-based Senior Whole Health, which provides health care to people who quality for both MassHealth and Medicaid and is known as a Senior Care Options plan, two out of three of our members do not speak English. The number of languages spoken by our membership is more than 30.

Navigating our complicated health care system is a challenge for anyone. For a non-English speaking person, the task is overwhelming – and can be deadly.

Non-fluency in English is associated with lower use of preventive services, higher utilization of expensive emergency room care, less ability to self-manage chronic diseases – and higher mortality, according to the Journal of the American Medical Association. In fact, according to JAMA, reading fluency is a more powerful variable than education for examining the association between socioeconomic status and health.

Navigating the system will get even more complicated next year when individuals and small businesses will be required to purchase health insurance under federal health reform. That will require them to compare and contrast various private health insurance policies through exchanges set up by the new law.

Meanwhle, immigration reform could add another seven million people, many of them not fluent in English, to Obamacare.

But there is a path to success. We have already helped over 10,000 people successfully navigate the health care system. Our model provides all-inclusive care directed by a case manager who provides one-stop shopping for the patient and his or her family in their native language. We emphasize preventive care and provide non-medical services, such as bilingual exercise classes, that support a healthy lifestyle.

Not only is this model keeping people healthier, but it’s saving taxpayer dollars by keeping poor seniors out of nursing homes longer and reducing hospital admissions by 25 percent, according to a study conducted for MassHealth.

Providing health care to the poor will require a new mindset about how to deliver — and define — health care.

Wayne Lowell is president and CEO of Senior Whole Health.

The Next Generation of “Patient-Centered”

5/24/2013 – By Kameron Gifford, CPC

Imagine a sustainable model of healthcare that could “touch” and engage every consumer. A system created for the patient and delivered on their own terms; a continually evolving structure that could simultaneously satisfy all the needs of patients, providers and payers. A design in which each stake holder adds value to the next.  This next generation of care will continue to be centered around the patient’s individual needs, but directed by them as well.

Shifting From Patient Centered to Patient Directed

Every small business owner in America intimately understands the inherent connection between their customers and success. There is an art to successfully being able to predict and meet consumer needs. This consumer knowledge is powerful and history has proven that enough power in the right environment, will disrupt.

Close your eyes for a moment and think about the last time that you, a family member or friend was sick or injured. Do you remember trying to navigate through the current system? Perhaps you were seen in the Emergency Room or were admitted to the hospital. Either way, if you are eligible for Medicare, you were probably given strict instructions to follow up with your PCP and probably had an appointment before leaving the hospital.

Just as you were instructed (or your friend, or relative were), you made your follow up appointment and even remembered your discharge papers. When the nurse calls you in and asks, “What brings you in today?” You don’t tell her about how your son had to call in sick to bring you in because he will get fired if he misses another day; or about how you had to leave the house 2 hours early because you can only make it a few feet in your walker before having to take a quick break on the seat or about the stress of the medical bills that you won’t be able to pay.  Ten minutes later, when the Doctor finally comes in he tells you that he has no notes from the hospitalist and without those, he has nothing to reconcile.  After quickly scribbling a note for the girls to get records he says, “See you next week.”

Four hours after leaving you are finally back home. Exhausted and turned off by the system.

Managed Care plans attempt to reduce cost by “tightening” the network. This 3 day follow up rule is meant to reduce cost and improve outcomes through medication reconciliation. Great idea; in theory. Medicine is not one size fits all. This “72 hour rule” may work great for a 45 year old diabetic who is admitted for elective surgery, but what about the 96 year old who was just discharged from rehab after open heart surgery or the 73 year old that fractured their hip?

How will this negative experience influence the Consumer’s interaction with the system in the future? Will the patient feel up to making the journey again next week? Will transportation be an issue?

More times than not, this experience does have an effect on the consumer and when they do return, it won’t be for 2-3 weeks; thus perpetuating the cycle of readmissions.

Medication reconciliation is a great solution to reducing hospital readmissions, but if the solution is not meaningful to the patient then it will never be effective.

Now, close your eyes again and think about this same visit, but this time in the context of the future… directed by the patient.

This follow up visit could have taken place in the patient’s home, from their desk at the office, from their smart phone or in the PCP’s office. The consumer’s “personal” health team would already know the patient’s history because her admit to the hospital would have alerted the on-call “Transition Specialist” who worked with her PCP.  And if the patient still decided to go into the office, the visit would have included a live comprehensive follow up with the “whole team.” One where the cardiologist and the hospitalist would be included in the visit. Real time, shared decision making across the entire continuum of care – all in the presence of the patient.

The magic of all this does not lie in the LCD screens that vividly display the multiple specialist coordinating care in unison from around the world.

It doesn’t lie in the better outcomes, greater engagement or tremendous savings, but instead it is in the simplicity of the solution.

 This transparent care coordination translates to knowledge, and this knowledge then becomes the power that drives the system.  True Innovation.

What Health Insurance Doesn’t Do

By ROSS DOUTHAT

IN one of the most famous studies of health insurance, conducted across the 1970s, thousands of participants were divided into five groups, with each receiving a different amount of insurance coverage. The study, run by the RAND Corporation, tracked the medical care each group sought out, and not surprisingly found that people with more comprehensive coverage tended to make use of it, visiting the doctor and checking into the hospital more often than people with less generous insurance.

But the study also tracked the health outcomes of each group, and there the results were more surprising: With a few modest exceptions, the level of insurance had no significant effect on the participants’ actual wellness.

Needless to say, experts have been arguing about what the RAND results mean ever since. But the basic finding — that more expensive health insurance doesn’t necessarily lead to better health — just received a major boost. The state of Oregon expanded its Medicaid program via lottery a few years ago, and researchers released the latest data on how health outcomes for the new Medicaid users differed from those for the uninsured. The answer: They didn’t differ much. Being on Medicaid helped people avoid huge medical bills, and it reduced depression rates. But the program’s insurance guarantee seemed to have little or no impact on common medical conditions like hypertension and diabetes.

As liberals have been extremely quick to point out, these findings do not necessarily make a case against the new health care law, which includes a big Medicaid expansion as well as subsidies for private insurance. After all, the first purpose of insurance is economic protection, and the Oregon data shows that expanding coverage does indeed protect people from ruinous medical expenses. The links between insurance, medicine and health may be impressively mysterious, but staving off medical bankruptcies among low-income Americans is not a small policy achievement.

This is true. But it’s also true that the health care law was sold, in part, with the promise (made by judicious wonks as well as overreaching politicians) that it would save tens of thousands of American lives each year. There was so much moral fervor on the issue, so much crusading liberal zeal, precisely because this was not supposed to be just a big redistribution program: it was supposed to be a matter of life and death.

But if it turns out that health insurance is useful mostly because it averts financial catastrophe — which seems to be the consensus liberal position since the Oregon data came out — then the new health care law looks vulnerable to two interconnected critiques.

First, if the benefit of health insurance is mostly or exclusively financial, then shouldn’t health insurance policies work more like normal insurance? Fire, flood and car insurance exist to protect people against actual disasters, after all, not to pay for ordinary repairs. If the best evidence suggests that health insurance is most helpful in protecting people’s pocketbooks from similar disasters, and that more comprehensive coverage often just pays for doctor visits that don’t improve people’s actual health, then shouldn’t we be promotingcatastrophic health coverage, rather than expanding Medicaid?

Liberals don’t like catastrophic plans because, by definition, they’re stingier than the coverage many Americans now enjoy. But this is where the second critique comes in: If the marginal dollar of health care coverage doesn’t deliver better health, isn’t this a place where policy makers should be stingy, while looking for more direct ways to improve the prospects of the working poor? Some kind of expanded health security is clearly a good thing — but if we want to promote economic mobility as well, does it really make sense to pour about a trillion dollars into a health care system that everyone agrees is deeply dysfunctional, when some of that money could be returned to Americans’ paychecks instead?

There are a variety of ways this could be accomplished — a bigger child tax credit for struggling families, a payroll tax cut to boost workers, an expanded earned-income tax credit to raise wages at the bottom, health savings accounts that roll over money left unspent. In each case, the goal would be to help people rise by giving them more money and more options for what to do with it, rather than just expanding 1960s-vintage programs that pay medical bills and only medical bills.

It’s to the Republican Party’s great discredit that these policies and goals don’t have enough conservative champions at the moment. But it’s to liberals’ discredit that they remain wedded to the dream of a health care bureaucracy that pays and pays and pays, when in all likelihood we could be spending much less with similar results, and finding better ways to help the poor.