Last week, our Quality Matters blog took a speculative look towards the future of quality care in cardiology, but no look forward would be truly complete without a retrospective look back at the momentous events of the past eight months and a consideration of the COVID-19 impact on care and quality in health care.
Over the past eight months, the challenges we face – as individuals, within our families, as colleagues – have evolved. Their evolution has prompted changes in our approaches to meet them, as well as in our measures of success. In the case of the Covid-19 pandemic, our attempts to meet the challenges before us have taught us many lessons.
“Leadership is a series of behaviors, rather than a role for heroes.”Margaret Wheatley
These two blogs explore the complexities of organizational change in the face of the pandemic. Looking at changes in the delivery of care, and the impact of those changes on the quality of care, we hope to offer healthcare providers actionable insights that we can take with us well beyond the current moment. As the Covid-19 pandemic continues to shape what we do, which of our adjustments and insights will have the greatest long-term impact?
Racial Disparities and Covid-19 Impact on Care
By April, we began to understand the outsized impact of Covid-19 among “socially marginalized populations,” which was further clarified and complicated by an ongoing national conversation surrounding racial injustice in the United States. As a result, many institutions have begun looking more closely at how racism, injustice, and inequality should be addressed in healthcare.
Many are making moves to identify and address social determinants of health not only from an individual perspective, but through a more structural lens. At Brigham and Woman’s Hospital, Cheryl Clark (assistant professor of medicine, Harvard Medical School), has worked with organizations to better understand social determinants of health within their patient population, and come up with new community health initiatives.
Some examples are new communication protocols for high-risk patients; setting up neighborhood test sites in more affected areas; and delivering food directly to homes in response to the increased food disparities brought on by Covid-19.
Ultimately, though, as Dr. Sachin Jain suggests in this interview, which is a part of Harvard Medical School’s ongoing video series on Addressing Health Disparities, the question of health equity comes down to organizational leadership. “If we don’t have people in leadership who come from and are representative of the community, we will have massive blind spots.”
Incorporating more community perspectives into the management of healthcare institutions may be a step many take going forward, whether that means creating new channels for community input into hospital development, or looking directly within the community to fill administrative leadership roles. Collecting and analyzing more comprehensive data on patients’ social determinants of health is likely to be an effect of the Covid-19 pandemic overall as well.
Employee Emotional Awareness
Provider burnout is a crucial part of the discussion of the COVID-19 impact on care. Stress, trauma, and burnout are common in healthcare, and their effect on the healthcare workforce has been accelerated by Covid-19. As employee mental health outcomes continue to be examined in the context of the pandemic, many institutions have created new roles, or instituted new programs focused on physician wellbeing. Physician wellness professionals are being added to hospital C-suites, hospitals are seeking to increase the number of doctors on staff, and teamwork is being more heavily emphasized as a guiding medical principle.
This increased attention to the wellbeing of healthcare staff coincides with an ongoing dialogue around what the next “normal” will look like for both healthcare providers and patients. Some have even proposed that thinking of the next healthcare iteration as a new “normal” is a mistake, and that our “New Existence” should be thought of in more transformational terms.
In any case, as healthcare teams and leaders grow into the future, the ways in which care delivery affects the lives of patients and professionals will likely be explored with renewed vigor and focus. Already, we can see growing research pointing to the importance of “social support offered by supervisors and colleagues, a climate of open communication, and employee commitment to the organization.” These measures, tied to the long-term sustainability and performance of health care providing organizations, are likely to grow in development and application as we move through the Covid-19 pandemic.
Cardiovascular and Societal Impact of Covid-19 and Caregiver Approach
Throughout the duration of the pandemic, links between Covid-19 and cardiovascular complications have continued to be uncovered, which has pushed us to better understand the importance of cardiovascular co-morbidities, the efficacy and safety of various medications, and the interaction between the “viral spike (S) protein and angiotensin-converting enzyme 2” in the trajectory of the disease in patients.
Early on in the Covid-19 pandemic, studies demonstrated a decreased case rate and increased mortality rate for patients hospitalized with AMI, which provided some clarity regarding the cardiovascular impact of the disease. Continued study into the links between Covid-19 and cardiovascular health have raised questions about the efficacy of prolonged CPR in certain subsets of the patient population. These questions are especially important to consider given the increased risk of performing CPR on patients with disease that drastically impacts the respiratory system.
As we continue to examine the impact of Covid-19 on endothelial function, new treatment modalities are being explored by cardiovascular care teams faced with the disease. Anti-inflammatory therapies, like dexamethasone for example, have been shown to improve 28-day mortality rates among the critically ill Covid-19 patient cohort, though this result varies depending on the level of respiratory support patients need at the time of treatment.
Not only has the disease demonstrated complex linkages between pathophysiologic factors, but between population health and economic factors as well. This complexity has pushed some to start re-thinking the invocation of the Hippocratic Oath of ‘do no harm,’ arguing that a more appropriate invocation may be to ‘do maximal good.’ The balancing act of large-scale treatment of a global disease forces us to consider “the risk of a large number of immediate deaths from the disease [against] the longer-term risks of a lower number of deaths from the loss or absence of economic growth.”
The ties between health and wealth have been documented, as a “1% increase in unemployment was associated with a 0.24% increase in the overall mortality rate (95% confidence interval 0.07–0.42) in countries with no changes in social protection.” This intrinsic connection between population health and socio-economic factors will be critical for us to measure and account for in a coordinated approach to combatting the pandemic.