Supporting Interdisciplinary Collaboration to Improve Health Outcomes

Earlier this spring, Duke’s Collaborative to Advance Health Equity (CACHE) Initiative awarded 1-year grants for three proposals to improve care in the Duke Health system. Focused on addressing areas where current approaches to care and support could be improved, the three projects include identification and treatment of chronic kidney disease (CKD), transitions of care for patients with opioid use disorder (OUD), and improving screening for lung cancer, all of which pose substantial challenges among patients served by Duke Health.

CACHE offers teams in-kind support in the form of access to faculty mentorship, training in quality improvement methodology, project management, analytics, and informatics.

“We wanted to focus on work that brings together elements of care that have been shown to be effective but haven’t yet been widely integrated into clinical workflows or scaled,” notes CACHE Director Michael Pignone, MD, MPH. CACHE offers teams in-kind support in the form of access to faculty mentorship, training in quality improvement methodology, project management, analytics, and informatics. Following an initial request for applications, which included a letter of intent incorporating a brief synopsis of objectives, significance, and team composition, a subset of those projects were invited to submit a more detailed full application for evaluation by the CACHE team. From this cohort, the finalists were chosen.

Facilitating Optimal Care and Unified Screening for Kidney Disease (FOCUS-Kidney)

Chronic kidney disease (CKD) affects millions of Americans, but many patients do not receive the full array of guidelines-based care, including the prescription of effective medications. These shortcomings are particularly pronounced for Hispanic and Black patients.

“We already know that there are around 70,000 patients in the Duke Health system who have CKD, and many more who are at high risk for developing it,” says project principal investigator and Duke Health nephrologist Matthew Sinclair, MD.

Dr. Kevin Shah, who serves as the DUHS Vice President for Primary Care and Chief Medical Officer for Duke Primary Care, points out that the number of patients at Duke Health who could benefit from screening and care related to CKD far exceeds the capacity of kidney specialists to provide it.

“Primary care providers can help fill this gap, but they’ll need a new set of tools,” notes Shah.

“By spotting the gaps in CKD screening and care and implementing proven strategies, we can bend the curve on the trajectory of this disease and improve outcomes.”

This is where FOCUS-Kidney steps in. By implementing CKD-focused care pathways and clinical decision-support tools within Duke Health’s electronic health record, clinicians can more readily identify patients with type 2 diabetes and/or CKD, allowing them to expand screening and intervene earlier and more effectively. “By spotting the gaps in CKD screening and care and implementing proven strategies, we can bend the curve on the trajectory of this disease and improve outcomes,” says Sinclair. “We’ve already shown that this can yield better outcomes in a pilot study. With CACHE’s support, we can extend these strategies within EHRs to see if we can create a more efficient, less labor-intensive approach that lets us reach more patients.” Ultimately, says Sinclair, the project has the potential to slow progression of kidney disease, reduce the number of hospitalizations resulting from it, and reduce the health disparities due to this condition.

Improving Transitions of Care for Patients with Opioid Use Disorder

Opioid use disorder (OUD) is especially acute in Durham County, where rates of drug overdose deaths exceed state and national averages. Effective, evidence-based medical treatments for OUD exist, but only about a quarter of the people who could benefit from them actually receive them.

Although Duke University Hospital has already demonstrated the potential benefits of ensuring that patients receive evidence-based medication for OUD through its successful COMET (Caring for patients with Opioid Misuse through Evidence-based Treatment) program, the high quality of care and support possible with inpatient healthcare settings can falter when patients leave the hospital.

“The transition from inpatient to outpatient care is especially challenging for patients with opioid use disorder who have recently started on medications,” says project PI and Duke Health primary care physician Meredith Niess, MD, MPH. She notes that many barriers, such as the stigma associated with opioid use and lack of trust for the health system among patients, are made worse by a lack of systematic referral for critically important outpatient services, leaving many patients to fall through cracks in the system.

“The benefits of better transitions from inpatient to outpatient care for persons with OUD are hard to overstate.”

The first step in addressing this problem is to better understand patterns of referral and follow-up for OUD treatment, as well as patterns that affect whether patients successfully attend those appointments and remain engaged with their treatment programs. As part of a collaboration between Duke CACHE and the Duke Hospital COMET program, data from patient electronic health records will be analyzed to better understand what works in OUD care as well as to identify points of failure. That information will then be used along with best practices from around the country to lower barriers to accessing treatment and support. “The benefits of better transitions from inpatient to outpatient care for persons with OUD are hard to overstate,” notes Niess. “The COMET team works with these individuals to start lifesaving medications, but these medications can only save lives if they are continued after discharge. At a minimum, continuing buprenorphine for OUD protects patients from overdose, but it’s also highly effective at helping patients reach their goal of reducing or illuminating illicit drug use and its associated adverse outcomes, facilitating better health outcomes along with improvement in broader outcomes like housing stability and employment. Minority patients and those in lower socioeconomic groups are disproportionately affected by these adverse outcomes including overdose, and even more so in Durham County, so it’s essential that we at Duke Health improve the processes to better care for these individuals.”

Improving Lung Cancer Screening

Although lung cancer is a leading cause of death in North Carolina, fewer than one in five persons who could potentially benefit from lung cancer screening actually receive it. Screening people at higher risk for the disease has been shown to result in earlier detection and treatment, ultimately saving lives.

“The barriers some people face in accessing screening is a key problem we must address to reduce lung cancer mortality,” says project PI and Duke Health pulmonologist Neelima Navuluri, MD, MPH.

“We typically see lower rates of screening among minority communities, underinsured or uninsured patients, and people living in rural areas, which also has downstream effects on clinical outcomes.”

Navuluri’s team is marshaling data from multiple sources across Duke Health including electronic health records, but is also utilizing other sources to accurately assess rates of lung cancer screening. One important source of data for this project is the patient MyChart portal, which may provide additional detailed information about a person’s smoking history—a key risk factor for lung cancer.

“The barriers some people face in accessing screening is a key problem we must address to reduce lung cancer mortality.”

“Once we have a better understanding of where along the process we need to apply the greatest efforts to improving screening, we hope to be able to leverage Epic electronic health record at Duke Health and the MyChart portal to improve screening rates in our community,” says Navuluri.

“We hope to incorporate direct-to-patient shared decision-making tools into these systems to increase awareness and education about lung cancer screening, in addition to doing things like combining multiple cancer screenings at a single patient visit. So, if a person is being screened for breast cancer and we also see from the data we’ve accessed from these sources that that person is at high risk for lung cancer, we can conduct that screening at the same time.”

Moving Forward

Each of the three projects is designed to demonstrate improvement within 12 months, using rapid-cycle improvement methods. Other key measures of success include being able to demonstrate scalability and positive impact on clinical workflow. “It’s been tremendously exciting to see these and other CACHE projects moving from the concept to implementation,” said Duke Health Senior Vice President, Chief Quality Officer and Chief Medical Officer Richard Shannon, MD, who also served as CACHE’s founding director. “One unique strength that we’re able to tap into with CACHE is the support of an engaged and highly motivated collaborative community spanning Duke Health Integrated Practice, Duke Primary Care, Duke Health Technology Services, and the School of Medicine.” “We’re interested in seeing what we can do when we put all the pieces together,” agrees Pignone. “These projects are drawing on multiple areas of expertise — quality improvement, implementation science, epidemiology, data science, clinical informatics, and community engagement,” he continued. “What we’re trying to do here is to see these problems in health equity in all their dimensions, so that we can more effectively intervene and improve outcomes for everyone.”