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Michigan Heart Surgery Outcomes Improved After Medicaid Expansion, Study Finds

Expanding Medicaid coverage is associated with better outcomes for heart surgery patients, according to a study led by University of Virginia School of Medicine researchers.

Researchers examined outcomes from heart surgery quality databases in Michigan, which expanded Medicaid, and Virginia, which did not. Outcomes in both states were reviewed over the same three-year period – the 18 months before Michigan expanded Medicaid and the first 18 months after Michigan expanded Medicaid.

In Virginia, there were no significant changes in outcomes between the two 18-month periods. But among Michigan Medicaid patients, the risk-adjusted likelihood of a serious postoperative complication dropped by 30 percent after Medicaid expansion. Reducing complications may also help reduce the overall costs of care, the researchers said.

How Medicaid Expansion May Impact Patient Care

Post-expansion Michigan Medicaid patients also had a lower predicted risk of major complications or mortality, which the researchers said might reflect increased access to primary care.

“Once covered, these patients can now access necessary preventative services and primary care, hopefully leading to improved control of chronic medical conditions, such as diabetes and high blood pressure,” said Eric J. Charles, MD, a study co-author and surgical resident at UVA Health System. “This improvement in baseline health status prior to needing an operation may translate into lower preoperative predictive risk scores and subsequently lower postoperative rates of major complications.”

Another possibility, he said, is that patients newly eligible for Medicaid are younger and lower-risk, which could explain the lower risk scores and better outcomes for Michigan patients in the 18 months following Medicaid expansion. An important next step in evaluating the impact of Medicaid expansion, Charles said, would be separate analyses of outcomes for Medicaid patients based on whether they qualified for Medicaid under the traditional criteria or through the expanded criteria.

Findings Published

The research team involved in the study included partners from the University of Michigan, Inova Heart and Vascular Institute, the Virginia Cardiac Services Quality Institute and the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative.

Charles and colleagues have described their findings online in The Annals of Thoracic Surgery. The research team consisted of Charles; Lily E. Johnston MD, MPH; Morley A. Herbert PhD; J. Hunter Mehaffey, MD; Kenan W. Yount, MD, MBA; Donald S. Likosky, PhD; Patricia F. Theurer, BSN; Clifford E. Fonner, BA; Jeffrey B. Rich, MD; Alan M. Speir, MD; Gorav Ailawadi, MD; Richard L. Prager, MD; and Irving L. Kron, MD.

The work was supported by the National Heart, Lung and Blood Institute, grants UM1 HL088925 and T32 HL007849; and by the Agency for Healthcare Research and Quality, grant R01 HS022535. Blue Cross and Blue Shield of Michigan and Blue Care Network provide support for the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative.

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UVA Health System is an academic health system that includes a 612-bed hospital, the UVA School of Medicine, a level I trauma center, nationally recognized cancer and heart centers and primary and specialty clinics throughout Central Virginia. UVA is recognized for excellence by U.S. News & World Report, Best Doctors in America and America's Top Doctors.

Related items

  • An End to Dieting for People With Type 2 Diabetes?

    For people with type 2 diabetes, the prescription is typically “lose weight.” But a University of Virginia School of Medicine researcher has received $2.7 million from the National Institutes of Health to test an alternative strategy that could let people with diabetes eat as much as they want.

    Researcher Daniel Cox, PhD, of UVA’s Department of Psychiatry and Neurobehavioral Sciences, developed the approach after being diagnosed with type 2 diabetes, in which the body produces insulin but can’t use it properly. “I knew myself,” he said. “I’d been trying to lose weight forever, and that wasn’t going to happen.”

    His new, three-pronged approach aims to use blood glucose monitoring to “educate, activate and motivate.” The underlying principle is that making people more aware of changes in their glucose levels may encourage them to avoid foods that spike their blood sugar and help them appreciate the benefits of physical activity. With that information, he hopes, they will be better equipped to manage their diabetes – possibly without the need to lose weight or even take medication. “We’re not trying to change your behavior,” he said. “We are trying to give you choices. It’s up to you.”

    Real-Time Feedback

    Cox has tested his approach previously using finger-stick blood monitoring, but now he’s adding a new, high-tech dimension: continuous glucose monitoring, performed by an electronic sensor that reports blood sugar levels to a smartphone app in real time. Participants equipped with the sensor will be able to see, right away, how a carbohydrate-rich meal spikes their blood sugar and how physical activity can bring it back down.

    The goal, he said, is to help people make healthy choices. By choosing foods that don’t spike their blood sugar, they don’t need to count calories, as they would on a diet. By getting more exercise – and by being less sedentary in general – they gain more control over their glucose levels. “The food selection prevents their blood glucose from going up, and the physical activity helps bring the blood glucose, whatever rise there is, back down,” he said.

    He recalled checking his blood sugar before and after going for a walk following lunch one day: “I saw my blood glucose had dropped 50 points, and that really encouraged me to repeat this,” he said.

    Clinical Trials

    Cox and UVA’s Anthony McCall, MD, are planning two clinical trials. The first includes 30 participants whose diabetes is not well-controlled by medication; 20 will receive Cox’s intervention, and the remaining 10 will continue working with their doctor to find a medicine that works for them.

    The researchers will follow that up with a much larger study in 200 people examining the effectiveness of three variations of his program. One uses no monitoring, one uses conventional blood testing and the third uses continuous glucose monitoring. “If it turns out to be better [than existing treatments], this new option, this paradigm shift, should be the first choice,” Cox said. “And if it’s only equal to the existing options, that would give patients a much-needed alternative.”

    All trial participants will need to make three visits to UVA over six months. There will also be three required educational programs at UVA, but those can be done by phone or Internet, he said. Participants will receive free testing supplies, free medical tests, a Fitbit and $100 upon completion of the study.

    The smaller study (IRB #19313) is being funded through a $200,000 grant from DexCom, the glucose monitor manufacturer. The larger study (HSR No. 19370) has received $2.7 million in support from NIH grant 1R01DK108957.

    For more information, call 434.243.6520 or email This email address is being protected from spambots. You need JavaScript enabled to view it.. Additional details are available at https://med.virginia.edu/psychiatry/t2dm/

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    UVA Health System is an academic health system that includes a 612-bed hospital, the UVA School of Medicine, a level I trauma center, nationally recognized cancer and heart centers and primary and specialty clinics throughout Central Virginia. UVA is recognized for excellence by U.S. News & World Report, Best Doctors in Americaand America's Top Doctors.

  • Inpatient Satisfaction Improved by Five-Minute Intervention, Study Finds

    As hospitals seek to improve inpatient satisfaction, one effective way takes only a few minutes and no expensive equipment. A study at the University of Virginia School of Medicine recently found that a daily five-minute conversation that focused on hospitalized patients “as people” significantly improved their satisfaction with their medical care.

    Family Medicine doctors at the University of Virginia Health System studied whether making a small but significant change – talking with patients about their overall well being as well as medical symptoms – would make a difference in patient satisfaction. UVA associate professor and clinical psychologist Claudia Allen, JD, PhD, regularly teaches a brief psychosocial intervention called BATHE (which stands for Background, Affect, Trouble, Handling and Empathy) to Family Medicine doctors in training, known as residents. Patients often share psychological or life problems as well as medical symptoms, and BATHE is designed to help doctors address those psychosocial issues briefly and effectively. Doctors using BATHE encourage patients to talk about anything that is bothering them, and then doctors respond with empathy and encouragement.  

    Knowing that doctors – especially those on inpatient units – can be pressed for time, the BATHE technique can be adjusted based on how much time a care provider has available. “BATHE includes an entry and an exit script,” Allen said. “You can spend three minutes doing it or you can spend an hour doing it.”

    BATHE is used frequently in outpatient clinics nationally, Allen said, but had not been tested with inpatients. After a Family Medicine resident told Allen that he had found BATHE helpful with distressed patients in the UVA Emergency Department, she and a team of residents decided to examine the technique’s effectiveness with Family Medicine inpatients at UVA Medical Center.

    From February-March 2015 and February-March 2016, 25 UVA Family Medicine inpatients were randomly chosen to receive either BATHE or standard care, which is focused on treatment plans and how patients are recovering from their illness or injury.

    Patients who had the brief BATHE conversation daily with a resident were significantly more likely to rate their medical care as excellent and to express a high degree of satisfaction with their hospital stay. Asked to rate on a five-point scale whether their medical care was excellent, patients receiving BATHE gave their doctors an average score of 4.77 compared with an average score of 4.0 for patients receiving standard care, which is a statistically significant difference.

    Interestingly, that improvement in patient satisfaction didn’t occur because BATHE patients had lengthier visits with their doctors, Allen said. There was no significant difference in the average score of BATHE and non-BATHE patients when they were asked to rate how much time they spent with their doctors.

    Rather, the improvement in satisfaction was associated with the BATHE patients’ perceptions that their physician “showed a genuine interest in me as a person.”  

    The technique also received good reviews from the Family Medicine doctors, who reported that using BATHE didn’t add significantly to the time they spent with patients; it just better focused their conversations. “The beauty of the intervention is that it doesn’t ask doctors to do anything radically different or add something totally extra,” Allen noted. “It just tweaks what they’re already doing to make it significantly more effective.”

    Physicians also noted that using BATHE might save time. Patients receiving BATHE were less likely to seek extra attention from doctors or nurses out of anxiety. 

    Allen is now exploring ways to study whether the use of BATHE improves medical outcomes and to expand the use of BATHE on UVA inpatient units.

    Findings Published

    Researchers from the UVA Department of Family Medicine and the Virginia Commonwealth University Department of Psychology conducted the study, which has been published in the journal Family Medicine. The research team included Emma J. Pace, Nicholas J. Somerville, Chineme Enyioha, Joseph P. Allen, Latrina C. Lemon and Claudia Allen.

    The work was supported by the National Institute of Child Health and Human Development, grant 9R01 HD058305-11A1.

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    UVA Health System is an academic health system that includes a 612-bed hospital, the UVA School of Medicine, a level I trauma center, nationally recognized cancer and heart centers and primary and specialty clinics throughout Central Virginia. UVA is recognized for excellence by U.S. News & World Report, Best Doctors in Americaand America's Top Doctors.

  • New Triage Tool Helps Doctors Save Lives by Identifying Patients at Greatest Risk

    In situations where medical resources are most limited, doctors are often forced to make life-or-death decisions with very little information and very little time. But now an international team of researchers has developed a simple way for healthcare providers to quickly identify and prioritize patients at the greatest risk of death.

    The new scoring system calculates risk based on patients’ vital signs – information doctors can access without advanced medical equipment. The resulting “universal vital assessment score” (UVA score) then indicates whether the patient is at low, medium or high risk.

    The researchers say the UVA score should be useful both for assessing patients when they arrive at the hospital in resource-limited areas and as a way to identify deteriorating conditions among those already admitted. It can also be useful for standardizing the mortality risk of patients enrolled in clinical trials.

    “Resource-limited settings such as most of sub-Saharan Africa shoulder the highest burden of critical illness. For example, it is estimated that there are 1.2 [million] to 2.2 million cases of sepsis and 6.5 million deaths due to infection annually in sub-Saharan Africa. Identification of patients at the highest risk for poor outcomes is important in order to provide them with early interventions that can improve survival,” said researcher Christopher C. Moore, MD, of the University of Virginia School of Medicine’s Division of Infectious Diseases and International Health. “However, existing clinical early warning scores were derived from patient populations in Europe and North America, which don’t necessarily apply to hospitalized patient populations in Africa, which are younger and have a higher prevalence of HIV infection.”

    Predicting Risk of Death

    The researchers developed the tool by analyzing data from more than 5,500 patients in six African countries – Gabon, Malawi, Sierra Leone, Tanzania, Uganda and Zambia – where medical resources are often minimal. The tool looks at six clinical variables, such as the patient’s temperature and heart rate, and whether they have HIV infection.  

    In evaluating the effectiveness of the scoring system, the researchers found that patients the tool classified as medium risk had three times the odds of dying as patients in the low-risk group. Patients scored as high risk had 10 times the odds of dying.

    The researchers noted that the tool also worked well for patients suspected of having an infection, suggesting it may be useful for identifying patients with sepsis, a frequently deadly condition in which an infection has spread throughout the body.

    Overall, the new tool outperformed two existing scoring systems, the modified early warning score (MEWS) and the quick sepsis-related organ failure assessment (qSOFA), in predicting patients’ risk of death. “The next step in this research is to pair the UVA score with diagnostic and therapeutic interventions,” Moore said. “Patients with low UVA scores are likely to do well receiving the local standard of care. However, patients at medium to high risk may benefit from more frequent clinical evaluations and additional testing, such as blood cultures or other diagnostics. This is an active area of our research.”

    Findings Published

    The researchers have shared their new tool in the scientific journal BMJ Global Health. The article can be read for free.

    The work represents a collaboration of UVA’s School of Medicine, College of Arts & Sciences and School of Engineering with many institutions in the United States and abroad: Georgetown University, Uganda’s Mulago National Referral and Teaching Hospital, Uganda’s Mbarara University of Science and Technology, Vanderbilt University, Sweden’s Karolinska Institutet, Uganda’s Masaka Regional Referral Hospital, New Zealand’s Centre for International Health, the University of Amsterdam, the University of Washington, the University of Illinois at Chicago School of Medicine, the University of Southern Denmark, the Zambia Emory Research Project, Uganda’s Kitovu Hospital, Duke University Medical Center, the Liverpool School of Tropical Medicine and Tulane University.

    The research team consisted of Moore, Riley Hazard, Kacie J. Saulters, John Ainsworth, Susan A. Adakun, Abdallah Amir, Ben Andrews, Mary Auma, Tim Baker, Patrick Banura, John A. Crump, Martin P. Grobusch, Michaëla A.M. Huson, Shevin T. Jacob, Olamide D. Jarrett, John Kellett, Shabir Lakhi, Albert Majwala, Martin Opio, Matthew P. Rubach, Jamie Rylance, W. Michael Scheld, John Schieffelin, Richard Ssekitoleko, India Wheeler and Laura E. Barnes.

    The work was supported by the UVA Center for Global Health, the National Institutes of Health, the UVA Pfizer Initiative in International Health and a UVA undergraduate Harrison Research Award to Riley Hazard under the supervision of Moore and Barnes.

    To keep up with all the latest medical research news from UVA, subscribe to the Making of Medicine blog at http://makingofmedicine.virginia.edu.

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    UVA Health System is an academic health system that includes a 612-bed hospital, the UVA School of Medicine, a level I trauma center, nationally recognized cancer and heart centers and primary and specialty clinics throughout Central Virginia. UVA is recognized for excellence by U.S. News & World Report, Best Doctors in Americaand America's Top Doctors.

  • Exercise Can Make Cells Healthier, Promoting Longer Life, UVA Finds

    Whether it’s running, walking, cycling, swimming or rowing, it’s been well known since ancient times that doing some form of aerobic exercise is essential to good health and well-being. You can lose weight, sleep better, fight stress and high blood pressure, improve your mood, plus strengthen bones and muscles.

    “Whether muscle is healthy or not really determines whether the entire body is healthy or not,” said Zhen Yan, PhD, of the University of Virginia School of Medicine. “And exercise capacity, mainly determined by muscle size and function, is the best predictor of mortality in the general population.”

    But why? Yan might have some answers. He and colleagues at UVa are peering inside the cell to understand, at a molecular level, why that workout, like it or not, is so vital to the body. They found that one important benefit involves the cellular power plant – the mitochondria – which creates the fuel so the body can function properly.

    Exercise Stresses Mitochondria

    Yan and colleagues have completed a study in mice that, for the first time, shows that just one bout of moderate to intense exercise acts as a “stress test” on mitochondria in muscles. They discovered that this “stress test” induced by aerobic exercise triggers a process called mitophagy, where the muscle disposes of the damaged or dysfunctional mitochondria, making the muscle healthier. Yan compares exercise-induced mitophagy to a state vehicle inspection that removes damaged cars from the streets.

    “Aerobic exercise removes damaged mitochondria in skeletal muscle,” Yan said. “If you do it repeatedly, you keep removing the damaged ones. You have a better muscle with better mitochondrial quality. We clean up the clunkers, now the city, the cell, is full of healthy, functional cars.”

    How Exercise Removes Mitochondria ‘Clunkers’

    For this study, Yan and colleagues assessed the skeletal muscle of a mouse model where they had added a mitochondrial reporter gene called pMitoTimer. The mitochondria fluoresce green when they are healthy and turn red when damaged and broken down by the cell’s waste disposal system, the lysosomes.

    The mice ran on a small treadmill for 90 minutes and Yan’s team observed mitochondrial stress (signs of “state inspection”) and some mitophagy (towing of the clunkers) at six hours after exercise. Yan explained that exercise in these mice also stimulated a kinase called AMPK, which in turn switched on another kinase called Ulk1. These chemical reactions appear to be important in control of the removal of dysfunctional mitochondria.

    “When its turned on, Ulk1 activates other components in the cell to execute the removal of dysfunctional mitochondria,” Yan said. “It’s analogous to a 911 call where a tow truck removes the clunkers. However, we still do not know how these activities are coordinated.”

    Some Mice Didn’t Benefit From Exercise

    Yan’s lab also deleted the Ulk1 gene in mouse skeletal muscle and found that, without the gene, the removal of damaged or dysfunctional mitochondria is dramatically inhibited, suggesting a new role for the Ulk1 gene in exercise and mitophagy.

    “Mice that were unable to do mitophagy did not have the benefit of exercise,” explained study co-author Joshua Drake, PhD, a postdoctoral fellow in the Yan lab. “Even though, from an exercise standpoint, they still were able to run just as far as normal mice, they didn’t benefit metabolically with training.”

    Drake pointed out that some people with type 2 diabetes don’t respond to exercise, which is a growing clinical problem. He hopes that continued research in the Yan lab will lead to new discoveries to help these non-responders.

    Findings Published

    The findings have been published online by the scientific journal Nature Communications.

    The study is the product of a collaboration among several laboratories at UVA, Brigham and Women’s Hospital and Harvard Medical School in Cambridge, Mass., and St. Jude’s Children’s Research Hospital in Memphis.

    The article is the work of Yan, Drake, Rhianna C. Laker, Rebecca J. Wilson, Vitor A. Lira, Bevan M. Lewellen, Karen A. Ryall, Mei Zhang, Jeffrey J. Saucerman, Laurie J. Goodyear and Mondira Kundu. 

    The research was made possible by grants from the National Institutes of Health and the National Institute of Musculoskeletal and Skin Diseases (R01-AR050429, ADA 1-16-PDF-030).

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    UVA Health System is an academic health system that includes a 612-bed hospital, the UVA School of Medicine, a level I trauma center, nationally recognized cancer and heart centers and primary and specialty clinics throughout Central Virginia. UVA is recognized for excellence by U.S. News & World Report, Best Doctors in Americaand America's Top Doctors.

  • Doctors Can Now Predict the Severity of Disease Just by Measuring Molecules

    An international team of researchers has found a way to diagnose disease and predict patient outcomes simply by measuring unbelievably small changes in interactions between molecules inside the body. The simple new technique could offer vastly superior predictions of disease severity in a huge range of conditions with a genetic component, such as Alzheimer’s, autism, cancer, cardiovascular disease, diabetes, obesity, schizophrenia and depression.

    Measuring Gene Mutations

    Gene mutations that cause disease physically alter the interactions of molecules that cells use to communicate with each other. Until now, scientists have had no easy way to measure the incredibly subtle changes in these interaction forces. But researcher J. Julius Zhu, PhD, of the University of Virginia School of Medicine, and his collaborators have developed a method to accurately and efficiently calculate these tiny changes. It’s a feat that requires incredible precision: Force is typically measured in newtons – the amount of force needed to accelerate one kilogram of mass one meter per second squared – but Zhu’s technique measures on a scale of piconewtons – one trillionth of a newton.

    Zhu, of UVA’s Department of Pharmacology, and his colleagues have used the new technique to show that gene mutations responsible for mental-health diseases change molecular interactions by a few piconewtons. These small changes then have a tremendous ripple effect. The researchers found the molecular changes lead to harmful changes in how the cells communicate – and, ultimately, in cognitive ability. By measuring the molecular changes, the scientists could predict the resulting cognitive impairment. In essence, the researchers are directly linking these tiny molecular changes to big changes in human behavior.

    Diagnosing Disease

    Zhu’s approach represents a new use for a high-tech scientific instrument called “optical tweezers” that uses a highly focused laser to hold and move microscopic objects, much like regular tweezers might be used to grip and move a splinter. Using the optical tweezers, the scientists can measure the force required to break up intermolecular bonds between the signaling molecules inside the body, allowing them gauge the effects of gene mutations in patients. The researchers say the technique is simple to do and will dramatically improve our ability to diagnose mental illness and many other diseases.

    Findings Published

    The researchers have described their work in an article published online by the scientific journal Small. The team consisted of Chae-Seok Lim, Cheng Wen, Yanghui Sheng, Guangfu Wang, Zhuan Zhou, Shiqiang Wang, Huaye Zhang, Anpei Ye and Zhu. The researchers are from UVA, Peking University in China, Rutgers’ Robert Wood Johnson Medical School, Zhejiang University School of Medicine in China and Radboud University in the Netherlands.

    The work was supported by the National Research Foundation of Korea, the National Natural Science Foundation of China, the Chinese Ministry of Education Project 111 Program, the National Key R&D Program of China and the National Institutes of Health. (NIH grants NS065183, NS089578, NS053570, NS091452, NS094980 and NS092548.)

    To keep up with the latest medical research news from UVA, subscribe to the Making of Medicine blog at makingofmedicine.virginia.edu.

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    UVA Health System is an academic health system that includes a 612-bed hospital, the UVA School of Medicine, a level I trauma center, nationally recognized cancer and heart centers and primary and specialty clinics throughout Central Virginia. UVA is recognized for excellence by U.S. News & World Report, Best Doctors in Americaand America's Top Doctors.

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