June 27, 2022

HOMERuN Collaborative: Environmental Health Focus Groups

The Hospital Medicine Reengineering Network (HOMERuN) is a rapidly growing collaborative made up of more than 50 Hospital Medicine groups from academic and non-academic hospitals across the United States.

Organizers and Facilitators: Katie Liu, MD, Lesley Gordon, MD, MS, Nicole Hudak, PhD, Sarah McKenna, PA-C, Will Jaffee, DO, Lewis B. Richards, MD, Tiffany Lee, Andrew Auerbach, MD, MPH, Jeffrey Schnipper, MD, MPH

Background: Organizers from Maine Medical Center in Portland, Maine used the HOMERuN Collaborative call on June 10, 2022, to discuss HOMERuN members’ experiences, thoughts, and attitudes surrounding the relationship between hospital medicine and environmental health (including climate change). The group used the following definition of environmental health:

“Clean air, stable climate, adequate water, sanitation and hygiene, safe use of chemicals, protection from radiation, healthy and safe workplaces, sound agricultural practices, health-supportive cities and built environments, and a preserved nature are all prerequisites for good [human] health.”

Current Role of Environmental Health Within the Field of Hospital Medicine Participants noted that environmental health is not a current priority in hospital medicine (HM). Most felt that environmental health has not been a feature of their practice (in any realm, including clinical practice, medical education, and health systems). A few referenced curriculum associated with medical education that touches on environmental health. This curriculum has been specifically in the area of social determinants of health, diversity, equity, and inclusion, and health disparities (examples given include questionnaires on admission to the hospital). Participants also commented that Pediatric Medicine is more in tune with environmental health, and that this may be more in the realm of primary care.

"We probably should be thinking about it more as hospital leaders. We certainly have potential for influence in this."

How the Environment Is Affecting Patients' Health

Participants had difficulty thinking of individual cases where it was clear that climate change had adversely affected a person’s health, but all agreed that in a macro sense the environment impacts health outcomes.  The impact was more obvious in the setting of true crisis (e.g., hurricane). Impacts are also very regionally specific (a major challenge), and within a given area there is also significant variation (e.g., rural versus urban). A few examples given were air quality and impact on COPD as well as the expanded range of tick-borne illness. One participant noted that diversion of funds toward disaster relief impacted preventive health.

"It's a little more subtle, but you can imagine, natural disasters, hurricanes, droughts, all those kinds of things fueling food insecurity. I think there are enormous implications. It probably affects everyone some way or another."

Barriers to Integrating Environmental Health Into HM Career

Participants noted that HM is always expanding our responsibilities; we may be spread so thin that we are unable to do anything well. Time and money are finite. There is currently a lack of institutional support and leadership/mentorship. There are a lack of educational resources and concrete tools. Geographic variation was noted as a barrier to developing a central curriculum. It is difficult to connect environmental health to patient health outcomes. In addition, the timeline of many environmental impacts is not immediate (e.g., some will not be apparent for years).

"No matter how passionately I feel, like how much I want to talk about patient counseling, there's just no time and also no ability for me to change my practice."

Motivators to Integrating Environmental Health Into HM Career

Participants reported feeling that they have limited resources to address issues of environmental health in a clinical context, thus concrete tools would be helpful, such as: A toolkit in order to identify resources available to our patients Training to improve our baseline knowledge about environmental health and its relationship to HM Participants noted a “top-down” approach is needed, because an individual cannot accomplish environmental health on their own. Time and money were also noted as factors; for example, whether implementing efforts toward environmental health could be reimbursed at a Centers for Medicare and Medicaid Services level, if efforts can be competency linked, or a metric with National Institutes of Health. Other participants noted that it could be a “niche” interest within advocacy, with someone in the HM group playing a larger role.

"I think it's fairly easy to have motivation for, given how significant this is not only for our patients' lives but for our lives."

Changes We Should Make to Current HM Practices in Relation to Environmental Health

While environmental health was not a current priority, some participants felt that it should be as it impacts our patients. HM practitioners could be advocates within health care systems for more sustainable practices (an example of a leadership role was raised). One participant noted that collecting patients’ stories may be an effective strategy, given we are witnesses to how the environment can directly impact health. Some felt the topic was better suited to just those with a specific interest (akin to gun control advocacy), rather than everyone. Regarding clinical care, ideas included patient education, home safety discussions, and discharge instructions relevant to a patient’s particular risk profile. One strategy raised was to align the goals of environmental health along with other system goals, such as reducing readmissions, addressing tobacco cessation, and improving transitions of care. Participants also considered linking it with “things we do for no reason,” e.g., reducing lab draws would be patient-centered, save money, and be environmentally sound. Environmental health is an unexplored area of research within hospital medicine.

"Should we be consolidating things because there are downstream implications both from a workforce perspective and materials perspective, and ultimately, an environmental perspective for all the things we end up doing?"

Key Takeaways At present, environmental health is not a feature of Hospital Medicine, in terms of clinical practice or health systems. It is, however, beginning to emerge as a topic in medical education at some institutions. There is no agreement among participants about whether environmental health should be prioritized in Hospital Medicine, given our already expansive responsibilities and that it does not neatly fit into our scope of practice. If we were to add environmental health into our practice, we would need practical tools to do so as well as institutional support. It would also help to identify a champion within our own departments who has the passion to be a leader in the field.

Become a Site for the RELIANCE Study: Roflumilast or Azithromycin to Prevent COPD Exacerbations

Purpose of RELIANCE: Both roflumilast and azithromycin have been shown to reduce the risk of COPD exacerbations compared to placebo. However, there has not been a head-to-head comparison of these two FDA-approved medications. RELIANCE is intended to support hospital efforts to reduce the risk of all-cause hospitalization and premature deaths in individuals with COPD.  RELIANCE is Seeking Community-Based Hospitalists: Hospitalists are critical in the development of post-discharge care plans and medications used by people with COPD. We found from preliminary work that identification of people with COPD while they are hospitalized is an efficient recruitment method for RELIANCE. Benefits and Compensation: $500/year honorarium for being a community partner (paid after registration) plus $200 per patient enrolled. Option to participate in clinical roundtables with COPD thought leaders. Contribute topic ideas for future grant proposals or publications related to hospitalist care. Community Partners will not be investigators / authors, but will be acknowledged in the RELIANCE publication.  Please reach out to Tiffany.Lee@ucsf.edu if you are interested in participating and would like more information about RELIANCE.

Our next meeting will be on July 8, 2022.

Check out the HOMERuN website for more information. If you would like to join the HOMERuN Collaborative calls, please reach out to Tiffany.Lee@ucsf.edu.