Mallika Mendu: Improving Operations

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University trying to get closer to the truth about health and healthcare. We’re excited to welcome Dr. Mallika Mendu today. But first, we always check in on current hot topics in health and healthcare. And Harlan, you pointed out to me that the Lasker Awards were awarded maybe 10 or 11 days ago. I hadn’t noticed it, and it’s a fascinating topic. Can you tell our audience a little about what are they and why this is exciting?

Harlan Krumholz: So Lasker Awards, there’s a lot of anticipation for them every year. They’re very prestigious awards that have been given out since, I don’t know, 1945 and were put out by the Albert and Mary Lasker Foundation. And the reason that they’re important is because they’re thought to be a prelude to the Nobel Prizes that sometimes people have called them the “American Nobels” because a lot of the people who got Laskers end up going on to get Nobels.

And they fall into three categories. You got a Basic Medical Award, a Clinical Medical Award, and then Bloomberg actually put in some money so that there would be a Public Service Award. And these are just highly respected and maybe some of the top international accolades that there are outside of the Nobel Prizes.

Howard Forman: And so who won the award this year?

Harlan Krumholz: Well, I wanted to talk about the Basic Medical Research Award. And it was given to two people who, it really was for their invention of AlphaFold, which is an artificial intelligence system, which predicts the three-dimensional structure of proteins from a one-dimensional sequence of their amino acids. Okay, so that’s a whole bunch of stuff. Let me just break that down just a little bit.

And just to say that we have DNA. DNA is our genetic code. Some parts of that DNA are transcribed into a messenger RNA that then produces a protein. The protein have amino acids. But when we were growing up, we would take biochemistry and learn about some of these proteins. And basically, we would learn the one-dimensional structure. We’d say, “Here’s the sequence of amino acids for a given protein.”

But in real life, these proteins actually fold in all sorts of different directions. And the way that they fold, it turns out, is very important for understanding how you might attack disease. Misfolding can cause problems, mutations can end up causing issues, and you can actually potentiate the effect of a particular protein by accentuating the kind of fold so that it hits the receptor in a different way. And so here’s a way that I’ve thought about it.

So imagine a protein is like a necklace with a series of beads, but imagine these beads each have a little bit of a magnetic force in north and south. So some of the beads are repelling each other, some are attracting each other. And if you just threw these beads up into the air, the thing actually falls into a configuration based on the ways in which these magnets act. Well, it turns out in real life, these amino acids can form bonds.

They actually are attracting or repelling certain other amino acids. And in addition, other things, hydrogens and so forth can join those proteins to accentuate their charge or polarity so that it turns out to be hard to predict what happens when they begin to fold. And so this is a problem that’s perplexed people for decades.

And with the advances in compute and with the advances in AI, this group that came out of a company called DeepMind that was eventually bought by Google was able to figure out how to do this really well. And so they could do this for... the truth is, the way we’ve been doing this is to use X-ray crystallography.

Howard Forman: Exactly. So we’ve been able to figure out the way they look after the fact, but we’ve never been able to predict just based on the sequences, right?

Harlan Krumholz: We have to go through the labor-intensive hard work, and that ended up maybe characterizing, I don’t know, only about 200,000 structures. Sounds like a lot, but there are probably eight million protein sequences. So if you really want to get to the endgame of characterizing all these protein sequences, it was thought you need to go a different route.

Howard Forman: But it’s more than that, right? Because as you said, it’s not just about what it is, it’s about what it could be and what might change if you were able to change a gene or change a protein sequence. So there’s a lot to the possibilities here.

Harlan Krumholz: So knowing the configuration, knowing what it looks like in three-dimensional space helps you understand: how might I block that protein? Or again, how might I put it in position? Or if it’s misfolded, if there’s been a mutation, how do I fix the protein? And we think this is going to be a boon to drug development and advancing our understanding of biology, and it’s already made a big impact.

There’s another thing here, Howie, that I think is interesting, which is these people who did this, Hassabis and Jumper, the two people who got the award, they’re like the Mozarts of our time. Hassabis was homeschooled by his parents. He was winning chess at a very early age, actually making a lot of money. He could have gone to college at age 15 or 16, took a gap year and started making computer games.

Everything he touched turned to something interesting and useful, even. And then he comes into DeepMind as a co-founder. And Jumper is a guy who gets his PhD looking at protein folding, but he gets his PhD in 2017. This is where we are, Howie. It used to be... Lasker Awards would be—

Howard Forman: 30 years.

Harlan Krumholz: Yeah, somebody invented something 50 years ago, 30 years ago. But because these are so profound... and this is a great equalizer of the AI. Young folks who are dedicated to trying to help make advances end up making just remarkable contributions. There’s one other piece to this that I thought was worth mentioning, Howie, which is you could say, “So when they predict a structure, how can you tell that they’re right? And what’s the way that this works?”

And it turns out there’s this organization that has characterized the folding of proteins but keeps it secret and serves as a means to evaluate groups that say, “We figured out how to predict folding of proteins.” And that’s an amazing thing. It’s called the Critical Assessment of Structure Prediction. And they have a meeting every two years and track progress in structure prediction.

But I’ve been thinking, Howie, how much we need that in AI, writ large. When somebody comes up and says, “I’ve got a predictive model for sepsis,” we need an independent group that actually has ground truth, knows what the answers are, but doesn’t disclose them and lets people tell you what they think the answers are and produces independent reports. I thought that was a very, very cool thing that there actually is a way to evaluate them.

Howard Forman: Pretty sure we’re going to keep coming back to this, and it’s a great introduction to this topic.

Harlan Krumholz: Yeah. So let’s get to our guest. We have a great guest today.

Howard Forman: Yes. Dr. Mallika Mendu is the vice president of Clinical Operations and Care Continuum at Brigham and Women’s Hospital. In this and previous roles at the Brigham, she has led numerous impactful quality improvement initiatives, including lean rounding efforts, addressing length of state concerns, a practicing nephrologist.

Dr. Mendu serves as an associate professor at Harvard Medical School. And in addition to being recognized as an innovative and strategic thinker within a large healthcare organization, she has authored over 80 peer-reviewed articles about quality, continuity, and innovations in care.

She holds a bachelor’s degree from Brown as well as an MD and MBA from the Yale School of Medicine and the Yale School of Management, respectively, which is when I was fortunate to first meet her. She completed her residency at Brigham and Women’s Hospital, followed by a nephrology fellowship jointly with Brigham and Women’s and Mass General Hospital.

So first of all, thanks very much for joining us here on the podcast. And I want to start off and draw a distinction between the work you do and some of our previous speakers in that you are deep in the weeds of operations. You are helping hospitals manage through one of the most challenging times when financial burdens make it almost an existential threat. And yet you are there trying to help them face up to that.

And there’s a whole host of innovations, and I want you to be able to talk about them. But they are about getting people out of their room earlier, getting people to a safe space, making sure they have a safe exit from the hospital, reducing readmissions, things like that. Can you give us a little sense of, number one, what got you motivated to do that and what you consider the most important work you’ve done at this....

Mallika Mendu: Yeah. Well, first off, thank you, Howie and Harlan, for having me on your podcast. I’ve long been an admirer of both of you, so it’s a real privilege. You’re right, Howie. I have a really unique role here at Brigham and Women’s Hospital. I’m very fortunate to have the role. I get to see patients on a regular basis, pursue clinical research that I’m passionate about, and advise mentees and trainees and pursue this phenomenal operations work in collaboration with other administrators.

So in my role, currently, I have three main areas of focus. So inpatient operations, care continuum management, and value-based care. And what we’re seeing is significant capacity constraints that we just didn’t see pre the COVID pandemic. The reason for that is multifold. So first, since the pandemic, we have seen a real exodus of staff in some critical areas. And I would highlight the post-acute area is really a critical area. And you can look at the U.S. labor statistics and see just the drop in staffing, skilled nurses and other staff.

So what that has resulted in then is closure and constraining of post-acute availability. And for the hospital, that means when we need to discharge patients to a rehabilitation hospital or other post-acute services, we just don’t have the capacity. And so then patients are staying in our beds longer. And that’s challenging because that reduces our inpatient capacity. That’s not ideal for patients who need to progress and they don’t get the rehab that they need in a timely way.

That constrains us further in terms of our emergency departments, where not infrequently, I would say once or twice a week, we have almost double the volume of our actual ED beds of patients in the hallways. And then that leads to further increased demand for services. And we’ve learned from the COVID pandemic that deferred care really can be exponential. If you’re looking at certain populations like patients with vascular conditions and need timely care, that builds up and then that puts further constraints on our staff.

And so it really is a circular challenge that we’re facing. What I will say, though, because I’m an optimist and I love operations and the type of innovation we can implement as a result of healthcare operations, is that it’s forcing us to think in different ways to be more efficient with existing resources because we are limited by staff. So we have to be. And it’s also offering an opportunity to create win-wins in areas where previously it was not as clear.

So as an example of this, value-based care and fee-for-service traditionally has been, definitely pre-pandemic, seemed at odds with one another. On one hand, you have the value-based care organizations, primary care primarily that’s trying to keep patients out of the hospital, out of the ED. And then the concern has been, “Well, is that going to encroach in our fee-for-service business?”

Now they’re in synergy because if we are successful with our value-based care business, and we’re able to keep patients out of the emergency department, it’s going to help us with their ED boarding situation. And similarly, in the inpatient side, if we’re able to keep patients who can be managed at home and we have a phenomenal home hospital program that we’ve developed here, if we can keep them at home in the hospital, then that’s going to give us more capacity.

And so that has really offered this ability to think about these win-wins. Some of the areas where we’ve thought about efficiencies, care continuum management is an area that I help oversee. We’ve developed a framework here where we’ve recognized that because of the capacity constraints and patients getting stuck in beds, we need to understand exactly what’s happening, which populations are actually getting stuck, and who might actually be able to go home if we’re able to come up with home services.

So we’ve created what we call an interdisciplinary care optimization dashboard. Our case managers are collecting data on a regular basis around who’s medically ready, and if they’re medically ready and not discharged, what are the barriers? And we’re cataloging those barriers and using that as a system to be able to say, “Here are some key populations, patients who are on dialysis, patients who have tracheostomies, substance abuse disorders. How do we work creatively with our post-acute partners to ensure that those patients have that throughput?”

Similarly, our case managers are implementing an early screening for a discharge planning tool where they’re actually identifying patients who may not need their services so they can then focus on those who are the most complex and do need their services. And then other creative strategies like expanding our hospice partnerships here in the hospital, because if we don’t have the post-acute capacity and we have someone who’s at the end of life, they may be more appropriate for hospice than a post-acute facility.

And frankly, we’ve had very low rates of hospice in the past, which has not served our patients well. So those are some of the areas that we are particularly focused on right now. And you can probably get a sense that even though it’s challenging, I’m very enthusiastic about what we’ve done and where we’re headed because pressure does make diamonds.

Harlan Krumholz: It seems to me like things blew up everywhere. And what I mean by that is when I’m hearing you talk, it’s kind of the same thing we’ve experienced here, long lines of people in the hallway, in the ED. You’re talking about length of stay in the way in which the hospital is stacked up, but try to get an elective MRI, try to get an elective CT scan, try to see a cardiologist electively.

In our place, you’re talking months. How are you thinking? You’re in operations, you’ve got this challenge, you’re trying to make things work every day. You’ve got a crisis an hour, probably, you’ve got to solve. But then the long thing is how do we get to a better day where we are breaking down these barriers?

Mallika Mendu: To me, yes, we are facing incredible challenges. This is the time for real innovation. So we recently published a paper in the Journal of General Internal Medicine that came out this month led by Dr. Isaac Chua, one of our phenomenal general internal medicine and palliative care junior faculty, where we implemented a positive feedback process, a standardized process as part of our mortality review.

And the reason we did this is that just as we, fortunately, now have across academic medical centers, a standardized transparent process around safety reporting and mortality review, we need to have a parallel process for positive feedback. I helped oversee our mortality review process for a number of years here at Brigham. And I reflected on, when I would review these reviews, obviously the opportunities to do better, provide better care. But when I would see a review come over that would happen to have positive gratitude, appreciation for an individual, a team, how much we learned from that.

And so we put this into place, which is to add a question to the standardized mortality review tool. We then looked at data over the course of a year. We had implemented this at Brigham and other hospitals across our system, and we found some really interesting information from this analysis.

First, when we look at key themes, and that really is what mattered to us initially in looking at this analysis. So some of the key themes, first, was the ability to provide exemplary patient and family-centered care was number one highlighted by our staff. Number two was demonstrating mastery of clinical medicine. And third was being an empathic team member and offering peer support. We also looked at dynamics between providers, role types, departments. We found, for example, that nurses were more likely to recognize those across role types. And then another example is surgeons are more likely to praise outside of their department versus inside their department, which might counter stereotypes about surgeons.

And so I’m really excited about this work. We are looking to expand it here at Brigham and think about how we tie this data to outcomes such as reporting on safety, culture, and teamwork and wellness for a couple of reasons. One is the organizations need to know what matters to their frontline staff, and they need to be sensitive to that, and they need to amplify those messages. Two, we can really learn from best practices. Just like we learn from what doesn’t go right, we need to learn from what does go right and then think about how to incorporate that into training and onboarding.

And then third is just what we talked about around staffing, which is we need to put some innovative solutions in place to really improve the culture, show our appreciation. And if we don’t do things in a different way now, we are going to be in even more trouble down the road. So that’s one example of some innovative work we’ve led.

Howard Forman: I wanted to reflect on the fact that you are a practicing nephrologist. You still publish in the nephrology literature. And I’m curious what lessons you’ve learned. This is end-stage renal failure, which is a big part of nephrology practice, or at least avoiding it is part of it. I’m curious to hear from you about how that microcosm, that small area of medicine has big lessons because there are a lot of areas where there’s overlap. Can you speak to that and what you’ve learned?

Mallika Mendu: Thanks for highlighting that. And I think sometimes it’s not quite apparent that nephrology and specifically our chronic kidney disease patients who have advanced chronic kidney disease, who some of them end up on dialysis or need a transplant, that in some ways that’s a microcosm of all of the challenges that we’re facing in healthcare.

And it’s interesting, when I was pursuing a fellowship and indicated I was going to pursue a fellowship in nephrology, I got advice from a lot of very well-meaning people to say, “If you want to do healthcare leadership, maybe don’t think about nephrology because you don’t see a lot of nephrologists out there.” But then as I started my fellowship, I realized, “Wow, this is the field that absolutely needs care, delivery, innovation, and operational excellence.”

I think what you’re highlighting, Howie, is that when you look at our clinical outcomes for patients who end up on dialysis, we have far to go compared to other areas of medicine where there’s been much more innovation. And similarly, if you look at the disparities in care, they’re incredibly pronounced. One out of 11 Black men will end up on dialysis in their lifetime. Patients who are Black are almost four times more likely to end up on dialysis than patients who are White.

It really lays bare just how many challenges we have in our healthcare system. I will say some of the positive work that’s happened over the last couple of years. One is the Advancing American Kidney Health Initiative, which was signed by President Trump, did put a focus on kidney disease in a way that frankly hadn’t happened since the 1970s. And the ESRD [end-stage renal disease] benefit as part of Medicare, where there’s this focus on dialysis. And specifically trying to improve the adoption of home dialysis and transplantation, knowing that it is better for patients to utilize those modalities as opposed to the default in this country, which is in-center hemodialysis.

In addition, there are these newer kidney care models that have emerged through CMMI, the Center for Medicaid and Medicare Innovation, which focus on how we can improve care both upstream for advanced CKD [chronic kidney disease] patients and then those patients who are already on dialysis. And one of the innovations that I’m particularly excited about is the Health Equity Incentive as part of this End-Stage Renal Disease Treatment Choices Model, which essentially recognizes that in order to bridge the gaps in outcomes for patients, you need to have investment.

So you need to incentivize and say, “We recognize that you, dialysis clinic, you, nephrology practice, you will need to invest resources in order to have comparable outcomes because there are real issues around social determinants of health and access.” So I’m excited about that. That was the first Health Equity Incentive that really came across through CMMI, and I’m hopeful that that has the opportunity... we’ll have to see based on the data, of having some impact in terms of disparities.

Howard Forman: We cannot thank you enough for what you’ve done for patients, for Yale. And you have a long and great career ahead of you, I know. So thanks for joining us on the podcast today.

Harlan Krumholz: It’s great to have you on.

Mallika Mendu: Thank you both. It’s been a real honor. Thank you.

Harlan Krumholz: Well, that’s a terrific interview, Howie. And as you said, here’s someone who’s really invested in operations, quality, and is an outstanding clinician and is a researcher.

Howard Forman: And teacher.

Harlan Krumholz: It’s really amazing. But let’s get to your segment this week, Howie. And I know that you’ve got a lot of things on your mind around social determinants this week.

Howard Forman: Yeah. So this is a topic that you have done a lot of scholarly work on. But I wanted to go up about 30,000 feet and highlight an update to a program that was begun by our former guest and the current CDC director, Mandy Cohen, when she was secretary of health for the state of North Carolina.

So the Healthy Opportunities Pilot, or HOP for short, aims to comprehensively test and evaluate how addressing the social determinants of health access to healthy food, transportation, safe and clean housing, interpersonal safety, and so on can improve health outcomes, all the while reducing healthcare utilization rates and emergency services for Medicaid members while improving other outcomes.

So this is lofty in terms of its goals, but it’s definitely what we would like to see. So there was a recent article I saw that had some nice anecdotes about how this program is beginning to help some of the poorest, some of the most underresourced North Carolinians get healthy food and more secure housing. But this is no small pantry. This is a $650 million undertaking that is approved by the federal government as a pilot using Medicaid funds.

And they’re hoping to see these improvements in outcomes and reduction in resources. Right now the jury is definitely still out, but we’re going to be building the data off of this longstanding pilot. So I wanted to bring it up, because you talk about social determinants of health, you’ve investigated it. What are you thinking when you hear about this?

Harlan Krumholz: So these are dominant influences on health, and for a long time, people were trying to think that this isn’t within our purview. But if we’re interested in the health of our patients and what happens to them, it must be. People would tell us to ignore social determinants because we should treat everyone the same regardless of their standing in social context.

But that can’t be true because their needs are different, and we need to address them. But let me just get something straight here, Howie, that’s the first time I ever heard a pilot project for $650 million. That sounds like an awful lot of money. Is it?

Howard Forman: So on the first hand, it sounds huge and it is huge. In my mind, $650 million is no small change for a state like North Carolina. But the Medicaid budget for North Carolina is 20 billion a year. So the $650 million is over five years. Here, we’re talking about they’re going to be spending probably more like $110 to $130 billion on Medicaid. This is chump change. This is 0.5%, perhaps, of the Medicaid budget, but it at least gives us some answers or hopefully will.

Harlan Krumholz: Would we be better off just writing people checks and trying to address poverty rather than try to build out these mitigation systems?

Howard Forman: There are other people that are investigating things like that, by the way. Not necessarily through the Medicaid program, but there are pilot projects going on like that. What we have learned is that just cutting people electronic benefit transfer funds and allowing them to spend their own money does not have the same impact as giving them the comprehensive exposure to why eating healthier is better, finding the right people who will benefit those that actually already have sicknesses and comorbidities. All those things intertwine. And so we believe at least that this is a more thoughtful approach.

Harlan Krumholz: What are the features of this? How’s it different than just handing out food in communities? What’s unique about it than food kitchens?

Howard Forman: Yeah. So it’s a lot. It’s comprehensive, it’s education for individuals, it’s finding the right people. So if you’re on Medicaid, you’re already impoverished, but then it goes steps further and says, “Are you already facing other social determinant of health obstacles? Do you already have a comorbidity like diabetes or obesity? Do your children have obesity?”

And then it’s not just the food, although the food is a central component, but it’s also safe and affordable housing. It’s making sure that families can have housing security as well as food security. It’s making sure that people don’t face violence in the home. So it’s a really comprehensive program addressing some of the biggest obstacles that some of the poorest people face, unfortunately.

Harlan Krumholz: And you have to be on Medicaid. So there are a lot of poor people who aren’t on Medicaid. So they don’t get in, right?

Howard Forman: They don’t get into the pilot project. But again, if we learn the right lessons, one would hope that if we find that this works, there will be other types of pilots that address how do we get to the many millions of people who are uninsured, ineligible for Medicaid, but nonetheless poor, also face these challenges.

Harlan Krumholz: So let me ask you just finally, it’s obviously the right thing to do. But if this doesn’t show an ROI, return on investment, doesn’t actually decrease healthcare utilization, do you think that there’s some concern that it just won’t be supported even though it will have improved health outcomes and again, been the right thing to do? Do we have to really show savings?

Howard Forman: I’m like you, Harlan, though. I think we’ve got to accept the data when we get it and figure it out. My guess is that it’s going to have pluses and minuses. Maybe it won’t reduce overall healthcare spending, but if it reduces patients’ risk factors for long-term survival to allow them a longer-term survival, if it gives people better quality of life, they’re measuring this on many, many different spheres. There are academics like you down in North Carolina. Maybe not quite like you I should say, but—

Harlan Krumholz: No, better, better.

Howard Forman: No, no. But people that really are taking this very seriously from a scholarly point of view. And we need that. We can’t throw money and just say, “Let’s see if it works.” We got to test it. And they are testing it.

Harlan Krumholz: We just have to fix this. But I really love this. Thank you for bringing this up. You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how’d we do? To give us your feedback or to keep the conversation going, you can find this on Twitter.

Harlan Krumholz: Or X or whatever it is.

Howard Forman: Yeah, I know.

Harlan Krumholz: I can’t give it up yet, but I’m @ H-M-K-Y-A-L-E. That’s @HMKYale.

Howard Forman: And I’m @thehowie. That’s @thehowie. You can also email us at health.veritas@yale.edu. And by the way, Harlan, I think one of our guests did contact us this week with a question.

Harlan Krumholz: Oh, yeah. So somebody was a little confused with our discussion about Sudafed last week and the two medications. And you’re the expert on this, so I must have fumbled the explanation. Sudafed was called that because it had ephedrine, which is effective, but has a lot of other issues including being used to make meth and put behind the screens. So the companies made another version of it.

Howard Forman: Correct.

Harlan Krumholz: Do you want to go ahead?

Howard Forman: Yeah. So you go back 30 years or 40 years, we thought there were three drugs that worked: phenylpropanolamine, pseudoephedrine, and phenylephrine. Now we’ve learned last week phenylephrine doesn’t work.

We took phenylpropanolamine off the market for adverse events, and we’re left with only pseudoephedrine, which actually does work. I went back today, you and I had a discussion about whether it works or not. There’s at least two randomized controlled trials I’m aware of. One in adults, one in children.

Harlan Krumholz: For cold symptoms.

Howard Forman: For cold symptoms. Just that. Right. Whether it reduces nasal congestion. And unlike phenylephrine, which seems not to work, pseudoephedrine, the original Sudafed, does work even if it’s harder to get behind the counter.

Harlan Krumholz: And that’s the one that’s usually locked up. And then, what we’re saying is they were selling the other ones, and it was actually ineffective.

Howard Forman: That’s right.

Harlan Krumholz: And that’s what the FDA group has said shouldn’t work.

Howard Forman: That’s right.

Harlan Krumholz: So pseudoephedrine works, but the other one—

Howard Forman: And to be clear, neither of us has any financial stake in the Sudafed brand.

Harlan Krumholz: No, I don’t. No, I don’t. And I still think we need more studies of all that stuff. Health & Veritas... Well, actually, you got to say you’re the faculty director. Howard, finish your part.

Howard Forman: Yeah. Okay. So I’m fortunate to be the faculty director of the healthcare track and founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information or check out our website at som.yale.edu/emba and keep the questions going. We will answer them if you send them in.

Harlan Krumholz: Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. Amazing, amazing, amazing. Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon.