Transcript Mission - RWJF Clinical Scholars - Robert Wood Johnson Clinical

The Robert Wood Johnson
Foundation
Clinical Scholars
Photo: Harold Shapiro
Change Agents In Medicine
For More Than 40 Years
Mission
Develop physician leaders to improve US health and
healthcare with a commitment to service and patients.
Alumna Tammy
Chang (second from
left, Michigan CSP 1113) and community
partner Zachary
Rowe (left) with
community members
Photo: Harold Shapiro
About the Program
• Founded in 1969; adopted by RWJF in 1972
• Oldest RWJF Human Capital program
• Long-standing collaboration with US Department of
Veterans Affairs (VA)
– RWJF and VA fund stipends and health insurance
– RWJF supports research expenses
– VA provides in-kind faculty, clinical and research resources
Diversity Commitment
The Program:
• Embraces racial, ethnic, gender, and
disciplinary diversity
• Encourages candidates with diverse
backgrounds
• Provides all qualified candidates an equal
opportunity to compete for a Clinical Scholar
position
Scholar Training Sites and National Program
Office
Training Sites:
• University of California, Los Angeles
• University of Michigan
• University of Pennsylvania
• Yale University
National Program Office
The University of North Carolina, Chapel Hill
Director
Desmond “Des” Runyan, M.D., Dr.P.H.
(former Clinical Scholar, UNC ‘79-’81)
Deputy Director
Kristin Siebenaler, MPA
Program Administrator
Kathy Donnald
National Program Office (NPO)
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Advise training sites on curriculum development
Provide technical assistance to training sites
Plan and host the annual Clinical Scholars research meeting
Direct nationwide applicant recruitment and program
marketing
Pursue an applicant pool from diverse medical specialty and
racial backgrounds
Oversee the scholar selection process
Engage the Clinical Scholars alumni network
Maximize expertise of the Clinical Scholars national advisory
committee
National Advisory Committee (NAC)
Selected national leaders in health and healthcare committed
to helping develop new scholars and leaders
NAC members involved in a wide range of activities:
• Curriculum design
• Scholar selection
• Scholar mentorship
• Training site selection
• Training site oversight
Program Results Report
Key Results: As of August 2013, the program had produced
1,212 scholars. In 2013, 54 Scholars are participating in the
program.
Graduates have become directors of major federal, state,
and local health agencies and departments; hospital CEOs;
leaders in the fields of health services research and health
economics; foundation executives; and leaders in
academic medicine.
Authors: Crum R, McKaughan M, & Heroux J
Program Results Report Cont.
• Clinical Scholars lead five of seven Pediatric Quality Measures Program
Centers of Excellence created by the federal Agency for Healthcare
Research and Quality
• Scholars helped “propel emergency medicine into the mainstream of
health care, especially in the academic world,” according to an article in
the April 2010 issue of Academic Emergency Medicine.
• Since 2005, Clinical Scholars have taken the lead in community-based
participatory research (CBPR).
Authors: Crum R, McKaughan M, & Heroux J
Scholar Experience
and Curriculum
Scholar Experience
• Unmatched post-residency opportunity for 20
physicians to:
– Conduct innovative research in health policy, health
services research, and CBPR
– Work in a leadership role with communities,
organizations, practitioners, and policy-makers
– Pursue two years of master’s degree study (degrees
awarded)
Scholar Experience, continued
• Funding provided for stipends, tuition, travel and
research
• Protected time for research (20%) and scholarship (80%)
• Attend annual national research meeting to present
research and foster networking
• Develop skills to serve as an innovative and
accomplished leader in healthcare
• Tap into program alumni network
of over 1,200 individuals who
serve as resources
Yale Clinical Scholars
Prepare Scholars for External Drivers in
Health Care System
• Disparities in access, quality, and outcomes
• Spiraling health care costs
• Aging of America
• Translating research into practice
Core Competencies
• Critically evaluate qualitative, quantitative, clinical, health
services, and related research
• Recognize different levels (e.g., molecular, familial,
community) of health problems and develop strategies for
addressing them at more than one level
• Design scientifically sound and important research
Core Competencies, continued
• Identify strategies for data analysis and
execute analyses
• Interpret and communicate results with
their public health, practice, and policy
implications
• Translate research findings into
creative interventions to improve health
care quality and outcomes
Approach
• Intensive summer orientation
• Core curriculum
• Seminars and courses
• Mentors
• Writing group
• Leadership training
Photo: Harold Shapiro
Curriculum
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The design and conduct of health services research,
clinical epidemiology, and health policy research
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Exposure to other fields of inquiry (e.g. economics,
sociology, and law) relevant to study of US Healthcare
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Centerpiece: one or more original
research projects
Core Curriculum: Topics
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Biostatistics
Population and clinical epidemiology
Health services research
Health policy
Social science
Community-Based Participatory Research
Other analytical methods
Project design and management
Professional development
Seminars and Courses
• Weekly seminars: works in progress
• Leadership seminar
• Didactic coursework
• Seminar series
Structured Transition to Faculty
• Completing manuscripts from Scholars’ research projects
• Writing grant applications
• Developing mentoring skills
Yale CSP Faculty
Examples of Scholar Publications
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Gordon Sun (Michigan CSP 11-13, VA Scholar) and Matthew M. Davis. “The
Patient Protection and Affordable Care Act of 2010: Impact on Otolaryngology
Practice and Research.” Otolaryngology – Head and Neck Surgery, 26 January
2012
Lisa Rosenbaum (Penn CSP 12-14, VA Scholar), "How Much Would You Give to
Save a Dying Bird? Patient Advocacy and Biomedical Research." New England
Journal of Medicine. 2012 Nov;367(18):1755-9. doi: 10.1056/NEJMms120711
Projects by Recent
Scholars
Social Relationships and Depression:
Ten-Year Follow-Up from a National
Community Survey of Adults
Alan R. Teo, M.D., M.S. (Michigan 11-13)
Portland VA Medical Center, Staff Psychiatrist
Oregon Health and Sciences University,
Assistant Professor of Psychiatry
Research Questions
1. Does quality and quantity of social
relationships predict development of
depression?
2.What is the relative impact of type of
one’s social relationship on
depression risk?
Hypothesis:
Study Sample
• Midlife in the United States (MIDUS)
• Community-residing adults age 25-75
recruited by random digit dialing
Baseline
1995-96
N = 4,642
1. Quality of social
relationships
2. Quantity of social
contact
Outcome
2004-06
Past-year
major depressive
episode
Social Relationship Quality Has “DoseDependent” Effect on Risk of Depression
Good quality
Poor Quality
Using Default Options to Improve Health Care
Value by Reducing the Use of Brand Name
Medications with Generic Equivalents
Mitesh S. Patel, MD, MBA (Penn 12-14, VA Scholar)
Philadelphia Veteran Affairs Medical Center, Philadelphia, PA
Robert Wood Johnson Clinical Scholars Program,
University of Pennsylvania, Philadelphia, PA
Background
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Health care costs in the United States
– Now account for nearly $3 trillion annually
– Estimated that 1/3 of health care spending is wasteful and unnecessary
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Improving health care value by reducing low-value services
– Brand name medications with existing equivalent generics are a prime
example of a low-value service
– In 2009, Medicaid wasted $329 million on brand name medications with
existing equivalent generics
– In 2011, UPenn Division of General Internal Medicine found up to 44% of
medications were prescribed as brand name
Study Design
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Objective
– To evaluate the impact of an intervention using the electronic medical
record (EMR) on the utilization of brand name medications with
existing equivalent generics
Design
– Quasi-experimental design with difference-in-differences approach
using internal medicine (IM) as the intervention group and family
medicine (FM) as control
Setting and participants
– Ambulatory clinics at the University of Pennsylvania Health System
– Attendings and residents from the IM and FM departments between
July 2010 and September 2012
Study Design
• Intervention
– In January 2012, the default in the EMR medication prescriber
was changed for all internal medicine providers from showing
brand and generic medications alphabetically to showing only
generics, with the ability to opt out and pick the brand if warranted
• Primary outcome measures
– Proportion of beta-blockers, statins, and proton-pump inhibitors
with existing generics that were prescribed as brand name
Results - Attendings
Unadjusted
Proportions of
Brand Name
Medications
Prescribed
Results - Residents
Unadjusted
Proportions of
Brand Name
Medications
Prescribed
Results – Multivariate Analyses
Attendings
Variable
Post-Intervention x IM Dept
Pre-Intervention Year 2 x IM Dept
Post-Intervention
Pre-Intervention Year 2
IM Dept
Constant
All Medications
Coefficient
P-value
-0.091
0.007
-0.02
0.566
-0.074
0.002
-0.071
0.006
0.109
0.052
0.25
<.001
Beta-Blockers
Coefficient
P-value
-0.162
<.001
-0.052
0.129
-0.013
0.663
-0.04
0.074
0.164
0.001
0.243
<.001
Statins
Coefficient
P-value
-0.101
0.023
-0.042
0.303
-0.041
0.251
-0.048
0.159
0.127
0.037
0.14
<.001
Proton Pump Inhibitors
Coefficient
P-value
-0.035
0.586
0.015
0.824
-0.149
0.004
-0.101
0.085
0.027
0.743
0.384
<.001
Residents
Variable
Post-Intervention x IM Dept
Pre-Intervention Year 2 x IM Dept
Post-Intervention
Pre-Intervention Year 2
IM Dept
Constant
All Medications
Coefficient
P-value
-0.008
0.839
0.017
0.689
-0.104
0.007
-0.084
0.033
0.002
0.96
0.239
<.001
Beta-Blockers
Coefficient
P-value
-0.139
0.024
-0.058
0.371
-0.009
0.871
-0.011
0.852
0.16
0.005
0.157
0.002
Statins
Coefficient
P-value
0.033
0.549
0.045
0.435
-0.084
0.103
-0.072
0.189
-0.079
0.104
0.194
<.001
Proton Pump Inhibitors
Coefficient
P-value
0.056
0.432
0.049
0.454
-0.207
0.001
-0.156
0.008
-0.046
0.515
0.353
<.001
Summary
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Key Findings
– Significant reductions in the use of brand name medications were
observed among providers in IM compared to FM for the post-intervention
period relative to the pre-intervention period
• Attendings – all medications, beta blockers, and statins
• Residents – beta blockers only
– Findings were sustained through nine months of follow-up
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Significance
– Default options were an effective methods to reduce the use of a lowvalue service
– Clinical decision support teams could leverage defaults in EMRs to create
a sustained change in provider behavior
– Lessons from behavioral economics could be leveraged in other contexts
to improve health care value
Comorbidity, Age, and Treatment
Decision Making in Men with
Early-Stage Prostate Cancer
Timothy J. Daskivich, MD, (UCLA 12-14, VA Scholar)
Department of Urology
University of California, Los Angeles
To Treat or Not to Treat?
• Survival benefits of aggressive treatment (surgery, radiation) for low- and
intermediate-risk prostate cancer are delayed for ~8-10 years after
treatment
• Men who die of other causes before 10 years may incur side effects of
treatment (erectile dysfunction, incontinence) without garnering any
survival benefit
• National guidelines recommend against aggressive treatment for men
with less than a 10-year life expectancy
• Despite this, men are often overtreated due to lack of a widely accepted
method for determining life expectancy incorporating both age and health
status
Bill-Axelson et al, NEJM 2011; Thompson et al, J Urol 2007; Mohler
et al, JNCCN 2010; Daskivich et al, Cancer 2011
Study Design
Study Population
Prostate Cancer Outcomes Study:
Population-based cohort of men diagnosed with prostate cancer
between 10/94-11/95 within six SEER registries: CT, UT, NM,
Atlanta, LA County, King County (Seattle).
Follow-up: 14 years
Variables
Covariates
Methods
Primary Outcome
Secondary Outcomes
Count of 12 Major Comorbidities
Age
D’Amico Tumor Risk
Race
Type of Treatment
Competing Risks Analysis
Other-Cause Mortality by Comorbidity and Age
Prostate Cancer Mortality by Tumor Risk
Other-Cause Mortality by
Age and Comorbidity Count
Age <60
Age 60-70
Age >70
26%
40%
71%
10-year Other-Cause Mortality for Charlson 3+
Daskivich et al. Ann Int Med 2013
Prostate Cancer Mortality
by D’Amico Tumor Risk
To Treat or Not to Treat?
Age and Comorbidity
DM, HTN, COPD
Probability of 10-year OtherCause Mortality
56 yo
26%
68 yo
40%
75 yo
71%
Conclusions
• A simple count of twelve common comorbidities is strongly
predictive of long-term, other-cause mortality in men with early-stage
prostate cancer
• Older men with more than 3 comorbidities had greater than 50%
probability of dying of something other than prostate cancer within
10 years of diagnosis
• This information will help older men with multiple medical problems
to make more informed treatment decisions and potentially avoid
unnecessary overtreatment of low- and intermediate-risk disease
What Drives Frequent Emergency
Department Use in an Integrated Health
System? National Data From the
Veterans Health Administration
Kelly M. Doran, MD, MHS (Yale 11-13)
Instructor, Department of Emergency Medicine and
Department of Population Health, NYU School of
Medicine / Bellevue Hospital Center
The Problem
• Small group of patients (frequent users)  large
share of ED visits and costs
• Prior studies limited in size and scope
• Frequent users may not be best defined by a
binary “cut-off” number
Veterans Health Administration 2010
• 5,531,379 total patients
 930,712 patients with ≥ 1 ED visit
 Number of ED visits
1:
53.0%
2-4:
38.3%
5-10:
7.6%
11-25:
1.0%
> 25:
0.1%
Strongest Correlates of Frequent ED Use
• Schizophrenia (OR 1.44 – 6.86)*
• Homelessness (OR 1.41 – 6.60)
• Opioid medication use (OR 2.09 – 5.08)
• Heart failure (OR 1.64 – 3.53)
* OR range for different ED use frequency categories (from 1 to >25
visits/year vs. 0 visits/year) in multivariable analysis, all findings p<.05
Conclusions
• Frequent ED use associated with high levels of medical
and psychosocial need
– Correlates were consistent across multiple levels of
ED use frequency
• Frequent ED use occurs even in a coordinated health
system where patients have access to other care
– And use of non-ED VA services was associated with
more, not less, ED use
Alumni Statistics
Clinical Scholar Alumni
• More than 1200 alumni located in 41 states + DC, 12 countries
• 45 Members of the Institute of Medicine
• Academic Medicine
– 8 Medical and Public Health School Deans
– >145 Chairs, Vice-Chairs, division chiefs
– 193 professors, 139 associate professors, 184 assistant professors
• Government
– Federal/International: DHHS, CDC, CMS, House of Representatives,
AHRQ, VA, NIH, WHO, Office of the Surgeon General
– State and Local Health Departments
• Hospital CEOs
Distribution of 365 Scholars By Major Specialty
2000-2013
8
29
33
24
Emergency Medicine
33
Family Medicine
Internal Medicine
17
Neurology
OBGYN
Pediatrics
126
71
Psychiatry
Surgery
Urology
15
9
Other
Scholar Distribution by US State (Updated October 2013)
51 and over
26 - 50
11 - 25
6 - 10
1-5
Scholars Outside of US
and Canada:
(Argentina 1; Australia 1;
China 1; Germany 1;
Japan 1; Nigeria 1; South
Africa 1; Switzerland 1;
United Kingdom 3;
Zimbabwe 1)
Scholars in Canadian Provinces:
(Alberta 2; British Columbia 4; Manitoba
1; Nova Scotia 2; Ontario 9; Quebec 13)
Alumni Feedback
“There is no other program like the RWJF Clinical Scholars
program for physician leaders who want to change America's
health care system." -- Comilla Sasson, M.D., M.S., Director of
Program Development, and Innovation, American Heart
Association & Adjunct Clinical Faculty, University of Colorado
School of Medicine
“Community-based work had a formative effect on my development. It’s
something I’ve always been committed to, and it’s actually one of the
reasons I chose to apply for the [Clinical Scholars] program.” –
Nathan Irvin, M.D., instructor in emergency medicine at Johns Hopkins
University School of Medicine
“For anyone who wants to be a catalyst for change in the health and health
care of our country, the Clinical Scholars program is an excellent opportunity
to do so.” Risa Lavizzo-Mourey, M.D., M.B.A., president and CEO of the
Robert Wood Johnson Foundation (Penn CSP 1983-1986)
Examples of Alumni Publications
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Anita Vashi (Yale CSP 11-13, VA Scholar) Justin Fox (Yale CSP 10-12),
Joseph Ross (Yale CSP 04-06), and Cary Gross (Hopkins CSP 97-99).
– “Use of Hospital-based Acute Care among Patients Recently Discharged
from the Hospital. JAMA, 23; 309(4):364-71, 2013
Z Song, D Safran, M Chernew, A. Mark Fendrick (Penn CSP 1991-93).
– The Impact of Bundled Payment on Emergency Department Utilization:
Alternative Quality Contract Effects After Year One. In press: Academic
Emergency Medicine Journal.
Lenard I. Lesser (UCLA CSP 09-12), Kayekjian, K., Velasquez, P., Tseng, C.H., Brook, R. H., Cohen, D. A.
– “Adolescent Purchasing Behavior at McDonald’s and Subway.” Journal of
Adolescent Health, 2012; 1-5.
Examples of Alumni Awards and
Achievements
• Margaret Gourlay (UNC CSP 02-04) won the Top 10 Clinical Research
Achievement Award from the Clinical Research Forum for her study on
bone density screening for older women.
• Eric Coleman (Washington CSP 95-97, VA Scholar) received a
MacArthur “Genius” Award/Foundation fellowship for his leadership in
geriatric and chronic disease care.
• Raina Merchant (Penn CSP 07-10), honored for leadership in health care
with the first ever RWJF Young Leader’s Award to commemorate the
foundation’s 40 year anniversary.
How to Apply
• Physicians who meet the eligibility requirements may may
apply online through the website site: http://rwjcsp.unc.edu
• Next application cycle opens November 2013 and closes
February 29, 2014 for cohort to start July 1, 2015
Contact Us
E-mail:
Phone:
Website:
[email protected]
919-843-1351
http://rwjcsp.unc.edu