The Medicine Institute’s Center for Value-Based Care Research (CVCR) conducts research on novel interventions that improve value in healthcare by increasing quality and/or decreasing costs. We seek to deliver the right care, at the right time, to the right patients, at lower cost. Established in 2013, CVCR includes eight full-time investigators (MDs and PhDs) with primary appointments as well as adjunct faculty from health services and outcomes research groups from across Cleveland Clinic. CVCR researchers will employ multidisciplinary teams and community partnerships to conduct research focused on identifying and disseminating high value healthcare.
Mission and Vision
To make quality healthcare possible for all Americans by conducting research to identify value in healthcare.
Medicine Institute Center for Value-Based Care Research (CVCR) will be leaders in the development, implementation, evaluation and dissemination of value-based, patient-centered healthcare. CVCR will focus on the following areas:
- Development and use of personalized risk assessment and shared decision-making tools.
- Delivery system changes, including new care structures, payment models, incentive programs and care paths.
- Observational studies that take advantage of variation in care among a large number of providers to assess comparative effectiveness of interventions and to identify best practices to improve the quality of care.
- Novel uses of health IT, including decision support at the point of care, incorporating patient-reported information into medical decision-making, smart reminder systems and patient education.
- End-of-life care, with an emphasis on improving quality of life, patient autonomy, dignity and comfort.
A Unique Environment for Value-Based Care Research
The Cleveland Clinic and the Medicine Institute have a number of resources that make it uniquely positioned to pursue this work:
- The culture of Cleveland Clinic has always embraced innovation, and there are multiple initiatives under way to improve value-based care across the enterprise.
- As a staff model, integrated healthcare system using a shared electronic health record (EHR), Cleveland Clinic can both implement new programs and collect data on clinical outcomes through its EHR. With more than five million visits annually, the EHR provides valuable information for comparative effectiveness and quality of care research.
- Tens of thousands of patients report their own outcomes each month through the Knowledge Program (KP), a system that allows patients to record a self-assessment directly into their EHR. Over the past four years, the KP has collected electronic patient-reported information for hundreds of thousands of encounters.
- With more than 200 primary care physicians practicing in 18 family health centers, 18 community practices and main campus, the Medicine Institute provides an ideal setting for conducting research about how to better structure primary care delivery. Innovative structures being studied include team care, in which medical assistants take on a larger role in the visit, including scribing, and the hiring of case managers to assist with care coordination.
- CVCR investigators work closely with statisticians in Quantitative Health Sciences to build personalized risk calculators based on data obtained from the EHR. These mathematical models can predict which patients will benefit from particular treatments and recommendations from the models can be incorporated into the EHR for use at the point of care.
Michael Rothberg, MD, MPH
Michael B. Rothberg, MD, MPH, is the Vice Chair for Research in Cleveland Clinic Community Care and Professor of Medicine at Case Western Reserve University. He practices general internal medicine and directs the Center for Value-Based Care Research. His research examines quality of care and decision making for common medical conditions, with an emphasis on tailoring treatment to patients based on individual risk and preferences. His methods include large observational studies, risk modeling and cost-effectiveness analysis. His areas of interest include pneumonia and influenza, venous thromboembolism, coronary artery disease and public reporting of healthcare quality. The goal of his research is to help physicians and patients make better healthcare decisions in order to improve outcomes and control costs.
Dr. Rothberg completed a research fellowship in Medical Informatics from the National Library of Medicine and has received research funding from AHRQ, NHLBI, NIA, the Doris Duke Charitable Foundation and the Informed Medical Decisions Foundation. Dr. Rothberg received his medical degree from New York University and his Master’s in Public Health from Harvard University.
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Abhishek Deshpande, MD, PhD
Abhishek Deshpande, M.D., Ph.D. is an Assistant Professor of Medicine at Cleveland Clinic Lerner College of Medicine and Associate Staff in the Department of Medicine and the Department of Infectious Diseases, Cleveland Clinic.
His diverse research interests include evidence synthesis, comparative effectiveness, health services research outcome studies, clinical practice guideline development and infectious diseases epidemiology. His research focuses on prevention of healthcare-associated infections with an emphasis on Clostridioides difficile infection (CDI). His methods include large observational studies, evidence synthesis including meta-analyses, outcomes research and clinical trials. His areas of interest include hospital-acquired infections, pneumonias and infection control. The overall goal of his research is to help reduce the burden and prevent hospital-acquired infections.
Dr. Deshpande has authored over 100 peer-reviewed articles, scientific presentations and book chapters in medical and health services research journals. His research is funded by extramural grants from Agency for Healthcare Research and Quality (AHRQ) and private industry sources. He is as a member of the Health Care Research Training (HCRT) Study Section, AHRQ and serves as an Academic Editor for PLOS One.
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Phuc Le, PhD, MPH
Phuc Le is Staff at Cleveland Clinic Community Care and Assistant Professor of Medicine at Cleveland Clinic Lerner College of Medicine. Her research focuses on the application of decision science and health economics to support evidence-based medical decision making and inform public health policy. Her methods include costing, disease modeling, cost-effectiveness analysis, and observational data analysis. Dr. Le currently leads multiple health economics and disease modeling studies in different areas including Haemophilus influenzae type b and herpes zoster vaccines, venous thromboembolism prophylaxis, antibiotics use in patients with community acquired pneumonia, comparative cost-effectiveness of screening and treatment for nonalcoholic fatty liver disease in patients with diabetes and pre-diabetes.
She was awarded the Lee B. Lusted prize for the best abstract in Applied Health Economics and the Best Paper by a Young Investigator Award, both from the Society for Medical Decision Making.
Dr. Le obtained a Bachelor's Degree in Pharmaceutical Sciences in Vietnam. She then earned her MPH in Community Health and Ph.D in Health Economics at the University of Texas School of Public Health at Houston. Dr. Le received the Steven M. Teutsch Prevention Effectiveness Fellowship and AcademyHealth Delivery System Science Fellowship for her postdoctoral training. Her research has been funded by the NIH Fogarty International Center, International Society for Infectious Diseases, American Academy of Implant Dentistry Foundation, and Agency for Healthcare Research and Quality.
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Kathryn Martinez, PhD
Kathryn A. Martinez, PhD, MPH is Staff at Cleveland Clinic Community Care.. Dr. Martinez is a health services researcher with an emphasis on medical decision making. Her specific interest is in how patients and physicians use information about risks and benefits of different treatment strategies to inform patient-centered and evidence-based decisions.
Dr. Martinez holds a BA from Carnegie Mellon University, an MPH from the University of California, Los Angeles, and a PhD in Health Services Research and Policy from the Johns Hopkins Bloomberg School of Public Health. Her dissertation work was funded by the Medical Outcomes Trust for advancing the science of patient-centered outcomes research. Following her PhD, Dr. Martinez completed a postdoctoral fellowship at the VA Ann Arbor Center for Clinical Management Research and the University of Michigan in the Division of General Medicine, where she was a member of the Cancer Surveillance and Outcomes Research Team.
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Anita Misra-Hebert, MD, MPH
Anita D. Misra-Hebert, MD, MPH is Director of the Healthcare Delivery & Implementation Science Center at Cleveland Clinic and Associate Professor of Medicine at the Cleveland Clinic Lerner College of Medicine. She is a practicing physician in the Department of Internal Medicine and a clinician investigator in the Center for Value-Based Care Research, both in Cleveland Clinic Community Care. Her research involves studying initiatives to improve population health through primary care redesign efforts using mixed methods, funded by a K08 grant from the Agency for Healthcare Research and Quality. Dr. Misra-Hebert holds a secondary appointment in the Department of Quantitative Health Sciences, where she focuses on diabetes outcomes research with a multidisciplinary team using electronic medical record data. Her methods include observational studies and implementation research using quantitative, qualitative, and mixed-methods.
Dr. Misra-Hebert completed her undergraduate training at Northwestern University, obtained her medical degree from the Ohio State University College of Medicine and Public Health, completed her residency training at the University of Cincinnati Hospitals, and previously served as clinical faculty in General Medicine at the University of Chicago Hospitals. She completed the Veterans Affairs National Quality Scholars Fellowship program and earned a master’s degree in public health at Case Western Reserve University in 2013.
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Matthew Pappas, MD, MPH
Matthew Pappas, MD, MPH, FHM is an Associate Staff Physician in the Department of Hospital Medicine and a Research Investigator in the Cleveland Clinic’s Medicine Institute. Dr. Pappas is a hospitalist and health services researcher whose goal is to make medicine simultaneously more personalized and more rigorously grounded in the best-available evidence. His ongoing work focuses on personalizing decisions to prescribe anticoagulants and to order preoperative stress tests.
Prior to the Cleveland Clinic, Dr. Pappas was at the University of Michigan, where he completed medical school, residency, and was on faculty as a Clinical Lecturer. He also completed a health services research fellowship in the Robert Wood Johnson Foundation’s Clinical Scholars Program curriculum, funded by the Ann Arbor VA. Dr. Pappas' published research has focused on the balance of benefits and harms for common decisions facing general internists and hospitalists. He is currently funded by the National Heart, Lung, and Blood Institute (NHLBI).
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Elizabeth Pfoh, PhD, MPD
Elizabeth R. Pfoh, PhD, MPH is Staff at Cleveland Clinic’s Medicine Institute and an Assistant Professor of Medicine at Case Western Reserve University. Dr. Pfoh is a Health Services Researcher interested in understanding how best to deliver high quality outpatient care, particularly for patients with multiple chronic conditions. She has expertise in evaluating the impact of system changes on process measures of care and patient outcomes, the impact of health information technology on patient safety and physician satisfaction, and long-term physical and mental health outcomes after hospital discharge. Dr. Pfoh has used both quantitative and qualitative methods in her work. She is currently working on several projects related to increasing patient-centered, evidence-based care in the primary care setting. In 2021, Dr. Pfoh received the Excellence in Research Award from Cleveland Clinic Lerner College of Medicine.
Prior to coming to Cleveland Clinic, Elizabeth was a General Internal Medicine postdoctoral fellow at Johns Hopkins School of Medicine. She received her PhD in Health Services Research and Policy from Johns Hopkins Bloomberg School of Public Health in 2014. Her dissertation, “The Value of Measuring Quality of Primary Care using Patient-Reported Depression Collected Through Electronic Health Records”, has been published in the Journal of the American Geriatrics Society and Psychiatry Services. In 2010, she received a MPH from Columbia Mailman School of Public Health where her focus was health promotion. She was supported on a pre-doctoral institutional training grant from Agency for Healthcare Research and Quality and a post-doctoral institutional training grant from the Health Resources and Services Administration. Her dissertation work was fully supported by the Alvin R. Tarlov & John E. Ware Jr. Doctoral Award in Patient Reported Outcomes from the Health Assessment Lab.
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Glen Taksler, PhD
Glen Taksler is Assistant Professor of Medicine at Cleveland Clinic Lerner College of Medicine and Associate Staff at Cleveland Clinic’s Medicine Institute. His research focuses on disease prevention, with particular attention to improving the understanding of factors that improve long-term health. Some of Dr. Taksler’s recent work includes developing methods to personalize major preventive health care guidelines based on the unique risk factors of individual patients, prioritizing preventive health care services based on their potential to improve longevity, analyzing communitywide (herd immunity) benefits of influenza vaccination, and explaining racial disparities in vitamin D deficiency and prostate cancer mortality. His methods include decision analytic modeling, predictive risk modeling, economic analysis and observational study designs using large datasets.
He was awarded the Most Outstanding Paper by a Young Investigator Award by the Society for Medical Decision Making and the Milton W. Hamolsky Award for Most Outstanding Junior Faculty Abstract by the Society of General Internal Medicine.
Dr. Taksler holds a BA in Economics and Mathematical Sciences from Johns Hopkins University, an AM and PhD in Economics from Harvard University, and a postdoctoral fellowship in Population Health and Medicine from New York University School of Medicine. Dr. Taksler’s research has been funded by the National Institutes of Health, Agency for Healthcare Research & Quality, Clinical and Translational Science Collaborative of Cleveland, New York State Health Foundation, and Dana-Farber Cancer Institute.
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Nazleen Bharmal, MD, PhD, MPP
Nazleen H. Bharmal, MD, PhD, MPP is the Associate Chief of Community Health & Partnerships for Cleveland Clinic Community Care and Population Health. In this role, she works with an interdisciplinary team to implement a community health strategy for Cleveland Clinic focused on health equity, social determinants of health, and partnerships with community stakeholders. Dr. Bharmal practices primary care internal medicine focused on disease prevention and health promotion.
She previously was the Director of Science and Policy at the Office of the Surgeon General (OSG) in the U.S. Department of Health and Human Services. Prior to her time at OSG, she was a clinician-investigator at the RAND Corporation and UCLA Department of Medicine, Division of Health Services and General Internal Medicine with a research focus on health disparities, chronic disease prevention, and social determinants of health using quantitative, qualitative, and community-based participatory research methods.
She has published in several scientific journals and received awards for her public health research and leadership activities. She received her MD from Harvard Medical School, PhD in health policy and management from the UCLA Fielding School of Public Health, and MPP from the John F. Kennedy School of Government.
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Michelle Beidelschies, PhD
Michelle Beidelschies, PhD is Assistant Professor of Medicine in the Cleveland Clinic Lerner College of Medicine and Staff in the Cleveland Clinic Center for Functional Medicine where she is the Research and Education Director. Dr. Beidelschies is responsible for developing the evidence base for the functional medicine model of care and other innovative care delivery models developed at the Center such as shared medical appointments. In October 2019, Dr. Beidelschies and her team published the first-ever study on the functional medicine model of care in JAMA Network Open.
Dr. Beidelschies began her research career in the Department of Physiology and Biophysics at Case Western Reserve University studying ischemia/reperfusion cardiac injury as an undergraduate in 2000. She then joined the department as a doctoral trainee, and received her PhD in 2009. Her dissertation research was performed in the Department of Orthopaedics on aseptic loosening of orthopaedic implants. Following graduation, she held a post-doctoral fellowship in the Department of Nutrition at Case Western Reserve University. Shortly thereafter in 2010, Dr. Beidelschies accepted a position at Cleveland HeartLab, Inc., a Cleveland Clinic start-up company focused on the development and commercialization of innovative cardiovascular diagnostics, where she held the position of Director of Education and Clinical Affairs until 2016. She has coauthored numerous peer-reviewed academic research publications.
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Andrei Brateanu, MD, FACP
Andrei Brateanu, MD, FACP, is the Senior Associate Program Director of the Internal Medicine Residency Program in the Medicine Institute of Cleveland Clinic and Associate Professor of Medicine at Case Western Reserve University and Cleveland Clinic Lerner School of Medicine. He practices general internal medicine and directs the Cleveland Clinic Internal Medicine Residency Program Evaluation Committee. His research focus is in the area of clinical education, with particular interest in emerging strategies to improve residents’ teaching and evaluation. Over the course of his academic career, he was the principal investigator of several research grants, co-authored numerous peer-reviewed articles, three book chapters and co-edited two books. On multiple occasions, he chaired sessions at national and regional professional meetings and led workshops aimed at resident education and competency assessment. He is currently a member of three Medicine Institute committees and two Cleveland Clinic research awards committees, including the William E. Lower Award.
Dr. Brateanu received his medical degree from Iasi Medical University, Romania and completed a postdoctoral fellowship with the Center for Value, Quality and Effectiveness Research at Cleveland Clinic.
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Jarrod Dalton, PhD
Dr. Dalton is Associate Staff with expertise in data science, risk prediction modeling, econometric analysis, and simulation. My research is focused on collaborative, systems-based approaches to understanding heterogeneity in risk, treatment effectiveness and outcomes among populations. He has developed methods for evaluating real clinical treatment decisions within the context of model-recommended treatments which optimize outcome risk, and shown through this methodology that hospitals with greater rates of discordant therapy in relation to model recommendations have worse risk-adjusted outcomes.
After completing an NIH-funded post-doctoral (KL2) training scholarship in translational science within the Clinical and Translational Science Collaborative of Cleveland, Dr. Dalton partnered with investigators at MetroHealth System on an NIA-funded R01 project to develop forecasting models for atherosclerotic risk in heterogeneous populations defined according to SEP and age. In another population health research effort, he is partnering with Maryam Valapour, MD, who is a Cleveland Clinic transplant pulmonologist with health policy expertise, on an NHBLI-funded R01 project to improve the methodology used to build risk-predictions for the lung transplant population focusing on illness severity, timing of transplant, and maximizing of post-transplant survival benefit.
His scientific contributions have earned the designation of Top-Ranked Abstract at 3 recent Annual Meetings of the Society for Medical Decision Making (SMDM; 2014, 2016 and 2018), and, in 2018, the 2018 SMDM Outstanding Paper by a Young Investigator Award for his Annals of Internal Medicine paper on neighborhood-level risk variation in atherosclerotic cardiovascular disease. He currently has 89 peer-reviewed publications with a total of 3,207 citations (h-index: 31).
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Aaron Hamilton, MD, MBA, FACP, SFHM
Dr. Aaron Hamilton is a practicing Hospitalist and he currently serves as the Chief Medical Officer at Cleveland Clinic Hillcrest Hospital.
As CMO at Hillcrest, Dr. Hamilton works with Hillcrest’s Executive Leadership team to help direct, coordinate and evaluate the operation of the hospital. Fiscal Responsibility, driving high reliability in Quality and Safety, Culture and Process Improvement, Patient and Family Centered Care for better patient outcomes including active research studies on VTE prevention, inpatient pneumonia care and patient mobility are key areas of focus. In addition supporting the integrity of our culture and caregivers at Hillcrest and throughout the health system is also a top priority.
He is an active leader nationally and locally in several professional organizations including: American Society for Healthcare Risk Management and the Society of Hospital Medicine.
Dr. Hamilton earned both his medical and business degrees from the University of Chicago. He completed a residency in internal medicine at the Hospital of the University of Pennsylvania, Philadelphia.
Dr. Hamilton has leaned into the Hillcrest’s DI Council and also the healthcare partners group – representing the hospital leadership team.
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Jessica Hohman, MD, MSc, MSc
Jessica Hohman, MD MSc MSc is the President and Medical Director of the Cleveland Clinic Accountable Care Organization. In this capacity, Dr. Hohman oversees 90,000 beneficiaries, with a particular focus on designing interventions to improve healthcare quality and value. She has led a portfolio of population health initiatives—including the development of a data-driven performance management program, new home-based post-acute care models, and collaborative approaches to improve end-of-life care.
Dr. Hohman is also a physician investigator in the Center for Value-Based Care Research. She is a grant-funded researcher who has presented at national meetings and co-authored publications on health IT, telemedicine, healthcare financing, and post-acute care. She maintains an active clinical practice in Internal Medicine, seeing both outpatients and inpatients and is involved in the teaching and mentorship of Case Western and Cleveland Clinic Lerner School of Medicine students and residents.
Previously, Dr. Hohman was the Founder and Chief Medical Officer of CarePort Health, an end-to-end platform managing patient transitions across the care continuum and early pioneer in post-acute outcomes management. Her prior work experience spans health technology, academic, and governmental sectors, including positions at LSE Health, the Massachusetts Health Connector, and the Institute for Strategy and Competitiveness. Her co-authored studies of value-based initiatives have been published in the Harvard Business Review and are used as core teaching materials in Harvard Business School’s healthcare curriculum.
Dr. Hohman earned an MSc Health Policy, Planning, and Financing and an MSc Social Research Methods (Health Economics) as a Marshall Scholar at the London School of Economics. She graduated from Harvard Medical School and completed Internal Medicine-Primary Care residency at the University of California-San Francisco (UCSF) followed by General Internal Medicine Fellowship at Harvard.
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Joshua K. Johnson, DPT, PhD
Joshua K. Johnson, DPT, PhD is a physical therapist researcher with a primary professional staff appointment in the Department of Physical Medicine and Rehabilitation. He treats patients hospitalized across the various clinical institutes at Cleveland Clinic Main Campus. His research focuses on using patient outcomes and clinical process measures to evaluate and improve the value of health services provided by rehabilitation clinicians across the continuum of care. His work incorporates principles of a learning health system in which internal clinical data and experience is combined with external evidence to facilitate enhanced value-based care. In those efforts, Dr. Johnson primarily employs observational study designs while incorporating components of implementation science in partnership with health system administrators and clinicians across multiple disciplines.
Dr. Johnson completed his undergraduate training at Brigham Young University. He holds a Doctor of Physical Therapy degree from Arcadia University and a PhD in Rehabilitation Science with an emphasis in evidence-based practice from the University of Utah. Dr. Johnson’s research has been funded by the Foundation for Physical Therapy Research, the Center on Health Services Training and Research (CoHSTAR), the Academy of Acute Care Physical Therapy, the Learning Health System Rehabilitation Research Network (LeaRRn), and the Cleveland Clinic Neurological Institute.
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Susannah Rose, PhD, MS
Susannah Rose joined the Professional Staff at Cleveland Clinic in 2011, and is currently the Associate Chief Experience Officer & Director of Research in the Office of Patient Experience. She is an Assistant Professor at Cleveland Clinic’s Lerner College of Medicine and in the Department of Bioethics at Case Western Reserve University, where she teaches healthcare economics, population-based bioethics, and international comparative health policy. She is also an Instructor at Harvard University’s T.H. Chan School of Public Health, where she teaches public health ethics.
She received her Ph.D. from Harvard University's Health Policy Program (with a concentration in Ethics) in 2010. Dr. Rose was a National Institute of Mental Health (NIMH) pre-doctoral research fellow; a Harvard Edmond J. Safra Center for Ethics Graduate Fellow; a Safra post-doctoral lab fellow; and she was also a pre- and post-doctoral fellow at Massachusetts General Hospital, sponsored by the National Cancer Institute (NCI) through the Program in Cancer Research Outcomes Training (PCORT). Prior to her doctoral studies, she earned an MS in Bioethics from Union College/Albany Medical Center in 2006, and a MS in Social Work from Columbia University in 1998. Dr. Rose worked as a clinical social worker and researcher at Memorial Sloan-Kettering Cancer Center in New York City.
During her career, Dr. Rose has received multiple mentorship and teaching awards. She has published two books focused on helping patients and family members cope with cancer, and she has published and presented in academic venues on topics related to technology diffusion in healthcare, conflicts of interest in medicine, health policy ethics, and bioethics. Her publications have appeared in high-ranked peer-reviewed journals, such as: JAMA Internal Medicine, Journal of General Internal Medicine (JGIM), The Journal of Clinical Oncology (JCO), The New England Journal of Medicine (NEJM), PLOS One and The Hastings Center Report, and her book chapters on health policy ethics and end of life care have been published by the Oxford University Press. She frequently presents at peer-reviewed national and international conferences, and is invited to speak at conferences all over the world.
Her current research focuses upon testing the impact of innovations in technology and communication interventions on health outcomes and patient satisfaction, and developing big-data approaches to improve patient experience. Dr. Rose’s research has been generously funded by multiple funding sources, including the National Institutes of Health (NIH), Harvard University’s Edmond J. Safra Center for Ethics, NIH’s Clinical & Translational Science Collaborative (CTSC) at Cleveland Clinic & Case Western Reserve University, and The Greenwall Foundation, in addition to internal Cleveland Clinic funding sources.
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Robert Saper, MD, MPH
Dr. Saper is Chair, Department of Wellness and Preventive Medicine, Cleveland Clinic. He graduated from Harvard Medical School in 1988 and completed family medicine residency and chief residency at UCSF in 1992. After being in private practice for eight years in the San Francisco Bay Area, he completed the Harvard NIH-funded research fellowship in integrative medicine research. In 2004 Dr. Saper joined the faculty of Boston University and Boston Medical Center and founded the Program for Integrative Medicine and Health Disparities. Dr. Saper was Professor of Family Medicine at Boston University School of Medicine and held many roles including Director of Integrative Medicine, Chair of Appointments and Promotions, Academic Fellowship Director, and Patient Experience Champion. His research studies the safety and effectiveness of integrative medicine approaches for common primary care problems such as back pain, particularly in underserved populations. Dr. Saper’s JAMA 2004 and 2008 publications demonstrating the presence of lead, mercury, and arsenic in traditional Indian medicines are highly cited and catalyzed reform in dietary supplement regulation nationally and internationally. His 2017 Annals of Internal Medicine paper demonstrating non-inferiority of yoga to physical therapy for chronic low back pain has contributed to the growing evidence base for nonpharmacologic therapies for chronic pain. He has authored over 65 peer-reviewed publications and received NIH career development, R01, U01 and PCORI grant funding. Dr. Saper is a past chair of the Academic Consortium for Integrative Medicine & Health. He teaches and mentors medical students, residents, fellows, and junior faculty.
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Cholesterol Screening in Primary Care
For patients without known cardiovascular disease, current guidelines recommend statin treatment based on individual risk. This project examines past treatment at the Cleveland Clinic to understand how physicians used risk and other factors in making treatment decisions. Using new risk assessment tools we project what treatment would look like under the new guidelines, including the number of patients treated, events prevented, and overall costs to the system. We will also explore the impact of changing treatment thresholds. Finally, we will explore which screening strategies are most cost-effective based on known patient risk factors.
Cost-effectiveness of Herpes Zoster Vaccine
Herpes zoster affects about 1 million Americans every year. Currently, the live attenuated herpes zoster vaccine is recommended by the Advisory Committee on Immunization Practices (ACIP) for people ≥60 years. This project examines several questions. First, we analyze the cost-effectiveness of HZ vaccine among people aged 50-59 years, who are out of the recommended age range by the ACIP although the vaccine is effective. Second, we determine the optimal age to get vaccinated among those ≥60 years. Given the current recommendation, most patients will likely get vaccinated when they turn 60 years, whereas we do not know at which age the vaccine will produce the greatest benefit. The last question we will address arises from the fact that a new adjuvanted HZ subunit vaccine has a much higher efficacy than the current licensed live attenuated vaccine. We will examine which vaccine is more cost-effective if the patients only get it once at age 60 years or above.
Cost-effectiveness of Prophylaxis for Venous Thromboembolism
This project is a part of a larger AHRQ-funded project named “Patient-Centered approach to reducing harm from VTE”. Although most previous decision-tree models of VTE prophylaxis concluded that prophylaxis was cost-effective compared to no prophylaxis, they did not examine the cut-off values for the risks of VTE and of bleeding at which prophylaxis was no long cost-effective. In addition, model inputs were dependent on a single randomized control trial which included severely ill patients rather than a general medically ill population. We aim to use a more comprehensive approach to model inputs selection which will reflect a general internal medicine inpatient population. We will also identify the risks of VTE and bleeding at which prophylaxis would cause harm than good, and apply these values into a clinical decision tool which will be tested in another component of the mother project.
Patient-Centered Approach to Reducing Harm from VTE
Venous thromboembolism (VTE) is a serious source of hospital morbidity and mortality. It can be prevented with heparin prophylaxis, but treatment should be reserved for high risk patients because prophylaxis increases the risk for bleeding and is costly and uncomfortable. Identifying low risk patients is difficult, because there are no validated risk prediction tools for use in US hospitals. Thus many hospitals offer near-universal prophylaxis, putting patients at unnecessary risk. The aim of this proposal is to use data from the Cleveland Clinic to create tools to assess risk of both VTE and bleeding and to weigh those risks. We will then incorporate them into our electronic health record in the form of a smart order set and assess the effects of the order set on physician behavior and patient outcomes using a randomized trial design. Knowledge gained from this study will inform best practices for VTE prophylaxis for millions of hospitalized medical patients each year.
Quality of Care and Outcomes of Healthcare-Associated Pneumonia
This study will provide important insight into a clinical dilemma faced by physicians who care for as many as 300,000 patients each year with Healthcare-Associated pneumonia (HCAP). This study will assess whether patients with HCAP are receiving care consistent with the recommendations found in guidelines developed by the American Thoracic Society and the Infectious Disease Society of America, and whether those treated according to the guidelines have better outcomes than patients who are treated with other antibiotics. These results will help clinicians balance the potential benefits of the recommended antibiotics against the potential harms of antibiotic side effects, future antibiotic resistance, and increased costs. If recommended therapy is beneficial but underutilized, these results will alert quality improvement officers and policy makers to an important opportunity to improve patient care for a common and deadly illness.
Understanding the Relationship between Surgeon Volume and Complications in Medicare Patients
This study uses Medicare data to assess the relationship between individual surgeon volumes and outcomes for common elective procedures, including hip and knee replacement, laparoscopic cholecystectomy, prostatectomy and spine surgery. Whereas other studies have assessed either low volume procedures or hospital volumes, this study seeks to understand the impact of individual surgical experience on outcomes. We will assess millions of procedures performed by thousands of surgeons all across America. We hope to determine lower limits for the number of procedures performed to ensure patients safety and also to examine upper limits after which complications may begin to rise again. This study may help to inform future quality metrics around surgical volumes.
Derivation of Clinical Prediction Rule for Recurrent Clostridium Difficile Infection
Clostridium difficile infection (CDI) is the most common cause of hospital acquired diarrhea in the developed world. CDI therapy is initially effective for most patients, but an estimated 20-30% of patients develop symptomatic recurrence within 2 weeks of successful completion of therapy. However, it is not clear as to why some CDI patients develop recurrence while others do not. Using a Cleveland Clinic system wide cohort, this project will evaluate the risk factors for recurrent CDI (rCDI) among patients with an initial episode of CDI. The data will be used to develop a clinical prediction rule for identifying patients who may be predisposed to rCDI.
Identification of risk factors and derivation of a Clinical Prediction Rule for Recurrent Clostridium difficile Infection in transplant recipients
Clostridium difficile infection (CDI) is the most common cause of hospital acquired diarrhea in the developed world. CDI therapy is initially effective for most patients, but an estimated 20-30% of patients develop symptomatic recurrence within 2 weeks of successful completion of therapy. Many observational studies have demonstrated that CDI recurrence rates are higher in transplant recipients and patients receiving chemotherapy for malignancies when compared with the general population. It is not clear as to why some transplant recipients develop more recurrence while others do not. Using a Cleveland Clinic system wide cohort, this project will evaluate the risk factors for recurrent CDI (rCDI) among transplant recipients with an initial episode of CDI. The data will be used to develop a clinical prediction rule for identifying transplant recipients who may be predisposed to rCDI.
Using Large Observational Datasets to Improve Antibiotic Prescribing for Community-Acquired Pneumonia
Community-acquired pneumonia (CAP) is a leading cause of hospitalizations and death in the United States. Identification of the causative organism’s antibiotic susceptibility is the key to appropriate antibiotic prescribing. Current treatment guidelines encourage physicians to consider local antimicrobial resistance, but actionable information, such as the resistance patterns for CAP, is rarely available. The aim of this proposal is to use data from three large observational datasets to describe the microbial etiology and antimicrobial resistance patterns of CAP in a US and describe the relationship between local antibiotic resistance patterns, physician prescribing and patient outcomes. We will also compare the effectiveness of an early switch from intravenous to oral antibiotics with the standard course of intravenous antibiotics. Knowledge to be gained will inform best practices for CAP antimicrobial therapy and lead to similar interventions for other pneumonias.
PI: Aaron Hamilton, MD
Dedicated Ambulator-Assisted Physical Activity to Improve Hospital Outcome Measures in Elderly Patients: A Randomized Controlled Trial
Patients who are hospitalized for acute medical problems often become deconditioned very quickly. Although nurses embrace the need to mobilize patients early in their hospital stay, they may not have time to get patients out of bed and walk them in the hallways. This pilot study will test whether a dedicated ambulator who is assigned to help elderly patients ambulate 3 times per day will impact patient outcomes in terms of length of stay, hospital complications, cost, and discharge disposition. Data from this study should inform a larger randomized tri
Effect of Financial Incentives on Cardiovascular Risk Factor Control
Financial incentives to achieve treatment goals may encourage patients to optimize self-management of their chronic disease. We are evaluating the effects of financial incentives offered by our employee health plan on cardiovascular risk factor control. This model, if successful, may be extrapolated to create incentive programs in primary care practices or through community-based programs to improve population health.
Evaluation of Team Based Primary Care Redesign Implementation
Primary care delivery is rapidly evolving to team-based models to improve the value of care provided to patient populations. We are studying outcomes of transitioning to team-based models in the Cleveland Clinic Health System. Our projects have included studying the effects of team-based care on physician-patient Interaction, evaluating the quality of progress notes written by physicians vs. medical assistant scribes, exploring views of providers and patients in redesign efforts, and understanding the role and outcomes related to embedding social work services in outpatient primary care. As Chair of the Medicine Institute Primary Care Stakeholder Advisory Panel, I work to ensure that patient perspectives guide the focus of our ongoing study of primary care redesign.
Predicting Severe Hypoglycemia Events
This work will identify all serious hypoglycemia events defined as Emergency Department (ED) visits or hospitalizations for hypoglycemia in patients with type 2 diabetes(T2D) receiving care in the Cleveland Clinic Health System (CCHS) and treated with antidiabetic medications (ADM) from 2005-2015. We will describe patient characteristics associated with serious hypoglycemia events and create predictive models to identify risk of developing a serious hypoglycemia event and for recurring serious hypoglycemia events for patients with T2D.
Primary Care Physician Decision-Making Behavior
Variation in physician practice style, while necessary for personalizing care to the needs of individual patients, also affects implementation of evidenced-based guidelines. We are exploring determinants of physician behavior that may be correlated with practice patterns. We are examining physician empathy related to other physician factors, exploring physician views about prescribing patterns, and evaluating the approach to ordering of screening tests for which shared-decision making with individual patients is recommended.
PI: Chun-Teh Lee, MD
Comparative Cost-effectiveness of Endodontically Treated and Retreated Teeth with Single Implants
This project will compare the survival/success rates of single implant and various endodontic therapies in an unprecedentedly large population. Using decision modeling, we will assess the cost-effectiveness of these treatment modalities. These results will vertically advance understanding of the clinical outcomes of implant and endodontic therapies, and facilitate value-based choice of treatments which will ultimately have positive impacts on patient outcomes.
Funding: American Academy of Implant Dentistry Foundation
The Demand for Primary Care and Emergency Department Use in Low-Income Population under the Affordable Care Act Medicaid Expansions
The Affordable Care Act (ACA) Medicaid Expansions aimed to improve insurance coverage which would theoretically increase access to primary care and reduce unnecessary emergency department (ED) use in the low-income population. Previous studies found that the ACA Medicaid Expansions has improved insurance coverage, access to care, and increased overall utilization in low-income population. Its effects on ED use, however, were mixed. There is no national estimate of the demand for primary care and ED visits to inform decision making in the rapidly changing US healthcare policy environment. In this study, we will use pooled observational design and the two-part hurdle model to estimate the demand for primary care visits and for emergency department (ED) visits in low-income population, and examine the trends from 2007-2014.
Examining Variation in Length-of-stay and Inpatient Cost as a Function of Hospitalist Experience
This project aims to investigate whether hospitalists improve at reducing costs and length-of-stay with increasing experience in post-residency practice, to both guide Hospital Medicine’s future growth as a sustainable profession and ensure the highest value of care for medical inpatients. The hospitalist model of care is associated with reduced length of hospital stay and lower expenditures compared with inpatient care provided by general internists, but those outcomes vary considerably among hospitalists. While theory would suggest that more experienced hospitalists reduce length of stay to a greater degree than do inexperienced hospitalists, that question remains unanswered. If patient outcomes improve with hospitalist experience, increased compensation for more experienced hospitalists may represent a worthwhile investment. Hospitals would seek to ensure that retention packages were appropriately generous, while efforts to counteract troubling signs of burnout would take on new importance. On the other hand, if little relationship exists between inpatient experience and outcomes, other models of care may represent a better value for the health system more broadly.
Personalizing Anticoagulation Decision-making Advice
Patients with atrial fibrillation are commonly managed using vitamin K antagonists (VKAs), such as warfarin, to reduce the probability of stroke. But interruptions of warfarin are common, and patient risks of bleeding and stroke vary widely. Dr. Pappas has developed a microsimulation model of anticoagulation in atrial fibrillation, which he uses to enable more personalized decisions for patients with atrial fibrillation.
Understanding and Improving Preoperative Stress Testing
The overall goal of this project is to develop more personalized approaches to mitigating the cardiac risk of noncardiac surgery, the approach to which is currently focused on preoperative stress testing and is based on limited evidence. Cardiac complications following noncardiac surgery are a considerable cause of morbidity, mortality, and expense. Current guidelines recommend preoperative stress testing for patients whose predicted risk of perioperative complications exceeds 1% and whose functional status is limited or unclear. The results of that stress test guide further preoperative testing and, if indicated, intervention. But while preoperative stress tests are associated with improved outcomes in administrative databases, stress testing is a purely diagnostic, not therapeutic, test. If stress testing is causally related to improved outcomes, the interventions that lead to improved outcomes are unclear. We are looking to better understand patterns of stress test usage before noncardiac surgery, to understand what interventions lead to lower morbidity and mortality, and to guide future decision-making regarding testing before noncardiac surgery.
The Impact of Depression Screening on Receipt of Depression Treatment and Remission
Depression is a prevalent disease, affecting between 7-27% of the population. Unfortunately, depression is often under-diagnosed and under-treated. Routine depression screening as part of quality reporting programs, despite the fact that depression screening alone has not been found to improve patient outcomes. However, the harms associated with depression screening are low, and providing appropriate treatment along with depression screening can save lives. This study will provide timely, policy-relevant information related to whether depression screening increases depression treatment.
Assessing the Effect of a Population-wide Program to Reduce Hypertension on Cardiovascular Health
Hypertension, or high blood pressure, affects one in three Americans. Hypertension is a major contributor to cardiovascular disease. Blood pressure can be effectively lowered, and lowering blood pressure results in improved cardiovascular health. Nevertheless, fifty-percent of individuals with high blood pressure do not have it controlled. This study evaluates the effectiveness of a system-wide intervention to increase hypertension control through medication intensification.
Do Older People Benefit from Younger People Getting Flu Vaccines?
Prior research has found a possible inverse association between vaccination coverage of schoolchildren and influenza-like illness in households or the general population. Using the largest data ever compiled on herd immunity (>3 million individuals across >13 million person-years), we expand these findings to assess whether influenza vaccination of nonelderly adults across the United States confers additional disease protection on the elderly.
Funding: National Center for Advancing Translational Sciences, Clinical and Translational Science Collaborative of Cleveland, New York University Clinical and Translational Science Institute
Integrating a Model of Personalized Healthcare for Health Systems, Physicians, and Patients
One important reason why the US health system does not consistently implement preventive care guidelines may be insufficient personalization and prioritization. To fully evaluate and implement all preventive care guidelines would consume 70%-85% of a physician’s day, making prioritization essential. This work seeks to further develop and translate a mathematical model to personalize and prioritize each of the 25 United States Preventive Services Task Force grade A and B guidelines applicable to non-pregnant adults, based on the gain in life expectancy that would occur if a particular patient were to adhere to each recommendation. Results are informed by each individual patient’s unique medical history, lifestyle, demographics and family history. Novel methods are employed to better understand how health care systems, physicians, and patients interact with personalized health care information at the point of care.
Funding: National Center for Advancing Translational Sciences and Clinical and Translational Science Collaborative of Cleveland
The Medicine Institute CVCR Fellows Program seeks to engage clinical staff in value-based care research by providing access to seasoned research personnel via structured weekly meetings. Fellows are appointed for a period of 18 months and are expected to attend weekly meetings as a group, to complete at least one research project, and to contribute their research knowledge to their colleagues’ projects.
Those interested in the 2018 cohort may contact Michael Rothberg, MD, MPH at firstname.lastname@example.org.