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, Director
Michael B. Rothberg, MD, MPH, is the Vice Chair for Research in the Medicine Institute of Cleveland Clinic 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, 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.
Abhishek Deshpande, MD, PhD, Investigator
Abhishek Deshpande, M.D., Ph.D. is an Assistant Staff in the Department of Medicine and the Department of Infectious Diseases, Medicine Institute, Cleveland Clinic. His diverse research interests include evidence synthesis, comparative effectiveness, clinical practice guideline development and infectious diseases epidemiology. His research focuses on prevention of healthcare-associated infections with an emphasis on Clostridium 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 earned his medical degree from Manipal University, India and his PhD in biomedical sciences from the Kent State University/Cleveland Clinic Collaborative Program. He completed his postdoctoral fellowships from Cleveland Clinic and Case Western Reserve University. He has authored over 60 peer-reviewed articles, scientific presentations and book chapters and his research has been funded by federal and private industry sources.
Phuc Le, PhD, Research Fellow
Phuc Le is a Postdoctoral Research Fellow at the Medicine Institute Center for Value Based Care Research, Cleveland Clinic. Her research focuses on disease prevention, particularly vaccine and health screening programs. Her methods include costing, modeling, cost-effectiveness analysis, and observational data analysis. She has modeled the demand for primary care, Haemophilus influenzae type b vaccine in Vietnam, herpes zoster vaccine and blood lead screening in the US. She has also performed a costing study of pneumonia and meningitis, and analyzed the cost-effectiveness of colorectal cancer screening alongside a randomized trial.
Dr. Le obtained her first degree in Pharmaceutical Sciences in Vietnam. She 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 Academy Health Delivery System Science Fellowship for her postdoctoral training. Her research was funded by the Fogarty and International Society for Infectious Disease.
Kathryn Martinez, PhD, MPH, Investigator
Kathryn A. Martinez, PhD, MPH is Associate Staff at Cleveland Clinic’s Medicine Institute. Dr. Martinez is a health services researcher with an emphasis on cancer. Her interests include the use of patient satisfaction metrics to evaluate medical care quality, health disparities by race/ethnicity and socioeconomic status, and medical decision making. Her methods include survey research, scale development and testing, and secondary analysis of large datasets. Some of her recent work includes a comprehensive review of the role of patient autonomy in cancer treatment decision making, the application of conjoint analysis to explore women’s preferences for breast cancer chemoprevention, and an assessment of the stability of decision regret over time. She is currently working on a number of projects related to correlates of decision quality and decision satisfaction in cancer. The goal of Dr. Martinez’s research is to align patient preferences and values with decision making for evidence-based medical care.
Dr. Martinez holds a BA in History and Policy from Carnegie Mellon University, an MPH in Community Health Sciences 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. 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. Dr. Martinez has received funding from the Agency for Healthcare Research & Quality and the Veterans Administration. In addition, her dissertation work was fully supported by an award from the Medical Outcomes Trust for advancing the science of patient-centered outcomes research.
Anita Misra-Hebert, MD, MPH, FACP, Investigator
Anita D. Misra-Hebert MD, MPH, FACP is Staff physician in the Department of Internal Medicine, clinician investigator in the Center for Value-Based Care Research, Cleveland Clinic, and Assistant Professor of Medicine, Cleveland Clinic Lerner College of Medicine. Her current research focuses on improvement in population health through primary care redesign and the use of financial incentives to improve health. She is also interested in empathy in physician-patient communication, and improving health through health system/community collaboration. Her methods include observational studies, qualitative research, and analysis of electronic health records and administrative claims data. She has received research funding from the American Board of Internal Medicine Foundation, and the Clinical and Translational Science Collaborative (CTSC) at Case Western Reserve University.
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, and completed her residency training at the University of Cincinnati 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.
Matthew Pappas, MD, MPH, Investigator
Matthew Pappas, MD, MPH 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 through the Ann Arbor VA, which participated in the Robert Wood Johnson Foundation’s Clinical Scholars Program curriculum. Dr. Pappas’ published research has focused on the balance of benefits and harms for common decisions facing general internists and hospitalists.
Elizabeth Pfoh, PhD, MPD, Investigator
Elizabeth R. Pfoh, PhD, MPH is Associate Staff at Cleveland Clinic’s Medicine Institute. Dr. Pfoh is a Health Services Researcher interested in understanding how best to deliver high quality outpatient care, particularly for complex patients. She has expertise in evaluating the impact of policies on process measures of care, 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 a number of projects related to increasing patient-centered, evidenced-based care in the outpatient setting.
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.
Glen Taksler, PhD, Investigator
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.
Deshpande A, Pasupuleti V, Rothberg MB. Statin therapy and mortality from sepsis: a meta-analysis of randomized controlled trials. American Journal of Medicine 2015 Apr 128(4):410-417
Deshpande A, Pasupuleti V, Thota P, Pant C, Rolston DDK, Hernandez AV, Donskey CJ, Fraser TG Risk Factors for recurrent Clostridium difficile infection: A systematic review and meta-analysis. Infection Control & Hospital Epidemiology 2015 Apr 36(4):452-60
Donskey CJ, Kundrapu S, Deshpande A. Colonization versus carriage of Clostridium difficile. Infect Dis Clin North Am 2015 Mar 29(1):13-28
Lloyd A, Pasupuleti V, Thota P, Pant C, Rolston DDK, Hernandez AV, Benites-Zapata VA, Fraser TG, Donskey CJ, Deshpande A Accuracy of loop-mediated isothermal amplification for the diagnosis of Clostridium difficile infection: a systematic review. Diagnostic Microbiology and Infectious Disease 2015 May 82(1):4-10
O'Donnell M, Harris T, Horn T, Midamba B, Primes V, Sullivan N, Shuler R, Zabarsky TF, Deshpande A, Sunkesula VCK, Kundrapu S, Donskey CJ: Sustained increase in resident meal time hand hygiene through an interdisciplinary intervention engaging long-term care facility residents and staff American Journal of Infection Control 2015 Feb 43(2):162-164
Osanai T, Pasupuleti V, Deshpande A, Thota P, Roman Y, Hernandez AV, Ucino K Acute endovascular therapy in ischemic stroke: a systematic review and meta-analysis of randomized controlled trials. PLOS One 2015 Apr 10(4):e0122806
Pant C, Deshpande A, Sferra TJ, Gilroy R, Olyaee M Emergency department visits for acute pancreatitis in children: results from the Nationwide Emergency Department Sample 2006 - 2011. Journal of Investigative Medicine 2015 Apr 63(4):646-8
Pant C, Olyaee M, Freund ML, Deshpande A Risk of Clostridium difficile infection in following surgical procedures in the United States, 2002-2011 American Journal of Surgery In press
Pant C, Olyaee M, Gilroy R, Pandya PK, Olson JC, Oropeza-Vail M, Rai T, Deshpande A Emergency Department Visits Related to Cirrhosis: A retrospective study of the Nationwide Emergency Department Sample 2006 -2011 Medicine 2015 Jan 94(1):e308
Pant C, Olyaee M, Gilroy R, Pandya PK, Olson JC, Oropeza-Vail M, Rai T, Deshpande A. Emergency department visits related to cirrhosis: a retrospective study of the nationwide emergency department sample 2006 to 2011. Medicine (Baltimore). 2015 Jan 94(1):e308
Pant C, Olyaee M, Sferra TJ, Gilroy R, Almadhoun O, Deshpande A Emergency department visits for gastrointestinal bleeding in children: results from the Nationwide Emergency Department Sample 2006 -2011. Current Medical Research and Opinion 2015 Feb 31(2):347-351
Pant C, Olyaee M, Sferra TJ, Gilroy R, Almadhoun O, Deshpande A Emergency department visits for gastrointestinal bleeding in children: results from the Nationwide Emergency Department Sample 2006-2011. Curr Med Res Opin. 2015 Feb 31(2):347-351
Pant C, Sferra TJ, Olyaee M, Gilroy R, Anderson AP, Rastogi A, Pandya PK, Deshpande A Emergency department visits related to Clostridium difficile infection: results from the Nationwide Emergency Department Sample 2006 -2010 Academic Emergency Medicine 2014 2015 Jan 22(1):117-9
Pant C, Sferra TJ, Olyaee M, Gilroy R, Anderson MP, Rastogi A, Pandya PK, Deshpande A. Emergency department visits related to Clostridium difficile infection: Results from the Nationwide Emergency Department Sample, 2006 through 2010. Acad Emerg Med. 2015 Jan 22(1):117-119
Ruff AL, Teng K, Hu B, Rothberg MB Screening for abdominal aortic aneurysms in outpatient primary care clinics Am J Med 2015 Mar 128(3):283-288
Sivarajan G, Taksler GB, Walter D, Gross CP, Sosa RE, Makarov DV. The effect of the diffusion of the surgical robot on the hospital-level utilization of partial nephrectomy. Med Care. 2015 Jan 53(1):71-78
Sobieraj DM, Coleman CI, Pasupuleti V, Deshpande A, Kaw R, Hernandez AV. Comparative efficacy and safety of anticoagulants and aspirin for extended treatment of venous thromboembolism: A network meta-analysis. Thrombosis Research 2015 May 135(5):888-96
Taksler GB, Cutler DM, Giovannucci E, Keating NL. Vitamin D deficiency in minority populations. Public Health Nutr. 2015 Feb 18(3):379-391
Wong KK, Fraser TG, Shrestha NK, Fatica C, Deshpande A Low incidence of clostridium difficile infection (CDI) in patients treated with outpatient parenteral antimicrobial therapy (OPAT) Infect Control Hosp Epidemiol 2015 Jan 36(1):110-112
Wong KK, Fraser TG, Shrestha NK, Fatica C, Deshpande A Low Incidence of Clostridium difficile Infection (CDI) in Patients Treated with Outpatient Parenteral Antimicrobial Therapy (OPAT) Infection Control and Hospital Epidemiology 2015 Jan 36(1):110-2
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 [email protected].