The Robert Wood Johnson Foundation Clinical Scholars Change Agents In Medicine For More Than 40 Years

1. The Robert Wood Johnson Foundation Clinical ScholarsChange Agents In Medicine For More Than 40 Years Photo: Harold Shapiro

2. 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 11-13) and community partner Zachary Rowe (left) with community members Photo: Harold Shapiro

3. 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

4. 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

5. Scholar Training Sites and National Program Office Training Sites: University of California, Los Angeles University of Michigan University of Pennsylvania Yale University

6. 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

7. National Program Office (NPO) 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

8. 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

9. 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

10. 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

11. Scholar Experience and Curriculum

12. 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)

13. 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

14. 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

15. 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

16. 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

17. Approach • Intensive summer orientation • Core curriculum • Seminars and courses • Mentors • Writing group • Leadership training Photo: Harold Shapiro

18. Curriculum • The design and conduct of health services research, clinical epidemiology, and health policy research • Exposure to other fields of inquiry (e.g. economics, sociology, and law) relevant to study of US Healthcare • Centerpiece: one or more original research projects

19. Core Curriculum: Topics • 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

20. Seminars and Courses • Weekly seminars: works in progress • Leadership seminar • Didactic coursework • Seminar series

21. Structured Transition to Faculty • Completing manuscripts from Scholars’research projects • Writing grant applications • Developing mentoring skills Yale CSP Faculty

22. Examples of Scholar Publications 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

23. Projects by Recent Scholars

24. 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

26. Research Questions • Does quality and quantity of social relationshipspredict development of depression? • What is the relative impact of type of one’s social relationshipon depression risk? Hypothesis:

27. Baseline 1995-96 Outcome 2004-06 Study Sample • Midlife in the United States (MIDUS) • Community-residing adults age 25-75 recruited by random digit dialing N = 4,642 Quality of social relationships Quantity of social contact Past-year major depressive episode

28. Social Relationship Quality Has “Dose-Dependent” Effecton Risk of Depression Good quality Poor Quality

29. 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

30. Background • 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 • 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

31. Study Design • 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

32. 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

33. Results - Attendings Unadjusted Proportions of Brand Name Medications Prescribed

34. Results - Residents Unadjusted Proportions of Brand Name Medications Prescribed

35. Results – Multivariate Analyses

36. Summary • 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 • Significance • Default options were an effective methods to reduce the use of a low-value 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

37. 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

38. 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

39. Study Design 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 Study Population Count of 12 Major Comorbidities Age D’Amico Tumor Risk Race Type of Treatment Variables Covariates Methods Competing Risks Analysis Other-Cause Mortality by Comorbidity and Age Prostate Cancer Mortality by Tumor Risk Primary Outcome Secondary Outcomes

40. 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

41. Prostate Cancer Mortality by D’Amico Tumor Risk

42. To Treat or Not to Treat? Probability of 10-year Other-Cause Mortality Age and Comorbidity DM, HTN, COPD 26% 56 yo 40% 68 yo 71% 75 yo

43. 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

44. 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

45. 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

46. 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%

48. 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

49. 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

50. Alumni Statistics