David Meltzer M.D., Ph.D. May 10, 2013

1. Building a Learning Healthcare City:The Chicago Learning and Effectiveness Advancement Research Network (Chicago LEARN) David Meltzer M.D., Ph.D. May 10, 2013

2. Comparative Effectiveness and Patient-Centered Outcomes Research Infrastructure • Comparative effectiveness research (CER) seeks to understand the relative benefits of medical interventions • Patient-centered outcomes research (PCOR) focuses on relative benefits for patient subgroups and individuals • Chicago LEARN (Learning Effectiveness Advancement Research Network) objective: • To establish state of the art infrastructure for CER and PCOR in the inpatient setting in Chicago with the potential for national impact through partnership with UHC (University HealthSystem Consortium) • Embrace concepts of a learning healthcare system

3. Timeline for Chicago Inpatient CER 1997 UC Hospitalist Project started • Interview hospitalized patients @ admission & 30 days post D/C • ~ 90,000 subjects enrolled to date 2001 Multicenter Hospitalist R01 • Medicare linkage • Hospitalist Scholars Program started 2006 UC CTSA Funded – focus on personalized medicine • Center for Education and Research in Therapeutics (CERT) (UC, UIC) • NU CTSA funded • UIC CTSA funded • ARRA $1.1 Billion for CER – CONCERT RC2 (UC, UIC), NIH KM1 (UC, UIC) 2010 ACA Passed – PCORI established with focus on patient-centered outcomes 2010 UC CTSA External Advisory Committee encourages development of CER • Chicago Effective Health Care Conference - CER Infrastructure, Informatics 2010 Infrastructure conversations with Computation Institute 2010 Chicago CTSAs Meeting – Julian Solway’s charge 2011 Chicago Effective Health Care Conference – UHC/Indiana University 2011 CTSA CER Supplement 2012 UC CTSA Renewal – CER Core, CMMI Innovation Challenge Award

4. Key Ideas for Chicago LEARN • Observational and experimental studies • Patterns/context of use • Causal inference • Large sample sizes • Faster trials that can include subgroups (PCORI) • Cluster randomized trials to study health service organization (IOM CER, CMMI) • Multiple inpatient data sources • Administrative • Chart/EHR (Learning Health Care System Model) • Patient interviews (PCORI) • Collect/use biospecimens • Follow patients after discharge • Integrated health system (Northshore) • Medicare data → Consent essential → Multipurpose use • Economies of scale in subject screening and recruitment (vs. single-study RAs) • Economies of scale in informatics infrastructure (multi-disease, multi-mission)

5. Chicago LEARN (Learning Effectiveness Advancement Research Network) • Multifunctional infrastructure for hospital-based patient-centered outcomes research for Chicago-area AMCs (UC, Rush, NS, UIC, NU, Loyola) with potential for national impact • Human infrastructure (RAs) with aim to spread hospitalist project model • Informatics infrastructure with UHC • Clinical Data Base/Resource Manager has chargemaster-level administrative data for >250 hospitals from >100 AMCs • All disease categories • All inpatient and some outpatient data • Supported by AMC CEOs for operations/quality benchmarking/ improvement • Invest $30 million over 3 years to add EHR data • Local partners can help develop and demonstrate value • Situates us to be early adopters in use of resulting data • Progress/Funding • Monthly meetings, UHC data transfers starting, QA/QI studies • CTSA CER Supplement, UC CER Core, CMMI grant, NIA Anemia study • Medicare data

6. Early Studies • Pharmacogenetic testing for warfarin dosing • EHRs to screen, Shared RAs • Transfusion for anemia • UHC for study design & collaboration

7. Physician Location and Quality/Cost of Care • Controlling healthcare costs requires focus on high cost patients • Most spending for high cost patients is repeatedhospitalization • Repeatedhospitalizationstronglyaffected bypoorcarecoordination • Worse since traditional primary care physicians replaced by hospitalists • 10-50% lower utilization possible with care coordination by own physician • Growth of hospitalists partially a spatial problem – transport costs • $6.1 Million CMMI Comprehensive Care Physician study to test if having same doctor care for patients in inpatient & outpatient setting can improve costs/outcomes • Locate clinic in hospital; focus on high cost patients • 2,000 patient randomized clinical trial - $50 mil/yr • Innovative delivery mode l for Accountable Care Organizations (ACOs)

8. Urban Contextual Data to Improve Health • Neighborhood resources and context • Environmental data to study healthcare productivity • Hospital length of stay (LOS) a critical policy variable • Unclear if faster discharge increases readmissions, costs • LOS is a behavior • LOS = f (observables, unobservables) • Hard to understand, study effects of LOS • Readmission = f (LOS, observables, unobservables) • Wish one had experimental data • Contextual data to infer effect of increased LOS on costs and outcomes • Hint: Chicago winter, summer

9. Instrumental Variable Approach to Identification Admit Date Diagnosis-driven probability of ideal discharge 1/2 1/3 1/6 1/3 Extend LOS 1/2 Extend LOS 1/6 Shorten LOS

10. Urban Contextual Data to Improve Health • Neighborhood resources and context • Use of environmental data to learn about productivity • Hospital length of stay (LOS) a critical policy variable • Unclear if faster discharge increases readmissions, costs • LOS is a behavior • LOS = f (observables, unobservables) • Hard to understand, study effects of LOS • Readmission = f (LOS, observables, unobservables) • Wish one had experimental data • Contextual data to infer effect of increased LOS on costs and outcomes • Hint: Chicago winter, summer • Use to test productivity across cities, clinical areas

11. Conclusions • Academic medicine and healthcare institutions in cities provide important opportunities for research to improve healthcare outcomes and costs • Chicago LEARN as model for collaboration among urban academic medical centers and across cities • Chicago’s rich set of institutions in healthcare create unique opportunities for researchers and for the city