How long have you been at Duke? How long have you been at the Division?
I started as a post-doc with the Division of General Internal Medicine and VA Center for Health Services Research in Primary Care (HSR&D Center) in December of 2003. I am currently a Research Health Scientist with the VA HSR&D Center and Associate Professor in the Division.
What other roles do you have at Duke? How to they inform your work at the Division?
I am a healthcare epidemiologist with a background in health administration. My research focuses on how the structure and processes of primary and specialty care impact health outcomes, especially for patients with diabetes, hypertension, and cancer. Additionally, I lead the Implementation Science Lab/Core within the VA HSR&D Center. The overall goal is to enhance the capacity of the Center to conduct studies of the process and impact of implementing innovative health services interventions in the VA and other healthcare systems. I am fortunate to also be collaborating with a fantastic group of colleagues to enhance these capabilities within DGIM more broadly.
You recently attended AcademyHealth’s Annual Research Meeting in San Diego. What was the most interesting finding or new research that you learned?
The sessions I attended concentrated on the transition of healthcare systems that have operated within a fee-for-service environment to taking a more population-focused view of healthcare. This is embodied in the development of accountable care organizations (ACOs) and patient-centered medical homes (PCMHs). Both provider organizations and third-party payers throughout the country need to respond to issues such as how to define patient populations (e.g., assignment of patients to ACOs for the purpose of risk sharing and primary care providers to meet PCMH requirements). Addressing the needs of patient populations will require the establishment of new care teams and use of tools to address processes like self-management support. DGIM is very well positioned to utilize the clinical, administrative, and research expertise of faculty members to develop practical mechanisms to address these challenges and conduct research on the process of implementing new interventions.
One of your major research areas is implementation science. Can you tell me more about that?
Research suggests numerous ways to optimize the structure and process of care with the goal of improving outcomes. However, simply having such knowledge does not lead to the best organization or delivery of care. Implementation science examines the practical issues involved in implementing new care innovations (e.g., telephone disease management) or mechanisms for organizing care (e.g., PCMHs). We try to determine the impact of implementation strategies such as quality improvement collaboratives for implementing innovations on both the effectiveness of the implementation process (e.g., was an innovation implemented as intended; did appropriate patients get cancer screening) and innovation effectiveness as measured by clinical outcomes, patient and staff experience, and economic impact. This involves a variety of quantitative and qualitative methods. Teams with which I work are conducting implementation research or evaluation projects in areas such as the implementation of telephone disease management, lung cancer screening, and integration of mental health and chaplain services.
You’re also the Principal Investigator for a clinical trial examining interventions for veterans with hypertension. What have you found so far? How do the needs of veterans with hypertension compare to other people with hypertension in the general population?
Many disease management programs that have different levels of services include triggers to intensify program intensity without having plans to reduce program intensity as patients’ health improves. It is likely that healthcare systems considering the needs of their population of patients with chronic illness can’t provide the highest level of disease management resources indefinitely. The goal of the trial is to learn more about our ability to make the optimal use of resources to appropriately meet patient’s healthcare needs.
Our team is examining whether programs aimed at matching resources to patient disease control lead to superior outcomes than simply having maintenance phone calls in addition to usual care. Examining changes in systolic BP, the 18-month trial is testing the impact of an intervention using titrated disease management in which patients’ hypertension control, assessed at baseline, 6, and 12 months to decide the resource intensity of strategies: 1) Medium/level 1 resource intensity: a registered nurse providing monthly tailored behavioral support telephone calls + home BP monitoring; 2) High/level 2 resource intensity: pharmacist providing monthly tailored behavioral support telephone calls + home BP monitoring + pharmacist-directed medication management; and 3) Booster (low) resource intensity: a license practice nurse (LPN) providing bi-monthly, non-tailored behavioral support telephone calls to patients whose systolic BP comes under control. In the control arm, a LPN provides bi-monthly non-tailored behavioral support telephone calls.
What’s one thing that you like to do when you’re not at Duke?
My wife and I have two-year-old twins, a boy and a girl. We enjoy taking them to places like the Museum of Life and Science.
