Randall D. Cebul, MD
Professor Emeritus of Medicine
Case Western Reserve University at MetroHealth Medical Center
Senior Scholar and Past Director, Center for Health Care Research & Policy
Past President and CEO, Better Health Partnership
Greetings to Colleagues and Friends:
On May 23, 2016, Center Faculty and Senior Scholars gathered at CWRU’s Squire Valleevue Farm to begin strategic plans for the Center’s future. In the preceding months, we had re-committed to our two-fold mission and identified relevant programmatic strengths that warranted greater focus and additional investment. Specifically, we committed to program growth in clinical research informatics and methods relevant to population health, including sophisticated statistical modeling and the design of transformative approaches to clinical care that explicitly recognize non-medical factors that influence health. I am pleased to report that we are well on our way, as I describe briefly below.
I also am pleased to report that I will be making a personal transition effective January first, formally relinquishing my roles at MetroHealth to serve as Professor Emeritus of Medicine at CWRU and contribute to a state-wide program to reduce disparities among our patients with cardiovascular disease. I am especially thankful to Professor Douglas Einstadter, MD, MPH, who will serve as Interim Director of the Center during this transition.
Our investments in informatics and population health recognize the benefits of collaborating across scholarly disciplines, a strength of the Center since its inception. Our collaborations also are strengthened by the Center’s Friday seminars and hallway conversations among Center faculty, visiting scholars, and colleagues from other health care systems and community organizations.
In addition, our students over the past more than 20 years are becoming our teachers. A majority of our over 300 peer-reviewed publications since 2015 have multiple Center authors, many including our current and past students. External support during 2017 from federal and state sources, as well as national and regional foundations, are increasingly led by our former trainees. We are proud that these former trainees will lead our programs in clinical research informatics (David Kaelber, MD, PhD) and population health (Shari Bolen, MD, MPH and Adam Perzynski, PhD), and that faculty and fellows in informatics will soon reside alongside other faculty on the Rammelkamp Research and Education Building’s second floor at MetroHealth.
The CWRU-MetroHealth Center for Health Care Research and Policy is now in its 24th year as the region’s leader in research and training in health care delivery and health policy. I am thankful to CWRU and MetroHealth, as well as many community colleagues and friends, for your support. I look forward to passing the baton to our new leaders.
Thank you, again, and best wishes for a happy and healthy new year.
Better Health Partnership (BHP) is a primary care focused regional health improvement collaborative founded in 2007. Its mission is “to create a safe space for health care competitors to collaborate” and is catalyzed by publicly reported data from our partners’ EHRs to identify and disseminate best practices that focus on chronic medical conditions that disproportionately affect disadvantaged populations. BHP’s initial focus reported improvement in diabetes care and outcomes in adults1; more recently, we have highlighted the value of health information exchange2, use of EHRs to improve outcomes in a safety net Medicaid waiver program3, and reductions in ambulatory care sensitive hospitalizations and costs.4 Members currently include over 1200 primary care providers who report care and outcomes for more than 400,000 adults and children in 12 health care systems in 9 counties in northeast Ohio. In addition to diabetes, adult quality measures now also include hypertension, heart failure, and colorectal cancer screening. Recent children’s health initiatives include obesity5 and asthma, with a focus on links of Better Health’s clinics to community-based resources for improvement. Support for BHP initiatives is provided by the Centers for Disease Control, Ohio Medicaid, regional foundations, CWRU’s CTSA program, and member fees.
Identifying Social Determinants of Health and Their Implications: Faculty spanning the Center’s expertise in population health, clinical informatics, and statistical methods are collaborating to better understand non-medical determinants of health at the neighborhood and community levels. Led by Population Health co-director Adam Perzynski, PhD, Center faculty documented a digital divide in high speed broad-band access in Cleveland and its relationship to patients’ access and use of personal health records6, drawing the attention of policy-makers at the Federal Communications Commission and Cleveland’s City Council. More recently, they have documented the much stronger relationship of the Neighborhood Disparities Index (NDI) with cardiovascular disease events than the predictions that use clinical indicators of the ACC/AHA Pooled Cohort Equations Risk Model7. Based on this work on over 109,000 patients, the team currently is funded by the National Institute on Aging (co-PIs Perzynski and Jarrod Dalton PhD) to improve current approaches to prediction and patient management by understanding the complexity of neighborhood, economic and clinical factors and how they interact to influence heart disease risk.
The eReferral & Teachable Moment project is a collaborative effort between Case Western Reserve University (led by Sue Flocke, PhD) and MetroHealth (led by Eileen Seeholzer, MD) that is focused on tobacco cessation assistance for primary care patients. The project builds on work of using teachable moments for discussing tobacco cessation and weight management.8 The current project tests the combined effect of this brief clinician communication strategy with a systems change initiative using an eReferral to the Ohio Quitline. The systems approach involves: 1) enabling the eReferral capacity to prompt a pro-active call from the state quitline for patients who are interested in quitting smoking; 2) changes to the EHR to include documentation and prompts; and 3) role and process changes for medical assistants. The system change has been implemented in 8 community primary care sites with sustained increases in the documentation of tobacco status and brief advice, with more than 1200 patients who are interested in quitting and referral to the quitline for assistance. Implementation of the Teachable Moment training is underway. This project is funded by an award from PCORI.
Statewide Cardiovascular Disease Quality Improvement: Based on Better Health Partnership’s documented improvement of hypertension control among disadvantaged patients in northeast Ohio, Ohio’s Department of Medicaid awarded a $1.5 million grant to CWRU and the Center’s Population Health Program co-leader Shari Bolen, MD MPH to improve the quality and reduce disparities among safety net patients with hypertension throughout Ohio. Guiding the work based at four medical schools across the state, Dr. Bolen and other Center colleagues will expand the program to improve the recognition and outcomes of other types of cardiovascular disease in the fall of 2018. This work is informed by Dr. Bolen’s prior work on the effectiveness of diabetes medicines10 and the importance of hypertension treatment intensification11.
Improving the Diagnosis and Management of Pediatric Hypertension. Even though children’s blood pressure is routinely checked during office visits, physicians aren’t interpreting the results and following the appropriate guidelines for treatment. Between 1999 – 2014, Dr. Kaelber and other researchers nationwide analyzed the electronic health records of 400,000 children from nearly 200 pediatric primary care sites across the country.12 They found that only 23 percent of those who had high blood pressure were diagnosed with the disease, and only 10 percent who were presenting with blood pressures that were in the pre-hypertension range and properly diagnosed. Among those children and adolescents with diagnosed high blood pressure for a year or more, fewer than 10 percent received guidelines-recommended antihypertensive medications. The results of this research affirms the findings of an earlier award-winning study that Dr. Kaelber conducted in 2007. In that study of approximately 15,000 patients, less than 25 percent were diagnosed with hypertension.13
- Cebul RD, Love TE, Jain AK, Hebert CJ. Electronic health records and quality of diabetes care. N Engl J Med. 2011 Sep 1;365(9):825-33. doi: 10.1056/NEJMsa1102519. PubMed PMID: 21879900.
- Kaelber DC, Waheed R, Einstadter D, Love TE, Cebul RD. Use and perceived value of health information exchange: one public healthcare system’s experience. Am J Manag Care. 2013 Nov;19(10 Spec No):SP337-43. PubMed PMID: 24511888.
- Cebul RD, Love TE, Einstadter D, Petrulis AS, Corlett JR. MetroHealth Care Plus: effects of a prepared safety net on quality of care in a Medicaid expansion population. Health Aff (Millwood). 2015 Jul;34(7):1121-30. doi: 10.1377/hlthaff.2014.1380. Erratum in: Health Aff (Millwood). 2015 Sep;34(9):1611. PubMed PMID: 26153306.
- Tanenbaum J, Cebul RD, Einstadter D, and Votruba M. Association of a primary care health improvement collaborative with regional rates of ambulatory care sensitive hospitalizations and associated costs. Health Aff. 2017. In press.
- Benson L, Baer HJ, Kaelber DC. Trends in the diagnosis of overweight and obesity in children and adolescents: 1999-2007. Pediatrics. 2009 Jan;123(1):e153-8. doi: 10.1542/peds.2008-1408. PubMed PMID: 19117837.
- Perzynski AT, Roach MJ, Shick S, Callahan B, Gunzler D, Cebul R, Kaelber DC, Huml A, Thornton JD, Einstadter D. Patient portals and broadband internet inequality. J Am Med Inform Assoc. 2017 Sep 1;24(5):927-932. doi: 10.1093/jamia/ocx020. PubMed PMID: 28371853.
- Dalton JE, Perzynski AT, Zidar DA, Rothberg MB, Coulton CJ, Milinovich AT, Einstadter D, Karichu JK, Dawson NV. Accuracy of cardiovascular risk prediction varies by neighborhood socioeconomic position: a retrospective cohort study. Ann Intern Med. 2017 Oct 3;167(7):456-464. doi: 10.7326/M16-2543. Epub 2017 Aug 29. PubMed PMID: 28847012.
- Flocke SA, Step MM, Antognoli E, Lawson PJ, Smith S, Jackson B, Krejci S, Parran T, Marsh S. A randomized trial to evaluate primary care clinician training to use the Teachable Moment Communication Process for smoking cessation counseling. Prev Med. 2014 Dec;69:267-73. doi: 10.1016/j.ypmed.2014.10.020. Epub 2014 Oct 30. PubMed PMID: 25456811; PubMed Central PMCID: PMC4312229.
- Antognoli EL, Seeholzer EL, Gullett H, Jackson B, Smith S, Flocke SA. primary care resident training for obesity, nutrition, and physical activity counseling: a mixed-methods study. Health Promot Pract. 2017 Sep;18(5):672-680. doi: 10.1177/1524839916658025. Epub 2016 Jul 8. PubMed PMID: 27402722.
- Bolen SD, Samuels TA, Yeh HC, Marinopoulos SS, McGuire M, Abuid M, Brancati FL. Failure to intensify antihypertensive treatment by primary care providers: a cohort study in adults with diabetes mellitus and hypertension. J Gen Intern Med. 2008 May;23(5):543-50. doi: 10.1007/s11606-008-0507-2. Epub 2008 Jan 25. PubMed PMID: 18219539; PubMed Central PMCID: PMC2324132.
- Maruthur NM, Tseng E, Hutfless S, Wilson LM, Suarez-Cuervo C, Berger Z, Chu Y, Iyoha E, Segal JB, Bolen S. Diabetes medications as monotherapy or metformin-based combination therapy for type 2 diabetes: a systematic review and meta-analysis. Ann Intern Med. 2016 Jun 7;164(11):740-51. doi: 10.7326/M15-2650. Epub 2016 Apr 19. Review. PubMed PMID: 27088241.
- Kaelber DC, Liu W, Ross M, Localio AR, Leon JB, Pace WD, Wasserman RC, Fiks AG; Comparative Effectiveness Research Through Collaborative Electronic Reporting (CER2) Consortium. Diagnosis and medication treatment of pediatric hypertension: a retrospective cohort study. Pediatrics. 2016 Dec;138(6). pii: e20162195. PubMed PMID: 27940711; PubMed Central PMCID: PMC5127074.
- Hansen ML, Gunn PW, Kaelber DC. Underdiagnosis of hypertension in children and adolescents. JAMA. 2007 Aug 22;298(8):874-9. PubMed PMID: 17712071.