University of Washington Clinical Scholars Program Interim Report March 18, 2005

This report summarizes the activities and accomplishments of the University of Washington Clinical Scholars Program for the period of July 2004 through March 2005. Dr. Deyo welcomes comments and suggestions.

PROGRAM EVENTS

Summer Programs: The six first year Scholars began the year with our annual Research Methods Mini-Course in July and August. Once again this was taught by Associate Director Joann Elmore, with the help of second year Scholar Mike Porter. This course focuses on research designs that Clinical Scholars might use in their work, with examples presented by second year and former Scholars. We also continued with the recent tradition of having informal seminars during summer quarter with key faculty and alumni, intended to improve networking and to introduce some of the key faculty to the incoming Scholars.

Summer course in Health Care Administration and Leadership: The second year Scholars once again took a course in healthcare administration taught by Dr. Bill Dowling, Professor and Chair of Health Services. As with last year’s version of the course, this program had a strong emphasis on leadership and change, as well as conveying major theories of healthcare management and leadership. Panel discussions with local healthcare leaders were among the highlights.

Fall Seminar Series: The fall seminar series included a mix of presentations on policy issues and practical skills. Dr. Fred Mann, from the Department of Radiology gave a brief presentation on preparing a CV. Dr. Tom Gallagher, from the Department of Medicine, spoke on physician attitudes regarding disclosing medical errors to patients. Dr. Cindy Watts from the Department of Health Services spoke on the political economics of public insurance and Dr. Scott Barnhart spoke on running a safety-net hospital. Tina Mankowski and Walter Neary from the UW Medicine News and Community Relations Office gave a presentation on the media and medicine, and Vic Snyder from the UW Center for Career Services gave a presentation of job interviewing. Finally, Dr. Will Hollingworth, an economist from the Department of Radiology, gave a presentation on cost-effectiveness of new diagnostic imaging techniques.

Annual Meeting Participation: Current Scholars and alumni were well represented on the Annual Meeting Program in November. Our five current second year Scholars all gave presentations, including Heidi Blume, Mandy Dempsey, Mike Porter, Louise Davies, and Marjorie Wang. In addition, newly graduated alumni Josh Fenton and Allison Galbraith presented work that they did as Clinical Scholars. Several alumni also attended and gave presentations, including Gil Welch, Gary Winzelberg, Carol Horowitz, and Mike Silverstein. Finally, UWCSP alumnus Chris Elias was one of the guest speakers for the annual meeting.

Guest Faculty Visits: We have the pleasure of having three program guest this year. Dr. Tracy Lieu, Associate Professor in the Department of Ambulatory Care and Prevention at Harvard Medical School and Director of the Center for Child Health Care Studies visited in March. She gave a presentation on decision analysis and the evolution of vaccine policy. Dr. Gil Welch, Professor of Medicine and Community and Family Medicine at Dartmouth Medical School will visit the program in April. He will address some of the risks of disease screening and early diagnosis. Our third guest is Dr. Donald Redelmeier, Professor in the Department of Health Policy, Management and Evaluation at the University of Toronto, where is Director of the Clinical Epidemiology Unit. He will visit the program in May, and will present his current work in Clinical Epidemiology. Each of our guest meets with the individual Scholars, provides a formal seminar, and attends a dinner for informal conversation at the end of the day.

Winter Seminar Series: The Winter Seminar Series included a variety of useful methodologic and career planning topics. Speakers included Dr. Dick Hoskins from the Washington State Department of Health who spoke about using geographic mapping software for epidemiologic analysis, and Dr. Janet Rasey, Director of the Research Funding Services who spoke about Grant Writing Resources. Other speakers included Betty Bekemeir, discussing the Washington State Public Health Association and Dr. Jim Krieger, former UW Clinical Scholar who gave a presentation on careers in public health. Finally, Vic Snyder, from the UW Center for Career Services gave a presentation on job negotiations.

Mid-Year Retreat: The Scholars, Program Directors and Staff met in January for our semi-annual retreat, to review various aspects of program structure and activities and to engage in collective problem-solving. We selected three outstanding faculty members to receive emphasis area funds from the program, and identified faculty members to invite to the annual meeting.

ACTIVITIES OF CURRENT SCHOLARS

First Year Scholars

Ingrid Binswanger (VA Scholar) is a general internist with a strong interest in healthcare for correctional institutions. She has began working closely with Dr. Mark Stern, Medical Director of the Washington State Department of Corrections, to analyze what seems to be an increased risk of mortality in the early weeks following release from prison. Ingrid is collecting data both from the State Department of Corrections and from the National Death Index for this purpose. She also completed a Health Policy Practicum in Washington, D.C., where she was able to learn a great deal about policy issues and research being conducted within the National Institute of Justice and the Bureau of Justice Statistics. She was also able to meet with the Office of Juvenile Justice Programs and the American Correctional Association. Overall, she felt that her three weeks experience was extremely valuable.

In addition, Ingrid has been working on a study of soft-tissue infections among injection drug users, in collaboration with Drs. Tracy Takahashi, Joe Merrill, and Kathy Bradley. This study is using hospital medical records to examine what proportion of injection drugs users who visit the emergency room have soft-tissue infections, what proportion have recurrent visits for soft tissue infections, and what proportion require hospital care. Ingrid has been attending a weekly General Internal Medicine Clinic at the Seattle VA Medical Center.

Alison Brooks is a pediatrician with a strong interest in exercise and athletic injury among adolescents. One major project is a study of pre-season conditioning and its potential benefits in preventing sports injury. For this purpose, Alice is validating a pre-season conditioning questionnaire which she then will use to study high school student athletes engaged both in soccer and track. This will make use of a sample of both public and private high schools in the Western Washington Region. Alison is also pursuing a case-control study of helmets and their protective role with regard to ski injuries.

Jason Mendoza is a pediatrician with a strong interest in childhood obesity. He has been working with Dr. Adam Drewnowski, Director of the Nutritional Sciences Program in the Department of Epidemiology. Jason has already presented an abstract on low socio-economic status and its association with food insecurity and with energy-dense diets. This study made use of the continuing survey of food intakes for individuals, and suggested that minority status, limited economic resources, and food insecurity are associated with more energy-dense diets. Another study involves the National Health and Nutrition Examination Survey, which is being analyzed to provide additional information on energy density and glycemic index, and their relationships to obesity and Hemoglobin A1C. Further, Jason is working on a “walking school bus project.” This involves an evaluation of a component of an RWJ healthy community grant. Jay is assessing whether or not the walking school bus program increases the proportion of children who walk to school on a daily basis.

Beth Tarini is a pediatrician with a strong interest in excessive use of diagnostic testing. She is working on a study that examines parental attitudes towards information from diagnostic testing at the time of their children’s hospitalizations, seeking to determine if parental self-efficacy and activation are associated with better understanding of test results and purposes. This study will take the form of a survey of parents whose children are being admitted to a general medical unit at Children’s Hospital. The long term goal is to develop interventions that activate parents around their child’s health care with the goal of helping them become partners in ensuring quality inpatient care. Beth was successful in obtaining some funding from Children’s Hospital for this study. Another potential study would examine the use of routine and repeat CBCs in the evaluation of bronchiolitis. The goal would be to describe variation in the initial ordering of CBCs and patterns of repeat testing. Finally, Beth has worked with Dr. James Taylor on a project to examine the utility of the transcutaneous bilirubinometer in the identification of newborns at risk of severe hyperbilirubinemia.

Darcy Thompson is also a pediatrician, who has a major interest in Latino health and in television viewing behavior among young children. She is designing a survey of beliefs and attitudes of Latino parents regarding television viewing, based in part on an impression that Latinos may regard television viewing differently than white parents. Available data suggest that Latino children watch more television than white children, but that parents may believe this provides useful language exposure and cultural experience for children in Spanish-speaking families. A second project is an evaluation of computer kiosks with pediatric preventive information that is being implemented in community sites located in low-income neighborhoods. The evaluation is intended to determine whether people self initiate the use of the kiosks, find them easy to use, and feel that the information they acquire will change health behavior or lead them to seek further medical advice. These kiosks are currently deployed. Darcy has submitted three abstracts to the Spring Meeting of the Pediatric Academic Society and will be presenting all of them. She also has had one manuscript regarding television viewing and sleep habits in young children accepted for publication in Pediatrics.

Judy Zerzan (VA Scholar) is a general internist with a particular interest in state health policy, and especially drug policy. Judy is well under way with a study of Medicaid data to examine how different state formulary restrictions have affected the use of various medications, and especially non-steroidal anti-inflammatory drugs and expensive long-term opiod analgesics. This requires not only obtaining pharmacy data from all fifty states, but also developing a method for identifying state policies and changes in state policies. A second project is examining the use of dementia drugs and anti-psychotics among nursing home patients. This study would make use of Washington State Medicaid data and examine patients who have had at least a three month stay in a nursing home. The study is aimed at learning the extent of use of dementia medications in this population where effectiveness may be dubious. Judy will try to determine if nursing home admission leads to the initiation of these drugs, how drug use may be affected by profit or non-profit status, and whether patients every receive a drug holiday to determine effectiveness. Judy maintains a regular weekly clinic in the General Internal Medicine Clinic at the Seattle VA Medical Center.

Second Year Scholars

Heidi Blume continues with her strong interest in neonatal encephalopathy. Her main research project uses a Washington State registry that combines vital records with hospital utilization data to examine circumstances around the time of birth such as maternal age, socio-economic status, maternal co-morbidity, and details of the delivery. Among other things, this analysis suggests the importance of fever alone as a possible intrapartum risk factor. This work is close to completion and is nearing submission for publication. In addition, Heidi is collaborating on a study of EEG results for children with first time seizures that are unprovoked, in comparison to children with first time seizures that are provoked. The goal is to identify EEG findings that may predict a higher risk of seizure recurrence. For next year, Heidi is investigating positions in Pediatric Neurology here at the UW.

Louise Davies(VA Scholar) is well along in her study of patient shared decision- making with regard to treatment for head and neck cancer. She has completed interviews with over 20 patients, has succeeded in recording the doctor-patient interactions, and has had success with about half the patients keeping a tape-recorded diary of day to day thoughts and concerns. She has worked with Lorna Rhodes from Anthropology and with David Grossman to analyze her transcribed data. This study involves patients with head and neck cancer, and has the long term goal of improving patient participation in the decision-making process. Louise has also completed a series of analyses of the SEER database to examine prevalence of head and neck cancer. Among other things, she has identified an important trend towards rapidly increasing rates of thyroid cancer. The explanation for this remains unclear, but one concern is that some of the discovered cases have a relatively benign prognosis, and may to lead to excessive intervention. Louise remains clinically active at the VA Hospital where she sees patients in clinic. Louise has accepted a faculty position at Dartmouth, where she will be a member of the Department of Otolaryngology and will have a primary base in the Health Services Research Program at the White River Junction VA.

Mandy Dempsey has completed her survey regarding parental attitudes about human papilloma virus vaccines. Such vaccines are potentially controversial because they are intended to prevent cervical cancer, which is regarded as the result primarily of papilloma virus acquired from sexual activity. For maximal efficacy, the vaccine would be targeted at pre-adolescents, where parental attitudes about disease and sexual activity may be important. An innovative feature of this study was an embedded trial of educational interventions. In a randomized fashion, some parents received educational materials along with the survey while others did not, providing a randomized trial of potential educational intervention. Mandy hopes that this will lead to more successful design of public health education materials. Mandy is now turning efforts to examining broader patterns of care for cervical cancer, and the potential cost-effectiveness of different vaccination strategies. She also is currently analyzing data on the potential for implementing contraceptive counseling and care in the context of a sexually transmitted disease clinic. Mandy has applied locally for cancer prevention and STD fellowships, but is also investigating faculty positions at the University of Michigan.

Mike Porter (VA Scholar) continues his work on bladder cancer screening and treatment. He has successfully obtained the combined SEER-Medicare database, which provides him data on prevalence and costs of care for bladder cancer. He is currently analyzing these data to provide estimates of disease prevalence and cost which will be used in a cost-effectiveness analysis of bladder cancer screening strategies. Mike is also using data from the HCUP database maintained by the Agency for Health Care Research and Quality to analyze trends in nephrectomy for renal tumors. This work has demonstrated that the mean length of hospitalization after nephrectomy is decreasing; that the proportion of short stay hospitalizations has increased rapidly; and that the proportion of partial nephrectomies has steadily increased in recent years. Mike has also completed writing a book chapter on randomized clinical trials of surgical procedures, as well as an original article just published in Prostate on obesity and the risk of prostate cancer. Mike remains clinically active at the Seattle VA Medical Center, where he has a regular surgical schedule. He has accepted a position as Assistant Professor in the Department of Urology and the Seattle VA Medical Center here at the University of Washington.

Marjorie Wang continues a series of investigations related to head and neck injuries. Her study on the timing of surgery for orthopedic injuries among patients with closed head injuries has been completed, and a manuscript is in preparation. This study made use of data from two randomized trials of pharmaceutical agents for minimizing the impacts of traumatic brain injury. Within these trials, detailed testing made it possible to examine neuropsychological outcomes of patients who had very early surgery (within 24 hours), and those who had later surgery for their ancillary injuries. In a second project, Marjorie is examining the utility of CT scan monitoring among children with head injuries. This has involved reviewing records on a substantial number of children hospitalized for observation. A third project is focused on patterns of cervical spine surgery. Marjorie is examining recent trends in surgical rates and in the types of operations being conducted. In addition, her analysis of national databases will permit an examination of complication rates associated with different types of surgery. Finally, Marjorie continues to examine the utility of arteriography among patients with neck injuries. Marjorie has accepted a hybrid faculty/spine fellowship position in Neurosurgery at the Medical College of Wisconsin for next year.

ALUMNI/ALUMNAE ACTIVITIES

Eric Larson (75-77) recently moved from the position of Medical Director of the UW Medical Center to become the Director of the Group Health Center for Health Studies. He also received Robert J. Glaser Award from the Society of General Internal Medicine in 2004, the highest award given by the Society. In addition, he recently became chair of the American College Physicians Board of Regents. Eric was also elected Master of the ACP.

Tom Koepsell (77-79), CSP Program Director Emeritus, just finished a 3 year term on the Executive Board of the Society for Epidemiologic Research, and completed his year as its past president.

Steve Fihn (79-81) has been appointed Acting Chief of Research & Development for the Department of Veterans Affairs. In this position, he has responsibility for the entire $400 million VA research program, and he continues to serve as the Division Head for General Internal Medicine at the University of Washington.

Nancy Fisher (79-81) is on the American Heart Association Board of Directors. She was recently the Medical Chair for the group’s luncheon-education program on heart disease.

Rick Deyo (79-81) received the John M. Eisenberg award for Career Achievement in Research from the Society of General Internal Medicine. He also recently received funding from the NIH Roadmap Initiative for a new clinical research training program. Finally, his book “Hope or Hype: the Obsession with Medical Advances and the High Cost of False Promises”, written with Dr. Donald Patrick, was published in January by AMACOM Press.

Ed Boyko (82-84) received the UW Medicine Center of Excellence in Women’s Health Award for Outstanding Mentorship.

Laura-Mae Baldwin (84-86) has been appointed to the Health Services Organization and Delivery Study Section for the NIH. She also was recently promoted to Professor of Family Medicine at the University of Washington.

Michael Grey (87-89) recently assumed a new position as Medical Director of a community health center in Springfield, Massachusetts. This is part of the Bay State Health System, a Tufts Medical School affiliate.

David Grossman (88-89), former UW Clinical Scholars Program Co-Director, recently became the Medical Director of Preventive Care at Group Health Cooperative.

Laura Jenkins (91-93) returned to the U.S. after 8 years at the University of Zimbabwe. She is now in the Department of Family Medicine at the University of Pittsburgh.

Jerry Jarvik (93-95) recently became the chief of Neuroradiology at the University of Washington where he was also promoted to full Professor of Radiology and Neurosurgery, and Adjunct Professor of Health Services.

Leighton Chan (94-96) received the Presidential Citation Award from the American Association of Physical Medicine and Rehabilitation. He also received the Outstanding Continuing Medical Education Faculty Award from the University of Washington.

Christina Nicolaidis (97-99) received the Robert Wood Johnson Depression in Primary Care Leadership Award.

Harrison Alter (97-99) recently was appointed Associate Research Director in the Department of Emergency Medicine at Alameda County Medical Center in Oakland, California.

Chris Feudtner (98-00) is the Director of Research and Attending Physician for the palliative care team at Children’s Hospital of Philadelphia, where he is Assistant Professor of Pediatrics.

Ed Weaver (98-00) has received the American Geriatrics Society Dennis W. Jahnigen Career Development Scholars Award; the Triological Society Research Career Development Award; and also an NIH Mentored Research Career Development Career.

Maryanne O’Hara (98-00) recently received the Malcolm L. Peterson Award from Washington Physicians for Social Responsibility for “dedication, perseverance, and creativity in preserving public health and the environment”. She also has been appointed to the Board of Directors for the Academy of Breastfeeding Medicine and to the Washington State Perinatal Advisory Committee. Finally, she received the Physician Leadership Award from the Healthy Mothers-Healthy Babies Coalition of Washington.

David Flum (00-02) Leighton Chan (94-96) and Tom Koepsell (77-79) were authors of an article on the benefits of intraoperative imaging during Cholecystectomy, which was named as one of the top 10 clinical research articles of 2003 by the Archives of Surgery.