Front: Pan Wu, Ph.D., Biostatistician, Value Institute; Kristen Miller, DrPH, MSPH, Associate Director, Human Factors, Value Institute; Tim Gardner, M.D., Executive Director, Value Institute, Medical Director, Center for Heart & Vascular Health; Janice Nevin, M.D., MPH, President and CEO, Christiana Care; Eric V. Jackson, Jr., M.D., MBA, Director, Center for Health Care Delivery Science, Associate Director, Value Institute. Back: Dominique Comer, PharmD, MS, Senior Clinical Investigator, Value Institute; Mark Cipolle, M.D., Ph.D., FACS, FCCM, Director, Outcomes Research Surgical Service Line; Muge Capan, Ph.D., Associate Director, Health Systems Optimization, Value Institute; Edmondo J. Robinson, M.D., MBA, FACP, Chief Transformation Officer, Christiana Care; Justin Glasgow, M.D., Ph.D., Clinical Investigator, Value Institute; Robert Locke, DO., MPH, FACOP, FAAP, Co-director, Center for Neonatal Evidence-Based Care and Population Health, Christiana Care; Marissa Band, JD, Supervising Attorney, Community Legal Aid Society, Inc.; Susan Howard-Smola, JD, MBA, Senior Clinical Researcher, Value Institute; Claudine Jurkovitz, M.D., MPH, Senior Physician Scientist and Clinical Epidemiologist, Value Institute.

Annual Value Institute Symposium Illustrates the Wide Scope of Projects at Christiana Care

In a transformative era when reimbursement models are rewarding quality improvements in medicine, Christiana Care is well-positioned to bring evaluative science to clinical practice because of the research generating from the Value Institute.

“If we are going to be successful in achieving optimal health for our patients and exceptional patient experience, as well as maintaining organizational vitality, we need the Value Institute,” said Janice E. Nevin, M.D., MPH, president and CEO of Christiana Care. “They are a critical partner in all that we do.”

Dr. Nevin praised the Value Institute’s focus on achieving excellence in patient-centered care during the Value Institute’s Spring Symposium on June 10th at the John H. Ammon Medical Education Center. More than 200 participants gathered to celebrate the growth and success of the Value Institute, learning about representative research to improve clinical outcomes for patients, as well as the creation of a collaborative clinical/research culture devoted to health care delivery science applied across Christiana Care Service Lines.

The Value Institute has also earned prestigious awards from funders, including The National Institutes of Health, the National Science Foundation, the Centers for Medicare and Medicaid Services, and The Patient-Centered Outcomes Research Institute. “This is a form of external validation, showing that our work is significant and is being shared on a national platform,” said Eric V. Jackson, Jr., M.D., MBA, director of the Value Institute’s Center for Health Care Delivery Science and associate director of the Value Institute. Dr. Jackson said programs highlighted during the symposium were a snapshot of how the Value Institute is moving forward, stressing that the triple aim is a guiding principle – working on projects to promote exceptional patient experience, improve population health and reduce the cost of care.

“We are working closely with clinicians to help define best practices and what is valuable to our patients,” Dr. Jackson said. Another example is a Big Data initiative to create a sepsis early-prediction system that will overcome barriers to timely diagnosis by integrating electronic health records and clinical expertise to provide an evidence-based framework. “Sepsis is the leading cause of death in hospitals and something we want to better understand,” Dr. Jackson said. Dr. Gardner shared a new organizational model called “Value Institute 2.0.” To create a more collaborative and interactive environment, the new model is one of overlapping centers with the Center for Health Care Delivery Science at the heart of research activities. The guiding ethos of the model is in support of the Service Line structure within the hospital system. “We have strong collaborations and evidence that we are an integral part of daily life at Christiana Care,” Dr. Jackson said.

Nearly 200 clinicians, researchers and community leaders attended the Value Institute Spring Symposium 2016.

NEW VALUE INSTITUTE STRUCTURE
The Value Institute 2.0 Emphasizes Collaborative Projects

The Value Institute has a new organizational model – the Value Institute 2.0 -- reflecting a collaborative spirit among the more than two dozen researchers, project managers, biostatisticians and clinical providers, who are part of an innovative program of clinically-oriented pragmatic implementation science.

Under the new model, the Center for Health Care Delivery Science is at the heart of the multi-disciplinary team effort to transform the delivery of health care. Activities -- such as funded research, quality and safety, and clinical health services research – are functions that are all strongly connected to and overlap with the Center for Health Care Delivery Science.

“In this restructuring, we have gone from four centers of semi-independent activity to a much better coordinated and focused unit that is creating and analyzing system-based processes to create better outcomes for patients, increase their access to care and lower costs,” said Timothy J. Gardner, M.D., executive director, Value Institute; medical director Center for Heart & Vascular Health.

Within Christiana Care, the Service Line structure has reorganized clinical health care delivery, with the Value Institute providing essential evaluation and process improvement expertise, said Eric V. Jackson, Jr., M.D., MBA, director of the Value Institute’s Center for Health Care Delivery Science and associate director of the Value Institute.

“We are dedicated to supporting the work of the Service Lines and we have created a Service Line Ambassador program of committed team members who work collaboratively with all the major stakeholders within a particular Service Line,” Dr. Jackson said. “In this way we are a catalyst for institutional clinical transformation.”

One measure of success can be seen in the numerous publications and presentations at national meetings that the Value Institute has played a role in since 2012, as well the many research funders, which include: The National Institutes of Health; the National Science Foundation; the Centers for Medicare and Medicaid Services; and The Patient-Centered Outcomes Research Institute.

Center for Health Care Delivery Science
PCORI Award to Value Institute Helps Patients with Chronic Kidney Disease

The Patient-Centered Outcomes Research Institute (PCORI) has given the Value Institute a two-year Eugene Washington PCORI Engagement Award to engage with patients and stakeholders in developing patient-centered outcomes research projects to utilize a statewide Chronic Kidney Disease Registry currently under construction in Delaware.

“In this project we will inform patients and stakeholders about the value of the registry and ask for guidance in research that is important to them,” said nephrologist epidemiologist Claudine Jurkovitz, M.D., MPH, Value Institute senior physician scientist and a PCORI principal investigator.

A conference will be held on Sept. 16, 2016 at the John H. Ammon Medical Education Center at Christiana Hospital to trigger engagement by patients and stakeholders in conjunction with the award. Following the first conference, participants will be asked to join a work group to explore patient-centered outcomes and comparative effectiveness questions. A subset of the group will take part in six weeks of community and comparative effectiveness research training in an effort to draw on a curriculum created through the Delaware Center for Translational Research (CTR)-ACCEL Community-Engaged Research (ACE) Awards.

Patients who have chronic kidney disease often also have multiple comorbidities and, as a result, numerous specialists care for them. In 2012, there were 2,172 Delaware patients in chronic renal replacement therapy.

By engaging patients and stakeholders, the PCORI award complements the efforts of Dr. Jurkovitz to create a Chronic Kidney Disease Registry, which blends data from electronic health records. The registry is funded through a two-year grant from the Delaware CTR-ACCEL Big Data Pilot Program, awarded in December 2014. At present there are more than 12,000 patients in the database.

To build the registry, the team acquired and integrated information from multiple data sources to create a unified longitudinal description of care. The first research goals are to develop models and methods for predicting hospital admission, and to access transition-of-care information for children with chronic kidney disease as they grow into adults.

“Ultimately, we would like to reduce hospitalization rates of patients and predict the rate of hospitalization within a defined time-frame from an office visit,” said Dr. Jurkovitz. “We also hope to improve the care coordination of patients with chronic kidney disease but most importantly we want the patients and the health care providers to tell us what outcomes and research topics are most important to them.”

PCORI is an independent, non-profit organization authorized by Congress in 2010 to fund comparative effectiveness research that provides patients, their caregivers, and clinicians with the evidence needed to make better-informed health and healthcare decisions. PCORI is committed to seeking input from a broad range of stakeholders to guide its work.

Christiana Care’s Blood Pressure Ambassador, Laurie Ridout, attends to Denise Wilsons during Wilmington Wellness Day. The Blood Pressure Ambassador Program was the subject of a recent Academy Health Annual Research Meeting.

Poster Presentation on Blood Pressure Ambassador Program Details Outcomes and Effectiveness

The innovative outreach of Christiana Care’s Blood Pressure Ambassador Program, which has conveyed vital information on the dangers of hypertension to more than 2,000 residents in the greater Wilmington area since 2011, was the subject of a poster presentation at the AcademyHealth Annual Research Meeting in Boston, Mass. in June.

The poster was entitled “Each One, Reach One! Improving Blood Pressure Awareness in the African American Community Using Peer Education” and showed the value of sending trained laypeople into their communities to take blood pressure readings. These Blood Pressure Ambassadors also inform participants about the dangers of hypertension and urge follow-up with primary care physicians because of the elevated risks for stroke and heart failure. Currently, there are about 90 blood pressure ambassadors.

“This kind of work is different from traditional research in that this program requires a lot of commitment to build necessary relationships with churches, community centers, and clinics where screenings take place,” said Dominique Comer, Pharm.D, MS, senior clinical researcher of the Value Institute’s Health Care Delivery Science.

Data for the poster presentation span from July to December of 2015 and show that the Blood Pressure Ambassador Program reached 979 community participants, with nearly 62 percent identifying as African American. Over one-third of African American participants were found to be hypertensive and a significant number of those participants were not taking medication for high blood pressure.

Additionally, the Value Institute compares data from the Blood Pressure Ambassador Program with similar data from The National Health and Nutrition Examination Survey (NHANES), which annually assesses the health and nutritional status of U.S. adults and children on an array of measures. Nationally, 62 percent of African Americans surveyed have hypertension under control compared with only 35 percent of African American participants in the Blood Pressure Ambassador Program.

“With this program there is a great opportunity to improve the awareness of hypertension, educate the community on ways to manage it, and to improve the community’s access to healthcare,” Comer said.

The Value Institute is studying ways to further engage the Blood Pressure Ambassadors to enhance program sustainability and connect the impact of the program to participant clinical results.

Maureen Springer, MSN, APRN-BC, Advance Practice Nurse, Christiana Care Vascular Specialists, and Angela Prince, Vascular Technologist, measure a patient’s Ankle Brachial Index (ABI) in the Limb Preservation Clinic. The ABI test is a quick, non-invasive procedure that compares blood pressure measured at the ankle to blood pressure in the arm and can indicate risk of peripheral artery disease. This test is one of the many diagnostic and therapeutic procedures the clinic offers.

New Limb Preservation Clinic Offers Research-based Multidisciplinary Approach

The Value Institute has collaborated with dedicated partners within the Center for Heart and Vascular Health for the launch of Christiana Care’s Limb Preservation Clinic, which will coordinate timely and appropriate care for patients at risk for lower limb amputations.

Opened in June, the Limb Preservation Clinic is an innovative multidisciplinary approach to providing optimal care for patients with critical limb ischemia, peripheral artery disease and diabetes, bringing together vascular specialists, cardiologists, podiatrists, endocrinologists and other key caregivers.

“Over the past year the Value Institute conducted an extensive literature review of existing clinical guidelines from multiple medical specialties and societies in order to develop a comprehensive best practice model for a center dedicated to amputation prevention,” said Pete Lodato, MPH, research associate.

Studies have demonstrated that multidisciplinary clinics, aimed at preventing major lower extremity amputations, can lead to a reduction in amputation rates that range from 40 percent to 70 percent for at-risk patients. These studies also have identified that the two vital components of a successful limb preservation clinic are the diabetic podiatrist and vascular surgeon -- sometimes called a “toe and flow” team -- who address structural and vascular problems, with the frequent inclusion of other specialists in consultations.

“Open communication lines are necessary to efficiently identify early warning signs and prevent disease progression,” said Lodato.

An analysis of data from Christiana Care has shown that amputation patients tend to have multiple ailments that increase their risk of amputation, with 64 percent of patients having four or more comorbidities.

“We found that a high proportion of limb amputation patients had limb ischemia, hypertension, some form of diabetes, and more than half had coronary artery disease,” said Lodato.

The late Seema Sonnad, Ph.D., the inaugural director of Health Services Research at the Value Institute, was an early shepherd of limb preservation research at Christiana Care, and helped guide the involvement of student researchers Christine Manta and Bryan Taylor.

The literature review and research findings strengthen the argument that amputations are often preventable if at-risk patients are identified early and receive well-coordinated care at a clinic like the one established at Christiana Care. Over the coming weeks, the Value Institute will collect data from the Limb Preservation Clinic to help evaluate its progress and opportunities for improvement.

Maxwell Braverman, D.O., PGY-3, General Surgery, discuses his poster presentation on the outcomes of trauma resuscitation involving thromboelastography with Bailey Ingraham, MS, biostatistician, Value Institute.

Strong Resident Participation in Inaugural Research Symposium

For the Inaugural Research Symposium on June 9th, 23 Christiana Care residents participated in oral and poster presentations at the John H. Ammon Medical Education Center, an event that drew close to 40 participants.

The symposium was organized by the Value Institute Academy, to showcase the residents and fellows participating in the two-year multidisciplinary Resident Research Training Program. This program provides infrastructure, education and support so residents can successfully complete, present and publish an independent research project. The course introduces the language of research, ethical principles, and the elements of the research process within quantitative, qualitative and mixed-method approaches. Value Institute scholars are involved in teaching and mentoring residents and serve as co-authors on publications.

The program expands on a similar effort begun by the Department of Medicine several years ago. “We moved our program to the Value Institute so we could open it to all residents and fellows, as we knew there were unmet needs at Christiana Care for this type of training,” said course director Marci Drees, M.D., MS, FACP, DTMH, who is infection prevention officer, a Value Institute Scholar and director of Resident Research for the Department of Medicine.

“Through this program, our next generation of clinicians grows more adept at figuring out best practices in approaches to health care delivery,” said Dr. Drees.

“The resident presentations were outstanding,” added Eric V. Jackson, Jr., M.D., MBA, director of the Value Institute’s Center for Health Care Delivery Science and associate director of the Value Institute. “It’s a great program.”

The Value Institute Academy will be opening up enrollment for new residents and fellows to join the Resident Research Training Program this summer.

A May 6 Open House at the Value Institute focused on a reinvigorated Value Institute Scholars Program and the benefits that accrue to Christiana Care clinicians who become Scholars and collaborate with Value Institute faculty through investigation of pressing clinical issues. The Scholars Program develops future leaders who are highly trained in the tools of clinical investigation, and able to work creatively with colleagues in other disciplines, with the goal of strengthening the Triple Aim. Scholars also learn about quality improvement, patient safety, issues of cost effectiveness and process management, as well as the Value Institute’s shared accountability approach to improving clinical practice. “We hope to increase collaboration and expand our present roster of Scholars, who are integral partners for quality improvement and research-based initiatives, across Christiana Care,” said Kimberly Williams, MPH, research associate, and co-chair of the Value Institute Scholar Program with Ryan Arnold, M.D., MA, FAAEM, Emergency Medicine and Value Institute clinical investigator. At the Open House, continuing benefits of the Scholar Program were highlighted - such as assistance with study design, grants, publication planning, data acquisition and analysis -- as well as the educational value of general meetings, which have been likened to multidisciplinary grand rounds. At present there are 66 Scholars representing approximately 25 Christiana Care departments. Program objectives include: To improve the quality and efficiency of patient care. To provide cost effective practice patterns with the appropriate utilization of facilities and resources. To provide a framework for appropriate ethical and moral medical decision making.

This rejuvenated program builds on the work of the late Seema Sonnad, Ph.D., director of Health Services Research, and is in keeping with the triple aim of delivering health solutions that improve patient experience and population health while reducing health care costs.

If you are interested in becoming a Value Institute Scholar or have questions, please contact:
Program Co-chairs Ryan Arnold or Kimberly Williams; or Program Administrator Lisa Maturo.

Getting Involved

The Value Institute is built on a model of high-level collaboration. The Value Institute partners with academic institutions, corporations, health care professionals, and thought leaders who share our commitment to improving health care value and delivery by turning evidence into reality. We cultivate relationships with patients, clinicians, sponsors, and professional colleagues who recognize the importance of improving health care delivery and health outcomes, organizational excellence, and quality and safety.

You can partner with the Value Institute on collaborative research, including clinical trials, database studies, and demonstration projects. Christiana Care providers can connect with the Value Institute by submitting a Consultation Request. One of our team members will then contact you to discuss your research plans. Value Institute staff members are actively involved in 75 research projects in a variety of disciplines.


Contact: Email Sarahfaye Heckler or call 302-733-5868.

Awards

Claudine Jurkovitz, M.D, MPH, received the Patient Centered Outcomes Research Institute’s Eugene Washing Award for “Engaging Stakeholders for a Patient-Centered Research Agenda for Chronic Kidney Disease in Delaware.”

Kristen Miller, DrPH, MSPH, received the National Institutes of Health Clinical Loan Repayment Program Grant, awarded by the National Institute of General Medical Sciences.

The Value Institute was recognized on Earth Day, April 22, 2016 for achieving Green Workspace Certification.

Selected Publications

Cipolle MD, Ingraham Lopresto BC, Pirrung JM, Meyer EM, Manta C, Nightingale AS, Robinson EJ, Tinkoff GH. Embedding a trauma hospitalist in the trauma service reduces mortality and 30-day trauma-related readmissions. Journal of Trauma and Acute Care Surgery. 2016 Jul;81(1):178-183. PMId: 27032003.

Rosini JM, Davis JJ, Muenzer J, Levine BJ, Papas MA, Comer D, Arnold R. High single-dose vancomycin loading is not associated with increased nephrotoxicity in emergency department sepsis patients. Academic Emergency Medicine. 2016 Jun;23(6):744-6. PMID: 26850378.

Shackford SR, Cipolle MD, Badiee J, Mosby DL, Knudson MM, Lewis PR, McDonald VS, Olson EJ, Thompson KA, Van Gent JM, Zander AL. Determining the magnitude of surveillance bias in the assessment of lower extremity deep venous thrombosis: A prospective observational study of two centers. Journal of Trauma and Acute Care Surgery. 2016 May;80(5):734-41. PMID: 26891155.

Ziegler KA, Paul DA, Hoffman M, Locke R. Variation in NICU admission rates without identifiable cause. Hospital Pediatrics. 2016 Mayk6(5):255-60. PMID: 27117951.

Selected Presentations

K Miller, M Capan, D Mosby, Tao J, A Goodwin, R Arnold. Sepsis Visual Risk Profiling Model. Presented at: 6th Biennial National IDeA Symposium of Biomedical Research Excellence (NISBRE). 2016 June 26-28; Washington, D.C.

KD Williams, AL Schwartz, S Smola, JH Silverstein, E Booker, LJ Lang. Integrating Behavioral Health into Primary Care: An Evaluation of Patient and Provider Experiences with Behavioral Health Consultant Services. Presented at: AcademyHealth Annual Research Meeting; 2016 June 26-28; Boston, MA.

B Taylor, P Lodato, B Ingraham, E Ivey, F McCarthy, R Ierardi, T Gardner. Understanding and Preventing Lower Limb Amputation. Presented at: CTR ACCEL Community Research Exchange; 2016 May 23; Wilmington, DE.

C Jurkovitz, P Kolm, D Elliott, C Russo, W Weintraub. Reducing 30-day Readmission After Percutaneous Coronary Intervention in Patients with Chronic Kidney Disease and Multiple Comorbidities. Presented at: National Kidney Foundation Spring Clinical Meetings; 2016 April 13-16; Boston, MA.

S Smola, C Torrance, R Hayman. Patient with Unmet Legal Needs: Who They are and Gaps in Service. Presented at: Medical Legal Partnership Summit; 2-16 April 6-8: Indianapolis, IN.

Collaborations is a quarterly release of Value Institute news and events. Visit our website to read our 2014 annual report, watch our video and learn more about the Value Institute. Christiana Care providers can connect with the Value Institute by submitting a Consultation Request. To subscribe to Collaborations, please send an e-mail with “Subscribe to Collaborations” in the subject line.