AcademyHealth’s Delivery System Science Fellowship: training embedded researchers to design, implement, and evaluate new models of care

Participant Host Site Level

Two selected examples of how DSSF researchers have engaged high-priority topics that contributed to health system operations are provided here.

Kaiser Permanente Southern California: Assessing adherence with “Choosing Wisely” recommendations in oncology. In partnership with preceptor Dr. Michael Gould, 2013-2014 DSSF fellow Dr. Erin Hahn worked with the Kaiser Permanente Southern California (KPSC) Care Improvement Research Team to lead a project addressing several KPSC priority areas. Focusing on “Choosing Wisely” recommendations from the American Society of Clinical Oncology,¹² the project evaluated appropriateness of imaging and laboratory services for early-stage cancer patients and survivors between and within 2 integrated health systems, Kaiser Permanente (KP) and Intermountain Healthcare.^13,14 Results were presented to KP national leaders, including an external health policy advisory board. In close collaboration with clinical and operational leaders in medical oncology, this multiregional, multisystem project is contributing to targeted quality improvement efforts and improved healthcare value, including audit and feedback of nonrecommended labs.

Dr. Hahn subsequently received a KPSC Incubator Award, a competitive internal grant, to further study factors associated with use of nonrecommended surveillance lab tests for early-stage breast cancer patients. The study focused on medical oncologists within KPSC, categorizing them as high or low utilizers of the tests.¹⁵ Results indicate that high utilizers perceive that the tests help manage patient anxiety about recurrence, while acknowledging that the tests do not provide clinical utility. These findings are contributing to the development of targeted survivorship services across the organization.

Intermountain Healthcare: Formative evaluation of large-scale implementation of shared decision-making. Preceptor Dr. Lucy Savitz assembled a team to conduct a formative evaluation of Intermountain Healthcare’s efforts to implement shared decision-making (SDM) as part of its Center for Medicare and Medicaid Innovation Challenge Award. The 2015-2017 DSSF fellow at Intermountain Healthcare, Dr. Kim Brunisholz, served as a core member of the project team, focusing primarily on a mixed-methods evaluation of the SDM program.

Dr. Brunisholz engaged operational leads, clinical teams, patient and family advisory councils, and senior executives to conduct the program assessment. Results demonstrated significant variation in invited participation in SDM among eligible patient populations: preference sensitive conditions (1 in 30 patients), oncology-related diagnosis (1 in 3 patients), and chronic conditions (1 in 74 patients). Provisional analysis of patient-level clinical outcomes demonstrated that among those invited to the SDM program compared to those that were not, total joint replacement was decreased (10.1% vs 17.3%; P < 0.001) and a trend towards breast conservation emerged (61.8% vs 56.4%; P = 0.10). No difference in treatment choice for lower back pain was observed. Qualitative program analysis suggested need for improvements in the areas of (1) routine and continuous staff training, (2) workflow standardization, and (3) active data monitoring with meaningful, actionable feedback to caregivers. In response to these results, a chartered SDM Steering Committee was created (Dr. Brunisholz is a member of that group) to develop a strategic plan for SDM, with an accompanying organizational response to reimplement SDM in a targeted manner. Learning from this program is being leveraged to support a subproject analysis on a large scale using data from the High Value Healthcare Collaborative as part of an AHRQ-funded Center of Excellence award. (See https://www.ahrq.gov/news/newsroom/press-releases/2015/pcorawards.html. For more information on the High Value Healthcare Collaborative, please visit: https://www.highvaluehealthcare.org.)

Moving forward, the DSSF will continue working with progressive delivery systems. Partnerships between organizations that are interested in integrating rigorous research practice to drive continuous system improvement and maximize the value of care will have substantial need for technical skills and analytic capacity. They will also need to ensure that researchers working in their systems have sufficient understanding of cultural and political context within the organization to be effective leaders who can manage change.

AcademyHealth created the DSSF in response to the field’s request to build a research workforce that reflects the vision for a 21st Century Health System, as laid out by the NAM.¹⁶ We anticipate that as the US Department of Health & Human Services’ goals for payment reform and new measures to promote quality and high-value care are implemented, the DSSF trainees’ skill set will be increasingly valuable and will provide needed thought leadership on strategies to generate and apply evidence in practice.

Disclosure

Ms. Kanani received funding from Intermountain Healthcare, Kaiser Permanente Southern California for support for the Delivery System Science Fellowship. Drs. Hahn, Gould, and Brunisholz have no conflicts to disclose. Dr. Savitz has received funding from HRQ COE, PCORI LHSNet; received funding for lectures from the Institute from Healthcare Improvement, Department of Epidemiology, University of Utah; received funding for travel, accommodations, and meeting expenses from AHRQ NAC, EDM Forum, AH CAPP, AARP NPC, and PROM TEP; and received additional funding from Dartmouth University. Dr. Holve received funding from Intermountain Healthcare, Kaiser Permanente Southern California for support for the Delivery System Science Fellowship, provided by our delivery system partners, several of whom are coauthors on this manuscript.