1. Building a Learning Healthcare City: The Chicago Learning and Effectiveness Advancement Research Network (Chicago LEARN) David Meltzer M.D., Ph.D. May 10, 2013

2. Comparative Effectiveness and Patient- Centered Outcomes Research Infrastructure Comparative effectiveness research (CER) seeks to understand the relative benefits of medical interventions –Patient-centered outcomes research (PCOR) focuses on relative benefits for patient subgroups and individuals Chicago LEARN (Learning Effectiveness Advancement Research Network) objective: –To establish state of the art infrastructure for CER and PCOR in the inpatient setting in Chicago with the potential for national impact through partnership with UHC (University HealthSystem Consortium) –Embrace concepts of a learning healthcare system

3. Timeline for Chicago Inpatient CER 1997 UC Hospitalist Project started –Interview hospitalized patients @ admission & 30 days post D/C –~ 90,000 subjects enrolled to date 2001 Multicenter Hospitalist R01 –Medicare linkage 2004 Hospitalist Scholars Program started 2006UC CTSA Funded – focus on personalized medicine 2007 Center for Education and Research in Therapeutics (CERT) (UC, UIC) 2008 NU CTSA funded 2009 UIC CTSA funded 2009 ARRA $1.1 Billion for CER – CONCERT RC2 (UC, UIC), NIH KM1 (UC, UIC) 2010 ACA Passed – PCORI established with focus on patient-centered outcomes 2010 UC CTSA External Advisory Committee encourages development of CER 2010 Chicago Effective Health Care Conference - CER Infrastructure, Informatics 2010 Infrastructure conversations with Computation Institute 2010 Chicago CTSAs Meeting – Julian Solway’s charge 2011 Chicago Effective Health Care Conference – UHC/Indiana University 2011 CTSA CER Supplement 2012UC CTSA Renewal – CER Core, CMMI Innovation Challenge Award

4. Key Ideas for Chicago LEARN Observational and experimental studies –Patterns/context of use –Causal inference Large sample sizes –Faster trials that can include subgroups (PCORI) –Cluster randomized trials to study health service organization (IOM CER, CMMI) Multiple inpatient data sources –Administrative –Chart/EHR (Learning Health Care System Model) –Patient interviews (PCORI) Collect/use biospecimens Follow patients after discharge –Integrated health system (Northshore) –Medicare data → Consent essential → Multipurpose use –Economies of scale in subject screening and recruitment (vs. single-study RAs) –Economies of scale in informatics infrastructure (multi-disease, multi-mission)

5. Chicago LEARN (Learning Effectiveness Advancement Research Network) Multifunctional infrastructure for hospital-based patient-centered outcomes research for Chicago-area AMCs (UC, Rush, NS, UIC, NU, Loyola) with potential for national impact –Human infrastructure (RAs) with aim to spread hospitalist project model –Informatics infrastructure with UHC Clinical Data Base/Resource Manager has chargemaster-level administrative data for >250 hospitals from >100 AMCs All disease categories All inpatient and some outpatient data Supported by AMC CEOs for operations/quality benchmarking/ improvement Invest $30 million over 3 years to add EHR data Local partners can help develop and demonstrate value Situates us to be early adopters in use of resulting data Progress/Funding –Monthly meetings, UHC data transfers starting, QA/QI studies –CTSA CER Supplement, UC CER Core, CMMI grant, NIA Anemia study –Medicare data

6. Early Studies Pharmacogenetic testing for warfarin dosing –EHRs to screen, Shared RAs Transfusion for anemia –UHC for study design & collaboration

7. Physician Location and Quality/Cost of Care Controlling healthcare costs requires focus on high cost patients Most spending for high cost patients is repeated hospitalization Repeated hospitalization strongly affected by poor care coordination –Worse since traditional primary care physicians replaced by hospitalists –10-50% lower utilization possible with care coordination by own physician Growth of hospitalists partially a spatial problem – transport costs $6.1 Million CMMI Comprehensive Care Physician study to test if having same doctor care for patients in inpatient & outpatient setting can improve costs/outcomes –Locate clinic in hospital; focus on high cost patients –2,000 patient randomized clinical trial - $50 mil/yr –Innovative delivery mode l for Accountable Care Organizations (ACOs)

8. Urban Contextual Data to Improve Health Neighborhood resources and context Environmental data to study healthcare productivity –Hospital length of stay (LOS) a critical policy variable –Unclear if faster discharge increases readmissions, costs LOS is a behavior –LOS = f (observables, unobservables) Hard to understand, study effects of LOS –Readmission = f (LOS, observables, unobservables) Wish one had experimental data –Contextual data to infer effect of increased LOS on costs and outcomes Hint: Chicago winter, summer

9. Instrumental Variable Approach to Identification 1/3 1/2 1/6 Diagnosis-driven probability of ideal discharge Admit Date Extend LOS Shorten LOS 1/3 1/2 1/6

10. Urban Contextual Data to Improve Health Neighborhood resources and context Use of environmental data to learn about productivity –Hospital length of stay (LOS) a critical policy variable –Unclear if faster discharge increases readmissions, costs LOS is a behavior –LOS = f (observables, unobservables) Hard to understand, study effects of LOS –Readmission = f (LOS, observables, unobservables) Wish one had experimental data –Contextual data to infer effect of increased LOS on costs and outcomes Hint: Chicago winter, summer Use to test productivity across cities, clinical areas

11. Conclusions Academic medicine and healthcare institutions in cities provide important opportunities for research to improve healthcare outcomes and costs –Chicago LEARN as model for collaboration among urban academic medical centers and across cities Chicago’s rich set of institutions in healthcare create unique opportunities for researchers and for the city