H. Myra Kim is a Research Scientist at the Center for Statistical Consultation and Research and and Adjunct Professor at the Department of Biostatistics. She received her Sc.D. in Biostatistics from Harvard University in 1995 and worked at Brown University as an Assistant Professor from 1995 to 1997. She has worked at UM since 1997 and has collaborated with various researchers from around the UM community as well as from other universities.
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Darin B. Zahuranec, M.D. (Residency 2005), is an associate professor of neurology in the University of Michigan Medical School. He joined the U-M faculty in 2005 as a clinical lecturer in the Department of Neurology, and was promoted to assistant professor of neurology in 2007.
Funded by National Institutes of Health.
Funding Years: 2014-2019.
Stroke is common, nearly 800,000 strokes occur annually, and a leading cause of disability in the U.S. Non-Hispanic Black/African American (Black) adults have the highest stroke prevalence and suffer the most post-stroke disability of any U.S. racial/ethnic group. Even though racial disparities in post-stroke disability are widespread, little it is known about how to reduce this disparity. Racial differences in disability arise in the post-stroke period;however it is unclear if these differences arise shortly after strke in the early recovery period, when many stroke survivors are undergoing rehabilitation, or after stroke survivors return to the community. This project will address the critical questions of when racial disparities in post-stroke disability arise and determine the drivers of this disparity in ech period. Answering these questions is an essential step to designing interventions to improve health in Black stroke survivors and reduce disparities. To address these questions, we will rely on the newly available National Health and Aging Trends Study (NHATS) linked to Medicare claims and functional assessment data. NHATS is a national, longitudinal survey of Medicare beneficiaries focused on understanding the causes and consequences of disability in the elderly. NHATS performs annual face-to-face interviews to carefully characterize disability in the elderly and measures a vast array of disability predictors including social, community and disability accommodation factors. Additionally NHATS's linkage to Medicare claims will enable measurement of important medical and rehabilitation factors that may also explain racial differences in post-stroke disability. These data sources will be used to develop the first comprehensive measures of rehabilitation intensity across all rehabilitation settings-home health, outpatient, skilled nursing and inpatient rehabilitation-compare intensity by race and estimate the effect of rehabilitation intensity on disability disparities. At the completion of the study, the timing and drivers of race differences in post-stroke disability will be identified. Furthermore, our novel measures of rehabilitation intensity can serve as a prototype for use in studying the role of rehabilitation in other diseases such as traumatic brain injury and arthritis. This proposal is particularly responsive to the NIMHD solicitation in that it focuses on modifiable drivers of racial differences in post-stroke disability from a policy standpoint and will directly inform stroke survivor and family level strategies to reduce disability and decrease disparities.
PI(s): Lesli Skolarus, James Burke
Co-I(s): Vicki Freedman, Lynda Lisabeth, Lewis Morgenstern
Funded by Health and Human Services, Department of-Agency for Health Care Research and Quality
Funding Years: 2013 - 2018.
The 2011 HHS report on multiple chronic conditions highlighted the prevalence, morbidity, and cost associated with clusters of co-occurring chronic conditions, both physical and mental. Collaborative chronic care models (CCMs) are effective in treating chronic medical and mental illnesses at little to no net healthcare cost. To date CCMs have primarily been implemented at the facility level and adopted by larger, public healthcare organizations. However, the vast majority of primary care and behavioral health practices providing commercially insured care are far too small to implement such models. Health plan-level CCMs can address this unmet need. Based on a groundbreaking partnership with Aetna Inc., the goal of this study is to implement a cross-diagnosis CCM designed to improve outcomes for persons with mood disorders with an eye towards developing a business case for a generalizable plan-level CCM for solo or small practices. Mood disorders (depression and bipolar disorder) were identified by Aetna as priority conditions because of their chronic nature and high healthcare costs. While evidence-based care parameters have been well established, quality of medical and psychiatric care and health outcomes are suboptimal for persons with mood disorders. We will conduct a randomized controlled trial of the cross-diagnosis CCM vs. education control among Aetna beneficiaries across the country who were hospitalized for unipolar depression or bipolar disorder and treated in solo or small primary care or behavioral health practices. At hospitalization discharge a total of 172 solo or small practices involving a total of 344 patients will be randomized to one year of outpatient treatment augmented by the CCM or education control. CCM care management will be fully remote from practice venues and patients, implemented by the Aetna care management center in Salt Lake City. The primary health outcomes are mood disorder symptoms, health-related quality of life, hospitalizations, and guideline-based mood disorders and cardiometabolic management. Secondary outcomes include determining the provider and organizational factors associated with CCM uptake and outcomes, cost effectiveness of the CCM compared to education control, and development of a business plan based on empirical data and stakeholder input. This proposed R18 addresses AHRQ?s research demonstration and dissemination priorities, particularly around prevention and care management. In addition to this groundbreaking practice-research partnership focused on solo or small practices to further implement CCMs at the health plan level, this study may also lead to the evolution of the business case for cross-diagnosis CCMs in general, and the utility of plan-level panel management and remote technologies, especially with the advent of accountable care organizations and similar initiatives.
PI(s): Amy Kilbourne
Co-I(s): Daniel Eisenberg, H. Myra Kim
Funded by Health and Human Services, Department of-National Institutes of Health
Funding Years: 2014 - 2017.
Suicide is a leading cause of death and suicide attempts are a major cause of disability, lost productivity, and health care costs. Suicide prevention is a research priority of the National Institutes of Health, and the US Surgeon General's National Strategy for Suicide Prevention calls for a shift towards recovery-oriented prevention efforts which promote hope and social support. Hopelessness and social isolation are two proximal risk factors for suicide which may be improved via peer mentorship, a form of peer support effective for preventing depression and repeat psychiatric hospitalizations. The primary aims of this study are to develop and pilot test a peer mentorship intervention for psychiatrically hospitalized patients at high risk for suicide. The intervention will be adapted by an expert panel from existing peer support training protocols to target suicide risk factors and to enhance suicide risk management. Protocols for training and supervising peer mentors and measures of intervention fidelity will also be developed. The intervention will then be pilot teste among 60 participants randomly assigned to receive the peer mentorship intervention plus usual care or usual care alone. Participants will be recruited from the inpatient psychiatry unit at the University of Michigan Health System. Inclusion criteria will include medical record documentation of suicidal ideation or suicide attempt at admission, and exclusion criteria will include significant cognitive impairment (according to the Mini-Cog), current receipt of peer support, or determination that peer mentorship may cause distress to the patient or the peer mentor. The peer mentorship intervention will include an in-person visit on the inpatient unit and regular in-person or telephone follow-up for 3 months post-discharge. The intervention will be delivered by peer specialists--individuals in stable recovery from serious mental illness who have received formal training and certification in peer support from the state of Michigan--with at least 6 months of professional peer support experience. The primary outcomes of the pilot study are acceptability and feasibility of the intervention as determined by: 1) >50% of eligible participants enroll in the study, 2) >70% of enrollees complete final follow- up measures at 6 months, and 3) among those assigned to the peer mentorship intervention, >80% complete an inpatient session and the median number of total sessions is at least 4. Peer mentorship sessions will be recorded and rated for fidelity. Measures of suicidal ideation and suicide attempts (the intended primary outcomes of a subsequent efficacy study) and secondary outcomes such as quality of life, functioning, depression, and service use will be obtained at baseline, 3 months, and 6 months post-enrollment by a research assistant blinded to study arm. An exploratory aim will be to measure potential mediators of intervention effectiveness including belongingness, burdensomeness, and hopelessness according to the interpersonal theory of suicide. If acceptability and feasibility are demonstrated, the study will result in a novel recovey-oriented suicide prevention intervention ready for a fully-powered randomized controlled efficacy trial.
PI(s): Paul Pfeiffer
Co-I(s): Mark Ilgen, H. Myra Kim, Cheryl King, Marcia Valenstein
Funded by Health and Human Services, Department of-National Institutes of Health
Funding Years: 2014 - 2016.
Mexican Americans (MAs) suffer more from stroke than non-Hispanic whites (NHWs). Ischemic stroke is more common in MAs and their neurologic, functional and cognitive outcomes after stroke are worse than in NHWs. The reasons for the disparity in post-stroke outcome are unclear. Pre-stroke function and initial stroke severity are similar between the two groups as are ischemic stroke sub-types. One potential explanation for the worse post-stroke neurologic, functional and cognitive outcome in MAs compared with NHWs is allocation and effectiveness of post-stroke rehabilitation. There is remarkably little data demonstrating whether rehabilitation is dosed differently for MAs compared with NHWs, and still less information about whether, for a given dose of rehabilitative services following stroke, there is differential benefit by ethnicity. The current application will utilize the existing population-based Brain Attack Surveillance in Corpus Christi (BASIC, NSR0138916) project's infrastructure and strong community relations to develop and pilot a method to collect the necessary data to determine the role of rehabilitation in ethnic disparities in post-stroke outcomes. Previous studies have suggested that looking at overall time spent in rehabilitation does not predict post-stroke outcome. However, specific components of physical, occupational and speech therapy, a practice-based approach, has been shown to be associated with stroke outcomes, and these associations have been shown to vary by race. However, this practice-based approach has not been implemented in a population-based manner across the range of settings where stroke patients receive rehabilitation services, and no study has used this approach in an ethnically diverse population. Therefore, our plan is to build on previous work by developing and utilizing a practice-based design in our population-based stroke study. Specifically, we will 1) continue to build the needed relationships with rehabilitation service providers in the community;2) work with local rehabilitation therapists to refine data collection instruments as part of the practice-based design;3) pilot test data collection of specific rehabilitation components of post-stroke rehabilitation across all rehabilitation settings;and 4) analyze this data to determine the feasibility of this approach for a larger study and to provide preliminary data on differences in access and effectiveness by ethnicity. In total, our infrastructure development, refinement of tools to measure specific therapy modalities and pilot testing will position us perfectly to submit an R01 application to identify ethnic differences in access to rehabilitation and specific rehabilitation services associated with improved functional outcome in MAs and NHWs.
PI(s): Lynda Lisabeth, Lewis Morgenstern
Funded by National Institutes of Health
Funding Years: 2014-2016
Nearly half of patients undergoing coronary artery bypass grafting (CABG) nationwide are exposed to red blood cell (RBC) products. While large volumes (3+ units) of transfusions may be delivered to a given patient to preserve life in cases of acute blood loss, evidence suggests that even small amounts (1-2 units) of RBCs often transfused to address poor oxygen delivery are associated with a 16% increase in a patient's risk of mortality and a 27% increase in morbidity, even after case mix adjustment. It is vitally important to allocate RBC products appropriately, given both that cardiac surgery utilizes between 20-25% of the total national blood supply, and the Red Cross reports that 32 of their 36 regions had less than a day's supply available to meet hospital needs. In short, it is important to improve our understanding of how and in what context decisions are made regarding 1-2 units of RBCs, given its association with morbidity, mortality and resource utilization. Growing evidence suggests that some transfusions may be discretionary. In the state of Michigan, nearly 40% of CABG patients are exposed to 1-2 units of RBCs, although the absolute rate varies 32% across institutions. Center-specific variation in transfusion practices is likely attributed to thelack of consensus regarding the indications, setting and hematocrit trigger for transfusions. Given this uncertainty, transfusion rates may be the consequence of differences in organizational (e.g. protocols, types of decision-makers, lack of performance feedback regarding transfusion practice) and provider (e.g. knowledge, beliefs concerning the benefit/harm of transfusions, and inclination to transfuse) factors. Interventions to reduce the rate of unnecessary transfusions first require identifying the set of determinants (at the organizational or provider level) that mot fully explain the observed variation in RBC utilization across regional medical centers. We will use the prospective data and infrastructure of the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC), a consortium of all 33 cardiac surgical programs in Michigan, to: (1) Develop, pilot, and implement surveys to hospitals and clinical providers within the state of Michigan to describe determinants of 1-2 units of RBC transfusions during cardiac surgery, and (2) Identify the primary organizational and provider characteristics contributing to variability in transfusions. Results from this study will set the sage for a behavioral modification study aimed at reducing the rate of RBC transfusions in the setting of cardiac surgery.
PI(s): Richard Prager, Donald Likosky
Co-I(s): Darin Zahuranec, Min Zhang, Marc Zimmerman, Milo Engoren
Funded by the National Institutes of Health
Funding Years: 2012-2017
Intraventricular hemorrhage (IVH) occurs in many patients with intracerebral and subarachnoid hemorrhage (SAH). Recent studies have found IVH is a predictor of poor outcome after intracerebral hemorrhage and that hydrocephalus develops in 55% intracerebral hemorrhage patients with IVH. Hydrocephalus is also a major problem in SAH. Early hydrocephalus occurs in 20-50% SAH patients and is associated with poor clinical grade. However, the mechanisms of IVH-induced hydrocephalus are not well understood. Lysis of erythrocytes results in iron accumulation in the brain and causes brain damage after intracerebral hemorrhage. However, the role of erythrocyte lysis and iron toxicity in IVH-induced brain injury and hydrocephalus has still to be elucidated. Erythrocyte lysis after IVH may start very early. Hemoglobin released from red blood cells reaches its peak concentration by the second day following injection of blood into the cerebrospinal fluid of dogs. Hemoglobin release, from lysis of erythrocytes in human intracranial hemorrhage, increases during the first few days. Erythrocyte lysis appears to result from either depletion of intracellulr energy reserves or activation of the complement system. We have established an IVH model in rats and long-term ventricular dilatation has been observed. Recently we have found that hydrocephalus occurs in a model of SAH which results in intraventricular blood. Our preliminary data have demonstrated: 1) Intraventricular injection of autologous whole blood causes iron accumulation, hydrocephalus, neuronal death and brain tissue loss in the hippocampus; 2) Intraventricular injection of lysed erythrocytes rather than packed erythrocytes causes hydrocephalus by 24 hours; 3) Heme oxygenase-1 and ferritin levels are increased significantly in the hippocampus and periventricular areas following IVH; 4) Intraventricular injection of iron alone can also result in acute hydrocephalus; 5) Deferoxamine, an iron chelator, reduces IVH-induced hydrocephalus and hippocampal tissue loss. In this application, we propose to test the following specific aims: 1) Determine whether erythrocyte lysis and hemoglobin release cause hydrocephalus and neuronal death following IVH; 2) Determine whether complement inhibition reduces erythrocyte lysis and IVH/SAH-induced brain injury; 3) Examine the natural time courses of iron buildup, oxidative stress and upregulation of iron handling proteins in the brain after IVH; 4) Determine whether heme oxygenase inhibition reduces heme degradation and IVH/SAH-induced brain injury; and 5) Determine whether iron chelation reduces oxidative stress, hydrocephalus and neuronal death after IVH/SAH in aged rats. The purpose of our project is to investigate the mechanisms of brain injury after IVH. The long-term goal of our studies is to limit hemorrhagic brain damage in patients.
PI(s): Guohua Xi
Co-I(s): Ya Hua, Richard Keep, Lewis Morgenstern
Funded by VA Health Services Research and Development Career Development Award
Funding Years: 2015-2019
Heart attack and stroke, which together are called cardiovascular disease, cause over 1/3 of all deaths in VA patients. The current guidelines for the prevention of these conditions focus on lowering patients'blood pressure and cholesterol levels. A new treatment strategy, which I call benefit-based tailored treatment, that instead guides treatment decisions based on the likelihood that a medication would prevent a heart attack or stroke could prevent more cardiovascular disease, with lower medication use, and be more patient centered. The purpose of this Career Development Award is to develop and assess tools and approaches that could enable the implementation of benefit-based tailored treatment of cardiovascular disease, in particular a decision support tool and educational program for clinicians and a performance profiling system. The decision support tool will enable better care by showing clinicians patient-specific estimates of the likelihood that their medication decisions will prevent a cardiovascular disease event. The performance profiling system will encourage better care by assessing the quality of care provided at VA sites and in PACT teams based on how well the medical care provided follows this treatment strategy. The project will have three aims:
Aim 1 : In the first aim, I will seek to understand clinicians'and patients'perceptions of and receptivity to the use of benefit-based tailored treatment for cardiovascular disease. Information gained from qualitative research with clinicians will help assess and improve the usability and effectiveness of the decision support tool and educational program for clinicians, along with the acceptability of the treatment strategies in general. Information gained from focus groups with patients will help learn their priorities in cardiovascular disease prevention, to help identify ways to make the interventions and their assessments more patient-centered.
Aim 2 : In the second aim, the decision support tool and educational program will be assessed in a real-world randomized pilot study involving thirty clinicians. Half of the clinicians will be provided the decision support tool and education intervention for ten patients each, the other half will receive a traditional quality improvement program and treatment reminders. The study will have formative goals of ensuring that clinicians and patients believe the tool is valuable and does not disrupt care processes or workflow for anyone in the PACT team. This will be studied with qualitative and survey assessments. The primary summative outcome will be the influence of the intervention on clinicians'treatment decisions. Secondary outcomes will assess patients'satisfaction with their visits and their clinicians.
Aim 3 :
The third aim will develop and evaluate a novel performance measurement system based on benefit- based tailored treatment. First, the performance profiling system will be developed. Then the profiling system's ability to reliably differentiate high quality from low-quality care will be evaluated.
PI: Jeremy Sussman
Funded by Veterans Affairs Health Services Research & Development CDA-2
Funding Years: 2014-2015
Despite the availability of evidence-based strategies to prevent type 2 diabetes mellitus (T2DM), engagement in these strategies is low among at-risk Veterans. A key opportunity to engage at-risk Veterans in interventions to prevent T2DM is when they are informed they have prediabetes. It remains unclear how VHA communications to patients diagnosed with prediabetes could be optimized to improve their engagement in evidence-based preventive strategies.
- Aim 1: To describe at-risk Veterans' current engagement in behaviors to prevent T2DM and the mediators of this engagement.
- Aim 2: To examine the effects of receipt of a prediabetes diagnosis on at-risk Veterans' weight and engagement in behaviors to prevent T2DM.
- Aim 3: To identify the effects of 4 strategies from behavioral economics and health psychology on weight, HbA1c, and engagement in behaviors to prevent T2DM among Veterans with prediabetes.
To accomplish Aim 1, we will survey 189 non-diabetic Veterans with risk factors for T2DM about their engagement in behaviors to prevent T2DM and mediators of this engagement such as risk perception, motivation, and awareness of and preferences for preventive strategies. To accomplish Aim 2, we will conduct a pilot randomized trial among the same 189 non-diabetic Veterans from Project 1 in which we will randomly assign 126 of these Veterans to undergo screening for T2DM using a hemoglobin A1c (HbA1c) test. The 63 Veterans who we project will have HbA1c values in the prediabetes range will receive that diagnosis and preventive recommendations from their PACT provider via brief standardized counseling. All 189 Veterans will have their weight tracked over the next year and will be surveyed immediately after the screening and brief counseling process, at 3 months, and at 1 year. Then we will compare changes in weight, engagement in behaviors to prevent T2DM, and mediators of this engagement between the 63 Veterans who we project will have prediabetes and the 63 Veterans who were not screened. Among the 63 Veterans with prediabetes, we will conduct 20 semi-structured interviews to gain insights into the effects of this diagnosis and brief counseling. To accomplish Aim 3, we will conduct a fractional factorial design experiment to evaluate the effectiveness of 4 innovative strategies from behavioral economics and health psychology in promoting weight loss, decreasing HbA1c, and increasing engagement in behaviors to prevent T2DM among 144 Veterans who are identified as having prediabetes through an HbA1c test. We will conduct qualitative evaluations of the acceptability of these strategies to patients.
PI(s): Jeffrey Kullgren