The uninsured: problems, solutions, and the role of academic medicine.

The number of uninsured persons in the United States--46 million--is more than the number covered by Medicare. The author discusses why there are so many uninsured, the health effects of being uninsured, and strategies to help the uninsured, with an emphasis on changing the safety net and employer-based insurance for smaller businesses. He then asks "What can academic medicine (AM) do now?" and proposes that (1) AM can help eliminate waste in health care. For example, AM can research areas of potential waste such as how often patients with chronic disease need to be seen and what tests they need (not to restrict care, but to determine what is appropriate). AM can also continue to develop electronic medical records that eliminate unnecessary repetition of work and can have embedded national practice guidelines with reminders. (2) AM can act as a large employer and develop novel benefit plans that provide various important choices and develop ways to educate employees to choose the appropriate health plan. The University of Virginia has established the Consumer Health Education Institute, which is researching ways to educate consumers in the format most accessible for them as individuals (i.e., tailored to their health literacy). (3) AM can work with state governments to develop innovative coverage models. Because it appears that innovation in health care may be at the state level at least for the next few years, individuals in AM can be extremely helpful in making suggestions to formulate policy and implement programs. The current estimate is for the United States to have 56 million uninsured by 2013--an increase to 19.4% of the population. Academic medicine can help slow this increase.     

How the practice of allergy shows the promise and challenge of personalized medicine

Personalized medicine seeks to stratify therapies according to individual characteristics, and by so doing improve effectiveness and reduce complications. However, there are not many models of care that is highly stratified within a single diagnosis in this manner. One potential model is the practice of allergy, in which care is tailored to specific allergens for individual patients within the broader context of care for rhinitis or asthma. Allergists have already confronted many of the same regulatory issues anticipated for personalized medicine. The history of allergy practice also anticipates some of the patient safety concerns that may arise from tracking and using highly personalized medical information. Finally, the therapy of allergy and asthma has been at the forefront of attempts to incorporate pharmacogenomics information into patient care. Individualized therapy has always been central to the practice of allergy, and so provides a useful proving ground for personalized medicine as a concept of care.     

Meeting the challenges facing clinical research: solutions proposed by leaders of medical specialty and clinical research societies.

The development of a robust national clinical research enterprise is needed to improve health care, but faces formidable challenges. To define the impediments and formulate solutions, the Institute of Medicine's Clinical Research Roundtable convened leaders from medical specialty and clinical research societies in 2003. Participants considered how to influence clinical research funding priorities, promote mechanisms to train physicians and other health care professionals to conduct clinical research, and how to encourage health care providers to follow evidence-based medical practice. Consensus emerged on multiple issues, including intersociety collaboration, the need for a core clinical research curriculum for training the new cadre of clinical researchers, joint advocacy for increased funding of clinical research and for the education of policymakers and the public on the benefits of clinical research. Specific recommendations were made on mechanisms for recruitment, training, and retention of clinical research trainees and mentors. Steps were outlined (1) to overcome career disincentives and develop appropriate reward systems for mentors and trainees, (2) to encourage use of web-based and continuing-medical-education-based mechanisms to bring practitioners up to date on issues in and results of clinical research, and (3) to create incentives for individuals, clinics, and hospitals to practice evidence-based medicine (EBM). Collectively, the response and proposed strategies can serve as a roadmap to improve clinical research funding and training, evidence-based medical practice, and health care quality.     

A Focus on Empirically Supported Outcomes: A Commentary on Search for Empirically Supported Treatments

Psychiatry in Australia has prepared clinical practice guidelines, and in doing so identified empirically supported treatments, but has been loath to implement those guidelines. Clinical psychology, excluded from being reimbursed by health insurance, has shown less interest in systematically identifying such treatments. There is considerable official interest in how to make science inform practice, with comments from the payers that routine outcome assessment would be used in setting reimbursement schedules. Efficacy, effectiveness, and efficiency are popular words, evidence‐based medicine is to be adopted by all, but no one is clear about how this will be achieved. Does all this sound familiar?     

Prospective Payment for Hospital Costs Using Diagnosis-Related Groups: Will Cost Inflation Be Reduced?

In response to rapidly rising costs in the medical care industry, especially for inpatient hospital charges, the Reagan administration has sent the first component of a plan for prospective payment of medical care to Congress. This first phase would involve changing reimbursement for hospital charges under Medicare using a system of predetermined rates for particular illnesses. Reimbursement rates have been set for 467 patient-illness categories, or diagnosis-related groups (DRGs), in an attempt to eliminate the variance in hospital costs and stem inflation under Medicare for patients with similar illnesses. But such a system is still subject to manipulation by hospitals that seek to increase reimbursement either to meet costs not covered by the appropriate DRG or to increase profit. The DRG reimbursement system does not prevent cost shifting to private insurance patients and does not involve physicians in efforts to improve cost efficiency. Although the DRG approach may seem conceptually appropriate, implementation will be difficult and the dampening effect on rapidly rising medical care costs may be overestimated. An alteration in the reimbursement mechanism for all medical care may be indicated to reduce significantly the inflation in medical care costs.     

Organizational models for medical school-clinical enterprise relationships.

Changes in the organization, financing, and delivery of health care services have prompted medical school leaders to search for new organizational models for linking medical schools, faculty practice groups, affiliated hospitals, and insurers-models that better meet the contemporary challenges of governance and decision making in academic medicine. However, medical school leaders have relatively little information about the range of organizational models that could be adopted, the extent to which particular organizational models are actually used, the conditions under which different organizational models are appropriate, and the ramifications of different organizational models for the academic mission. In this article, the authors offer a typology of eight organizational models that medical school leaders might use to understand and manage their relationships with physicians, hospitals, and other components of clinical delivery systems needed to support and fulfill the academic mission. In addition to illustrating the models with specific examples from the field, the authors speculate about their prevalence, the conditions that favor one over another, and the benefits and drawbacks of each for medical schools. To conclude, they discuss how medical school and clinical enterprise leaders could use the organizational typology to help them develop strategy and manage relationships with each other and their other partners.     

The Genome Clinic: A Multidisciplinary Approach to Assessing the Opportunities and Challenges of Integrating Genomic Analysis into Clinical Care

Our increasing knowledge of how genomic variants affect human health and the falling costs of whole‐genome sequencing are driving the development of individualized genetic medicine. This new clinical paradigm uses knowledge of an individual's genomic variants to guide health care decisions throughout life, to anticipate, diagnose, and manage disease. While individualized genetic medicine offers the promise of transformative change in health care, it forces us to reconsider existing ethical, scientific, and clinical paradigms. The potential benefits of presymptomatic identification of at risk individuals, improved diagnostics, individualized therapy, accurate prognosis, and avoidance of adverse drug reactions coexist with the potential risks of uninterpretable results, psychological harm, outmoded counseling models, and increased health care costs. Here, we review the challenges of integrating genomic analysis into clinical practice and describe a prototype for implementing genetic medicine. Our multidisciplinary team of bioinformaticians, health economists, ethicists, geneticists, genetic counselors, and clinicians has designed a “Genome Clinic” research project that addresses multiple challenges in genomic medicine—ranging from the development of bioinformatics tools for the clinical assessment of genomic variants and the discovery of disease genes to health policy inquiries, assessment of clinical care models, patient preference, and the ethics of consent.     

Cardiovascular care in the urban melting pot

The widespread prevalence of cardiovascular diseases does not spare poor or heterogeneous urban communities. Since the inflationary spiral of health care costs has continued unabated, it will require intentional and creative maneuvers to preserve and develop new or existing programs which do not deny ready access to quality care for all classes. It is the opinion of the author that the present health care system promotes indifference on the part of health care providers and the purveyors of technology. The traditions of altrusim in medicine should be extended to health systems planning at the institutional and regional level. Although preventive medicine is a vital public issue, it is not the only priority agenda for populations experiencing already existing cardiovascular derangements. The private practice paradigm is an obsolete and inflation promoting system for the delivery of complex tertiary care. Modern cardiovascular diagnostics and therapeutics require efficient and economical team efforts. If the few remaining historically black medical centers are to properly serve a heterogeneous base, innovation and reorganization are inevitable.     

The role of academic medicine in improving health care quality.

Academic medicine, often entrenched in biomedical and clinical research, has largely ignored the development and application of quality metrics to ensure the delivery of high-quality health care. Nevertheless, academic medicine has substantial opportunities to lead the charge in building a quality infrastructure with the goal of delivering high-quality and cost-efficient health care to all Americans. The American College of Cardiology (ACC) and American Heart Association (AHA) have worked jointly to measure and improve the quality of cardiovascular care. This effort has led to the development of clinical practice guidelines, performance measures, data standards, national registries, and appropriateness criteria for cardiovascular care. Academic medicine should actively embrace and promote the type of quality metrics and criteria developed by ACC and AHA and apply this model across the entire academic medicine community. Academic medicine, with its many resources, could lead the way in the expanding field of quality science by supporting fundamental research in quality improvement, supporting academicians to improve quality at their own institutions, developing educational models for quality assessment and improvement, creating and implementing data registries, and serving as a conduit for developing the emerging science of quality assessment. In this and many other ways, academic medicine must offer the health care community leadership for improving our nation's health care quality with the same fervor presently exhibited for the advancement of basic science, the development of specialized and experimental therapy, and as centers for tertiary and quaternary patient care.     

Carrying out the Medicine/Public Health Initiative: the roles of preventive medicine and community-responsive care.

Leaders in medicine and public health, recognizing the inherent interdependency of these fields, established the Medicine/Public Health Initiative in the mid-1990s as "an evolving forum in which representatives of both sectors can explore their mutual interests in improving health and [can] define collaborative mechanisms to achieve that goal." The Initiative's participants developed six goals that they and others in medicine and public health across the nation should implement: engage the community; change the education process; create joint research efforts by clinical, public health, and preventive medicine investigators; develop a shared view of illness between medicine and public health; work together to provide health care; and work jointly to develop health care assessment measures. The authors describe the six goals in depth and explain the important combined roles of clinically-oriented preventive medicine and community-oriented preventive medicine--as practiced in a model of health care delivery called community-oriented primary care (COPC)--in implementing the Initiative's goals. They then report recent efforts, including two in Boston and Dallas, to merge medicine and public health, and state that academic health centers, which are in the process of reshaping themselves, can help themselves as well as the public by embracing their key role in the effort to integrate medicine and public health. In particular, they can expand and strengthen existing training programs in preventive medicine and COPC or add these programs to their curricula.     

The SickKids Genome Clinic: developing and evaluating a pediatric model for individualized genomic medicine

Our increasing knowledge of how genomic variants affect human health and the falling costs of whole‐genome sequencing are driving the development of individualized genomic medicine. This new clinical paradigm uses knowledge of an individual's genomic variants to anticipate, diagnose and manage disease. While individualized genetic medicine offers the promise of transformative change in health care, it forces us to reconsider existing ethical, scientific and clinical paradigms. The potential benefits of pre‐symptomatic identification of at‐risk individuals, improved diagnostics, individualized therapy, accurate prognosis and avoidance of adverse drug reactions coexist with the potential risks of uninterpretable results, psychological harm, outmoded counseling models and increased health care costs. Here we review the challenges, opportunities and limits of integrating genomic analysis into pediatric clinical practice and describe a model for implementing individualized genomic medicine. Our multidisciplinary team of bioinformaticians, health economists, health services and policy researchers, ethicists, geneticists, genetic counselors and clinicians has designed a ‘Genome Clinic’ research project that addresses multiple challenges in pediatric genomic medicine – ranging from development of bioinformatics tools for the clinical assessment of genomic variants and the discovery of disease genes to health policy inquiries, assessment of clinical care models, patient preference and the ethics of consent.     

Barriers for integrating personalized medicine into clinical practice: A qualitative analysis

Personalized medicine—tailoring interventions based on individual's genetic information—will likely change routine clinical practice in the future. Yet, how practitioners plan to apply genetic information to inform medical decision making remains unclear. We aimed to investigate physician's perception about the future role of personalized medicine, and to identify the factors that influence their decision in using genetic testing in their practice. We conducted three semi‐structured focus groups in three health regions (Fraser, Vancouver coastal, and Interior) in British Columbia, Canada. In the focus groups, participants discussed four topics on personalized medicine: (i) physicians' general understanding, (ii) advantages and disadvantages, (iii) potential impact and role in future clinical practice, and (iv) perceived barriers to integrating personalized medicine into clinical practice. Approximately 36% (n = 9) of physicians self‐reported that they were not familiar with the concept of personalized medicine. After introducing the concept, the majority of physicians (68%, n = 19 of 28) were interested in incorporating personalized medicine in their practice, provided they have access to the necessary knowledge and tools. Participants mostly believed that genetic developments will directly affect their practice in the future. The key concerns highlighted were physician's access to clinical guidelines and training opportunities for the use of genetic testing and data interpretation. Despite the challenges that personalized medicine can create, in general, physicians in the focus groups expressed strong interest in using genetic information in their practice if they have access to the necessary knowledge and tools. © 2013 Wiley Periodicals, Inc.     

An integrated framework of personalized medicine: from individual genomes to participatory health care

Promising research developments in both basic and applied sciences, such as genomics and participatory health care approaches, have generated widespread interest in personalized medicine among almost all scientific areas and clinicians. The term personalized medicine is, however, frequently used without defining a clear theoretical and methodological background. In addition, to date most personalized medicine approaches still lack convincing empirical evidence regarding their contribution and advantages in comparison to traditional models. Here, we propose that personalized medicine can only fulfill the promise of optimizing our health care system by an interdisciplinary and translational view that extends beyond traditional diagnostic and classification systems.     

A framework for training health professionals in implementation and dissemination science

The authors describe a conceptual framework for implementation and dissemination science (IDS) and propose competencies for IDS training. Their framework is designed to facilitate the application of theories and methods from the distinct domains of clinical disciplines (e.g., medicine, public health), population sciences (e.g., biostatistics, epidemiology), and translational disciplines (e.g., social and behavioral sciences, business administration education). They explore three principles that guided the development of their conceptual framework: Behavior change among organizations and/or individuals (providers, patients) is inherent in the translation process; engagement of stakeholder organizations, health care delivery systems, and individuals is imperative to achieve effective translation and sustained improvements; and IDS research is iterative, benefiting from cycles and collaborative, bidirectional relationships. The authors propose seven domains for IDS training-team science, context identification, literature identification and assessment, community engagement, intervention design and research implementation, evaluation of effect of translational activity, behavioral change communication strategies-and define 12 IDS training competencies within these domains. As a model, they describe specific courses introduced at the University of California, San Francisco, which they designed to develop these competencies. The authors encourage other training programs and institutions to use or adapt the design principles, conceptual framework, and proposed competencies to evaluate their current IDS training needs and to support new program development.     

Observations on primary health care in Ontario, Canada.

The Canadian health care system has developed very differently from that of its neighbour, the United States of America. It has a publicly financed and administered universal insurance plan which provides good access to high quality medicine, free at the point of delivery. Increasing costs, however, mean that painful political decisions on health will have to be made. Experiments with alternative means of financing primary health care provision and the Canadian approach to postgraduate education may offer useful ideas for general practice in the United Kingdom.     

Treating chronic migraine headaches: an evidence-based practice approach

Psychologists and other mental health care professionals are generally trained to incorporate empirical evidence into clinical practice, but few have been taught formal techniques for doing so. Given the rapidity of progress in the clinical sciences, there is a growing need among practitioners to access current, clinically relevant research and have strategies for integrating these research findings into the clinic. In the field of medicine, evidence-based medicine took hold in the early 1990s to provide a framework and skill set for translating research into practice. This method is now widely known as evidence-based practice (EBP) to reflect its applicability to multiple disciplines. In this article, we present a general overview of EBP, illustrate how we used this approach to develop a treatment plan for a patient who had chronic migraine headaches, and discuss some of the opportunities and challenges EBP presents to mental health professionals.     

Evaluation of a one-year Masters of Public Health program for medical students between their third and fourth years.

For physicians to better treat and advise their patients on the roles of behavioral and social factors in health and disease, greater levels of competency in social and behavioral sciences are needed. Physicians should also understand the structure, financing, and administration of the health care delivery system, so that they will be able to practice medicine effectively and participate in planning and managing the delivery of care. And, improving overall public health requires that physicians understand the basic tenets of population-based medicine. One way to achieve these goals is to develop education and training programs for integrating formal public health training with formal medical training.There are many models by which a medical student or practitioner can obtain a master of public health (MPH) degree. In this article, the authors describe an accelerated one-year MPH program for competitively selected New York City medical students who have completed their third year of training and enroll at the Mailman School of Public Health, Columbia University. The Macy Scholars Program, offered between 1999 and 2007 to 12 students per year, is completed between the third and fourth years of medical school. Under full-tuition scholarships, students complete a practicum experience, attend seminars, and write a master-level paper or thesis, among other requirements. Data from an evaluation of this program demonstrate participant satisfaction and support of the program, outstanding academic performance, and the effect of public health training on their residency and career choices.     

Comparative effectiveness research and genomic medicine: An evolving partnership for 21st century medicine

The American Recovery and Reinvestment Act has provided resources for comparative effectiveness research that will lead to evidence-based decisions about health and health care choices. Some have voiced concerns that evidence-based comparative effectiveness research principles are only relevant to “average” patients and not as much to individuals with unique combinations of genes, exposures and disease outcomes, intrinsic to genomic medicine. In this commentary, we argue that comparative effectiveness research and genomic medicine not only can and should coexist but also they will increasingly benefit from each other. The promise and success of genomic medicine will depend on rigorous comparative effectiveness research to compare outcomes for genome-based applications in practice to traditional non–genome-based approaches. In addition, the success of comparative effectiveness research will depend on developing new methods and clinical research infrastructures to integrate genome-based personalized perspectives into point of care decisions by patients and providers. There is a need to heal the apparent schism between genomic medicine and comparative effectiveness research to enhance knowledge-driven practice of medicine in the 21st century.