ARM 2005: Striving for Health Care Excellence through Research

Overview
The Imperfection of Medicine
The AcademyHealth Awards
Medicare and Medicaid: Celebrating 40 Years
Filling the Gaps

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Overview
In a city recognized for medical excellence, AcademyHealth held a meeting on June 26-28 to foster vital research that will help lower health care costs, improve people’s access to high-quality care, and ultimately save lives. In the process, the organization raised its own bar for success: The 2005 Annual Research Meeting (ARM) in Boston drew the largest number of participants in the conference’s 22-year history, with nearly 2,400 health services researchers, policymakers, practitioners, and decision-makers in attendance.

The meeting’s agenda included research and policy presentations related to 17 themes, including health care coverage and access, health information technology, Medicare, public health, patient safety, and–for the first time–Medicaid and the State Children’s Health Insurance Program (SCHIP) and translating research into policy and practice.

In a compelling keynote address, Atul Gawande, M.D., a Harvard surgeon and widely published author, noted that the field of health services research has the potential to transform health and health care globally--perhaps even more so than biomedical research.

“Research on our health care system can save more lives in the next decade than bench science, research on the genome, stem-cell research, cancer vaccine research, and everything else we hear about on the news,” he said.

The meeting featured more than 130 sessions–a 5 percent increase over the 2004 conference in San Diego--550 speakers, 800 poster presentations, 80 exhibitors, and more than 50 adjunct meetings. “This year, the ARM planning committee introduced new features that respond to contemporary issues and emerging trends in health services research,” said 2005 ARM Conference Chair Tom Rundell, Ph.D., the Henry J. Kaiser Professor of Organized Health Systems in the department of Health Policy and Management at the University of California, Berkeley.

For example, AcademyHealth formed nearly 50 percent of its sessions in 2005 through a rigorous abstracts review process–the highest percentage for any AcademyHealth meeting–in order to increase the number of ARM presentations that featured cutting-edge health services research. “I am very proud of that,” said Rundell.

The Imperfection of Medicine
Atul Gawande set the tone for the meeting with a keynote speech exploring the nature of fallibility in medicine, and the critical role that health services research can play in minimizing medical errors and improving the quality of care. Gawande is a surgeon in the Division of General and Gastrointestinal Surgery, Endocrine Surgical Unit at the Brigham and Women’s Hospital and Dana Farber Cancer Institute in Boston, as well as a staff writer for the New Yorker magazine. His book, Complications: A Surgeon’s Notes on an Imperfect Science, was a finalist for a National Book Award in 2002.

In his remarks, Gawande referenced the work of two philosophers–Samuel Gorovitz and Alasdair MacIntyre–who, in a 1976 essay, highlighted the two core sources of human fallibility: ignorance and ineptitude. Errors made out of ignorance are caused by a limited understanding of the world, Gawande explained; those born of ineptitude occur when knowledge is available but individuals fail to apply it correctly.

Over the past half century, scientists and physicians have learned a great deal about the origin of diseases and how to diagnose and treat them. “The fascinating thing is that the more capable medicine has become, the more human it has become,” said Gawande.

With so many advances in health care knowledge and technology, errors of ignorance have become less and less cause for concern in the 21st century. “Now the role of failures of performance rather than ignorance has become increasingly important.”

Gawande drew on numerous examples of how health services research can prevent such failures and save lives. For example, he cited military research indicating that most U.S. soldiers who died in the Vietnam war after having first been wounded were those who did not make it to an operating room. This finding led to the formation of surgical teams that travel with military units to the battlefield, contributing to a lower rate of lethal war wounds in recent conflicts.

The AcademyHealth Awards
At a luncheon on June 27, AcademyHealth recognized new and veteran research and policy professionals through its awards program. This year, AcademyHealth presented Linda Aiken, Ph.D., with its distinguished investigator award, which recognizes researchers who have made a significant and lasting contribution to the field of health services research.

Aiken is the Clair M. Fagin Leadership Professor of Nursing, professor of sociology, and senior fellow at the Leonard Davis Institute of Health Economics at the University of Pennsylvania. She has conducted and published a large body of research on nursing and patient safety, providing solid evidence that inadequate nurse staffing and chaotic work environments lead to poor patient outcomes.“If you don’t do it right in nursing, patients will die,” Aiken said.

Aiken and her co-authors documented the effect of nurse staffing on surgical mortality in a 2003 study in the Journal of the American Medical Association, for which she was honored previously with AcademyHealth’s article-of-the-year award. “Increasing nurse staffing is the best way to increase patient safety,” she said.

This year, AcademyHealth presented its Alice S. Hersh New Investigator Award to Katrina Armstrong, M.D., M.S.C.E., assistant professor of medicine and epidemiology, senior fellow and director of research at the Leonard Davis Institute of Health Economics. Armstrong’s research seeks to elucidate the relationship among people’s social environment, their use of cancer screening and treatment, and cancer outcomes.

Anthony T. LoSasso, Ph.D., received the 2005 article-of-the-year award for his lead authorship of “The Effect of the State Children’s Health Insurance Program on Health Insurance Coverage,” which appeared in the September 2004 Journal of Health Economics.

LoSasso is associate professor and senior research scientist in the Health Policy and Administration Division of the University of Illinois at Chicago’s School of Public Health.

AcademyHealth’s dissertation award went to Rachel Werner, M.D., Ph.D., who is an assistant professor of medicine at the University of Pennsylvania and a staff physician at the Philadelphia VA medical center. Her thesis drew on evidence from New York’s coronary artery bypass graft report card to test theories of discrimination in health care.

Finally, the award for best student poster was given to Rada Dagher, M.P.H., a doctoral student in health services research and policy at the University of Minnesota for her poster, “A Longitudinal Analysis of Postpartum Depression among Employed Women.”

Medicare and Medicaid: Celebrating 40 Years
This year marks the 40th anniversary of the enactment of Medicare and Medicaid. In recognition of the occasion, AcademyHealth convened a special panel to reflect on the origins and goals of these programs, how they have evolved, and the challenges they face moving forward.

Today, people take for granted that health care is an integral part of U.S. policy and politics, but that wasn’t always the case. Prior to the creation of these programs in 1965, many of our nation’s oldest and poorest citizens lacked any source of consistent health care. Indeed, according to a 1963 survey, only half of elderly individuals reported having a source of health coverage at that time. Today, Medicare provides care to 40 million adults aged 65 and older, while Medicaid insures 52 million low-income and disabled individuals.

Medicare has served seniors well for four decades, said Karen Davis, president of the Commonwealth Fund. But with the population of older adults projected to double over the next 30 years, and the number of workers paying into the system estimated to fall significantly in that same period, the program will need to adapt in order to meet the needs of tomorrow’s beneficiaries.

“Medicare will face financial strain when the baby boomers retire, and it needs to be prepared by being an innovative leader in improving quality and efficiency in our health care system,” said Davis. “It needs to do that in a way that finds savings, but also lessens the financial burdens on beneficiaries.”

Among the policy options that show great promise, according to Davis, are expanding coverage for older and disabled adults, providing a Medicare-based alternative to Medigap (supplemental insurance that covers Medicare’s gaps), using Medicare’s purchasing power for leveraging health system performance, and improving care coordination and high price case management.

Medicaid, the nation’s largest health care program, had its origins as the companion legislation to Medicare. When the Medicaid program began, it focused primarily on individuals who were eligible for welfare. Over the years, it evolved to cover a broader population that includes working families and the disabled, and to provide long-term care assistance.

“Medicaid today, after 40 years, has transformed from a small program of matching grants to states that elect to participate into a program that is available in every state and also in the territories,” said Diane Rowland, executive vice president of the Kaiser Family Foundation and executive director of the Kaiser Commission on the Uninsured.

As the program has grown, so too has its price tag. Jointly financed by states and the federal government, Medicaid coverage is estimated to cost $300 billion each year. Figuring out how to keep Medicaid affordable–without relinquishing its role at the center of the health care safety net--will be a major challenge for policymakers as they prepare for the program’s future.

“As we look at Medicaid reform growing in the public debate these days, we need to remember that what’s at stake is insurance coverage for millions of children and adults, assistance to Medicare beneficiaries and those in need of long-term care, and support for states’ capacity to provide health coverage,” said Rowland.

Filling the Gaps
Reflecting on the 40th anniversary of Medicare and Medicaid in a closing plenary, AcademyHealth board chair Sara Rosenbaum underscored the value of health services research in guiding the future of U.S. health care. Rosenbaum is the Hirsh Professor and Chair in the department of health policy at George Washington University’s School of Public Health and Health Services in Washington, D.C.

“In the roots of Medicaid lay a vision about the role of government and filling the void that the market in health coverage would inevitably leave behind,” she said. “Certainly the original vision had holes in it,” she continued, but “we, as health services researchers, study many of those holes.”

The idea that researchers provide a critical missing link between health care vision and action was echoed many times throughout the 2005 ARM. “There is a gap between what medicine can do and what we actually do,” said physician and writer Atul Gawande in the keynote address that opened the meeting. “And what researchers like you do is try to understand how we narrow that gap.”