FEATURE

Doris Duke Award Recipient's Research Focuses on Cost-Effectiveness
Michael Rothberg, MD, MPH, a clinician investigator in the Department of Medicine, has received a 2006 Doris Duke Clinical Scientist Development Award to study heparin prophylaxis in hospitalized general medicine patients. Dr. Rothberg came to Baystate in 2002. He has published papers on flu, coronary disease, dysuria, and varicella, explaining his wide-ranging interests by saying he is drawn to what he sees most - common problems encountered by general internists. His focus, however, has remained the same since he started his fellowship in Medical Informatics - cost-effectiveness and quality of care.

Venous Thromboembolism- Risk for Death and Illness in Hospitals
Rothberg is currently studying VTE, which can be successfully prevented in surgical patients with prophylactic use of heparin. But with non-surgical inpatients, according to Rothberg, the risk factors for VTE are not understood and the effectiveness of common interventions, including heparin, are not proven. As a result of this ambiguity, VTE prophylaxis is underutilized and millions of patients who might benefit do not receive it.

Since treatment with heparin increases the risk of bleeding, a patient's risk for VTE must be weighed against the benefits and complications of intervention. Rothberg and his co-investigators, Drs. Peter Lindenaur at Baystate and Harry Selker at Tufts, aim to estimate the prevalence of VTE prophylaxis and symptomatic thromboembolic events, determine the risk factors for those events, and compare the efficacy, adverse effects and costs of the three most common VTE treatments: low molecular weight heparin, unfractionated heparin, and compression boots.

Unique Database Yields Powerful Benefits
Rothberg considers his data source for this project, Premier's Perspective database, a largely untapped goldmine. Set up to monitor utilization, and quality and cost of care for its 400 participating hospitals throughout the U.S., it contains data on more than 1 million patients. Its level of detail includes what drugs were given on which days, data that Medicare lacks. This extraordinarily large data set also enables researchers to discern differences between events that are relatively rare, making them impossible to detect in a randomized trial.

Baystate is the only hospital to use Perspective's administrative data for clinical research, and it is stirring up interest in the research community. Rothberg reports that Baystate has been contacted by other institutions wishing to participate in their research, and says, “We welcome collaboration with any division in the hospital and beyond."

Using Clinical Data to Test Decision Models
Using diagnosis or service codes, Rothberg's group will assemble a cohort of patients who received VTE prophylaxis or had symptomatic VTE during the previous 2 years. Developing a propensity model to adjust for confounders, they will compare the outcomes of patients with similar propensity scores who received different treatments.

The goal of Rothberg's research is to create decision models for use both in individual risk assessment and decision-making, and in policy making. They will validate their findings against clinical data, testing whether their interpretations accurately predicted the presence or absence of a VTE diagnosis as recorded in the medical records of a sub-sample of Baystate patients. Within 5 years, Rothberg thinks his results will be able to provide decision support during physician order entry. Initially it will be rudimentary, perhaps providing a prompt such as, "Would you like to order VTE prophylaxis for this patient?" Such a benefit couldn't be timelier, since JACHO will start requiring hospitals to assess patients for VTE risk in 2007.

Further Reading:
Rothberg M, Bennish ML, Wong JB. Do the benefits of varicella
vaccination outweigh the long-term risks? A decision-analytic model for policymakers and pediatricians. Clin Infect Dis 2002;34:885-94.

Rothberg MB, Bellantonio S, Rose DN. Management of Influenza in Older Adults: Cost-Effectiveness of Rapid Testing and Antiviral Therapy.  Ann Intern Med 2003;139:321-329.

Rothberg MB, Abraham I, Lindenauer PK, and Rose DN. Improving Nurse to Patient Staffing Ratios as a Cost-Effective Safety Intervention. Med Care 2005;43:785-91.

Rothberg MB, Celestin C, Fiore LD, Lawler E, Cook J. Warfarin Plus Aspirin for Patients With History of Myocardial Infarction or Acute Coronary Syndrome:  Meta-Analysis With Estimates of Risk and Benefit.  Ann Intern Med 2005;143:241-50.