Scholars conduct two or more research projects during their fellowship experience. They are encouraged to consider at least one project that involves primary data collection and to engage in projects that employ different methodological approaches. Below are examples of research projects completed by Yale Scholars.
Jason Lott and colleagues examined surgical delay among Medicare beneficiaries with melanoma between 2000 and 2009, using the Surveillance, Epidemiology, and End Results-Medicare database. They included all patients undergoing surgical excision of melanoma diagnosed by means of results of skin biopsy. The study included more than 32,000 cases of melanoma. They found that 78 percent of melanoma cases underwent excision within 1.5 months, 22.3 percent underwent excision after 1.5 months, and 8.1 percent underwent excision after 3 months. Surgical delay longer than 1.5 months was significantly increased among patients 85 years or older compared with those younger than 65 years, those with a prior melanoma, and those with more co-existing medical conditions. Additionally, melanomas that underwent biopsy and excision by dermatologists had the lowest likelihood of delay. The highest likelihood of delay occurred when the biopsy was performed by a non-dermatologist and excised by a primary care physician. Results show that a delay of surgery for melanoma may be relatively common among Medicare beneficiaries. Minimizing delay is an important patient-centered objective of high-quality dermatologic care, especially given the potential harms of psychological stress associated with untreated malignant neoplasms.
The study highlights opportunities for quality improvement in dermatologic care and suggests that efforts to minimize the delay of surgery for melanoma might focus on increased access to dermatologic expertise and enhanced coordination of care among different specialists.
JAMA Dermatology,51(7):731-41, 2015.
Following a hospitalization, patients face many challenges as they transition home. Current efforts to improve and coordinate healthcare rely on hospital readmission rates as a marker of quality and transitions in care during the post acute care period. Dr. Vashi, a VA Clinical Scholar, and colleagues conducted a study to determine the degree to which ED visits (treat-and-release encounters) contributed to overall use of acute care services within 30 days of hospital discharge. In a study of 5,032,254 index hospitalizations among 4,028,555 adult patients, the team found that of all the hospitalizations in the study, 17.9 percent resulted in at least 1 acute care encounter in the 30 days following discharge; 7.5 percent of discharges were followed by at least 1 ED encounter; and 12.3 percent by at least 1 readmission. For every 1,000 discharges, there were 97.5 ED treat-and-release visits and 147.6 hospital readmissions in the 30 days following discharge. Visits to the ED comprised nearly 40 percent of the post-discharge acute care encounters. Moreover, patients commonly returned to the ED for reasons related to their index hospitalization. This study raises concerns that many more patients require acute medical care after hospital discharge than previously recognized. The use of hospital readmissions as a lone metric for post-discharge health care quality may be incomplete without considering the role of the ED.
JAMA, 309(4):364-71, 2013.
Dr. Edelman and colleagues investigated patterns of opioid receipt across 78,738 HIV infected and uninfected patients using 2005-2006 data from the Veterans Aging Cohort Study-Virtual Cohort (VACS-VC). Since patients with HIV are more likely to have substance use disorders, and opioids may be detrimental to the immune system and interact with antiretroviral treatments, opioid analgesics could present a greater risk to these patients than their uninfected counterparts. Dr. Edelman and her colleagues found that over 1 in 3 patients had received at least one opioid prescription during the study period. They also found that after controlling for factors known to be associated with opioid receipt, HIV-infected patients had 40 percent higher odds of receiving opioids than uninfected patients. As HIV is now a chronic disease, these findings underscore the need for further research examining the long-term risks and benefits of opioid analgesics in HIV-infected patients. The VACS-VC data provides an opportunity to examine these effects, and Dr. Edelman is pursuing this line of inquiry.J Gen Intern Med, 28(1):82-90, 2013.
Private insurance plans that offer reimbursement for out-of-network physician services are popular. However, the additional costs of using an out-of-network physician may be unexpected if patients involuntarily use out-of-network physicians or costs are not transparent. In an online survey, Kyanko and coworkers found that of 7,812 respondents with private health insurance, 8.3 percent used an out of network physician in the past 12 months. 40 percent who used out-of-network physicians did so involuntarily due to medical emergency or lack of knowledge of the physician’s out-of-network status. In comparison to those who use out-of-network physicians voluntarily, involuntary use was more likely to involve single marital status, low (<$35,000) income, and was usually for primary care services. About half of those who used out-of-network physicians noted nontransparent costs. Several states have already begun to address price transparency by mandating disclosure of out-of-network status.
Health Serv Res. 2012 Oct 22.