Systemic Solutions for Health Care
Release Date: 02-04-2009
Benjamin Littenberg, director of general internal medicine, will deliver his University Scholar seminar on the Vermont Diabetes Information System, Wednesday, Feb. 11 in Memorial Lounge, Waterman at 4 p.m. (Photo: Raj Chawla)
It was 1979, a time when the fields of "health services research" and "quality improvement" did not yet exist. But that didn't matter to first-year medical student Benjamin Littenberg. A recently graduated economics major, Littenberg was looking for someone at Case Western Reserve University School of Medicine who could teach him about the economics of health care. His request, first met with confusion by the faculty, eventually led Littenberg to someone referred to as "the fellow in the basement."
That fellow turned out to be Duncan Neuhauser, now a nationally recognized health systems management expert and book author. "For four years, he helped me do research and write papers," says Littenberg, Henry and Carleen Tufo Professor of Medicine and Nursing and director of general internal medicine at UVM. "That work kept me in medical school, and I managed to graduate," he adds, admitting that he found the lecture-based medical curriculum boring. Fueled by his work with Neuhauser, Littenberg maintained his research momentum. As an internal medicine resident at Hartford Hospital, a non-academic community facility in Connecticut, he developed and published a major study on steroid use in asthma patients in the emergency department. The work proved influential, informing a new standard of care for asthma cases in emergency departments across the world.
Fortunately for Littenberg, his star-studded training didn't end with Neuhauser. After residency, he received postdoctoral training as a Robert Wood Johnson Clinical Scholar at Stanford University, where he worked with such greats as Harold "Hal" Sox, then Stanford's chief of general internal medicine, now a leader in shaping clinical, educational, and public policy in the United States, and the late Moses Lincoln, a pioneer in the field of biostatistics. Among Littenberg's projects at Stanford was a meta-analysis of diagnostic tests, conducted with Lincoln, that established a new standard method for medical decision-making.
Systems of support
"I was interested in all of the non-biological aspects of health care, which was an offensive position to take in the '80s," says Littenberg. "Now this approach is called clinical and translational research," he adds with a smile. When Sox left Stanford to chair the department of medicine at Dartmouth, Littenberg followed. In 1999, his career path brought him to UVM.
"My goal has always been to improve the quality of primary care," Littenberg says. "We should optimize the interaction of the patient with the system and not just treat the health condition."
The Vermont Diabetes Information System, funded through a grant from the National Institute for Diabetes, Digestive and Kidney Diseases, is an example of another of Littenberg's system successes and will be the focus of his University Scholar seminar on February 11. As an internist, Littenberg sees patients with diabetes and understands the impact — both from a health disability and economic perspective. In 2000, he assembled a multi-disciplinary team of primary care, health care quality, clinical laboratory and information systems management specialists to develop a system to support primary care providers and adult diabetes patients to ensure they met basic clinical goals, mainly getting regular laboratory tests, in order to reduce the long-term complications of the disease.
"Developing systematic approaches to improving care can be applied everywhere in health care — blood banks, pediatrics, diabetes, heart failure, cancer," explains Littenberg, who helped bring VDIS from the academic realm into the commercial when he and a group of UVM colleagues formed a new company three years ago. That company, Vermont Clinical Decision Support, distributes software and other approaches to improving chronic care developed as part of the VDIS research project.
Mentee to mentor
Littenberg's leadership in the project highlighted another role for him, one he had been on the receiving end of for years — mentor. According to one of the colleagues who nominated him for University Scholar, "The ideal mentor helps his or her protégé by offering support, challenging the protégé to take risks, putting the protégé in the way of opportunities, and creating an environment that is conducive to success. Dr. Littenberg has created an environment in the Program for Research in Medical Outcomes where faculty can find this type of support."
Littenberg's enthusiasm for investigating better methods for ensuring better care is contagious, and has had a clear impact on his colleagues and protégé. "One aspect of his research that has to be highlighted is his permanent dedication to teach," said another colleague who nominated Littenberg for the University Scholar award, adding, "he presently has a (grant) that supports not only the investigation of barriers to optimum care for patients with diabetes, but especially the mentoring of research fellows and junior colleagues."
The bottom line for Littenberg is good health outcomes. "Cervical cancer is the leading cause of death in young women in Mexico," he says. Applying the clinical translational science approach to the problem has a simple, but profound impact, he explains — fewer orphans in Mexico.
"All of those connections are important to what we're trying to teach — how to do science that can extend beyond its own narrow focus to be an influence on social and health problems."