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Message from the Director

John Steiner, MD, MPH

"Personalized" Health Care
In his State of the Union address in January, President Obama proposed a federal research initiative that would lead to “a new era of medicine- one that delivers the right treatment at the right time”. A recent statement from the Food and Drug Administration expands on this concept. “…Personalized medicine (also known as precision medicine) may be thought of as the tailoring of medical treatment to the individual characteristics, needs, and preferences of a patient during all stages of care, including prevention, diagnosis, treatment, and follow-up”. Most proponents of this concept focus on achieving personalized care through genomics. For example, a recent definition from the NIH states that “Personalized medicine…uses an individual's genetic profile to guide decisions made in regard to the prevention, diagnosis, and treatment of disease”.

In a 2007 editorial, Burke and Psaty reminded us that personalized medicine comprises more than genomics alone. “Genuinely personal health care, as practiced by physicians for centuries, is based on the relationship between patient and physician rather than on any particular technology”. Still other commentators suggest that “N of 1” clinical trials, comparative effectiveness research or shared decision making are all ways to preserve the individual as the focal point of health care decisions. Why are so many different disciplines trying to claim this concept? Can they all be right?

The philosopher Ken Wilber proposes that human knowledge derives from four complementary perspectives: the individual self and consciousness; the “intersubjective” realm of human culture and relationships; the physical, natural and behavioral sciences; and the social systems and environment in which we live. He also points out that most scholars claim primacy for one of these perspectives, even as they engage all of them in their daily lives. Wilber’s “integral” perspective helps me untangle the claims about personalized, precision, or individualized health care, and see how they may actually require each other.

Analysis of genomic information, rich clinical data, or social and environmental information to understand an individual’s health concerns and needs all approach the individual “from the outside in”. They start with what is measurable in the natural sciences, in electronic health records, or in our rapidly growing datasphere, then build models and make predictions that progressively approximate the individual perspective. In contrast, an individual who declares his or her preferences and clinicians who develop strong relationships with their patients can personalize care “from the inside out”, focusing on information that is subjective and nuanced but less easily measurable.

When we try to keep all four perspectives in view, the limitations of each become apparent. Individual preferences or the recommendations of clinicians should be informed by evidence from the biological, behavioral, social and environmental sciences. Predictions from genomic or comparative effectiveness studies about the best drug for a specific disease should pass through the filter of the clinician’s experience and the patient’s goals. Even an exquisitely targeted treatment won’t work if the patient won’t take it or can’t afford it, or if the doctor doesn’t recommend it.

In the Institute for Health Research, we pride ourselves on conducting research within an integrated delivery system. The concept of personalized medicine challenges us to broaden our definition of what truly integrated care should be. Can we provide care that honors the individual, promotes strong clinical relationships, collects and applies information from the genomes (and all the other “omes”) of our members, link that information with clinical and behavioral data in our electronic health records, and augment that with a deep understanding of the social and environmental context that shapes the health of our members? That’s a challenge worth accepting.

Investigators in the IHR, other KP and HMO Research Network research departments, and our academic colleagues are all asking these questions. In 2015, IHR investigators will begin to recruit volunteer KPCO members into the national KP Research Bank, which will store information about their genomics, clinical care, family history and behaviors, and ultimately use that information to test new interventions to guide care decisions. Our research departments are nationally recognized for observational comparative effectiveness studies and pragmatic clinical trials that exploit the richness of our clinical information. IHR researchers are evaluating programs to promote health in communities and schools, outside the walls of our delivery system. We are conducting studies that deepen our understanding of the social forces - food insecurity, racial, ethnic and social disparities, insurance coverage and cost of care – which shape how patients live their lives and use the health care system. We are including patients as team members in our research so that we never drift too far from their priorities.

We should view anyone who tries to claim personalized medicine as the exclusive domain of a single discipline with a bit of skepticism, but a larger measure of compassion. They are all onto something, but truly personalized care is a bigger concept, and a more worthwhile goal, than any of their agendas.

Warm Regards,
John F. Steiner, MD, MPH
Senior Director

2014 Financial Results

2014 was a challenging year for federal research funding as the IHR saw a decline in external funding as American Recovery and Reinvestment Act (ARRA) grants ended.  Our decrease in revenue is largely due to the pass-through of sub-awards to other sites, as most of our ARRA grants involved collaboration with multiple research organizations across the country. In 2014, our researchers maintained a diverse portfolio of extramural grants, in addition to supporting numerous internal initiatives. The IHR is teaming up with Kaiser Permanente Colorado (KPCO) leaders to answer questions of organizational importance and to evaluate various operational projects and processes. For example, KPCO experienced unprecedented growth, largely due to the Affordable Care Act; investigators are assessing the onboarding of these new members as well as the impact of their utilization on the delivery system. Activities such as these help KPCO fulfill its mission to provide high-quality, affordable health care services to improve the health of our members and the communities we serve.

HMORN 2015

The 21st annual conference of the HMO Research Network was recently held in Long Beach, California. The theme of this year's conference, "Care Improvement Research: Partnering with Patients, Providers, and Operational Leaders," brought together researchers from across the country to showcase groundbreaking research in this area. Several members of the IHR were in attendance and presented on a variety of topics on care improvement. View all of the conference abstracts.

Research News

Evaluation Investigator Cheryl Kelly, PhD, MPH, had a paper selected for the 2014 Sarah Mazelis Paper of the Year award for the Health Promotion Practice journal. Dr. Kelly will be honored at the upcoming Society for Public Health Education Annual Conference in Portland, Oregon in April. Congratulations, Dr. Kelly!

Heather Spencer Feigelson, PhD, MPH, co-authored a study examining treatment patterns for ductal carcinoma in situ (DCIS) across 6 Kaiser Permanente regions. The study found significantly different treatment patterns for this cancer across regions and by patient age. These findings emphasize the need for evidence based guidelines on the treatment of DCIS.

Emily Schroeder, MD, PhD, Stan Xu, PhD, Marsha Raebel, PharmD, and John Steiner, MD, MPH, co-authored a study on the SUPREME-DM project examining trends in diabetes incidence across 7 million patients in the study network from 2006 through 2011. The study found no significant increase in the incidence of diabetes during this time across the entire study population, but did find a significant increase in incidence among racial minorities and the obese. As both of these populations are growing in the U.S., the findings of the study highlights the likelihood of increasing diabetes incidence in the future among these groups and confirms that the diabetes epidemic is not over.

Department News

Two members of the IHR have been nominated for the prestigious Summit Award, Kaiser Foundation Health Plan's highest honor in Colorado. IHR Investigator Jason Glanz, PhD, and Clinical Trials Senior Research Specialist Mabel Peters have both been nominated for their outstanding performance and contributions. Winners will be announced at the Summit Award Celebration on April 10th. Good luck to you both!

In January, the IHR welcomed two new research investigators, Drs. Ingrid Binswanger and Andrea Burnett-Hartman. Ingrid Binswanger, MD, MPH, joins us from the University of Colorado and has extensive experience in correctional health and substance abuse. Andrea Burnett-Hartman, PhD, comes to us from the Fred Hutchison Cancer Research Center in Seattle and brings her substantial experience in cancer epidemiology to the department. Look for more information about our new researchers in the next issue. Welcome!

In 2014 the IHR implemented a new program, ARISE (Accountability, Research, Innovation, Service, Excellence), to recognize staff for outstanding service and contributions to the department. Peer nominations were reviewed by a committee comprised of IHR staff to determine six finalists. Congratulations to all the nominees and to finalists Natalie Chlop, Glenn Goodrich, Akia Lynch, Susan Shetterly, and JoAnn Shoup--and to our 2014 winner Mabel Peters!


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