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Dr. Jeremy Brown, director of the new Office of Emergency Care Research, works to improve emergency medicine’s seat at the NIH research table   

Judith Tintinalli (EPM): You are from the UK. What made you decide to leave a country with the National Health Service for the United States?

Jeremy Brown, MB, BS: I thought I moved to one of the colonies! Seriously, I married a war bride. Or I guess I’m the war bride. While in medical school I met and fell in love with an American. Soon after I graduated from medical school I came to the States. Aside from my time in medical school in England, my medical practice has been in the United States.

EPM: Do you still work clinically?

JB: No, as this position requires a full time focus. My last faculty position was with the Department of Emergency Medicine at George Washington University. I worked clinically there and at the VA hospital in DC.

EPM: Why should clinically-focused emergency physicians be interested in the NIH Office of Emergency Care Research?

JB: I think there are three reasons. The first is that as we know, much of what clinically focused emergency physicians – and physicians in general – do isn’t based on rigorous research, but is an amalgam of what we were taught in medical school and residency, what our colleagues share with us and what seems to work well for our patients. How often have you wanted to say to a patient, “There really are several ways to proceed and I’m not sure which path to recommend.” Well there’s only one way to figure out the best diagnostic modality or treatment choice, and that of course is with research. I want the Office of Emergency Care Research to address the kinds of decisions that are made in the prehospital setting and in emergency departments, that are of clinical relevance to our patients and about which, if we are honest, we know too little.

The second reason is that, as someone who practiced in EDs for over 15 years, I understand that our work on the front lines can sometimes be routine, and not always challenging. Another appendicitis diagnosed. Another migraine treated. Another prescription refilled. It’s to those who have been doing this a while that I would ask, “what is it that you are doing each day that you want to do better?” I think that research can help reignite the knowledge seeker in all of us, whether we work in academic or community settings.

The final reason is that there are often new ways of doing things, new drugs and therapies that once in a while come along and really change how we do things. Think for a moment about the federally- funded NEXUS study which demonstrated the safety of clinically clearing the cervical spine in appropriate patients. Or the federally-funded study which has just ended that is examining the role of protocol-driven care of the patient with sepsis. Or the federally-funded study that shows that paramedics can safely treat patients in status epilepticus with IM meds rather than struggling to obtain IV access. These are all really important research findings that can benefit our patients and change the way emergency providers practice.

The office is here to encourage other research studies that can benefit our patients. The goal of clinical research, and the goal of emergency providers, is to benefit our patients.

EPM: Will the expansion of emergency department electronic information systems (EDIS) and electronic medical records (EMRs) encourage the movement of research out of academic centers and into community hospitals, where the majority of patients are seen?

JB: One of the interesting moves across NIH is the interest in what me might call “pragmatic clinical trials” –that is, clinical trials that ask a simple question and which can query networks or existing data to answer the question. Much of this is going to depend on, for instance, getting patient information into databases so that we can simply see what happens to outcomes when we tweak one part of the system. EDIS is really part and parcel of those databases. Exactly how we extract data from patient records and put them in some kind of database is a significant question, recognizing that not all EMRs are the same. While I don’t think we’re there yet, I think that there is great promise in this research.

We need to tackle the problem of sharing confidential information between different health care systems. For studies that are using several sites, one approach is to identify a principal investigator (PI) for each system to query the data within his or her own system and then report back, so that if you had three sites, you’d have three PIs querying the data within their system. Then you’d have a three-site multi-centered trial that was performed without anyone having to cross over into the other person’s protected health information.

EPM: How exactly will the Office of Emergency Care Research work? Will you set the foundation for specific questions that you want addressed? Put out an RFA1?

JB: There are a couple things that we need to make clear. The first is that the office has no funding authority – or funds for that matter. So this means that the only way for the office to work is for it to join with other institutes and centers at NIH and encourage them to support research in clinical emergency medicine. Legally I am not able to issue an RFA. I don’t have the funds for it and I don’t have the funding authority. The way that I’m working, therefore, is that I’m meeting with all of the other institutes and centers – the other funding units at NIH – and try and join with them to understand their interests in terms of emergency medicine and emergency care research, and what we can do to further that.

It’s also important to note that there are two philosophical approaches to how NIH works. One is the top-down approach, where an institute will say, “we’re really interested in funding the following areas because we think this is where the scientific questions need to be focused.” The other way is where we basically let the community decide what are the important questions to be asked. That’s sort of the RO-1 generated2, investigated-initiated approach. In the past, several of the institutes have adopted more of this top-down approach, where they published requests for proposals. But there appears to now be somewhat of a move away from that, at least at some of the institutes, towards having the community of researchers set the agenda. Researchers do that by submitting proposals to NIH which are reviewed by their peers, and then the top ones are funded.

Given those two facts – that the office doesn’t have funding and that there’s been a philosophical move away from directed research – I’m probably not going to be requesting funds put aside anytime soon.

EPM: It seems that, regardless of funding, simply your presence at the table at NIH will have a positive impact on emergency care research.

JB: Having been here seven or eight months, the reception has been overwhelmingly warm. The people are genuinely interested in seeing the office succeed and they, by-and-large, understand the need for somebody at NIH to be focused on this area of emergency care. I’ve spoken to all of the institutes that one might expect, and several have invited me back multiple times to take the discussion to the next level. It’s very, very early yet to see how all of this is going to play out, but I think this is a very exciting time for emergency care research, and I think the future is very bright.

EPM: Which are the top three institutes or centers that are the most interested in collaborating on emergency care research?

JB: I think that historically, if you look at the numbers, the National Hearth Lung and Blood Institute (NHLBI) is a big supporter of what emergency care providers do. They’ve put millions and millions into studies on resuscitation outcomes. The second one is NINDS, the National Institute of Neurological Disease. They have put many millions of dollars into emergency neurology. NETT, the Neurological Emergency Trials network, is viewed as a very, very successful network around NIH. It’s seen as a model of how to run a good research network. Then there’s the National Institutes on Alcohol Abuse and Alcoholism (NIAAA) and Mental Health (NIMH), which have put more moderate funds in emergency care research, but have nevertheless reached out because they understand that many of the patients that they serve are found in emergency departments.

Those are the four major institutes that have been receptive to what I’m trying to do at the NIH. But other institutes have been most receptive too. For example, I have had very good meetings with colleagues from the National Institute of Biomedical Imaging and Engineering – NIBIB. This is important for future work between the research community and NIBIB, and timely too, since in 2015 the Society for Academic Emergency Medicine will host a consensus conference looking at diagnostic imaging utilization in the emergency department.

EPM: Is anyone interested in cost? I’m sure you, like us, are tired of hearing how emergency care is so expensive, even though we’re 2-3% of the US healthcare expenditure. We have a lot of trouble getting people to understand the cost and benefits of emergency care relative to overall health care expenditures. Is anyone interested in that research?

JB: I share your frustration. We all saw the front page of The New York Times referring to a recent study out of Oregon that showed that emergency visits are increasing with the new health law. I’m very aware of that, but I see the entire Oregon experiment as a blessing. I don’t know where else people expect patients who are generally poor, underprivileged or underserved to go for their emergent needs or their chronic care needs other than the ED. Of course these patients are going to go to the ED! The next thing we have to do is build the system that enables them to get the kind of care that will impact them beyond that visit.

In terms of cost, everyone is becoming more aware of how challenging the American healthcare system is in terms of correlating the care we provide with the amount of money that we’re spending. Within NIH itself there is a Health Services Organization and Delivery Study Section. It’s one of the review groups in the Center for Scientific Review, and this shows that the NIH does have an interest in looking at healthcare outcomes in terms of health systems and in terms of costs. Of course, traditionally this is an area that has been more supported by, for instance, AHRQ3 and CMS4, but NIH definitely has an interest in studying areas of cost and quality. That is something about which I continue to educate my colleagues here at NIH.

EPM: Will you be working with the Emergency Medicine Foundation (EMF) in terms of helping further research?

JB: I have had some very good early
conversations with colleagues from ACEP, SAEM and EMF. I have had a number
of calls with colleagues from EMF in trying to strategize and think about how to promote the cause of emergency care research. These collaborations are definitely of great interest.

EPM: How do you keep up to date with the issues that are most pressing to practicing emergency physicians?

JB: I use the same kind of data sources that other EPs might use. I use the journals, I’m a reader of Emergency Physicians Monthly, and I read The New York Times. The Kasier Family Foundation provides me with several email updates each day, and so keeping my ear to the ground is not particularly challenging. For my first six months at NIH I basically listened to everything that was going on. Now I’m embarking on a series of trips to emergency departments across the country with the intent of finding out what practicing physicians want to see out of this office.

We now have a seat at the research table, and that is a big step towards more participation in the research pie.

 

Glossary

1. RFA
Request for Application

2. RO-1
This is a type of research grant program available through the NIH. It provides 3-5 years of support for a discrete project, which can be investigator-initiated, or a project proposed in response to a program announcement or a request for application (RFA). The application is made by the sponsoring institution, and the grant is given to the sponsoring organization. The Principal Investigator (PI) writes the grant application and is responsible for conducting the research. There are several hundred types of grants available through the NIH, but the RO-1 is the most commonly used grant program.

3. AHRQ
the Agency for Healthcare Research and Quality , an agency within the US Department of Health and Human Services. The agency’s goal is to improve qualify, safety, efficiency, and effectiveness of health care.

4. CMS
Centers for Medicare and Medicaid Services. Funds healthcare services for Medicare, Medicaid, the Children’s Health Insurance Program and the Affordable Care Act.

 

Dr. Judith Tintinalli is the editor-in-chief of Emergency Physicians Monthly

 

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