Department of Medicine Annual Progress Report 2011/2012 research education patient care
The commitment to exceptional patient care begins with revolutionary discovery. University Hospitals Case Medical Center is the primary affiliate of Case Western Reserve University School of Medicine, a national leader in medical research and education and consistently ranked among the top research medical schools in the country by U.S.News & World Report. Through their faculty appointments at Case Western Reserve University School of Medicine, physicians at UH Case Medical Center are advancing medical care through innovative research and discovery that bring the latest treatment options to patients. Table of Contents 1 Chairman s Message 3 Departmental Administration 4 Cardiovascular Medicine 5 Clinical and Molecular Endocrinology 6 Clinical Pharmacology 7 Gastroenterology and Liver Disease 8 General Internal Medicine and Geriatrics 9 Hematology and Oncology 10 Infectious Diseases and HIV 11 Nephrology and Hypertension 12 Pulmonary, Critical Care and Sleep Medicine 13 Rheumatology 14 Veterans Affairs 15 Educational Programs 16 Research 17 University Hospitals Harrington Discovery Institute 18 Faculty and Budget Trends 19 Research Funding 20 Education and Clinical Service 21 Significant Accomplishments 2011/2012 medicine.case.edu
Chairman s Message Welcome to the Annual Report of the Department of Medicine for the academic year 2011 2012. It was another banner year for our faculty, staff and trainees as a result of our ongoing pursuit of excellence in each of our missions. In February 2012, the $250 million Harrington Project for Discovery & Development was launched under the direction of Jonathan Stamler, MD. This unique initiative, catalyzed by a $50 million gift to University Hospitals Case Medical Center by the Harrington family, is designed to enhance the ability of physician-scientists to identify aspects of their research that have the potential to develop new drugs and accelerate these discoveries toward commercialization. In the basic science arena, last academic year saw major new research programs including an NCI SPORE focused on GI malignancy to Sandy Markowitz, MD, PhD, an NIH program project on Barrett s esophagus to Amitabh Chak MD, and a program project on inflammatory bowel disease to Fabio Cominelli, MD, PhD. Overall, new and competing renewal research proposals increased 35 percent. In spite of an austere research funding environment, total research expenditures remained at a constant level of $57.5 million. continued >> Richard A. Walsh, md Department Chairman << The clinical activity of our faculty remains robust. Our rankings in U.S.News & World Report remained steady or advanced in each of our eligible clinical areas.>> 1
Chairman s Message continued Finally, we were pleased that Mukesh Jain, MD, was elected Vice President of the American Society for Clinical Investigation to become President-Elect and President in succeeding years. The clinical activity of our faculty remains robust. Our rankings in U.S.News & World Report remained steady or advanced in each of our eligible clinical areas. Thirty departmental faculty members were recognized as Top Doctors by U.S.News & World Report, including 12 named as among the top one percent in the nation. In addition, 54 of our fulltime faculty were listed as Best Doctors in their respective specialty by Cleveland Magazine. Our inpatient and ambulatory clinical programs continue to grow while we focus on our tradition of providing the highest quality of care to our patients. The overall volume of patient care activities grew 5 percent, while our emphasis on cost-effective patient management again contributed significantly to the financial health of the hospital system and faculty practice plan. The excellence of our educational programs remains a strong focus of our faculty despite the challenges imposed by enhanced regulatory restraints in both clinical and teaching arenas. Our faculty provide approximately one-third of the teaching activity across the four years of medical student training at Case Western Reserve University School of Medicine. This year we experienced a 15 percent increase in applications for our housestaff training program and had one of the best intern matches in our history and by any national measure. I invite you to learn more about our department by perusing this report and by visiting our website: medicine.case.edu. You will see why it is such an honor and pleasure to lead our outstanding faculty, staff and trainees. Sincerely, Richard A. Walsh, MD Chairman and Physician-in-Chief << The excellence of our educational programs remains a strong focus of our faculty despite the challenges imposed by enhanced regulatory restraints in both clinical and teaching arenas.>> 2
Departmental Administration The principal goals of administration are first and foremost to facilitate the success of the full-time faculty, and to use decades of collective experience in the mentoring of colleagues and the enhancement of managerial effectiveness. The past academic year included several notable achievements for department and divisional administration. The administrative group successfully supported the financial stewardship of our $200 million enterprise that included not only a number of traditional responsibilities such as grants management and clinical business planning, but also important roles in staff mentorship, faculty recruitment, media/marketing support and hospital operations. During academic year 2011 2012, Department of Medicine administration was again validated by national benchmarking and external consultants as being cost-efficient and low in number relative to the size of our faculty, program complexity, and the span of management control over support staff. Select management metrics for administration from academic year 2011 2012 include: n Business planning and recruitment support of 30 new full-time faculty n $80 million of clinical/patient service revenue flow n $58 million of total research expenditures n $20 million of special purpose and endowment income n $15 million of operating and service agreement income In addition to financial resource management, the direct involvement in federally mandated programs that affect all faculty from the National Institutes of Health (NIH) and the Centers for Medicare and Medicaid Services (CMS), such as e-prescription and the Physician Quality Reporting System, required constant attention by the administrative group. Coupled with these national program mandates are significant local level changes including the implementation of a new professional fee billing platform, scheduling system and ambulatory electronic medical record. Implementation approaches developed by our institutions and the faculty practice plan for these initiatives rely heavily upon the experience of Department of Medicine administration. As health care reform and conditions in the general economy continue to pose challenges for the department s administration team in the areas of program management, cost containment and operational redesign, I congratulate this dedicated group of individuals who routinely perform above expected levels. Frederick Creighton, mha, facmpe, fache Director, Administration << Administration was again validated by national benchmarking and external consultants as being cost-efficient and low in number relative to the size of our faculty, program complexity, and the span of management control over support staff.>> 3
Cardiovascular Medicine Our clinical activities are based at University Hospitals Case Medical Center and extend to the UH Harrington Heart & Vascular Institute programs at 22 sites throughout northeast Ohio. Our faculty are nationally and internationally recognized authorities in cardiovascular conditions including atrial fibrillation, interventional cardiology and heart failure. University Hospitals has a unique reputation for personalized, yet sophisticated, cardiovascular care. All patients are offered the latest in minimally invasive device, ablative and surgical therapies. Division faculty spearhead Centers of Excellence for robotic AF ablation, optical coherence tomography, and 3-D echocardiography. The UH Case Medical Center holds Joint Commission Certification for Inpatient and Outpatient Heart Failure and Ventricular Assist Devices, a status achieved by less than one percent of U.S. hospitals. Our clinical programs are closely aligned with the Louis Stokes Cleveland Veterans Affairs Medical Center. UH Case Medical Center was ranked 29th by U.S.News & World Report for Cardiology & Heart Surgery in 2012. All faculty and fellows are engaged in research. The Cardiovascular Research Institute at Case Western Reserve University occupies over 13,000 square feet of laboratory space and is home to over 70 faculty and post-doctoral fellows. It was selected as a clinical trial site for both Transcatheter Aortic Valve Replacement (TAVR) and renal denervation for treatment of hypertension. Within the Center for Research & Innovation, we have cutting-edge translational and clinical research activities with particular strengths in stem cell and regenerative medicine, cardiovascular imaging, electrophysiology and interventional cardiology drug and device trials. Daniel Simon, md Cardiovascular Medicine Division Chief Our faculty received the Defense Advanced Research Projects Agency award for the development of drugs to promote performance of fighting soldiers at altitude. We have garnered over 15 R01 grants from the National Institutes of Health and 11 career development awards. Our total committed grant support from the NIH now exceeds $30 million. We are particularly proud of our junior faculty clinician-scientists and scientists. In addition, the acquisition of a T32 grant is a first for the Cardiovascular Medicine Division at Case Western Reserve University and provides support for trainees in cardiovascular research at Case Western Reserve University, Cleveland Clinic Foundation, and MetroHealth Medical Center. Finally, a Rodent Integrated Cardiovascular Physiology Laboratory was established in the CVRI and supports numerous investigators within Case Western Reserve University. Our strong trainee education programs are comprehensive and highly sought after with many graduates having gone on to successful academic careers. We have fellowship training programs in cardiovascular disease (14 fellows), electrophysiology (four fellows), interventional cardiology (four fellows), heart failure (one fellow), and cardiovascular imaging (one fellow). The UH Harrington Heart & Vascular Institute is committed to physician and community educational activities, including our annual Cardiovascular and Vascular Update CME programs and patient-oriented symposia for heart failure and atrial fibrillation. << We have garnered over 15 R01 grants from the National Institutes of Health and 11 career development awards. Our total committed grant support from the NIH now exceeds $30 million.>> 4
Clinical and Molecular Endocrinology The primary goals of the Division of Endocrinology are aligned with those of the Department of Medicine and the institution: to achieve excellence in patient care, research and education. The Division of Endocrinology at Case Western Reserve University has a long history of academic achievements, national recognition and productivity in several disciplines within the specialty. These include clinical and research excellence and expertise in diabetes mellitus, thyroid cancer and other thyroid illnesses as well as diseases of the pituitary and adrenal glands. The division has assumed a leading role in several recent, NIH-sponsored national clinical trials addressing diabetes management and its complications. The leading role of the division has culminated in several important publications by our faculty in prestigious journals. The outcome of these studies has made a major impact on the future management of the disease. Historically, the division had made a similar impact in earlier studies conducted in the 1970s and 1980s that addressed the management of diabetes mellitus. One of these studies, the Diabetes Control and Complications Trial (DCCT) was conducted in the 1980s and demonstrated that tight control of blood glucose levels in patients with type 1 diabetes mellitus leads to lower long-term diabetic complications. Since then, the conclusions of the DCCT study provided the basic guidelines for managing patients with type 1 diabetes mellitus. Other areas of major academic research interest include diseases of the pituitary and adrenals where the division has made important contributions leading to better understanding of these illnesses. The division prides itself for having a highly dedicated group of physicians, scientists, researchers, nurses and nurse practitioners all working together to achieve our goals and educate the new generation of endocrinologists. Our educational and training programs emphasize the importance of independent learning, inquiry, debate and critical appraisal of literature. Trainees are given ample opportunities to be involved in clinical, translational or bench research. Our trainees have had successful careers in academic institutions as well as in clinical practice. All of our faculty members are engaged in teaching and various and diverse research activities. The division has been recognized nationally and internationally for many years for its academic contributions and has been on the U.S.News & World Report list of Best Hospitals for several consecutive years. Baha Arafah, md Clinical and Molecular Endocrinology Division Chief << The division prides itself for having a highly dedicated group of physicians, scientists, researchers, nurses and nurse practitioners all working together to achieve our goals and educate the new generation of endocrinologists.>> 5
Clinical Pharmacology Our long-term research goal is to develop a strategy to decrease the excess myocardial injury in elderly patients following an acute myocardial infarction. We have developed an approach to study this problem in the elderly Fischer 344 rat model. The isolated, buffer perfused elderly heart sustains greater injury after ischemia and reperfusion compared to the adult heart. At baseline, aging-defects in the mitochondrial electron transport chain occur in only one population of heart mitochondrial (interfibrillar) in elderly Fischer 344 rats. Following ischemia there is further damage to the interfibrillar mitochondria. We have demonstrated that aging-related defects in mitochondrial oxidative metabolism present at baseline in the elderly heart predispose to the subsequent increase in injury during ischemia compared to the adult heart, and that the decrease in the energy charge and an excess of oxidative damage accounts for an increase in injury observed in the aging heart. We have devised a therapy that corrects the mitochondrial defect in the aged heart. The hearts from these treated rats only sustain ischemic injury similar to the young, adult rats. The mechanism of this effect is proposed to involve acetylation of a key mitochondrial ribosomal protein resulting in increased mitochondrial protein synthesis. We offer a series of clinical diagnostic tests for the evaluations of mitochondrial diseases and for disorders of fatty acid oxidation. A unique procedure is the isolation of intact mitochondria from skeletal muscle in patients suspected of having a mitochondrial disease. We study oxidation phosphorylation and metabolite pathways followed by detail enzymatic studies of the components of the electron transport chain. Charles Hoppel, md clinical pharmacology Division Chief << People come from all over the world to spend time with us learning, from an educational standpoint, our many unique applications.>> 6
Gastroenterology and Liver Disease Welcome to the Division of Gastroenterology and Liver Disease. With over 40 members, our nationally ranked group of gastroenterologists, hepatologists, PhDs, and nurse practitioners together create the medical anchor of the UH Digestive Health Institute. During the past year, significant growth and accomplishments were realized in all three facets of our tripartite mission To Heal. To Teach. To Discover. Our clinical programs continue their successes which produced the highest ranked U.S.News & World Report adult subspecialty within the health system (nationally ranked 14th). This past year, the American Society for Gastrointestinal Endoscopy (ASGE) reaffirmed our UH Case Medical Center Endoscopy Unit as a site that continues to provide the highest quality care in endoscopy, an achievement that when originally attained, was the first designation of its kind awarded to a hospital unit. July 2011 marked the opening of our Dworken Inpatient Unit at UH Case Medical Center, creating an exclusive and centralized service for patients with digestive disorders. This dedicated unit addresses the need for specialized and consistent care for our patients, which has been proven to increase quality of care and reduce length of stay. In addition, the unit enhances the educational experiences of our trainees. The division has also expanded its access in the community with new multidisciplinary sites at UH Ahuja Medical Center, UH Westlake Health Center and UH Chagrin Highlands Health Center. The division s internationally renowned investigators continue to boast a robust and rapidly growing research portfolio including basic, translational and clinical research activities with a strong focus on inflammatory bowel disease (IBD) and gastrointestinal and esophageal cancers. Over the next five years, the total awarded cost secured by our investigators exceeds $30 million including a new program project on innate immunity in IBD and a center grant on the genetics of Barrett s esophagus. We plan to build on this momentum with strategically focused recruitment of complementary investigators with the end goal of decreasing and eliminating symptoms of the aforementioned disease types. We are also very dedicated to training the next generation of academic gastroenterologists. Our highly competitive fellowship and education programs ensure the sustainability and progress of our clinical and research activities by providing 12 clinical gastroenterology, one advanced endoscopy, and three research fellowships. In addition to our fellowship program, we also support rotations for our medical students and residents on our Dworken Inpatient Unit and GI Consult service. Fabio Cominelli, md, phd Gastroenterology and Liver Disease Division Chief << The division s internationally renowned investigators continue to boast a robust and rapidly growing research portfolio including basic, translational and clinical research activities.>> 7
General Internal Medicine and Geriatrics The core mission of the division is to provide superior quality patient care, maintain high standards of education as well as pursue health services and clinical research. The division is home to a diverse group of physicians whose professional interests span across multiple areas including health services and outcomes research, hospital medicine, acute and long-term care of the elderly, primary care, chronic disease management, preventive medicine, palliative care, patient safety and quality improvement, health care disparities and medical education. As generalists, the faculty are proud to be the big picture people who have a specialized skill set in coordinating care and delivering a comprehensive treatment plan to restore health and wellness both in the hospital and ambulatory care setting. The section at University Hospitals Case Medical Center is primarily a clinical and educational enterprise with a focus on delivering high quality patient care and is home to several outstanding clinician-educators. The Louis Stokes Cleveland Veterans Affairs Medical Center boasts a core group of talented clinicianresearchers, primary care providers and inpatient clinicians who have been innovative teachers and role models for medical students and residents. Overall, 2011 2012 proved to be an excellent year for the division. Several new initiatives were started and some outstanding work was accomplished by the faculty in care delivery, education and research. Looking ahead, with the emergence of Accountable Care Organizations and issues such as value-based purchasing, patient satisfaction and physician accountability garnering more interest than ever, the Division of General Internal Medicine and Geriatrics will play a major role in tackling these key paradigm shifts. As part of this effort, the division will be looking into creative innovations in inpatient clinical care, including developing a Center of Excellence in Hospital Medicine and creating dedicated hospital medicine units. In the ambulatory setting, we will be exploring the concepts of a PCMH (Patient Centered Medical Home) both from a primary care delivery and primary care training perspective. With the division responsible for over one-third of the inpatient admissions at UH Case Medical Center and over 90 percent of the patient base at the VA, the General Medicine faculty are positioned to make a unique contribution to the changing landscape of our health care delivery system. Our faculty are proud of their contributions to medical education and patient care and look forward to the challenges ahead. Rajesh Chandra, md General Internal medicine and Geriatrics Division Chief << The division will be looking into creative innovations in inpatient clinical care including developing a Center of Excellence in Hospital Medicine and creating dedicated hospital medicine units.>> 8
Hematology and Oncology Welcome to the Division of Hematology and Oncology. With 60 members, our division is among the largest within the Department of Medicine, and has a scope of activities that span our research, patient care and educational missions. Our nationally recognized faculty have expertise and interest in benign hematologic conditions, including coagulation disorders and hemoglobinopathies, as well as hematologic and solid tumor malignancies. Our faculty include physician-scientists, PhDs conducting laboratory research, as well as clinical researchers and clinical members focused on patient care and teaching. In addition to training medical students, basic science graduate students, post-docs and medical residents, we have an ACGMEaccredited Hematology and Oncology Fellowship program. We provide care at University Hospitals Case Medical Center, the Louis Stokes Cleveland Veterans Affairs Medical Center, and through a regional network of community practices, all of which participate in clinical trials research. Twelve of our division members were recognized as Best Doctors by Cleveland Magazine in 2012. The Division of Hematology and Oncology is closely aligned with University Hospitals Seidman Cancer Center at UH Case Medical Center, a principal member of the NCI-designated Case Comprehensive Cancer Center, and our faculty play key roles in cancer center research and clinical activities. In 2012, University Hospitals Seidman Cancer Center was recognized as a top 20 cancer hospital by U.S.News & World Report. We are a research-intensive division, conducting wet-lab, dry-lab and clinical investigation. Our research efforts follow six general themes: 1) hematology and vascular biology; 2) cancer cell biology; 3) developmental therapeutics and translational research; 4) cancer genetics and genomics; 5) hematologic malignancies; and 6) patient decision-making and health services research. Division members hold an NCI U01 grant for phase I clinical investigation, and an NCI phase II contract, one of only seven programs nationally to hold both awards. In 2011, our faculty received an NCI Specialized Program of Research Excellence (SPORE) award for translational research in gastrointestinal cancers. Our faculty also oversee an NCIfunded K12 training program for clinical investigators. The overall goal of the Division of Hematology and Oncology is to advance the field through clinical and basic research, while providing innovative cutting-edge clinical care, and training the next generation of leaders in hematology and oncology. Neal Meropol, md Hematology and Oncology Division Chief << The overall goal of the Division of Hematology and Oncology is to advance the field through clinical and basic research, while providing innovative cutting-edge clinical care, and training the next generation of leaders in hematology and oncology.>> 9
Infectious Diseases and HIV Outpatient activities encompass HIV/AIDS (Special Immunology Unit), general ID (including orthopaedic infections, complex wound infections, endovascular infections and long-term antibiotic administration), transplant-associated infections, chronic hepatitis B and C, and travel medicine. The Special Immunology Unit (SIU) continues to grow and receives funding from the federally funded Ryan White program to deliver the highest quality care to our HIV-infected patients irrespective of their ability to pay. The inpatient Carpenter Service accommodates admissions of HIV-infected patients and other infectious disease problems, and admits 75 100 patients per month. This service is popular among trainees for the quality of care and educational activities. The ID Consultation Service regularly sees 150 consults per month. The division has performed at greater than the 90th percentile in terms of work relative value units, above most other ID academic programs in the country. The division is spearheading infection control efforts related to emerging and health care-associated infections. There are plans to implement an Antimicrobial Stewardship Program for the hospital system with a team of ID faculty, pharmacy and data management. These activities will also provide a venue for operational and clinical research. Major strengths of the division include basic, translational and clinical research in HIV/AIDS, tuberculosis, antimicrobial resistance, infections in the elderly, biodefense and emerging infections. Currently, the division s research funding totals over $24 million. VA faculty have garnered four Merit Review Awards and two VA Career Robert Salata, md Infectious Diseases and HIV Division Chief, Executive Vice-Chairman Development Awards. Several major program projects support our research activities, including the AIDS Clinical Trials Unit, Center for AIDS Research, Microbicides Trials Network, Oral HIV/AIDS Research Consortium, Tuberculosis Research Unit, phase 1 Clinical Trials Unit for Therapeutics of Emerging Infections, and Geriatrics Research, Education and Clinical Care Program based at the VA Medical Center. The ID-Immunology Institute (IDII) was created in December 2011 to better coordinate and conduct basic, translational, epidemiological and clinical research of the molecular biology, immunology, evolution and population dynamics of microbial pathogens and associated host responses as well as to promote the highest quality care of infectious diseases. Initial research priorities include virology, clinical research and molecular diagnostics. The division has an outstanding fellowship and education program, and currently has 11 trainees, one of whom is part of the newly established ID-Geriatrics Fellowship Training Program. The division continues to host local and regional CME programs (Northeast Ohio ID Roundtable, city wide ID conference). Our faculty consistently receive outstanding evaluations for their teaching and clinical activities. << The division has performed at greater than the 90th percentile in terms of work relative value units, above most other ID academic programs in the country.>> 10
Nephrology and Hypertension The Division of Nephrology and Hypertension has once again been recognized for its outstanding clinical care by U.S.News & World Report for Best Hospitals. Our group of experienced clinicians excels in renal replacement therapy, providing care for more than 400 hemodialysis patients throughout northeastern Ohio. Home hemodialysis (both peritoneal dialysis and home hemodialysis) is a unique University Hospitals Case Medical Center-based program empowering patients to conduct daily home based treatments. The division s longstanding relationship with the Centers for Dialysis Care (CDC) and their allied Leonard C. Rosenberg Renal Research Foundation culminated this year with a Master Clinician endowment that was awarded to Donald Hricik, MD, on behalf of the CDC and the Rosenberg Foundation. Members of the division play key roles in the kidney and pancreas transplant programs at UH Transplant Institute, including active participation in a new outreach clinic that provides services for the evaluation of potential transplant recipients in Akron, Ohio. Clinical collaboration between University Hospitals Case Medical Center and the Louis Stokes Cleveland Veterans Affairs Medical Center continues to be strong. The division has provided major leadership for key NIH-sponsored multicenter research trials including the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial, the African-American Study of Kidney Disease and Hypertension, the Chronic Renal Insufficiency Cohort and the NIH-sponsored SPRINT Trial. University Hospitals Case Medical Center is a leading participant in a multicenter consortium enrolling patients into the NIH s Clinical Trial in Organ Transplant initiative, evaluating the utility of noninvasive immune monitoring tests to facilitate individualization of immunosuppression in kidney transplant recipients. This year, Thomas Hostetter, MD, joined the Division as Associate Chief for Research (also serving as Vice-Chairman for Research in the Department of Medicine). His NIH-funded research focuses on the study of uremic toxins and factors that influence the progression of chronic kidney disease. The division has a successful training program for clinical nephrology fellows and an NIH training grant for the training of physicianscientists. We are also accredited by the American Society of Transplantation to train fellows in transplant nephrology. Our trainees benefit from both bench and translational opportunities in a multidisciplinary environment including the departments of Medicine, Pathology, Physiology and Biophysics. The ultimate goal is to prepare tomorrow s academic physicians, scientists and clinical educators to continue our legacy. Donald Hricik, md Nephrology and Hypertension Division Chief << The ultimate goal is to prepare tomorrow s academic physicians, scientists and clinical educators to continue our legacy.>> 11
Pulmonary, Critical Care and Sleep Medicine The division brings current knowledge to each patient, identifies areas where uncertainty exists, creates programs and plans to restore and preserve the quality of life of patients with critical illness, pulmonary diseases and sleep disorders. Physicians approach patients not only in terms of intervening in the disease process, but also in attending to their individuality, consistently forming well-conceived plans to address mechanisms, test therapeutic effectiveness and optimize patient management. Our centers of clinical expertise are in lung cancer, interstitial fibrosis, asthma, lung transplantation, pulmonary vascular disease, tuberculosis, cystic fibrosis, interventional bronchoscopy, sleep disorders, pulmonary rehabilitation and critical care. The MICU at University Hospitals Case Medical Center received the Beacon Award six years in a row, and is the only MICU in the nation to achieve such recognition. The cystic fibrosis center is in collaboration with our pediatric colleagues at Rainbow Babies & Children s Hospital, and is one of the largest in the country. Our lung cancer program is a leader in diagnostics and therapeutics through its multidisciplinary program at UH Seidman Cancer Center that brings together pulmonologists, medical oncologists, thoracic surgeons, radiation oncologists, chest radiologists, nuclear radiologists and pathologists. Our clinical program was ranked by U.S.News & World Report as one of the top 50 programs. In the past year, the Pulmonary research group for sleep disordered breathing at Case Western Reserve University established a Center for Sleep and Cardiovascular Health and created a health systemwide Sleep Program. These expand clinical research in sleep medicine and clinical epidemiology, with a focus on oxidative stress as a mediator linking sleep disordered breathing and cardiovascular disease. The Stimulation Therapy for Apnea Reduction trial (STAR) will evaluate an implantable electronic stimulation device called lnspire TM Upper Airway Stimulation (UAS) therapy designed to deliver mild stimulation to the main nerve of the tongue (hypoglossal nerve) on each breathing cycle during sleep. The division continues to develop the program for minimally invasive diaphragmatic pacing for respiratory failure. The Clinical Trials group continues to grow its programs, expanding out from pulmonary hypertension to COPD and asthma. To enhance our programs in undergraduate and fellowship education, we have developed new modules for the Block 4 rotation in the School of Medicine, and graduate fellowship competencies for the ACGME fellowships in Sleep Medicine, Pulmonary and Critical Care Medicine. In addition, the NIH Training Grant in Sleep Medicine Neurobiology and Epidemiology has been renewed for five years for its 16th year. Kingman Strohl, md Pulmonary, Critical Care and Sleep Medicine Interim Division Chief << Physicians approach patients not only in terms of intervening in the disease process, but also in attending to their individuality, consistently forming well-conceived plans to address mechanisms, test therapeutic effectiveness and optimize patient management. >> 12
Rheumatology The Division of Rheumatology at UH Case Medical Center and Case Western Reserve University School of Medicine is devoted to discovering new solutions for patients with osteoarthritis, rheumatoid arthritis and related rheumatic disorders. The clinical research program s cornerstones are investigations on cartilage and chondrocytes biology, autoimmunity and T-C biology, as well as animal models of arthritis and inflammation. In collaboration with the Case Western Reserve University School of Dental Medicine, the division is investigating the relationship between periodontal disease and rheumatoid arthritis. The Sjögren s Syndrome Center provides the highest standard of service for Sjögren s patients and has recently created a database for information on patients. Through its multispecialty team of physicians, including staff from ophthalmology, otolaryngology, neurology, urology, dental medicine, gynecology, gastroenterology and pathology, the center helps to eliminate multiple visits to numerous specialists. The Osteoporosis Center is where rheumatology experts can diagnose and treat osteoporosis at nearly any stage. Certified Dexa Scan technologists perform bone density scans, exposing patients to just 10 percent of the radiation used during a standard chest X-ray. The Infusion Center offers advanced care for infusions of biologic agents that decrease the swelling and inflammation of tissues. Basic research in the Division of Rheumatic Diseases focuses on those molecular mechanisms which we believe are highly relevant to immunemediated inflammation in autoimmune disorders including rheumatoid arthritis (RA), systemic lupus erythematosus (SLE) and Sjögren s syndrome. Over the past four decades, more than 55 highly qualified rheumatologists graduated from the Fellowship Program and were certified in Internal Medicine and the subspecialty of Rheumatology, and most are now involved in academic practice or clinical research across the country. The division s post-doctoral fellowship program, through Case Western Reserve University School of Medicine, is nationally recognized and fully accredited by the Accreditation Council for Graduate Medical Education. Fellows are trained as investigative diagnosticians, cuttingedge researchers and compassionate clinicians. Ali Askari, md Rheumatology Division Chief << Fellows are trained as investigative diagnosticians, cutting-edge researchers and compassionate clinicians.>> 13
Veterans Affairs Our core missions are to provide high-quality patient-centered care to the more than 100,000 veterans in northeast Ohio, educate the next generation of health care providers, and generate new knowledge through research programs. All the major disciplines of Internal Medicine are represented at the Louis Stokes Cleveland Veterans Affairs Medical Center (LSCVAMC). The General Internal Medicine section encompasses primary care services both at the Wade Park main campus, Parma, and at 13 LSCVAMC-affiliated community-based outpatient clinics, as well as inpatient hospital medicine (Hospitalist Service), specialized women s health clinics, and preoperative consultation. Our primary care clinics have been on the front line of implementing an innovative model of primary care, the patient-aligned care team (PACT). The Cardiology Section of the LSCVAMC is a major referral center within the state of Ohio for interventional cardiology, arrhythmias and electrophysiology, congestive heart failure, cardiac catheterization, cardiac imaging and echocardiography. Pulmonary, Critical Care and Sleep Medicine are dedicated to the care of patients with complex lung ailments. New approaches are being started in the genomics of respiratory rhythms and experimental lung injury as well as the electrophysiology of breathing and sleeping. Physicians in Gastroenterology treat conditions of the esophagus, stomach, small and large intestine, liver, gallbladder, pancreas and colon. Nationally funded research programs in colorectal cancer, Barrett s esophagus and hepatitis C are underway. The Endocrinology section offers care in the areas of diabetes and other endocrine diseases and a broad range of hormonal disorders. The Diabetes Registry and the ReSPECT trial actively enroll patients in research protocols to improve the care of patients suffering from diabetes. The section of Geriatrics emphasizes continuity of care of the elderly across multiple sites of health care delivery. Most notably, Geriatrics at LSCVAMC is expanding services to a new state-of-the-art community living and rehabilitation center (the CARES Tower) and has developed a highly regarded palliative care program. Nephrology conducts programs in hemodialysis, chronic ambulatory peritoneal dialysis, continuous veno-venous hemofiltration and kidney transplantation. In addition, our research continues in genetics of diabetes, diabetic renal diseases, genetics of renal diseases, and hypertension. The Infectious Disease service provides inpatient and outpatient clinical services related to the care of patients with infections and immunodeficiency. Research activities in ID at the VA-based Center for Antimicrobial Resistance and Epidemiology (CARE) span the breadth of bacterial, viral, parasitic and mycobacterial diseases through affiliations to the Center for Global Health, Center for AIDS Research, and Tuberculosis Research Unit. Robert Bonomo, md Vice-Chairman of Veterans Affairs << Our primary care clinics have been on the front line of implementing an innovative model of primary care, the patient-aligned care team (PACT).>> 14
Educational Programs Clerkship, Residency Program and Subspecialty Fellowships University Hospitals Case Medical Center and the Louis Stokes Cleveland Veterans Affairs Medical Center serve as the major teaching venues for our training programs. Department of Medicine faculty remain active participants in medical student teaching, annually contributing nearly 12,000 hours to the third-year core clerkship, basic science curriculum and fourth year students combined. This represents approximately 30 percent of total faculty teaching time at Case Western Reserve University School of Medicine. UH Case Medical Center and the Louis Stokes Cleveland Veterans Affairs Medical Center remain the teaching hospitals of choice for students doing their medical clerkships and acting internships in Internal Medicine (IM). Our residency program is based on two themes: patient care and career development. Our residents continue to succeed in academic careers, successfully competing for the most prestigious and rigorous fellowships or preparing for life as general internists. Noted below are select accomplishments from academic year 2011 2012. n The 2012 match was the most successful in Department of Medicine history, having matched our quota of residents at the most favorable level on our match list ever. n The recent residency match included four MSTP students and 11 students from Case Western Reserve University. n Our residents showed outstanding results in the 2012 IM specialty match with the majority receiving their first choice. n The IM residency has been a leader in innovation, particularly in the area of teaching patient safety and quality. In 2011 the training program won the Ohio Hospital Association Best Practices Patient Safety Award. n The leaders of our student and resident education programs have been active at national meetings on education, with five presentations and workshops in 2011 2012. In addition to these core accomplishments, the continuing education component of the educational program remains strong. As examples, the annual Department of Medicine Research Day included poster presentations by 46 residents and attendance by over 120 house staff, fellows and faculty. Department of Medicine faculty remain a central component in the CME programs as activity leaders for eight regional and national programs. Keith Armitage, md Vice-chairman of education << Our residents continue to succeed in academic careers, successfully competing for the most prestigious and rigorous fellowships or preparing for life as general internists.>> 15
Research Research within the department has prospered over the last year. Total grant support was over $55 million for the year with 114 faculty receiving funding from multiple government and nonprofit granting agencies as well as industry. Over 50 new grants came into the Department, 20 of which were for more than $100,000 annual direct costs. Among these new awards were three large multiple investigator grants from the National Institutes of Health a SPORE in cancer research to Sandy Markowitz, MD, PhD, a network for study of Barrett s esophagus to Amitabh Chak, MD, and a program project investigating inflammatory bowel disease to Fabio Cominelli, MD, PhD. The largest research event has been the inauguration of the Harrington Project for Discovery & Development funded by a projected $250 million investment and established by a major gift from the Harrington family. The project comprises the nonprofit University Hospitals Case Medical Center Harrington Discovery Institute directed by Jonathan Stamler, MD, and a commercial component, BioMotiv, designed to promote the development of new therapies to the level of commercial viability. The University Hospitals Harrington Discovery Institute has issued a call for a first round of applications for funding of physician-scientists under the Harrington Scholar-Innovator Program. Mukesh Jain, MD, was elected Vice President of the American Society of Clinical Investigation, an office from which he will, over two years, rise to presidency. In May 2012 our Research Day attracted over 80 poster presentations authored by 140 residents, fellow graduate students, post-doctoral students and junior faculty with nine of our subspecialty divisions contributing posters. Three superb presentations by young faculty Paul Drawz, MD, Goutham Narla, MD, and Saptarsi Haldar, MD highlighted the day. Thomas Hostetter, md Vice-Chairman of research << The largest research event has been the inauguration of the Harrington Project for Discovery & Development funded by a projected $250 million investment and established by a major gift from the Harrington family.>> 16
University Hospitals Harrington Discovery Institute The Department of Medicine has placed a strong emphasis on translational research and personalized medicine for many years in order to realize its mission: To Heal. To Teach. To Discover. The Harrington Project for Discovery & Development, an initiative that supports the discovery and development of drug and therapeutic breakthroughs, is set to catalyze the research of the nation s corps of physician-scientists. Through its flagship program, the Harrington Scholar-Innovator Grants, the University Hospitals Harrington Discovery Institute the nonprofit aspect of the Harrington Project for Discovery & Development will select up to 10 scholars for its inaugural class of Harrington Scholar-Innovators in November. The UH Harrington Discovery Institute is also aligned with a new for-profit development company, BioMotiv. This powerful syndicate provides a one-of-a-kind professional training environment that addresses the common challenges of the so-called valley of death with respect to drug development. It provides financial support and mentoring that together enable physician-scientists to seamlessly move their therapeutic innovations to commercialization. The UH Harrington Discovery Institute has created a Scientific Advisory Board (SAB) comprised of pre-eminent physician-scientists from institutions around the country; all members of the SAB are National Academy members and are recognized for their innovative contributions to the field of medicine. The SAB will make the selection of the Harrington Scholar-Innovator Grant winners and will further serve as mentors and guides. The grant winners, as well as participants in other UH Harrington Discovery Institute programs focused on physician-scientists, will additionally have access to the new Innovation Support Center s suite of high-impact, vital resources. The team at BioMotiv will use the medical and pharmaceutical industry s best strategies to assist Harrington Scholar-Innovators in business planning and development of their drug and therapeutic discoveries to a stage of clinical development that will attract further financial and industry partners. BioMotiv has reviewed and evaluated the feasibility of numerous physician-initiated technologies in the last few months. The Harrington Project for Discovery & Development will allow us to attract the brightest minds and give physicianscientists the opportunity to effectively advance their drug and therapeutic research, resulting in greater access to advanced treatments in such areas as cancer, heart disease, infectious disease, inflammation and neuroscience. Inspired by physician-scientists, the Harrington Project for Discovery & Development promises to truly revolutionize drug discovery and development. Jonathan Stamler, md UH Harrington Discovery Institute Director << The Harrington Project for Discovery & Development will allow us to attract the brightest minds and give physician-scientists the opportunity to effectively advance their drug and therapeutic research.>> 17
Faculty and Budget Trends The Department of Medicine is proud of its large, diverse faculty. Recent recruitment trends have equally favored the clinical-scholar and physician-scientist. The budgetary sources that support the faculty are well-balanced between research, the clinical practice of medicine and our institutions. Overall, the Department of Medicine self-funds approximately 85 percent of its research, clinical and educational missions. FULL-TIME FACULTY TRENDS FY 11/12 152 59 31 242 Clinician-Educators FY 10/11 146 59 31 236 Physician-Scientists FY 09/10 137 63 31 231 Research-Scientists Others Total FY 11/12 85 157 242 FY 10/11 78 158 236 FY 09/10 73 158 231 Female Male Total FY 11/12 6 75 16 145 242 FY 10/11 8 60 17 151 236 FY 09/10 8 62 13 148 231 African-American Mid-East/Asian Hispanic Caucasian Total FACULTY COMPENSATION FUNDING 5% 13% 8% 7% 13% 6% 12% 10% 8% UH Case Medical Center SOM Research 43% 14% 41% 13% 39% 11% VAMC Faculty Practice Other Sources 17% 20% 20% FY 09/10 FY 10/11 FY 11/12 OPERATING BUDGET SOURCES 12% 6% 3% 38% 12% 7% 2% 37% 13% 7% 3% 35% Research Clinical Income UH Case Medical Center VAMC 16% 17% 15% SOM Other Sources 25% 25% 27% FY 09/10 FY 10/11 FY 11/12 The budgetary sources that support the faculty are well-balanced between research, the clinical practice of medicine and our institutions. 18
Research Funding The Department of Medicine s MD and PhD faculty who are oriented toward basic, translational and applied research again demonstrated a high level of productivity and quality during academic year 2011 2012. This success is measured by both quality and quantity of research applications sent to various granting agencies, as well as the success rate and amount of structured funding that is obtained from these agencies. RESEARCH APPLICATIONS TOTAL COST in Millions of Dollars FY 11/12 99.1 FY 10/11 100.1 FY 09/10 99.0 TOTAL RESEARCH EXPENDITURES (Direct Costs) in Millions of Dollars FY 11/12 26.9 2.5 1.8 13.6 44.8 NIH FY 10/11 27.5 2.7 1.8 15.5 47.5 VA FY 09/10 32.5 2.2 2.2 6.5 43.4 Other Federal Non-Federal Total AWARDED TOTAL COST BY DIVISION in Millions of Dollars CV MEDICINE CLINICAL PHARM ENDO- CRINOLOGY GI GEN MED HEM/ONC ID/HIV MEDICINE NEPHROLOGY/ HYP PULMONARY/ CC/SLEEP RHEUMA- TOLOGY CANCER CENTER GRANT FY 11/12 10.6 FY 10/11 8.5 FY 09/10 9.3 FY 11/12.45 FY 10/11.48 FY 09/10.46 FY 11/12 1.2 FY 10/11 3.9 FY 09/10 5.3 FY 11/12 3.9 FY 10/11 3.4 FY 09/10 4.1 FY 11/12.31 FY 10/11.59 FY 09/10.40 FY 11/12 6.4 FY 10/11 11.7 FY 09/10 8.5 FY 11/12 24.8 FY 10/11 23.6 FY 09/10 26.7 FY 11/12 4.9 FY 10/11 6.0 FY 09/10 1.5 FY 11/12 2.6 FY 10/11 4.0 FY 09/10 8.2 FY 11/12 0 FY 10/11.20 FY 09/10 0 FY 11/12 6.5 FY 10/11 4.9 FY 09/10 4.9 19
Education and Clinical Service The Department of Medicine s educational and clinical programs remain robust. One metric used to evaluate clinical service volume are work relative value units (wrvu). Each clinical service delivered to a patient carries a corresponding wrvu based on complexity. This metric for our clinically oriented faculty continues to trend upward. The full-time faculty of the department continue to provide the majority of medical student teaching contact hours. The house staff program enjoyed another outstanding group of residents and fellows and continues to be the premier training program. RVU TREND CY 2009 CY 2010 CY 2011 CY 2012* Cardiovascular Medicine 174,711 182,269 193,389 210,480 * Projected based on January May actual data Endocrinology 12,339 13,634 12,506 12,713 Gastroenterology 53,141 55,203 67,512 71,630 General Medicine 42,602 48,752 49,406 54,190 Geriatrics 12,617 10,670 8,022 4,198 Hem/Onc 70,418 71,824 73,799 73,915 ID/HIV Medicine 41,499 40,129 42,484 38,710 Nephrology 42,501 39,727 41,520 40,807 Pulmonary/CC/Sleep 44,117 48,381 51,109 50,297 Rheumatology 16,348 13,243 14,008 12,674 Totals 510,293 523,848 553,766 569,614 STUDENT TEACHING TIME Third Year Core Clerkship Students Basic Science Curriculum Fourth Year Students 3,060 hours* 2,400 hours 3,020 hours* * 25 percent direct contact time Total hours represents approximately 30 percent of total faculty teaching time in the School of Medicine COMPOSITION OF THE HOUSE STAFF FY 11/12 104 16 81 Categorical FY 10/11 105 14 81 FY 09/10 100 12 82 FY 08/09 99 10 82 Special Programs International Health, Med/Peds, Med/Genetics Fellows The house staff program enjoyed another outstanding group of residents and fellows and continues to be the premier training program. 20
Significant Accomplishments 2011/2012 Research n The initiation of the $250 million Harrington Project for Discovery & Development. n Awarded $11.3 million NIH Cancer SPORE grant. n Awarded $5.4 million NIH Barrett s esophagus Network. n Awarded $6.7 million NIH IBD Program Project. Clinical n Seven divisions ranked in the 2012 U.S.News & World Report rankings Cardiology, Endocrinology, Gastroenterology, Geriatrics, Nephrology, Oncology and Pulmonary. n Thirty Departmental faculty members recognized as Top Doctors by U.S.News & World Report, including 12 named as among the top one percent in the nation. n Over $1 million contributed to faculty practice plan-based expense reduction initiatives. n Year over year in hospital and ambulatory clinical service growth in all divisions. Education n The most successful match in Department of Medicine history having matched our quota of residents at the most favorable level on our match list ever. n Outstanding Internal Medicine residency match including five MSTP students and 11 students from Case Western Reserve University n Active participants in medical student teaching, annually contributing nearly 9,000 hours to the third-year core clerkship, basic science curriculum and fourth year students combined. n The Internal Medicine Residency Program received the 2011 2012 Ohio Patient Safety Institute Best Practice Award for education in patient safety and quality. medicine.case.edu 21
compassionate clinical care with innovative research and outstanding education Case Western Reserve University School of Medicine is ranked in the Best Medical Schools in America by U.S.News & World Report University Hospitals Case Medical Center is also ranked in the Best Hospitals in America by U.S.News & World Report medicine.case.edu Department of Medicine University Hospitals Case Medical Center 11100 Euclid Avenue Cleveland, Ohio 44106-5029 216.844.3293