While COVID-19 has brought new and daunting challenges to those working in public health, academic medicine, and medical research, it has also resulted in some silver linings. With increased opportunities to access COVID-related funding and to collaborate, more institutions are sharing data and working together for the common good.
In one such partnership, research teams from The Dartmouth Institute for Health Policy and Clinical Practice (TDI), East Carolina University’s (ECU) Brody School of Medicine, and Dartmouth-Hitchcock Health (DHH), have been collaborating on several projects in an effort to mitigate the negative impacts of the current pandemic as well as those that may occur in the future.
In the following Q & A, Eugene Nelson, DSc, MPH, a professor of The Dartmouth Institute and of community and family medicine at the Geisel School of Medicine, who is helping to lead these efforts, talks about some of the innovative work that is underway.
Q: You’ve been a pioneer in bringing modern quality improvement thinking into the mainstream of healthcare. What are you currently focused on?
Nelson: We’re doing a lot of work around what we’ve come to call co-production learning health systems. It’s a conceptual model that we’ve published several papers on and that we’ve been applying to different chronic illness populations nationally—such as patients with cystic fibrosis, inflammatory bowel disease, multiple sclerosis, and arthritis.
At the heart of these systems are patient registries, which allow us to track and compare data on treatments and outcomes at different centers across the country. Basically, coproduction is a concept that emphasizes the importance of the collaboration between clinicians and patients. And learning health systems are those that are able to continuously use best evidence to improve care for individual patients as well as to contribute to research on effective treatments for future patients.
Q: What is the origin of your collaboration with Brody School of Medicine at ECU?
Nelson: It started with a call from an old friend and colleague, Pete Schmidt, in March of 2020, about the time that everyone was shutting down from COVID-19. Pete is now the vice chancellor of Brody School of Medicine, which is affiliated with Vidant, a large health system in North Carolina.
Prior to Pete joining ECU about three years ago, he and I had partnered to develop a registry-based coproduction learning health system for the Parkinson’s Foundation, which involved working with about 30 centers of excellence in the U.S. and abroad. He told me about some COVID funding that was coming into the State of North Carolina, and we decided to propose setting up a similar model to try to improve care for COVID across our respective health systems.
The North Carolina legislature approved our proposal and awarded us about half a million dollars to begin working together. Our research teams have been meeting weekly since, identifying the greatest areas of need and opportunity.
Q: Can you tell us about your first completed project?
Nelson: The Dartmouth Institute team advised and helped ECU design, build, and launch a COVID-19 website. ECU was under a tight timeline from the State of North Carolina to publish this data but had no prior experience with building websites and displaying data to different audiences. The project leveraged our expertise analyzing and publishing data from colleagues at the Dartmouth Atlas.
The first focus was on COVID cases and COVID mortality, at the regional, county, town, and even zip code levels. More recently, the platform has added information that helps them plan where vaccination distribution efforts should be targeted, based on where people are most at risk.
Q: Another exciting project involves the development of what’s called the COVID Compass—can you describe what this is and how it is different from other COVID research efforts?
Nelson: In essence, the COVID Compass can be thought of as a central framework for navigating the pandemic, which will allow us to more effectively monitor and mitigate harms caused by COVID-19 and future pandemics.
Right now, there are a number of reputable organizations providing useful, up-to-date information on COVID-19. But most are focused on showing case, fatality, and now vaccination rates. They don’t include key trends in other important areas such as economic vitality or social hardship. And they don’t track policies, actions, and behaviors that together have an effect on lives lost and livelihoods damaged.
Our project will include these kinds of data, taken from the best available public sources. We aim to provide information to guide local decisions by tracking state and local policies over time and their effect on a balanced set of outcomes—health metrics (such as COVID-19 incidence and mortality), economic trends (such as unemployment rates), and social hardship indicators (such as food insecurity). We plan to expand the scope of these efforts to include regional, national, and international studies.
Q: In a third major project, research and clinical teams from ECU and Dartmouth and their respective state health systems, are working together to improve care for a high-risk group of COVID-19 patients—what will that entail?
Nelson: It’s a multi-pronged project that will address one of the most troubling aspects of the pandemic—COVID-19 Long Term Syndrome, otherwise known as Post-Acute COVID Syndrome (PACS) or COVID “long-haulers” disease, which epidemiologists estimate may afflict as many as 30 percent of patients previously infected with COVID-19. This is particularly acute in rural areas of the U.S. that have many barriers to quality healthcare and where people have been victimized by multiple social determinants of health.
Using a coproduction learning health system model, like I talked about earlier, our aim is to improve health outcomes, quality of care, and research for rural populations with Long COVID syndrome.
We’re working on several fronts to achieve this. Drs. Jeff Parsonnet and Paul Bolin have started clinics in our regions where patients can be matched with resources and care plans based on the emerging science of treating this condition. Prof. Brant Oliver and colleagues are starting a patient-centered registry that will link patient characteristics with treatments and outcomes over time. And Dr. Sally Kraft is establishing a Project ECHO-based clinician network for research and improvement, and potentially a patient and family network for social support and vetted information on the condition and helpful resources.
We’re fortunate to have many talented and committed people at ECU and at Dartmouth who are making important contributions to these projects and our partnership. And we’re very excited to have the opportunity to be working together to address some of the major public health challenges brought by the pandemic.
NH-based team members of the ECU/Dartmouth partnership include:
Evans Amoah, MD, MPH, a physician completing his MPH at TDI
Andrea Austin, PhD, senior researcher scientist at TDI
Jonathan Ballard, MD, clinical associate professor of psychiatry, community and family medicine, and TDI, and chief medical officer for the NH Dept. of Health. and Human Services
Henry Feng, MD, MPH, a physician in General Internal Medicine
Elliott Fisher, MD, MPH, professor of health policy, medicine, and community and family medicine at TDI and Geisel
Ashleigh King, MPH, research programmer/analyst at TDI and Dartmouth Analytic Core
Sally Kraft, MD, MPH, assistant professor of medicine at Geisel and TDI, VP of population health at D-H
Christopher Leggett, PhD, research programmer/analyst at TDI
Falguni Mehta, MS, clinical quality improvement scientist
Jose Mercado, MD, assistant professor of medicine at Geisel, associate hospital epidemiologist at D-H
Gene Nelson, DSc, MPH, a professor of community and family medicine at Geisel and TDI
Brant Oliver, MPH, PhD, associate professor of community and family medicine and psychiatry at Geisel and TDI
Jeff Parsonnet, MD, professor of medicine at Geisel, and director of the D-H Post-Acute COVID Syndrome (PACS) clinic
Sukdith Punjasthitkul, MS, infrastructure programmer/analyst, project manager at TDI and the Dartmouth Analytic Core
Stephanie Tomlin, MS, MPA, director of the Data Analytic Core at TDI