Penn LDI Small Grants Program
2024 Projects
Annually, Penn LDI provides small grant funding for early-stage investigations that would otherwise not qualify for larger NIH or other institutional grants. In 2024, 12 Fellows have been awarded pilot grants for research projects across a range of topics involving the cost, access, quality, and equity of health care. Below are the researchers and their projects.
Assessing Organizational Capacity for a Suicidal Behavior Intervention in Emergency Department Settings for Victims and Perpetrators of Intimate Partner Violence
Principal Investigator: Millan AbiNader, PhD, MSW | School of Social Policy & Practice
As many as 6-7% of suicides occur in the context of intimate partner violence (IPV). Female emergency department patients with an IPV history report suicidal behaviors at more than six-times the rate of those without a victimization history, and IPV perpetrators account for the majority of IPV-related suicides. Importantly, there is currently no hospital-based intervention to treat suicidal behaviors and IPV as comorbidities in either victims and perpetrators of IPV. To address this gap, we will undertake a pilot project that assesses the capacity of Penn’s health care system to track and address these issues. This research will result in preliminary data to inform the development of an intervention for responding to IPV-SIB cases for practitioner use in hospitals and provide preliminary data for proposals for external funding.
Results:
We interviewed Penn and CHOP emergency department (ED) providers to explore current practices for suicide (SI) and intimate partner violence (IPV) interventions, provider perceptions of screening, and barriers to and facilitators of treatment across the life course. Providers reported complex workflows across hospital settings, with responses to IPV and SI heavily siloed. For both children and adults, SI protocols were robust and routinized, making providers feel confident in their ability to execute effective care. By contrast, in CHOP strong protocols for responding to IPV among parents increased provider confidence. Overall, providers who viewed their job as treating critical issues and then referring patients to outside care saw the ED as an appropriate site for IPV and SI intervention, while those that saw their role as “fixing” problems did not. Adequate training and clear protocols are critical to implementing IPV and SI crisis interventions in the ED.
Application of the New Global Definition of ARDS and Assessment of ICU Net Benefit in a Resource-Limited Setting: The South Africa Intensive Care Unit Capacity Strain (SAICU-Strain) Study
Principal Investigator: George Anesi, MD, MSCE | Perelman School of Medicine
The South Africa Intensive Care Unit Capacity Strain (SAICU-Strain) Study is a >8,000-patient two-site cohort study of critical care delivery and outcomes and capacity strain in the South African public health system and a longitudinal collaboration between Penn Medicine and the KwaZulu-Natal Department of Health. We propose two new specific aims. Specific Aim 1 will examine the epidemiology and outcomes of acute respiratory distress syndrome (ARDS) in the South African public health system deploying the 2023 New Global Definition of ARDS. Further validation of the new Global Definition of ARDS will provide growing confidence for adoption of this updated definition and allow for broader application in resource-variable settings. Specific Aim 2 proposes to measure the net benefit of ICU admission among patients referred for critical care in the South African public health system. A finding of ICU net benefit would be a powerful data-driven argument for augmenting critical care capabilities in the South African public health system.
Resulting Products:
- Operationalizing the New Global Definition of ARDS: A Retrospective Cohort Study From South Africa (CHEST Critical Care)
Identifying Meaningful Outcome Metrics in Severe Brain Injury
Principal Investigator: Catherine Auriemma, MD, MSHP | Perelman School of Medicine
Co-Investigator: Christopher Chesley, MD, MSCE | Perelman School of Medicine; David Fischer, MD | Perelman School of Medicine
Neuroprognostication for patients who have experienced a brain injury, such as after cardiac arrest or trauma, is critical. Predictions of an “unfavorable” recovery frequently result in withdrawal of life-sustaining treatment (LST), and therefore death. Most studies equate any degree of functional dependence as “unfavorable”, despite data that many functionally dependent survivors of coma report favorable quality of life, and that acceptability of dependence may differ across racial groups. The potential consequences of this oversimplified, and perhaps biased, interpretation of acceptable outcomes are profound, as they may result in inappropriate continuation or withdrawal of LST and thus avoidable morbidity and mortality. In this project, we will use surveys and semi-structured interviews to investigate the attitudes and preferences of patients and their families around acceptable outcomes after brain injury. We will further explore how these preferences may vary with respect to patient race. These results will inform future prognostication research, clinical practice, and health policy.
Access to Elective Surgery in the United States: Evidence from the Outpatient Surgery Market
Principal Investigator: Angela Chen, MA | Perelman School of Medicine | The Wharton School
Co-Investigator: Guy David, PhD | The Wharton School | Perelman School of Medicine
Elective surgeries comprise a majority of all surgeries in the United States at substantial cost to the health care system. These surgeries are shifting from inpatient to outpatient settings due to factors such as advancements in surgical techniques, technology, and processes accelerated by the COVID-19 pandemic. The impact of this shift on patient access to care is unclear. This project aims to investigate the underlying mechanisms—such as cost, geographic proximity, and convenience—that affect patient access to elective surgery by leveraging two Centers for Medicare and Medicaid Services (CMS) policies.
Result:
Rising health care expenditures have motivated policies aimed at moving surgeries from inpatient to lower-cost outpatient settings. This project examines hospital responses to these changes, using the 2018 removal of total knee replacement (TKR) from Medicare’s Inpatient-Only (IPO) list as a natural experiment. Leveraging Medicare claims data (2016–2019), I identify two hospital responses: procedure substitution and patient selection. Hospitals reduced TKR volumes by 3.2% while increasing total hip replacements (THR) by 3.8%, favoring more financially stable procedures. Additionally, hospitals treated healthier, lower-cost patients while reducing care for dual-eligible and Black beneficiaries. While removing TKR from the IPO list increased outpatient adoption and lowered expenditures, these hospital responses raise concerns about equity and access. The findings suggest that cost-cutting measures in elective care markets may unintentionally incentivize behaviors that disproportionately affect vulnerable populations.
Between Value and Recovery in Surgical Critical Care: Charting New Directions for Health System Success
Principal Investigator: Justin Clapp, PhD, MPH | Perelman School of Medicine | School of Arts and Sciences
Co-Investigators: Meghan Lane-Fall, MD, MSHP | Perelman School of Medicine; Ross Perfetti, MSc | School of Arts & Sciences
Calibrating ICU practices to measures of value should, in theory, help critical care achieve patients’ desired outcomes. However, several puzzles remain about what outcomes should be measured and when they should be assessed. The purpose of this project is to evaluate gaps between what patients want for their own recoveries from critical illness and what current value metrics assess, as defined by clinical and operational stakeholders. Patients who survive serious illness and injury are often afflicted by long-term complications of critical care interventions. We use ethnographic methodology to understand how patients and their families experience these impacts of critical illness and define recovery in their own terms. Then, we compare those data to outcome measures, describing differences between what patients desire for their long-term health and what is currently measured. Results from this pilot study will establish new directions for critical illness outcomes research and value-based incentives.
Result:
In critical care medicine, complications of escalating treatments can make achieving long-term mental and physical health difficult for patients. Meanwhile, health care financial policy is increasingly influenced by concepts of ‘value,’ which usually refers to better health outcomes per dollar spent. Calibrating clinical operations to current measures of value should, in theory, help critical care practices achieve patients’ desired outcomes. However, several puzzles remain about what outcomes should be measured, and how. In this project, we used ethnographic approaches to characterize a range of experiences among surgical critical care patients in the months following hospital discharge. In doing so, we identified several important gaps that remain between what patients want for their own recoveries from critical illness and what current value metrics assess, as defined by clinical and operational stakeholders. Results from this project help chart ways forward toward bridging institutional aims with the goals of patient-centered care.
Abortion Access for Active Duty Service Women
Principal Investigator: Caitlin Clason, PhD, MBE | Perelman School of Medicine
Co-Investigators: Marilyn Schapira, MD, MPH | Perelman School of Medicine; Julie Sochalski, PhD, RN | Penn Nursing; Laura Manzo, MAJ, RN
Following Dobbs v. Jackson, nearly 80,000 service women are assigned to states with abortion bans, leaving 40% of active duty women with no or severely restricted access to abortion care. These women are subject to the Hyde Amendment which only pays and permits the use of military medical facilities for abortion in cases of rape, incest, or if the mother’s life is in danger. In October 2022, the Department of Defense passed an unprecedented policy to assist women seeking abortion care. This policy provides mandatory time-off and compensation for travel costs for any elective abortion. The purpose of this study is to assess the barriers and facilitators service women currently experience while trying to obtain abortion care. The findings will inform policy makers as they continue trying to ensure access to safe and timely abortion care for service women.
Resulting Products:
- Abortion Access for US Active Duty Servicewomen – Presentation of preliminary results at the NCSP conference mid-November
- Military Service Members and Abortion Access | C-SPAN.org
Developing a Protocol for Postpartum Hypertension Screening in Ambulatory Infant Care Settings
Principal Investigator: Emily Gregory, MD, MHS | Perelman School of Medicine
Co-Investigators: Mario DeMarco, MD, MPH | Perelman School of Medicine; Adi Hirshberg, MD; Rebecca Clark, PhD, RN | Penn Nursing
Blood pressure changes related to pregnancy are a leading cause of maternal morbidity and mortality. These changes can emerge or worsen after pregnancy. Because of this, the American College of Obstetrics and Gynecologists recommends universal blood pressure evaluations at approximately 7 – 10 days postpartum. During this time frame, many postpartum individuals attend infant ambulatory visits. While there has been increased interest in delivering maternal health services through infant visits, existing models do not incorporate blood pressure screening. Barriers include perceived safety and feasibility, which may be addressed by clear protocols and referral pathways. We will (1) develop a protocol for postpartum blood pressure screening in ambulatory infant care settings, drawing on expert input from across the city of Philadelphia, and including interprofessional perspectives from obstetrics, pediatrics, adult care, and (2) test the protocol for feasibility and acceptability.
The Influence of Nursing Resources on Mortality Among Hospitalized Racial and Ethnic Minorities Diagnosed with Chronic Kidney Disease
Principal Investigator: Christin Iroegbu, PhD, RN | Penn Nursing
Co-Investigator: Margo Brooks-Carthon, PhD, APRN | Penn Nursing and School of Arts & Sciences
Chronic Kidney Disease (CKD) is a global public health problem, marked by notable disparities among racial and ethnic minorities. Hispanic and Black patients have a higher likelihood of CKD diagnosis, increased rates of hospitalizations, and suboptimal outcomes during and after hospitalization. These disparities may stem, in part, from differences in hospital quality where they receive care. One important aspect of hospital quality is care received by registered nurses. Existing literature links nurse staffing levels and the hospital work environment to patient mortality outcomes, particularly for racial and ethnic minorities. This study leverages unique survey data from over 16,000 hospital nurses, to identify if this relationship also exists among minority CKD patients. Given the prevalence, high mortality, and significant disparities associated with CKD, understanding how nursing influences outcomes in this population will support efforts to ensure equitable allocation of health care resources and proposed nurse staffing legislation across the United States.
Results:
A study investigating the impact of nursing resources on 30-day mortality in patients hospitalized with acute kidney injury (AKI) revealed significant associations. Analyzing data from 28,456 Medicare beneficiaries across 191 hospitals in New York and Illinois in 2021, researchers found a 30-day mortality rate of 10.7%. The study demonstrated that improved nurse staffing and higher education levels among nurses correlated with better patient outcomes. Specifically, each additional patient per registered nurse increased the odds of 30-day mortality by 7%, while a 10% increase in the proportion of nurses with a bachelor’s degree or higher reduced mortality odds by 10%. These findings highlight the crucial role of nursing resources in AKI management and suggest that hospitals should invest in both nurse staffing and education to improve patient care. The research underscores the potential for targeted improvements in nursing resources to significantly impact mortality rates among AKI patients.
Quality in Vertical Markets: FDA Oversight of Generic Drugs
Principal Investigator: Catherine Ishitani | The Wharton School
Generic pharmaceuticals have brought transformative medicines to millions in the U.S. and globally. Each month, 50% of American adults consume one or more generics, which are typically priced 80-85% lower than branded drugs. The benefits of generics, however, are threatened by the increasing unreliability of their supply. 2023 reported near record drug shortages, including of fourteen critical chemotherapies, proximally caused by low manufacturing quality. Optimal generic regulation trades-off between improving drug quality and reducing patient access to drugs. This project will provide one of the first empirical assessments of generic quality and access, and their effects on patient adherence and health. Is generic reliability too low, and what policies might improve it? Using variation in FDA enforcement timing and novel quality data, I will quantify the effects of different policy mechanisms on generic quality, access, and patient adherence, and simulate patient welfare under counterfactual policies.
Results:
Patients are uniquely uninformed about generic drug quality, which is conventionally assumed to be interchangeable. Instead, patients implicitly rely on intermediaries like wholesalers and pharmacies to select high-quality drugs for them. Using novel data—the universe of FDA manufacturing quality disclosures from 2000-2022—I provide evidence that these quality failures are pervasive in the U.S. market. Over half of manufacturers fail inspections during this period, and 12% of drugs are recalled, due to their patient health risks. The disclosure of these failures through recall announcements reduces intermediary purchases of recalled drugs by 60%, with effects persisting for up to a decade. A scoring auction model of generic procurement shows that intermediaries are willing to pay a substantial premium to avoid future recall risks, which ultimately increases the share of high-quality drugs available to patients by 27%. Counterfactual quality subsidies could improve static welfare but are likely to reduce long-run manufacturer competition.
Resulting Products:
In Defense of the Middleman: Quality Failures in the Generic Pharmaceutical Market (Presentation Slides)
Engaging the Other Half of the Equation: Emergency Contraception & Male Adolescents
Principal Investigator: Erin Sieke, MD, MS | Children’s Hospital of Philadelphia
Co-Investigators: Cynthia Mollen, MD, MSCE | Perelman School of Medicine; Sarah Wood, MD, MSHP | Perelman School of Medicine; Melissa Miller, MD
The teen birth rate in the United States is higher than in other industrialized countries, and the vast majority of births in this age group are unplanned. Although most interventions targeting adolescent pregnancy have focused on females, males also have a role in pregnancy prevention. One step that male adolescents can take to prevent unintended pregnancy is to discuss emergency contraception (EC) with their partner(s). However, little is known about adolescent male knowledge, attitudes, and beliefs towards EC. For many adolescents, the emergency department (ED) is their only contact with the health care system, highlighting the possible value of the ED as a venue for EC counseling and prescription. We will use a mixed-methods study assessing male adolescent and pediatric ED provider perspectives on EC counseling and prescription in the ED to inform future interventions that engage adolescent males to reduce unintended adolescent pregnancy.
Optimizing Outcomes for Patients with Pregnancy Loss: A Hybrid Type III Implementation-Effectiveness Study
Principal Investigator: Sarita Sonalkar, MD, MPH | Perelman School of Medicine
Co-Investigators: Rachel McKean, MD, MPH
The provision of equitable, evidence-based health care to women during pregnancy is imperative. This research focuses on the quality of care provided to pregnant women experiencing previable rupture of membranes in the second trimester, a diagnosis that often requires women to make the difficult decision to terminate their pregnancy in order to prevent serious maternal morbidity. The management of this condition varies greatly depending on location of care and services available. My research will further examine the care provided at multiple hospitals across the Penn Medicine network and look for opportunity to improve care through qualitative interviews with key stakeholders. This research will help to elucidate the care being currently provided and to identify the barriers and facilitators that will be important for the implementation of an evidence-based management protocol. We will additionally evaluate clinical outcomes resulting from a revised management protocol.
Results:
The ability for women to access equitable care in pregnancy is critical in reducing rates of maternal morbidity. In this research, we utilized the Consolidated Framework for Implementation Research (CFIR) to guide semi-structured qualitative interviews with OB/GYNs across different Penn Medicine care sites to better understand the counseling and management provided to patients experiencing previable rupture of membranes. These interviews allowed us to identify factors that will aid in the implementation of a comprehensive evidence-based care delivery system. Some of the pertinent themes identified include institutional support, resource availability, socio-political factors among patients and hospital staff, and the support and desire for an evidence-based counseling protocol that would help to standardize the care that patients receive.
Scaling Up Low Barrier Wound Care Services for People Who Use Drugs
Principal Investigator: Eleanor Turi, PhD, RN | Perelman School of Medicine
Co-Investigators: Shoshana V. Aronowitz, PhD, MSHP, FNP-BC | Penn Nursing; Amanda Bettencourt, PhD,
APRN, CCRN-K, ACCNS-P | Penn Nursing; Rachel McFadden, MPH, BSN, RN, CEN
There is high demand for wound care among people who use drugs (PWUD). The demand for care has exacerbated recently due to the presence of xylazine in the street opioid supply. Community-based providers have found that wounds among PWUD can be responsive to a few weeks of consistent treatment in low barrier settings, defined as care settings with flexible hours and harm reduction approaches. Yet, the current supply of low barrier care does not meet the demand. There are increasing hospital and emergency department visits among PWUD for unmanaged wounds. The purpose of this study is to explore barriers to, facilitators of, and strategies for scaling up low barrier wound care services. We will conduct qualitative interviews and community advisory board meetings with low barrier wound care providers, administrators, and clinical recovery specialists. The findings will inform implementation strategy testing to improve access to low barrier wound care for PWUD.
Results:
Scaling up wound care for people who use drugs (PWUD) in low barrier settings may relieve burdens on the acute healthcare system, yet it is unknown what factors influence implementation and how to address barriers. The purpose of this study was to identify determinants of and implementation strategies for scaling up low barrier wound care for PWUD. This was a prospective sequential exploratory mixed methods study that included qualitative 1:1 interviews (n = 20) and community advisory board (n = 10 members) meetings with an online survey. Common barriers to scaling up low barrier wound care include stigma, social needs, local policies, unstable funding, lack of specialized wound care knowledge, and unstandardized evidence. Promising strategies include using mass media, developing resource sharing agreements, revising professional roles, and working with academic institutions. Findings outline determinants and strategies for scaling up low barrier wound care that can be tailored based on local needs.
Resulting Products:
Improving Wound Care Delivery for People Who Use Drugs (Presentation at the National Clinician Scholars Program 2024 Annual Meeting)