Deaths Have Soared Since 2015, and Younger Black Women Are at Special Risk
The Penn/VA Health Equity Research Center Names New Director
LDI Senior Fellow Peter Groeneveld Discusses the Dual-Job World of CHERP and Its Researchers
It’s a long-held frustration for LDI Senior Fellow Peter Groeneveld, the new Director of the Penn/VA Center for Health Equity Research and Promotion (CHERP), that the larger Philadelphia Corporal Michael J. Crescenz Veterans Affairs Medical Center is not more widely recognized as the Penn-affiliated teaching hospital it actually is.
CHERP is a 21-year-old academic research center within the VA hospital primarily focused on health care quality and disparities among veterans from vulnerable populations. The work within CHERP as well as other departments of the Crescenz VA Medical Center is funded by the VA’s Health Services Research & Development Service (HSR&D). More than 100 of the Center’s faculty members and researchers also have dual jobs as faculty members and researchers in the University of Pennsylvania. And most of the medical students who rotate through the VA Medical Center’s wards are from Penn’s Perelman School of Medicine. More than 57,000 veterans make more than 500,000 patient visits to the Crescenz VA Medical Center annually.
“Over the years I’ve noticed how the VA hospital is frequently forgotten in some Penn campus community mentions of the peer institutions,” said Groeneveld, MD, MS. “It’s true that many years ago, the VA Medical Center was not necessarily viewed as a Penn teaching institution because it wasn’t, but that changed. It is now as much a Penn teaching facility as the hospitals owned by Penn or Children’s Hospital of Philadelphia (CHOP), which, like the VA Medical Center, is an entirely independent teaching institution staffed by Penn faculty.”
“The importance of making this better known,” continued Groeneveld, “has to do with what Penn faculty members and medical students may not understand about the benefits offered within the Penn/VA program that enables them to simultaneously have two employers and two jobs, with unique research opportunities and an additional federal funding resource included.”
“The leadership at Penn Medicine recognizes this and has been great in its support,” Groeneveld noted. “The Dean, and in particular Professor Lisa Bellini, Senior Vice Dean for Academic Affairs, has been an anchor go-to person. Her work has been essential, and she has really been a bridge in bringing together the VA faculty and Penn faculty.”
Over the last 19 years, Groeneveld has been one of 100 Penn faculty members in a dual position at the VA. At Penn, he is the Founding Director of the Perelman School of Medicine’s Cardiovascular Outcomes, Quality, and Evaluative Research Center (CAVOQER) and Co-Director of the Master of Science in Health Policy (MSHP) program. At the VA’s Medical Center, he has been a VA staff physician, researcher and member of the Research and Development Committee. Four years ago, he became Chair of that committee that oversees $17.6 million in annual VA-funded health care research throughout the entire Center. Some $4 million of that occurs within the CHERP organization he now also heads.
Paychecks from Penn and VA
Like the other dual faculty, Groeneveld gets paychecks from both Penn and the VA, but they don’t add up to anything more than they would if he was only a VA or Penn employee. Like other dual VA physicians, he benefits from the close affiliation on the Penn side at the same time the program opens all the resources of the VA in terms of its intramural research program, clinical opportunities, and its national network of hospitals.
“It provides the Penn faculty members with patients and clinics and a health system that is very different from Penn but very open to new ways of doing things,” said Groeneveld, pointing to the work of Robert Burke, MD, MS, as an example.
Burke is an LDI Senior Fellow, Associate Professor of Medicine at Penn, and VA CHERP faculty member and researcher. He is studying the implementation of different care practices across the VA’s integrated service network of hospitals throughout Pennsylvania, Delaware, and New Jersey.
“You can’t do that at Penn,” said Groeneveld, “because it’s a smaller network with a limited number of hospitals. The VA provides the opportunity to study impactful care across large networks, even up to nationwide networks of care. That can be an unparalleled opportunity for a Penn faculty member.”
Founding of CHERP
CHERP was founded in 2001 as a health services research collaboration between the VA Medical Centers in Philadelphia and Pittsburgh and their respective academic partners (Penn and the University of Pittsburgh). The founding Co-Directors were Penn’s David Asch, MD, MBA, now Senior Vice Dean for Strategic Initiatives in the Perelman School of Medicine, and Pitt’s Michael Fine, MD, MSc, Professor at the Pitt School of Medicine, and still Director of that CHERP.
Since its establishment, CHERP has been closely affiliated with Penn’s Leonard Davis Institute of Health Economics (LDI). Its founding Director Asch was also the Executive Director of LDI when he first co-created the VA program. Since then, all the Philadelphia CHERP Directors who came after him — Said Ibrahim, MD, MPH, MBA, Judith Long, MD, and now Groeneveld — have been LDI Senior Fellows. In addition, 29 of CHERP’s current corps of investigators are LDI Senior or Associate Fellows, including Rachel Werner, MD, PhD, the current Executive Director of LDI, who is also a practicing VA physician and Co-Principal Investigator of the five-year, $5.2 million “Implementing the age-friendly health system in VHA: Using evidence-based practice to improve outcomes in older adults” research project there.
“The CHERP/LDI association is not a legal or formal relationship, but the close connections historically made sense,” said Groeneveld. “David Asch’s founding position as Executive Director of both created a natural bridge between the two institutions. LDI was the campus hub of health services research that brings together researchers to collaborate and innovate. CHERP was an outgrowth of the VA’s HSR&D office that commissions research. To me, it has always felt like an organically natural partnership that comes out of the fact that so many of us are both VA and Penn investigators, and these are the respective homes of health services research from both sides of the street.”
60% of Patients are Minorities
CHERP is one of the 18 Centers of Innovation (COINS) created across the country by the VA’s HSR&D. Each focuses on a specific area of health care related to the 9 million veterans treated throughout the VA’s more than 1,700 medical centers, outpatient clinics and other facilities. The Philadelphia CHERP is primarily focused on health equity and the care and outcomes for ethnic and racial minority veterans — a strategy shaped by Philadelphia’s demographics. About 25% of veterans in the general national population are from ethnic or racial minority populations. In the Philadelphia region served by the VA Crescenz Center, more than 60% of patients are from ethnic or racial populations. Groeneveld notes that if other vulnerable veteran groups, like LGBTQ, women, and severely disabled patients are included, the Philadelphia percentage of vulnerable patients rises above 70%. Nearly 9,000 of the patients are women veterans.
Samples of some of recently funded CHERP research projects include: “Racial Bias in a VA Algorithm for High-Risk Veterans,” “Health Outcomes and Healthcare Use Among Transgender Veterans,” “Examining Pre-pregnancy Health and Maternal Outcomes Among Women Veterans,” “Investigating Multi-level Determinants of Racial/Ethnic Disparities in Quality End-of-Life Care for Veterans,” and “Access, Quality and Equity of Anticoagulants in Veterans with Atrial Fibrillation.”
Beyond just research findings, CHERP is also involved in implementing interventions that address care disparities in VA facilities. The most recent project is a computer tool and dashboard that analyzes an individual facility’s electronic medical records to identify and alert clinicians to disparities in patterns of their care. Launched in 2021, the Primary Care Equity Dashboard (PCED) supports local research teams studying disparities and developing solutions to close those gaps in care.
Thinking Like an Equitable Clinician
“We know that clinicians respond when they see how they are doing in comparison to how they think they are doing,” Groeneveld explained. “It’s typical for a clinician to say, ‘I send 90% of my diabetes patients to the eye doctor every year.’ But when presented with data showing they only send 40%, they adjust and begin sending more patients to the eye doctor. That’s a very normal sort of quality improvement method. We’re now using the PCED to add an equity focus to that. Not only should clinicians be focused on improving the quality of care but also on the equity of the care they deliver — because that does not happen automatically by thinking you’re an equitable person. It actually requires an effort to do the things that make you one.”
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Son of a statistician, Peter Groeneveld grew up in Ames, Iowa, a college town much like State College, Pennsylvania. His father, shaped by his own Great Depression experiences, urged his son to select an “employable” major for his studies. And the younger Groeneveld did, ultimately graduating from Harvard College in 1991 with a Bachelor of Science degree in Computer, Electrical, and System Engineering.
“But I didn’t like engineering to the point that I wanted to make a career of it,” Groeneveld explained. “Toward the end of college, I realized I did have scientific aptitude and I liked analysis, but I also liked the interpersonal aspect of working with people and helping them solve their problems on a very direct basis. Medicine seemed more suited to that.”
Four years later, he graduated from Tufts University with his MD and went on to his residency training at the University of California, San Francisco.
The 90s and Weak Scientific Evidence
“The late 90s was a remarkable time for American health care as the HMO revolution exploded around us,” he remembered. “Lots of people were starting to focus on why U.S. medicine cost so much. As part of an academic health system, I recognized I was ordering lots of tests and engaged in lots of treatments that cost a lot of money; but many weren’t particularly supported by scientific evidence. That got me interested in the whole idea of ‘are we getting value out of all the things we’re doing?'”
And that resulted in Groeneveld’s enrollment at Stanford University, where he earned his Master of Science degree in Health Services Research.
“I really went into health services research initially interested in the economic aspect, the value proposition in health care which, of course, was one of the reasons HMOs turned out to be right. The payers for health care were getting tired of simply writing checks and not having the providers of health care have any skin in the game in terms of getting value.”
VA Career Development Award
In 2003, simultaneously recruited by both institutions, Groeneveld arrived in Philadelphia to become a faculty member at Penn and CHERP, with the latter awarding him a VA Career Development Program grant that, much like a National institute of Health (NIH) K grant, provided training and support for junior faculty researchers.
“I benefited tremendously from the resources and infrastructure the VA grant provided,” said Groeneveld. “I had five years of support to build my career. That wouldn’t have happened if CHERP had not existed.”
He noted that unlike the NIH Research Career Development K award program that doesn’t care what institution the young researcher ultimately ends up working in, the VA program wants people who do their career development and become investigators focused on VA research — at least as a substantial part of their overall portfolio.
Groeneveld acknowledged that many outsiders view the VA Health Administration from afar as a topic of political controversy that has been the subject of a variety of negative news stories and vilified in movies like “Born on the Fourth of July.”
“The VA is a very big, complicated agency funded with taxpayer dollars that gets written up in the newspapers if anything goes wrong because it’s the federal government,” he said. “The VA I know has been very focused on quality health care management, delivery, and patient satisfaction. I don’t think it gets enough credit for the many ways it has been on the cutting edge of health care delivery and innovation. Benefits studies comparing the quality of care in VA and non-VA facilities have repeatedly demonstrated that the VA outperforms the private sector in all kinds of widely accepted measures of quality management.”
Impressive COVID-19 Response
“For instance, I have been consistently impressed by the way the VA rolled out COVID-19 vaccines among veterans. We vaccinated veterans very early in the outbreak when the vaccine first became available. We really reached out to minority veterans in Philadelphia to be able to increase vaccination rates in a population that was very skeptical about the vaccine. I think anyone who looks more closely will see that the VA is just as innovative as any health care system, and in many ways, because it is a national system, can outperform any comparable national health care network.”
Asked about major challenges that lay ahead for CHERP and the VA Medical Center, Groeneveld named four: the installation of the VA’s new electronic medical records system, the rapidly accelerating focus of the VA on personalized medicine based on the power of genomics, the replacement of the obsolete physical infrastructure of the VA Medical Center, and his new management duties.
Launched in 1997 as a pioneer in its field, the Veterans Health Information Systems and Technology Architecture (VistA) is an electronic records system that unified the clinical, administrative, and financial functions of all VA health care facilities across the country. Now long in the tooth, its replacement is an inevitably disruptive process. Currently being installed in VA facilities in other states, it will soon be coming to Philadelphia.
“This will be a real game changer in terms of the volume of data collected as well as the way we all currently practice health care,” said Groeneveld. “Every clinician will have to change, and it will come with benefits and drawbacks in terms of equity because we’ve been used to doing things one way for a long period of time.”
VA as Genomics Pioneer
In a second initiative, much the same as it led the way in national health care with its revolutionary electronic records system 25 years ago, the VA is doing a similar thing in the field of personalized medical care based on genomics.
“The VA has a program called the Million Veteran Program (MVP) which is cataloging the full genome of 1 million U.S. veterans to harness the power of genomics to treatments,” Groeneveld said. “It’s like the Penn Biobank on steroids. We have data from a huge number of veterans across the country, including large numbers of ethnic and racial minority populations. It will be a game changer to be able to determine from genomic predictors who is at particular risk for early cancer or heart disease or diabetes. And we want minority veterans to have as much access to those treatments as white veterans. This is a big focus around here.”
The third challenge is the VA’s aging physical infrastructure.
“Earlier this year, the Asset and Infrastructure Review Commission outlined the national problem,” Groeneveld said. “For instance, the newest section of our hospital was dedicated in 1992 by President George H. W. Bush. Like many other facilities across the country, it will have to be replaced at some point, and how that’s done has equity implications to it. That’s a big challenge.”
In the fourth challenge — a personal one — Groeneveld pointed to his predecessors. “Asch, Ibrahim, and Long have built a tremendous asset and legacy here at CHERP,” he said. “I stand on the shoulders of those giants in this new position. I hope to build on it in as meaningful a way as the three of them did.”
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