# Houston Veterans Affair Health Services Research and Development (HSR&D)

**[Post-Doctoral Fellowship]{.underline}**

Health services research can be defined as the study of the impact of
the organization, financing and management of health services on the
quality, cost, access to, utilization of, and outcomes of care. This
broad field of research as been growing in size, scope and influence.
Professions that participate in health services interdisciplinary
research endeavors include physicians, psychologists, economists,
sociologists, epidemiologists, statisticians, anthropologists, and
others. Broad areas of research include evaluation of health outcomes,
evaluation of the processes of care, interventions for improving process
and outcomes of care, and analysis of the structure within which health
care is provided.

## Goals and Overview of the Program

The goal of the fellowship is to create a basic health services research
foundation so the fellow can develop as an independent health services
researcher as well as a productive collaborator, and be competitive for
a research faculty position by the end of the fellowship. To attain this
goal, the Center will provide mentoring, basic didactics in health
services research, and opportunities for research experiences that are
tailored to each fellow's needs and ability. The Center is committed to
facilitating each fellow's progress, providing assistance in meeting the
fellowship goals, and preparing fellows for a successful career in
health services research.

The two principal goals of the fellowship program are: development of
and progress in the research agenda of the fellow, and increased
experience in health services research through participation in projects
being conducted by Center faculty. Development of the fellow's own
research is of primary importance; however, substantial knowledge and
skill in the designing and conduct of research can be gained through
collaboration on established projects. **These components of the
program, along with others, are discussed in more detail in the
Postdoctoral Trainee section of the Mentoring Policy brochure (see
Appendix A in the brochure, "Postdoctoral Trainee Mentoring Plan").**

#### Evaluation

The mentoring committee will meet at least monthly with the fellow to
discuss progress during the previous month and the tasks for the
upcoming month. The fellow's mentoring committee and other staff working
closely with the fellow, will meet quarterly to discuss the fellow's
progress toward meeting the fellowship goals. Any problems will be
identified and possible solutions proposed. Problems will be discussed
with the fellow at the subsequent monthly meeting. A formal letter will
be sent to the fellow summarizing each quarterly evaluation.

Individual meetings of the fellow with the Director of the Center (Dr.
Carol Ashton) and the Chief of the section of Health Services Research
at Baylor College of Medicine (Dr. Nelda Wray) will occur at six-month
intervals. The purpose is to obtain information for making any needed
changes in the individual fellow's program and to identify possible
revisions of the fellowship program. The fellow will be encouraged to
assess candidly the fellowship experience and to suggest changes that
should be made. Prior to each meeting, the Director and Chief will
contact the individual mentor to obtain the mentor's evaluation of the
fellow's performance, and that evaluation, too, will be discussed. The
evaluation includes input from other faculty (e.g., secondary mentors)
with whom the fellow has been working. The performance evaluation will
include objective criteria (e.g., presentation at national meetings,
manuscripts submitted for publication) that have been established at the
outset of the fellowship program.

## Center Resources

**The Mission of the Houston Center for Quality of Care & Utilization
Studies is to impact health and health care by conducting & translating
outstanding research and developing influential leaders in health
outcomes, quality, access, utilization & cost.**

The Houston Center for Quality of Care & Utilization Studies consists of
the Houston VA Health Services Research & Development (HSR&D) Center of
Excellence (one of 11 nationally), and the Baylor College of Medicine
Department of Medicine Section of Health Services Research. The HSR&D
Center of Excellence was established in 1990, and is led by Dr. Carol
Ashton, Director, and Dr. Michael Johnson, Associate Director. The
Section of Health Services Research was established in 1998 and is led
by Dr. Nelda Wray, Section Chief. Many of the Houston Center for Quality
of Care & Utilization Studies investigators are clinicians at the
Houston VA Medical Center, a member institute of the [Texas Medical
Center](http://www.tmc.edu/), and all investigators are [Baylor College
of Medicine](http://www.bcm.tmc.edu/) faculty members.

Over the eleven years of its existence, the Center has grown into a
research powerhouse that has an annual operating budget of \$10.5
million; 28 research team leaders - 13 from social science disciplines,
and 15 from medicine; and over 100 staff. All Center employees are
housed together in 25,000 square feet of contiguous office space in a
wonderful newly refurbished office building across from the VA hospital.

#### Fellowship Resources

### Stipend and Benefits

The fellowship term is one year, with a second year extension for
fellows making satisfactory progress. Annual salary is \$37,000;
benefits include health insurance.

[The Community of Scholars.]{.underline} In addition to VA HSR&D
Fellows, the Center houses and mentors VA Mental Illness Research
Education and Clinical Center Fellows in the Health Services Research
track (MIRECC Psychiatry and Clinical Psychology Fellows) and those
Baylor Primary Care Physician Fellows mentored by Center investigators.
Thus, Center Fellows have access to a multidisciplinary peer group that
includes both Ph.D. and M.D. trainees, providing a rich collegial
experience.

### Physical Resources

### The VA HSR&D Fellowship is housed within the Houston Center for Quality of Care & Utilization Studies. All Fellows receive individual private working space in Fellows Hall, an area of the Center designated for Fellows (including MIRECC and Baylor Primary Care Fellows). Fellows Hall allows Fellows to develop strong bonds with their peers, while providing a space that is quiet and conducive to working yet at the same time is proximal to the bustling daily activity of the Center.

### 

### All Fellows formally mentored by the Center are considered full members of the Center, and are provided with assigned working space including generous bookshelf and file storage, telephone and computer equipment, outstanding IT support, use of Center equipment and resources for research activities \[e.g., Center Library, Texas Medical Center Library, VA Library, University of Houston Library, Rice University Library, and other affiliated library access; Center computing lab equipment (high capacity black and white and color printers and copiers, slide maker, high capacity scanners, most popular academic software packages), Center statistical processing platforms (UNIX-based SAS, access to PC-based SPSS and SAS at student discounts through Baylor), limited Center secretarial support, and basic office supplies. 

### Health Services Research Conference attendance

Participation in national conferences focused on health services
research is an integral part of career development, and also provides an
opportunity to observe the breadth of research that is being undertaken
in health services. The HSR&D fellowship program funds travel to the
annual VA National Health Service Research conference for each fellow in
each year of the program. In addition, fellows are encouraged to attend
other conferences in health services research and the fellow's own
discipline; a \$700 travel allowance and \$400 registration fee
allowance is provided by the Fellowship.

##### Didactics

The major emphasis of the program is on individualized research skill
development working on projects with a mentor and research teams.
However, the Fellow is expected to attend three weekly seminars that
supplement these individualized experiences. All seminars are at the
noon hour, and everyone is encouraged to bring their lunch (drinks are
provided by the Center). The seminars are attended by the majority of
investigators and project staff as well as all Fellows, and thus are an
important communal activity.

-   [Foundations in Health Services Research Seminars: *What Is
    It?*]{.underline}

These seminars are intended to provide a broad overview of the topics
that serve as a foundation for health services research. Such topics
include a basic understanding of the current health care system in the
U.S., an understanding of the VA health care system, access to care,
quality of care, health care outcomes, health care cost, and funding for
health services research. While not intended to provide in-depth
instruction in these topics, these seminars will provide an introduction
to the ideas and concepts that form the core of health services
research, and provide direction for obtaining more in-depth instruction.
The Seminar Series is every Tuesday from September through January
(except the third Tuesday of the month), 12:00 - 1:00. Attendance is
mandatory for postdoctoral fellows mentored by HCQCUS who are new to the
Center (i.e., those who started fellowships since the end of last
year\'s series).

-   [Professional Development Seminars: *How Do I Do It?*]{.underline}

The HCQCUS Professional Development Seminars are presented to educate
staff on a multitude of topics related to the research process and the
administration of research. Past topics have included: Preparing for
Promotion and Tenure (presented by the Baylor Chief of Medicine); How to
conduct performance evaluations for employees (presented by a Management
Consultant); Methodological issues in survey development; Presntation
skills (presented by a Communications Consultant); Reference Manager;
Hierarchical modeling; Longitudinal data analysis; Missing data
techniques; Qualitative research methods; Health economics methods;
Stress Management; Project and staff management; Improving writing
skills (presented by a Medical Editor). Seminars are on alternate
Wednesdays from QOWW from noon to 1:00 p.m. In addition to fellows, all
investigators are expected to attend whenever possible, and all staff
are invited.

-   [QOWW Seminars: *Now That I've Done It, What Do You Think Of
    It?*]{.underline}

> The QOWW Seminar Series was developed to facilitate research
> presentations so that Center scientists can receive feedback about
> their work in progress. QOWW seminars are held *every other* (QO)
> *week* on *Wednesdays* (WW) from noon to 1:00 p.m. In addition to
> fellows, all investigators are expected to attend whenever possible,
> and all staff are invited.

#### Center Faculty and Research Portfolio

##### Overview

The Houston Center for Quality of Care & Utilization Studies has become
a highly regarded site for the development of both clinician and
non-clinician researchers due to its dedication to training young health
services researchers. In addition, the research being conducted at the
Center is of great diversity and high quality, providing an unparalleled
dynamic learning environment.

-   In FY01, researchers at the Center were active in over 40 funded
    research projects that were led by individual Center investigators.

-   Twelve Center faculty also hold career development awards: VA HSR&D
    Career Development Award (Hashem El-Serag MD MPH; Howard Gordon MD;
    Paul Haidet MD MPH; Rebecca Beyth MD MS; A. Lynn Snow PhD), VA
    Cooperative Studies Career Development Award (Anita Deswal, MD), VA
    Associate Investigator Award (LeChauncey Woodard MD MPH), VA Merit
    Review Entry Program Award (Michael Johnson PhD), K-08 career award
    from the National Institutes of Health (Thomas Giordano MD),
    American Geriatrics Society/Pfizer Career Award (Ursula Braun MD),
    RWJ Generalist Scholar Award, and Minority Medical Faculty
    Development Award from the Robert Wood Johnson Foundation (Tracie
    Collins MD MPH).

-   In 2001 a five-year, \$7.8 million award to conduct research on
    racial and ethnic variation in medicine, was granted to HCQCUS by
    the Agency for Healthcare Research and Quality and NIH's Office of
    Research on Minority Health. The grant, led by Dr. Carol Ashton,
    includes six research projects, each led by a different HCQCUS
    investigator, each of which will focus on medical interactions
    between patients and health care providers and address conditions
    that typically affect older adults.

-   In 2001, the VA HSR&D gave HCQCUS a three-year \$638,400 award to
    fund a Measurement Excellence Initiative. Headed by Dr.s Kimberly
    O'Malley and Nelda Wray, the Initiative is charged with providing a
    measurement knowledge resource to VA health services researchers,
    and with furthering the field of measurement.

-   In 1998, the VA awarded HCQCUS a five-year \$1,550,000 award to fund
    the Chronic Heart Failure Quality Enhancement Initiative
    Coordinating Center. Headed by Dr. Nelda Wray, the Center is charged
    to identify the gaps in science, practice, informatics, and health
    services administration that, if closed would yield the highest and
    most rapid returns in improving the process and outcomes of care for
    people with CHF; and to translate research results rapidly and
    effectively into routine clinical practice for CHF.

The size and diversity of the research staff at the Center insures that
faculty mentors appropriate for each fellow's interests are available.
Current faculty include 4 fellows (2 MD, 2 PhD), and 28 research
investigators representing disciplines including medicine (geriatrics,
GI, internal medicine, infectious disease, obstetrics, and
rheumatology), psychology (clinical, educational,
industrial-organizational, and social), psychometrics, epidemiology, and
biostatistics, as well as adjunct faculty and consultants in
anthropology, qualitative methodology, and communications; we are
currently recruiting faculty in economics and sociology.

[Faculty]{.underline}

Some faculty and their research interests are briefly listed below.
Investigators have more and broader interests that we are able to list
here. For more information on specific research interests of
individuals, please refer to the HCQCUS website
(<http://www.hsrd.houston.med.va.gov/>) and/or contact the post-doctoral
fellowship director (asnow@bcm.tmc.edu).

[Carol Ashton, MD, MPH.]{.underline} Dr. Ashton is a physician
investigator, Director of the Center, and a Professor of Medicine at
Baylor College of Medicine. Her research interest is in the use of VA
databases to assess variations in quantity and quality of care.

[Rebecca Beyth, MD, MS.]{.underline} Dr. Beyth is a physician
investigator and an Assistant Professor of Medicine, Division of
Geriatrics. Her research interest is in improving outcomes for patients
and patient-physician interactions in clinical decision-making.

[Ursula Braun, MD.]{.underline} Dr. Braun in a physician investigator
and an Assistant Professor of Medicine, Division of Geriatrics. Her
research interest is in dementia and how racial differences affect its
treatment, and the access and use of related specialized medical
services, particularly racial differences in decisions for percutaneous
endoscopic gastrostomy (PEG) tube feeding.

[Tracie Collins, MD, MPH]{.underline}. Dr Collins is a physician
investigator and an Assistant Professor of Medicine. Her research
interest is in peripheral arterial disease, and racial difference in the
treatment and mortality of PAD.

[Anita Deswal, MD.]{.underline} Dr. Deswal is a physician investigator
and an Assistant Professor of Medicine, Division of Cardiology. Her
research interest is in improving outcomes in patients suffering from
congestive heart failure.

[Nancy Jo Dunn, PhD.]{.underline} Dr. Dunn is a clinical psychologist
and a Clinical Assistant Professor of Psychiatry. Her research interest
is the outcomes of group psychosocial interventions for the combination
of PTSD and depression.

[Marvella Ford, Ph.D.]{.underline} Dr. Ford holds a Ph.D. in social work
and social psychology and is an Assistant Professor of Medicine. Her
research interest is in measurement, recruitment, and retention issues
in research and clinical trials with ethnic minority members.

[Hashem El-Serag, MD, MPH]{.underline}. Dr. El-Serag is a physician
investigator and an Assistant Professor of Medicine. His research
interests include studying gastric reflux disease and H. pylori
infections.

[Thomas Giordano, MD]{.underline}. Dr. Giordano is a physician
investigator and an Assistant Professor Medicine, Division of Infectious
Disease. His research interests is in the effect of race/ethnicity on
clinical outcomes in patients with HIV in the era of highly active
antiretroviral therapy.

[Laura Goetzl, MD. MPH.]{.underline} Dr. Goetzl is a physician
investigator and an Assistant Professor in the Department of Obstetrics
& Gynecology, Division of Maternal-Fetal Medicine (complicated
pregnancies). Her research interests include maternal and neonatal side
effects of epidural analgesia during labor, and treatments to reduce
these side-effects.

[Howard Gordon, MD.]{.underline} Dr. Gordon is a physician investigator
and an Assistant Professor of Medicine. His research interest is in
improving the understanding of racial variations in health care.

[Paul Haidet, MD, MPH.]{.underline} Dr. Haidet is a physician
investigator and is an Assistant Professor of Medicine. His research
interest is in developing innovative methods for teaching communication
skills and evidence-based medical practice.

[Michael Johnson, Ph.D.]{.underline} Dr. Johnson is a biostatistician
and an Assistant professor of Medicine. His research interest is in
pharmacoepidemiology.

[P. Adam Kelly, PhD, MBA.]{.underline} Dr. Kelly is an educational
psychologist and an Assistant Professor in the Department of Medicine.
Dr. Kelly's expertise is in the development of latent factors that
measure behavioral outcomes. He will be available to assist fellows in
measurement development.

[Mark Kunik, MD, MPH.]{.underline} Dr. Kunik is a physician investigator
and an Associate Professor of Psychiatry at Baylor College of Medicine.
His research interest is in developing best practices of assessment and
treatment of disruptive behaviors in patients with dementia. He is also
interested in psychological interventions to improve quality of life and
optimize service use in patients with chronic medical diseases.

[Robert Morgan, PhD.]{.underline} Dr. Morgan in an educational
psychologist and an Associate Professor of Medicine at Baylor College of
Medicine. His area of expertise is in evaluating service use in Medicare
databases. He will be available to assist in projects that use Medicare
databases.

[Laura Petersen, MD, MPH.]{.underline} Dr. Petersen is a physician
investigator and an Assistant Professor of Medicine at Baylor College of
Medicine. Her research interest is in the evaluation and development of
risk adjustment methodology in patients with medical and psychiatric
disorders. She will assist in the training of the use of VA databases.

[Nancy Petersen, PhD.]{.underline} Dr. Petersen is a statistician and an
Assistant Professor of Medicine at Baylor College of Medicine. She is
interested in variations of care in the VA. She will be available for
statistical consultation.

[Ken Pietz, Ph.D.]{.underline} Dr. Pietz is a statistician and an
Assistant professor of Medicine at Baylor College of Medicine. His
research interest is in methods for provider profiling.

[Kimberly O'Malley, PhD.]{.underline} Dr. O'Malley is an educational
psychologist and an Assistant Professor of Medicine at Baylor College of
Medicine. Her research expertise is in the development of latent factors
that measure behavioral outcomes.

[Julie Souchek, Ph.D.]{.underline} Dr. Souchek is a biostatistician and
an Assistant Professor of Medicine. She will be available for
statistical consultation.

[A Lynn Snow, PhD.]{.underline} Dr. Snow is a clinical psychologist and
an Assistant Professor in the Department of Medicine and the Department
of Psychiatry and Behavioral Sciences. Her research interest is in the
evaluation of pain in patients with dementia. She is also interested in
developing and evaluating assessments and treatments of psychosocial
disorders in demented individuals. Dr. Snow is the Director of the
Health Services Postdoctoral Fellowship.

[Maria Suarez-Almazor, MD, PhD.]{.underline} Dr. Suarez-Almazor is a
rheumatologist and epidemiologist, and an Associate Professor of
Medicine. Her research interests are in health services research and
clinical epidemiology in the field of musculoskeletal disorders.

[Research Portfolio]{.underline}

The Center conducts research in six broad areas. Active and recently
completed projects in each area are listed below. Although only the
Principal Investigator is noted in parentheses following each project,
all projects are the products of highly cooperative efforts from
multidisciplinary research teams. Research funding comes from primarily
from federal sources (VA, NIH, AHRQ), some foundation sources (RWJ, AHA,
Bayer) and a small amount of pharmaceutical sources.

###### Quality Assessment and Improvement; Organizational Transformation for Quality

•VA Chronic Heart Failure Quality Enhancement Research Initiative
(coordinating center) (Wray)

•Reducing readmissions in CHF (Wray)

•Provider profiling (Pietz)

•Pain assessment in severely demented people in nursing homes (Snow)

•Treatment and outcomes of diabetes, hyperlipidemia, and hypertension
(Johnson)

•Improving anti-thrombotic use in stroke prevention (Beyth)

####### Health Outcomes Assessment and Improvement

•A Controlled Trial for Arthroscopic Surgery for Osteoarthritis of the
Knee (Wray et al)

•Cognitive-behavioral intervention for depression & anxiety in people
with COPD (Kunik)

•Treatment of depression in PTSD (Dunn)

•Perioperative management of anticoagulants in patients with atrial
fibrillation (Beyth)

•Prevalence and determinants of GERD (El-Serag)

•Process of care and outcome in PAD (Collins)

•Patient-provider interaction and response to acupuncture
(Suarez-Almazor)

####### Racial and Ethnic Variations

•Health seeking and treatment selection in cardiac patients (Gordon)

•VA care and attenuation of quality inequities in acute MI care (L
Petersen)

•Factors related to cancer screening in African Americans (Ford)

•Retention of African Americans in the PLCO Trial (Ford)

•Effects of false positives on subsequent screening adherence in African
Americans (Ford)

•Treatment adherence in minorities with rheumatic diseases
(Suarez-Almazor)

•Improving informed consent in diverse populations (Ford)

•Medicare + Choice and minority elderly (Morgan)

•Racial and ethnic variations in medical interactions (program project
grant) (Ashton)

> --Congruence project (Haidet)
>
> --Trust project (O'Malley)
>
> --Lung cancer project (Gordon)
>
> --Mammography project, Rose Clinic (Paterniti & Ashton)
>
> --PAD project (Collins)
>
> --Osteoarthritis project (Suarez Almazor)
>
> --Office-based treatment of opiate addiction (Palacio)

**Health Services Utilization\
**•Medicare HMO enrollment and VA use (Morgan)

•Associations between changes in VA hospital use and survival (Ashton)

•Health care use and outcomes in Parkinson disease (N Petersen)

####### Methods

•Health-based capitation methods for VA resource allocation (L Petersen)

•Measurement Excellence Initiative (O'Malley)

•"Just-in-time" IRB approval (program evaluation) (Kelly)

•Improvement in post-secondary education (Haidet)

#### 

#### Applying for the Fellowship

To apply, please provide a curriculum vita, a statement of your research
interests and career goals, and three letters of reference.to Tamara
Lavin, Human Resources Recruiter,
[tlavin@bcm.tmc.edu](mailto:tllavin@bcm.tmc.edu), or mail to: Houston
Center for Quality of Care and Utilization Studies, VAMC (152), 2002
Holcombe Blvd., Houston TX 77030.

Following review of these materials, selected applicants will be invited
to participate in a one to two-day interview process that includes
giving a one-hour job talk on a current area of research. At such time,
an official transcript, copy of the dissertation, and a writing sample
(a publication or a manuscript in submission or preparation) will be
requested.

To request additional program information please contact Dr. A. Lynn
Snow, Assistant Director of Education, at <asnow@bcm.tmc.edu> .