Update March 27, 2018: New Research News post: “Dmitry Dukhovny investigates whether genome sequencing increases health care spending in adults.”
Dmitry Dukhovny, M.D., M.P.H., is an assistant professor of pediatrics and neonatologist at OHSU. His research focus is on cost-effective analysis and decision science to help optimize health care resources with a special emphasis on neonatal intensive care. He joined OHSU in October 2014.
Where are you from originally?
I was born in Kiev, Ukraine, though it was still the Soviet Union at the time my family emigrated. We moved to Santa Monica when I was 11 years old. I did my undergrad work at UC Berkeley and then went to medical school at Boston University School of Medicine and ended up staying in Boston for 14 years. I completed my residency in pediatrics in the Boston Combined Residency in Pediatrics at Boston Children’s Hospital and Boston Medical Center. Then I was a fellow in the Harvard neonatology program, a joint program between four major teaching hospitals of Harvard Medical School. I also did a pediatric health services research fellowship at Boston’s Children Hospital. I earned my MPH at that time and was an attending at Beth Israel Deaconess Medical Center and Boston Children’s Hospital for four years before coming here.
What brought you to OHSU?
A number of things. My wife [Stephanie Dukhovny, M.D.] is also a physician here. She’s originally from the West Coast as well, so we wanted to move closer to family. In addition, there were great opportunities here for both of us both clinically and academically. There’s a great group of neonatologists here to work with. Being in a large academic center gives me the opportunity to see the more acute and challenging cases and provide a high level of care. This is what I had in Boston, and I wanted to work in that same environment, so that was a big draw. From an academic standpoint, I’m particularly interested in health economics and resource utilization and how to improve value in care. The chair of OHSU’s Department of Ob/Gyn, Aaron Caughey, is also a health economist, and there’s also the Center for Health Systems Effectiveness, as well as pediatric health services researchers based here, so I saw many opportunities for mentorship and collaboration.
How do you conduct health economic research?
My mentor, John Zupancic, in Boston, who I still work with closely, conducted economic evaluations alongside randomized trials in neonatology, looking at cost effectiveness of different interventions. Because of my association with him, I was able to be involved in trial-based evaluations both in neonatology and post-partum depression based on his collaborations with national and international investigators. In a sense, we piggyback on clinical studies that are looking at a clinical outcome and try to assess the resource utilization and economic outcome at the same time.
What are some of the projects you’ve been involved with?
One of my first projects that I had a chance to do was the economic evaluation alongside the Caffeine for Apnea of Prematurity Trial study on which I was first author. This was a large international trial, and we did a retrospective evaluation looking at the cost effectiveness of caffeine as a treatment for apnea in premature infants. It turns out caffeine is cost saving because of its efficacy and ability to reduce bronchopulmonary dysplasia, a common lung condition in the NICU.
What are you working on now?
I’m involved in several projects right now. Some are in the finishing stages of analysis, and others are just starting to collect data for economic evaluations. One is looking at how to prevent postpartum depression in high-risk moms. High risk in this study is defined as being low socioeconomic status and on Medicaid, as well has having had a high-risk birth of a pre-term baby between 26 and 34 weeks. We’re looking at the costs that accumulate throughout that process over the first year of the baby’s life as well as at the mother’s quality of life. The study involves a problem-solving intervention where peers help moms effectively deal with the hardships they encounter. A trained counselor has six sessions with the mother on life-building skills and problem solving – three sessions are done while the baby is still in the NICU, and the other three are after the baby goes home. Part of the cost is the intervention itself, so that’s factored in. When doing economic evaluations, the results you get will change based on the perspective you undertake. So, most broadly, you can look at societal costs and benefits, or you can look at direct medical costs of the mother and child, as well as the cost of the intervention. It may be that from a societal perspective, this intervention is cost saving but from strictly a medical cost perspective, results may be different. The perspective is a critical component of economic evaluations as it avoids cost-shifting from the hospital to the patient (or in the case of the neonate, the family).
I’m also working on two other projects that involve genomic sequencing; one in adults and one in babies. With babies, we’re randomizing and carrying out whole genome sequencing compared to routine care for both sick babies and well babies and looking at the cost effectiveness of that intervention. It’s an interesting issue because obviously genome sequencing is extraordinarily expensive, in addition to multiple ethical and psychosocial implications that need to be assessed. We have to consider the psychological effects it may have on the family and questions arise: Do you talk to the family only about findings that will affect the baby in the immediate term? Do you inform them of something that may arise in childhood? Or do you let them know everything the screen shows, even though there may be no implications until well into late adulthood? From an economic perspective, one can hypothesize that learning more information early on can help personalize the care throughout the life span that then reduces healthcare costs.
How are results from this research incorporated into policies or practices?
There’s a big movement in medicine to increase cost awareness. There’s the Choosing Wisely initiative that calls upon medical professional associations to identify commonly used tests and procedures that they consider unnecessary or may cause harm and provide no benefit. These lists are a starting point of discussion between the patient and provider. Our group just published the list for neonatology in the journal Pediatrics. I was part of the team that put that together. So, that’s one way of translating the results into potentially better practices.
I think it’s intuitive that if we improve quality of care for the individual and the population, we are naturally going to reduce cost because you’re eliminating unnecessary care. There’s too much money being spent on unnecessary treatments in this country. Depending on what you read, between $800 billion and $900 billion is considered spent on wasted care. I do hope that my work going forward will be able to help decision makers (clinicians, hospital administrators, and policy makers) determine whether it’s “worth” it to introduce a new technology, drug or health intervention, or at the least assess the value (or “bang for the buck”) of that intervention. Particularly for trial-based work, so many trials come out with a neutral result, meaning there isn’t a benefit to an intervention, but it’s not really worse than another treatment. It’s interesting to then ask the question “Is there a cost difference?” If the clinical benefit is the same, then shouldn’t the cost be driving our decision making?
What do you do for fun?
Well, I have a two year old and a five year old, so that keeps me busy. Also, I’m still very much a New England sports fan, so I’m looking forward to fall (and the 2016 baseball season, it’s too late for this year)!