Can New Training Efforts Rein in Health Care Costs?

by | Feb 26, 2024 | 2022, global and local challenges 2022

Can New Training Efforts Rein in Health Care Costs?

Swati DiDonato, MD, MBA

Swati DiDonato, MD, MBA

Can New Training Efforts Rein in Health Care Costs?

When Swati DiDonato, MD, MBA, accompanies medical trainees on their morning rounds at Stanford Hospital to review admitted patients’ statuses and plans, she finds herself asking the same question again and again: Will that test (or medicine, or therapy) really improve the patient’s overall health and well-being? Is it necessary?

Over recent decades, health care costs in the United States have risen dramatically. Some of this increase is due to administrative costs and the complexity of the healthcare system, and some of it is due to an aging population and increases in chronic illnesses. But a part of the increase can also be attributed to how medicine is practiced — which tests or treatments doctors use for their patients.

DiDonato, a clinical assistant professor of hospital medicine, thinks clinicians can benefit from dedicated training in “value-based care.” Value-based care embraces the idea of prioritizing tests, procedures, and treatments that are likely to improve the quality of care that the patient receives, rather than turning to many tests or interventions right off the bat. It emphasizes the use of drugs and devices most probable to increase a patient’s quality of life or life span.

“Ultimately, by embracing the practice of value-based care, we can better serve our patients and our community.”

– Swati DiDonato, MD, MBA

positions. With support from a Medical Scholars Research Fellowship, she studied how a patient’s demographics and insurance coverage impact the type of prostate cancer surgery they receive. She also led a project asking whether a new electronic health record system changed how patients in the hospital fared.

“As doctors, we have unique insight into the challenges that our patients face,” says DiDonato. “I think we’re going to keep seeing changes to medicine happening from the government and insurance side, and it’s important to have doctors who can advocate for our patients and help shape and implement these policy changes.”

During her training, DiDonato also led the Stanford Resident Safety Council, a group with the goal of developing new, systemic solutions to improve the quality and safety of patient care at Stanford. The group worked on projects such as the effective rollout of Voalte, a new communication tool for Stanford providers that lets them communicate through an encrypted smartphone app, as well as new patient education materials on drug side effects. These kinds of projects can improve health care by reducing medical errors and miscommunications.

Today, as a junior faculty member, DiDonato helps lead that same Resident Safety Council, as the associate program director. She also serves as a career adviser for students in the MD/MBA program.

“I really want to empower our trainees so that when they see issues or opportunities for improvement here at Stanford, they have the tool kits and resources to take things to the next level,” says DiDonato.

Teaching medical trainees how to think like a businessperson is one way to encourage systemic change in healthcare… But getting more senior physicians to think and act in new ways is paramount as well.

Teaching medical trainees how to think like a businessperson is one way to encourage systemic change in healthcare… But getting more senior physicians to think and act in new ways is paramount as well.

A New Curriculum

Teaching medical trainees how to think like a businessperson is one way to encourage systemic change in healthcare — over the coming years, it can lead to more junior faculty like DiDonato, who are inspired and equipped to make a difference. But getting more senior physicians to think and act in new ways is paramount as well, DiDonato says. That’s why she began working with Horomanski on the new CME course, with encouragement from General Medicine Section Chief Jeffrey Chi, MD, clinical associate professor of hospital medicine, and Hospital Medicine Division Chief Neera Ahuja, MD, clinical professor of medicine.

Just like her morning rounds lectures, the course that DiDonato developed aims to make doctors pause and think twice before they order a test or drug.

“We provide examples of what it looks like to use evidence-based guidelines and clinical pathways to guide the ordering of different tests and procedures,” says DiDonato.

The final lesson in the course focuses on how to talk to patients about value-based care. When a patient requests a particular test or drug, for instance, clinicians can struggle to communicate with the patient about why it’s not needed.

Initially, the Stanford Value-Based Care Academy is rolling out the virtual course for faculty members in the Department of Medicine. But DiDonato and Horomanski plan to adapt it for other departments, as well as medical students, residents, and fellows at Stanford. They’re also developing an in-person version of the course, in which staff of a given division can participate together, brainstorming how they can apply value-based care in their own day-to-day practices.

DiDonato hopes that eventually her efforts will inspire similar courses in other health systems.

“Public payers and insurance companies are all making pushes toward value-based models, but the education of physicians on value-based care has lagged behind,” she says. “Our hope is that we can meet the moment with this training to better serve our patients and our community.”

Whatever Is Needed To Provide The Highest Quality Care

by | Feb 26, 2024 | 2022, global and local challenges 2022

Whatever Is Needed To Provide The Highest Quality Care

Model Program Streamlines Care for Veterans of the VISN 21

From left: Guson Kang, MD: Ian Chen, MD, PhD; William Fearon, MD; Neha Mantri, MD

From left: Guson Kang, MD: Ian Chen, MD, PhD; William Fearon, MD; Neha Mantri, MD

Whatever Is Needed To Provide The Highest Quality Care

Model Program Streamlines Care for Veterans of the VISN 21

Many veterans in rural locations face the challenges of shortages of physicians and staff. Although veterans can get care in the community if necessary, that can sometimes lead to disjointed care, duplication of effort, and missed diagnoses, says William Fearon, MD, professor in the Division of Cardiovascular Medicine and director of interventional cardiology at the Stanford Department of Medicine, chief of cardiology at the VA. “Ideally, we’d like to keep the veterans within the system for all these reasons. So that’s how the idea of the Clinical Resource Hub, or CRH, came about.”

The Veterans Affairs Palo Alto Health Care System has a long history of providing veterans residing in Palo Alto and neighboring areas with top-notch health care. Starting in 2021, as part of a new program, the VA has offered this high-quality care to other VAs in the region, as it has become the Clinical Resource Hub in Cardiology for all of the VA Sierra Pacific Network, or VISN 21. VISN 21 is one of 18 Veterans Integrated Service Networks (VISNs) in the Veterans Health Administration (VHA). VISN 21 serves veterans in Northern and Central California, Nevada, Hawaii, the Philippines, and U.S. Territories in the Pacific Basin. The hub-and-spoke healthcare service model allows for veterans in rural areas of the VISN to access specialty care at the hub, which is the Palo Alto VA.

This means that veterans outside the Palo Alto area who need more complex cardiology care than they can find at their local VA can access the Palo Alto VA via video visits from either their home or their local clinic. If they need to have a procedure done, the VA arranges transportation and all the preop testing as well as the procedure itself so that the patient can come to Palo Alto for their care in a “one-stop shopping” trip, if at all possible.

“The VA is really focused on providing timely and quality care to veterans,” says Fearon. “And there have been studies that show that veterans have better outcomes when they get their care at the VA compared to in the community, particularly in cardiovascular medicine. So there’s a lot of incentive, from the standpoint of quality care, to keep veterans in the VA system.” Plus, he says, most veterans say they prefer to get their care at the VA.

The veterans are getting really cutting-edge medical care, the kind that is only available at high-end academic facilities. And it’s a concierge-type care, where we have staff that can help them get their needs met.

– William Fearon, MD

The veterans are getting really cutting-edge medical care, the kind that is only available at high-end academic facilities. And it’s a concierge-type care, where we have staff that can help them get their needs met.

– William Fearon, MD

One Patient’s Journey

One of the first patients to benefit from the CRH program was Marvin Rogers, an 85-year-old Army veteran who lives in Reno, Nevada. He had been experiencing shortness of breath and dizziness and had lost 45 pounds over the past year. His VA cardiologist in Reno diagnosed him with major problems in both his aortic and mitral valves.

“The CRH Cardiology team in Palo Alto performed a clinical assessment for Rogers via videoconference, along with his Reno cardiologists,” says Neha Mantri, MD, assistant professor in the Division of Cardiovascular Medicine and a specialist in structural imaging and noninvasive cardiology at Stanford Hospital and the VA, who was on the team that cared for Rogers. After determining which additional cardiac imaging and potential procedures he required, the team transferred him to the Palo Alto VA. Once the physicians on the team knew what Rogers needed, structural heart nurse coordinators Donna Lynch and Cheryl Christianson arranged his flights, transportation to and from the airport, and accommodations at the VA’s on-campus housing in Palo Alto.

“Within one week of his arrival, we were able to conduct all pre-procedural imaging and successfully complete two very specialized minimally invasive cardiac procedures — a TAVR and a MitraClip,” says Mantri. Rogers’ trip combined his clinic visits, scans, and valve procedures. After spending just three nights in the hospital after his procedures, he was home in Reno and back to his regular routine with his new aortic valve and repaired mitral valve. “Previously, the whole thing could have taken months, with the patient first coming out for an evaluation, then having to come out for one procedure and go back home, and so on,” says Fearon. “This allowed us to deliver that care really efficiently.”

It has been incredibly gratifying to be able to provide specialty cardiac care to our veterans both near and far within our VISN.

– Neha Mantri, MD

It has been incredibly gratifying to be able to provide specialty cardiac care to our veterans both near and far within our VISN.

– Neha Mantri, MD

Guson Kang, MD, assistant professor of cardiovascular medicine and a specialist in structural and interventional cardiology at Stanford Hospital and the VA, says that the CRH has provided the resources and staffing to refine their workflow into “a well-oiled machine. It really works well for us and for the veterans. We’ve had people come from Guam, Hawaii, Reno, Albuquerque, everywhere. Most veterans don’t mind traveling, especially when they know that the VA will take care of them and make sure everything is coordinated properly.”

The beauty of the CRH is that it allows a very streamlined method of delivering highly personalized care, says Fearon. “The veterans are getting really cutting-edge medical care, the kind that is only available at high-end academic facilities. And it’s a concierge-type care, where we have staff that can help them get their needs met.” Electronic records allow the VA to communicate seamlessly with the patient’s local VA for follow-up care as needed.

While in most cases patients fly to Palo Alto for specialty procedures and testing, such as structural imaging and electrophysiology, some may need their physicians to come to them at their local clinics. At other times, the team in Palo Alto might consult remotely with the local VA. Everything is individualized to best meet the patient’s needs.

Paul Heidenreich, MD.

department is able to offer general cardiology, electrophysiology, and structural/interventional cardiology, with heart failure care to launch soon.

As the CRH expands, the VA hopes to build a network of providing care for more diverse patient populations, says Chen. They have recently launched a Women’s Health Cardiology Clinic at the Palo Alto VA and will be offering service to all spoke sites within VISN 21 through CRH. Further networking across VISNs may help bring the numbers of patients needed for the VA to offer the expertise to places that might not otherwise have access to this kind of care. Video visits, electronic health records, and other supportive telehealth technologies facilitate providing this kind of care despite geographic barriers.

Back in Reno, Marvin Rogers recovered well. He is breathing easier and walking well without dizziness. “He has done very well,” says Mantri. “It has been incredibly gratifying to be able to provide specialty cardiac care to our veterans both near and far within our VISN.”

One Leukemia Treatment to Rule Them ALL

by | Feb 26, 2024 | 2022, disease and chronic conditions 2022

One Leukemia Treatment to Rule Them ALL

One Leukemia Treatment to Rule Them ALL

For adults with acute lymphoblastic leukemia (ALL) that don’t respond to chemotherapy, the series of treatments that comes next can seem like the spin of a roulette wheel. Some patients receive a bone marrow transplant, which requires a lengthy testing process to ensure a good donor match, and months of recovery if everything goes well. Other patients instead begin with an immunotherapy, which can come with severe side effects and only helps quell disease in a fraction of people. If the first approach doesn’t work, their clinician may turn to the other. For a number of patients, their disease recurs even after both.

Now researchers and clinicians in the blood and marrow transplantation & cellular therapy division have developed a new option for ALL patients. Instead of trying a transplant followed by an immunotherapy—or vice versa—they have combined both therapies into one and added some new twists that could help improve the treatments’ success rates. The result: a single ALL treatment that integrates new avenues of research into the best way to fight the cancer.

“This new protocol really changes the paradigm. It combines multiple avenues of research that have been going on at Stanford for years,” says Lori Muffly, MD, associate professor of blood & marrow transplantation and cellular therapy. “We hope it’s a first step toward something really successful and exciting for our patients.”

This fall, Muffly and her colleagues enrolled the first ALL patients in a clinical trial to test the new combination approach, in which patients receive a customized cocktail of immune cells from a donor. The trial, she says, will advance the science of lymphoma and leukemia treatment, as well as give new hope to patients who have relapsed after chemotherapy.

“This trial is really showcasing Stanford’s strengths in both bone marrow transplantation and cell therapy,” says Muffly’s collaborator Melody Smith, MD, MS, an assistant professor of blood & marrow transplantation and cellular therapy.

Based on Basic Research

The human immune system has the ability to recognize cells and molecules that don’t belong — including tumor cells. In recent years, scientists have discovered how to take advantage of this natural power of the immune system to help fight cancer. One of the new mainstays of cancer immunotherapy is CAR T-cell therapy, in which clinicians remove a patient’s T cells, reengineer them with cutting-edge gene engineering technologies to better recognize cancer, and infuse them back into the patient.

Smith, who recently moved her lab to Stanford from Memorial Sloan Kettering Cancer Center to start her independent research lab, has spent the last eight years using mouse models of cancer to study how to optimize the use of cell therapies like CAR T-cell therapy following bone marrow transplants. Much of her research has revolved around the idea of creating CAR T cells from donor immune cells instead of immune cells harvested from patients themselves. The quality of these cells, she hypothesized, might be better. Plus, the CAR T cells could be given at the same time as a bone marrow transplant — all from the same donor. “I had really strong data in animal models that this combination approach could be successful in lymphomas and leukemias,” says Smith.

Smith’s move to Stanford to start her independent research lab opened up even more opportunities to fine-tune her approach, by combining it with specialized CAR T cells and a new transplant protocol that Stanford clinicians had already been working on.

Melody Smith, MD, MS

This trial is really showcasing Stanford’s strengths in both bone marrow transplantation and cell therapy.

– Melody Smith, MD, MS

This trial is really showcasing Stanford’s strengths in both bone marrow transplantation and cell therapy.

– Melody Smith, MD, MS

Lori Muffly, MD

Using Digital Health to Help Doctors Manage Blood Pressure More Easily and Equitably

by | Feb 26, 2024 | 2022, disease and chronic conditions 2022

Using Digital Health to Help Doctors Manage Blood Pressure More Easily and Equitably

Using Digital Health to Help Doctors Manage Blood Pressure More Easily and Equitably

If you don’t have high blood pressure, you probably have family, friends, colleagues, and acquaintances who do. Nearly half of all adults in the United States struggle with hypertension, and only one in four has their condition under control. Managing blood pressure often requires ongoing trial and error on the part of both clinicians and patients, making it difficult to fully treat with only occasional, short medical appointments.

To solve that problem, Stanford clinicians have designed a streamlined system that helps primary care physicians easily and quickly adjust their patients’ medications based on at-home blood pressure readings. The team, funded by a $2.5 million American Heart Association grant to Stanford Medicine’s Center for Digital Health in 2020, found that the new system could reduce patients’ blood pressure in a small pilot study. Now, they’re enrolling hundreds more patients in a larger clinical trial.

Their new program automatically calculates a two-week average blood pressure. If, at any point, that average blood pressure rises above a chosen threshold, the clinician receives a notification — along with information on the patient’s other medications, their allergies, and the preselected list of hypertension drugs, all in one place in the electronic health record. With a few clicks, the physician can order a new, adjusted prescription for the patient.

“What we’re trying to do with this project is to improve the way we monitor blood pressure,” says Division of Nephrology Chief Tara I. Chang, MD, an associate professor of medicine. “This technology has the potential to help us reach a broad community and level the playing field for typically underserved populations when it comes to hypertension.”

Mario Funes, MD (left), discusses hypertension with a patient.

For some patients who have the time, resources, and insurance coverage, this kind of care is possible. But for many people — including a disproportionate number of people in minority populations — it is not. This is one reason that, on average, hypertension tends to be the least well-controlled among non-Hispanic whites and most well-controlled among people with the greatest insurance coverage and access to health care.

This technology has the potential to help us reach a broad community and level the playing field for typically underserved populations when it comes to hypertension.

– Tara I. Chang, MD

This technology has the potential to help us reach a broad community and level the playing field for typically underserved populations when it comes to hypertension.

– Tara I. Chang, MD

Stepping up to the Challenge

Funes, currently in his third year of nephrology fellowship, has been interested in hypertension control, and the associated disparities, since he was in medical school. So in 2020, he jumped at the opportunity to help apply for a hypertension control grant through the Center for Digital Health, with center leader Mintu Turakhia, MD, MAS, professor of medicine in the division of cardiovascular medicine, and Paul Wang, MD, director of the Stanford Cardiac Arrhythmia Service and professor of medicine and of bioengineering. Now, Funes is a heart health tech fellow with the center, a responsibility he has to juggle alongside his clinical duties and his role as chief nephrology fellow. Since mid-2021, he’s been helping lead the effort to develop new data-driven technology to control patients’ blood pressure.

The interdisciplinary team at the Center for Digital Health wanted to make it easy for patients to track their blood pressure at home, upload the data directly to their primary care physician, and enable the physician to adjust the patient’s medications. In the past, this would have taken the clinician numerous steps — receiving an email or phone call from a patient and then accessing different electronic databases to review their medical history and other prescriptions.

“Most clinicians managing blood pressure already have a heavy burden due to the electronic health record,” says Wang. “Our insight is that by semiautomating the process, we can reduce the burden of blood pressure management, taking less effort but improving results.”

The system that the team settled on is one where a physician can preselect a list of blood pressure–lowering medications, in the order that they’d like a patient to try them. At an initial appointment, they start a patient on the first medication on the list. Then, using a blood pressure cuff and a connected smartphone app, patients track their blood pressure over the coming days and weeks.

“One value in the clinic doesn’t really tell a doctor the whole story of your blood pressure,” says Funes. “But in the past, the ability to get a longer time frame of data from patients was often unreliable; some patients might record their readings in a notebook and bring it to an appointment, but it wasn’t a streamlined process.”

Data-Driven Medicine

With the explosion of personal electronics over recent years has come the ability for people to more easily track measurements of their own health, through smartphones, watches, and other at-home devices. But using this information in the clinic has been trickier.

Some of the most successful systems to connect patient-collected data with clinicians have been for tracking blood sugar levels in people with diabetes. But none of those systems involved the same kind of decision-making tree that the Stanford team wanted to use, with customized lists of medications for each patient to try. That meant that integrating the system into Stanford’s electronic health record system, Epic, was a challenge.

Initial data on the system, though, has been positive, inspiring Funes and his colleagues to keep working. An early version of the system, tested in only a handful of patients and without the full capabilities, showed an average decrease in blood pressure of 12 mmHg for those who used it. That’s a big enough difference to push some patients from an at-risk, high blood pressure reading to a healthier zone.

Now, the researchers are launching the full-scale program in a clinical trial that aims to enroll 600 to 800 patients. They’ll collect data on how clinicians and patients like the system and how well it works at reducing blood pressure.

“For a whole host of chronic diseases, I think this kind of digital management is the future.”

– Mario Funes, MD

“Some digital solutions create a separate workforce to manage chronic conditions,” adds Wang. “Although some of these efforts may be successful, they remove patient care from the primary care team, eliminating opportunities to better integrate care and save resources. Integrated approaches like ours aim to reduce disparities of care rather than increasing them.”

The Stanford Center for Digital Health already has other initiatives aimed at treating conditions as diverse as heart health, atrial fibrillation, migraines, and hyperactivity. The award from the American Heart Association is part of a $14 million grant to several institutions around the country for work on reducing health care disparities with the help of technology. In addition to Funes, the grant is funding fellowships for three Stanford cardiology trainees working on heart failure management. As virtual health moves mainstream and digital apps become routine tools in patient care, these fellows will continue to take the lead in innovating creative new ways for technology to help patients and doctors alike.

Team Science: Battling Kidney and Heart Diseases

by | Feb 26, 2024 | 2022, disease and chronic conditions 2022

Team Science: Battling Kidney and Heart Diseases

Large Initiatives Evaluate New Treatments for Cardiovascular and Kidney Diseases

Team Science: Battling Kidney and Heart Diseases

Large Initiatives Evaluate New Treatments for Cardiovascular and Kidney Diseases

Glenn Chertow, MD

Physicians are often faced with critically ill patients who have more than one disease, which complicates treatment decisions. A cardiologist who wants to prescribe a diuretic to a patient with high blood pressure, for example, may need to worry about the medication causing kidney damage. So, she consults with the patient’s care team.

Designing and testing new therapies also requires a team, as evidenced by the large team science initiatives being conducted by the Stanford Center for Clinical Research (SCCR). For example, Stanford researchers are collaborating across different sectors (such as academia and industry), institutions, disciplines, and countries to find more effective treatments for kidney and cardiovascular diseases.

“Since early in my career, I saw that the lives of patients with kidney failure are very difficult and their life spans on dialysis are sadly very short. I’ve 

spent 30 years trying to improve their treatment and quality of life,” says Glenn Chertow, MD, the Norman S. Coplon/Satellite Healthcare Professor of Medicine in the division of nephrology.

Patients with end-stage kidney disease also have a high risk of cardiovascular disease, but they are typically excluded from studies due to the complexity of their health problems. That’s why Chertow is excited to help launch one of the few randomized clinical trials focused on patients receiving dialysis, he says.

The clinical trial will study the effects of clazakizumab—a monoclonal antibody that reduces inflammation—in patients with kidney failure. Scientists know that inflammation is a contributing cause of cardiovascular disease and that patients on dialysis have exceptionally high rates of both chronic and severe inflammation. So, they hypothesize that using clazakizumab could prolong and improve the quality of these patients’ lives.

After receiving final funding notification from the biopharmaceutical company CSL Behring, the team will begin with a phase 2B trial to figure out the appropriate dose of clazakizumab, followed by a larger phase 3 trial to measure the drug’s effect on patient outcomes.

Chertow and Myles Wolf, MD, chief of nephrology at Duke University School of Medicine, are co-principal investigators of the overall study. Kenneth Mahaffey, MD, professor of cardiovascular medicine and director of SCCR, will serve on the trial’s executive committee.

“Myself, Dr. Mahaffey, and others at SCCR have been involved in the design of the study from day one. It is a real partnership between academics and industry, between Stanford and Duke, and between nephrology and cardiology,” says Chertow. “It shows we actually work together — it’s not siloed to just one institution or one division.”

From left: Glenn Chertow, MD; Tara Chang, MD, MS; and Marco Perez, MD.

Patients are dying or suffering miserably from complications of diseases. Finding safe and effective therapies to treat these patients is a motivating force for me every day.

– Kenneth Mahaffey, MD

Patients are dying or suffering miserably from complications of diseases. Finding safe and effective therapies to treat these patients is a motivating force for me every day.

– Kenneth Mahaffey, MD

Marco Perez, MD.

The REACT-AF project represents an academic partnership among Stanford, Johns Hopkins, and Northwestern universities. Rod Passman, MD, professor of cardiology and preventive medicine at Northwestern University’s Feinberg School of Medicine, will oversee the overall initiative, while Mahaffey and Marco Perez, MD, associate professor of cardiovascular medicine, will co-lead Stanford’s efforts.

The faculty bring a lot of clinical and scientific expertise, and the operational research staff understand the regulations, policies, and procedures,” he says. “Together, they create synergies to enhance the design, conduct, and quality of clinical trials.

– Kenneth Mahaffey, MD

The faculty bring a lot of clinical and scientific expertise, and the operational research staff understand the regulations, policies, and procedures,” he says. “Together, they create synergies to enhance the design, conduct, and quality of clinical trials.

– Kenneth Mahaffey, MD

Kenneth Mahaffey, MD

Tara Chang, MD, MS

Collaborating Across Experience Levels

Although led by senior faculty, these large studies will also provide junior faculty, operational staff, and fellows with critical research training.

“Stanford is a learning environment. Dr. Mahaffey and I feel very strongly that we have a responsibility to train the next generation of scientists,” says Chertow. “For example, Dr. Tara Chang, associate professor and chief of nephrology, is a shining example of a physician who completed training at Stanford and is now a national leader at the crossroads of kidney and cardiovascular disease.”

In addition to providing funding and research opportunities, these projects allow Stanford patients to enroll in the studies — a fundamental incentive for the researchers who want to give their patients more options.

“Patients are dying or suffering miserably from complications of diseases,” Mahaffey says. “Finding safe and effective therapies to treat these patients is a motivating force for me every day.”

Team Science Players

CSL Behring study (dialysis patients, clazakizumab):

  • Glenn Chertow, MD, the Norman S. Coplon/Satellite Healthcare Professor of Medicine, will co-lead the overall study with Myles Wolf, MD, chief of nephrology at Duke University School of Medicine, in partnership with the biopharmaceutical company CSL Behring and Duke Clinical Research Institute.
  • Ken Mahaffey, MD, professor of cardiovascular medicine and director of the Stanford Center for Clinical Research (SCCR), will serve on the trial’s executive committee.
  • Tara Chang, MD, associate professor and chief of nephrology, will lead the adjudication committee at Stanford.

NIH REACT-AF study, A-fib study:

The REACT-AF project represents an academic partnership among Stanford, Johns Hopkins, and Northwestern universities.

Rod Passman, MD, professor of cardiology and preventive medicine at Northwestern University’s Feinberg School of Medicine, will oversee the overall initiative, while Ken Mahaffey, MD, professor of cardiovascular medicine and director of the Stanford Center for Clinical Research (SCCR), and Marco Perez, MD, associate professor of cardiovascular medicine, will co-lead Stanford’s efforts along with a team from cardiovascular medicine, the Center for Digital Health, neurology, and SCCR.

Stanford Rheumatology Vasculitis Clinic

by | Feb 26, 2024 | 2022, disease and chronic conditions 2022

Stanford Rheumatology Vasculitis Clinic

Restoring Normal Lives for Patients with the Rarest of Diseases

Stanford Rheumatology Vasculitis Clinic

Restoring Normal Lives for Patients with the Rarest of Diseases

It was 2013. Audra Horomanski was midway through an away rotation at Stanford as a medical student outside her home institution. That was when she encountered a young woman with newly diagnosed granulomatosis with polyangiitis, or GPA. The disease is one form of vasculitis, a rare condition characterized by inflammation of the blood vessels.

“The woman had a severe life-threatening ailment and made a quite significant recovery. That case really changed my whole trajectory and led to a growing interest in vasculitis during my internal medicine training and rheumatology fellowship,” says Horomanski, who earned her MD at Wright State University Boonshoft School of Medicine before completing postgraduate training at Stanford. Today, as a clinical assistant professor of immunology and rheumatology, she directs the Stanford Vasculitis Clinic.

A career in medicine, and rheumatology in particular, was a lifelong ambition for Horomanski.

“I’ve been interested in rheumatology since I was a kid. My sister, who’s three and a half years younger, has an autoimmune rheumatic disorder called juvenile idiopathic arthritis, or JIA. It went into remission when she was a teenager, but I spent a lot of my childhood going to pediatric rheumatology appointments with her and my mom. In fact, I recently came across a school project from first grade in which I answered the question, ‘What do you want to be when you grow up?’ My answer was, ‘I want to be a rheumatologist.’ It was spelled correctly, too! So, I’ve actually wanted to do this for as long as I can remember,” she says.

Audra Horomanski, MD

“I have a particular interest in patients who have vasculitis, which are multi system disorders that can be quite debilitating, and sometimes organ- or life-threatening. Easily the best part about being a rheumatologist is getting to see people recover and get back to their normal lives after presenting with serious illness. It’s great to witness patients achieve the maintenance phase, where they can get back to hobbies, vacations, going to look at colleges with their kids — all things that may have seemed very far out of reach when they were first diagnosed,” she explains.

Horomanski performs musculoskeletal ultrasound to evaluate for various rheumatologic and other joint musculoskeletal complaints.

Horomanski is a principal investigator in research supported by a grant from the Maternal & Child Health Research Institute. This aligns with her deep interest in how vasculitides affect young women, their fertility, and their decisions regarding if and when to have children.

“We’re actually talking about a collection of pretty heterogeneous diseases. Because vasculitides are all different, they affect very different populations. One of the vasculitides is Takayasu arteritis, for example. More than 80% of patients with Takayasu arteritis are women, and most of those women are under the age of 40, so it primarily affects people in their childbearing years. We don’t know enough about the maternal and fetal outcomes associated with pregnancy in vasculitis patients. A component of our current research involves the use of large databases to help answer such questions about these rare diseases,” Horomanski says.

Easily the best part about being a rheumatologist is getting to see people recover and get back to their normal lives after presenting with serious illness.

– Audra Horomanski, MD

Easily the best part about being a rheumatologist is getting to see people recover and get back to their normal lives after presenting with serious illness.

– Audra Horomanski, MD

Crossing organ systems

Rheumatology requires close collegial relations with other medical subspecialties, and Horomanski’s vasculitis work exemplifies that.

“Because blood vessels run throughout the body, these diseases can affect virtually every organ system. During the past two years, I’ve been able to create a network with colleagues in other subspecialties who can help with different manifestations of vasculitis. Whether it’s cardiology, nephrology, neuromuscular neurology, ophthalmology, neuro-ophthalmology, ENT, or pulmonology, I work with an expert in that specialty to treat patients. It’s been a big help to identify the providers in those divisions and departments who have an interest in vasculitis and who work well collaboratively,” she says.

Horomanski also has a particular interest in ultrasound and performs musculoskeletal ultrasound to evaluate for various rheumatologic and other joint musculoskeletal complaints in the Immunology and Rheumatology Clinic. In the past 20 years, specialists have recognized the value of vascular ultrasound to both diagnose and monitor large vessel vasculitis, and Horomanski received additional training in August 2022 to perform vascular ultrasound for patients with large vessel vasculitis.

“The best part about ultrasound is that it is noninvasive. Frequently these conditions need to be diagnosed by biopsy, and often temporal artery biopsy, which can be challenging to coordinate and schedule. And of course, it is an invasive procedure. If we can quickly and accurately diagnose people by ultrasound, it is a huge benefit to the patients,” she says.

As the clinic grows, greater involvement in clinical trials is expected, too.

Currently, Horomanski is working under principal investigator Matthew Baker, MD, assistant professor of immunology and rheumatology, on several trials related to IgG4-related disease and sarcoidosis, both of which can present with vasculitis. Horomanski, who did additional training during her fellowship on clinical trial design and management, is very interested in pursuing other vasculitis trials as the clinic continues to expand.

“That was one of the main objectives of this clinic. Stanford has a robust infrastructure to run these types of clinical trials, and we are looking forward to great things in the future,” she says.

Paying it back

Given that it was her own medical education that exposed her to vasculitis, it’s fitting that Horomanski would be passionate about an additional role as the Immunology and Rheumatology Fellowship associate program director.

“Part of the reason that I like this clinic so much is because it’s a teaching clinic. In addition to teaching courses at the medical school, we can expose all of our trainees to these extremely rare disorders in clinic and give them tools to treat these patients when they encounter them,” she says.

Working with severely ill patients is extremely stressful, so how does Horomanski deal with that?

At the start of the COVID-19 pandemic, she and her husband were searching for an activity that was safe, could be done outdoors, and allowed for social distancing. That led them to take up ceramics.

“I mostly do wheel throwing, which is super-therapeutic. You can completely zone out, and the clay feels really nice. You don’t have to think about anything. It’s great,” she says.

Patient Volume Increases at the Stanford Rheumatology Vasculitis Clinic

Since 2020, the number of vasculitis patients seen at the Stanford Rheumatology Vasculitis Clinic has doubled. As of July 2022, the clinic had close to 150 unique vasculitis patients who were being seen regularly. On average, Horomanski sees about three new vasculitis consults a week. 

“Part of the reason that I like this clinic so much is because it’s a teaching clinic. In addition to teaching courses at the medical school, we can expose all of our trainees to these extremely rare disorders in clinic and give them tools to treat these patients when they encounter them.”

– Audra Horomanski, MD

Referrals come from throughout California, Oregon, Nevada, Hawaii, and even the East Coast, but most patients live in California’s Central Valley, where providers do not have extensive experience with these rare illnesses. Horomanski tries to share care with each patient’s local rheumatologist, which allows the patient to see their nearby physician, while also getting the care they need from a large academic center.