Demographic and lifestyle factors are largely responsible for an alarming increase of diabetes in Qatar and other countries in the Middle East and North Africa, according to a new study from Weill Cornell Medical College and Weill Cornell Medical College in Qatar.

The study, published in the December issue of Qatar Medical Journal, found that a more “westernized” lifestyle, characterized by calorie-rich diets and reduced physical activity, has made people in the region more susceptible to developing type 2 diabetes mellitus and other associated chronic conditions. Investigators say the findings underscore a need to raise awareness of diabetes, promote physical activity and emphasize the risks associated with obesity.

"The Qatar National Health Strategy has identified diabetes as one of the high-priority diseases for preventive healthcare, and for good reason," said senior author Dr. Alvin I. Mushlin, the Nanette Laitman Distinguished Professor of Public Health and a professor of healthcare policy and research and of medicine at Weill Cornell Medical College. "In addition to its direct effect on health and quality of life, diabetes is a cause of conditions such as diabetic retinopathy, kidney failure, cardiovascular disease and associated heart attacks, strokes and earlier death."

Paradoxically, the increase of diabetes and other non-communicable diseases in this region is largely tied to major improvements in economic conditions, the investigators said. There have been remarkable improvements in the health infrastructure, a lengthening of life expectancy, an increasingly aging population, and a fast pace of urbanization.

To determine the risk factors that have led increased incidence of the disease, the investigators looked at patient records for more than 450 patients — including Qatari nationals and immigrants — with type 2 diabetes who had received care from Hamad Medical Corporation Hospital's outpatient adult diabetes clinics from 2006-2008. They compared these patients to nearly 350 other patients who received care from various outpatient and inpatient clinics at the hospital.

Since more than 80 percent of the population of Qatar consists of immigrants from countries throughout the Arab world, South Asia and other regions, the researchers also conducted a sub-analysis of only Qatari nationals to see if this group had a different risk factor profile than the population at large.

"In our study, Qatari nationality was the strongest risk factor for DM, followed by higher income, obesity, no college education and no vigorous or moderate exercise," said lead author Dr. Paul J. Christos, a lecturer in healthcare policy and research in the Division of Biostatistics and Epidemiology.

"While further evaluation of DM risk factors among the Qatari population (as opposed to the resident population) is important and of interest," said study co-author Dr. Laith Abu-Raddad, an associate professor and principal investigator of the Infectious Disease Epidemiology Group at Weill Cornell Medical College in Qatar, "these findings highlight the need to focus short-term DM interventions on addressing demographic/lifestyle risk factors to achieve substantial and timely declines in DM levels."

Dr. Donald D'Amico, chairman of the Department of Ophthalmology, the John Milton McLean Professor of Ophthalmology, the Betty Neuwirth Lee and Chilly Professor in Stem Cell Research and professor of ophthalmology, gave the LuEsther Mertz Lecture at New York University on April 29. His talk was titled "Confronting Our Limits in Vitreoretinal Surgery: Where We Are Stalled and How we Might Improve."

Dr. Alvin I. Mushlin, the Nanette Laitman Distinguished Professor of Public Health , professor of healthcare policy and research and professor of medicine, chaired the Patient-Centered Outcomes Research Institute Advisory Panel on Assessment of Prevention, Diagnosis, and Treatment Options Meeting in Alexandria, Virginia, April 28-29. The panelists discussed and made recommendations for potential funding by the institute for projects on the prevention, detection, or treatment of a wide variety of medical conditions. Dr. Mushlin was selected to be chair of this panel in May 2013 for the two following years.

More than two dozen of Weill Cornell's faculty received Excellence in Teaching Awards on June 19:

• Erika L. Abramson, M.D. — Medicine, Patients and Society
• Olaf S. Andersen, M.D. — Molecules, Genes and Cells
• Raymond H. Coll, M.D., B.Ch. — Brain and Mind
• Lawrence E. Cutler, M.D. — Obstetrics and Gynecology
• Todd Cutler, M.D. — Medicine Clerkship
• Kirk W. Deitsch, Ph.D. — Advanced Biomedical Science
• Ernie L. Esquivel, M.D. — Introductory Clerkship
• Domenick Falcone, Ph.D. — Host Defenses
• Meghann M. Fitzgerald, M.D. — Anesthesiology Clerkship
• Kelly A. Garrett, M.D. — Surgery Clerkship
• Robert M. Gelfand, M.D. — Medicine, Patients and Society I, Small Group Leader
• Thanakorn Jirasevijinda, M.D. — Pediatric Sub-Internship
• Steven C. Karceski, M.D. — Neurology Clerkship
• Nicole E. Kucine, M.D. — Pediatric Clerkship
• Ellen C. Meltzer, M.D. — Medicine, Patients and Society III
• Rameen M. Miarrostami, M.D. — Medicine, Patients and Society I Office Preceptor
• Robert C. Post, M.D. — Primary Care Clerkship
• Angela R. Selzer, M.D. — Anesthesia, Circulation and Ventilation
• Susan K. Seo, M.D. — Human Structure and Function
• Eugenia L. Siegler, M.D. — Medicine Sub-Internship
• Harjot K. Singh, M.D. — Medicine, Patients and Society I Office Preceptor
• Thomas J. Walsh, M.D. — Basis of Disease
• Cecilia J. Yoon, M.D. — Medicine, Patients and Society II

Dr. Alvin I. Mushlin, the Nanette Laitman Distinguished Professor and chairman of the Department of Public Health at Weill Cornell Medical College and public health physician-in-chief at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, was selected for one of four new advisory panels of the Patient-Centered Outcomes Research Institute. PCORI received 1,295 applications for panel membership and selected 84. Dr. Mushlin is the first faculty member based at Weill Cornell Medical College to serve PCORI in an official capacity as a member of a standing PCORI board or committee.

PCORI was authorized by Congress in 2010 as part of the Affordable Care Act. As an independent, non-profit organization, PCORI's mission is to fund research that will provide patients, their caregivers and clinicians with the evidence-based information needed to make better-informed health care decisions and to speed the implementation of patient-centered knowledge into practice.

Dr. Mushlin will be a member of the Advisory Panel on Assessment of Prevention, Diagnosis and Treatment Options. This panel will examine research on the comparative effectiveness of alternative strategies for prevention, treatment, screening, diagnosis and management of diseases. The other new panels will focus on patient engagement, improving health care systems and addressing disparities.

The new panels will advise PCORI on critical research questions for possible funding and on ways to ensure that PCORI's work remains patient-centered. Members will help PCORI identify and prioritize research questions in their respective areas and will provide ongoing feedback on evaluating and disseminating resulting research. Each panel has 21 members representing different sectors across the health care community, including researchers, clinicians, patients, caregivers, insurers, employers and industry. The panels are critical to PCORI's ongoing effort to ensure that stakeholder input helps to refine its research portfolio and other activities. We asked Dr. Mushlin to tell us more about the importance of the PCORI panels and his own work in comparative effectiveness research.

How has your own research prepared you to be an active player in this field?

I have always thought that we can make medical care more effective and efficient, and thereby help more people and do a better job for our patients. Although I recognize the need for more and better biomedical research, I have thought that just having more knowledge about diseases and what causes them was not enough. While basic science insights are critically important, in order to determine how to optimize care and achieve the best outcomes, we need research methods and approaches from the public health and social sciences. Studies to help understand the effectiveness of diagnostic tests, treatments and clinical strategies, as well as how to deliver care most efficiently, are necessary. One of my early mentors helped me to learn about such efforts in the fields of clinical epidemiology and health services research, and I entered a training program that included graduate education to gain those research skills.

During my career I have studied and evaluated a number of important clinical strategies and technologies, including diagnostic tests and radiologic procedures such as magnetic resonance imaging (MRI). My work has always focused on new and significant technologies, but it has also included the development and testing of new research methods that help to improve our understanding of their effectiveness and efficiency in the future. I was involved in the first randomized controlled trials evaluating automatic implantable cardioverter-defibrillators (ICDs) for patients with coronary artery disease at risk for fatal arrhythmias (the MADIT trials), and led the economic analyses alongside these trials. The methods we developed still represent a model for how to perform such studies.

What is the current focus of your research?

My major research interest now is to develop further the methods and capability to improve our knowledge base for informing clinical decision making, thereby enhancing the value of medical care. Examples include the development and use of patient registries and large observational data sets to track outcomes and assess the effectiveness and safety of medical devices, tests and technologies. I am also still involved with projects that use decision analysis to help define clinical use recommendations. Through these and related approaches we can do more to inform the intelligent use of medical resources and to reduce the future costs of medical care, particularly in the United States.

How successfully do you think comparative effectiveness research is currently being translated into policy and practice worldwide?

I have always thought that when the evidence was clear and compelling, doctors would use it to change what they are currently doing, and that hospital and health care systems would follow their lead. My thinking now is changing a bit, as it seems increasingly clear that this is not always the case. I recently completed a study with a young cardiologist colleague here on the use of medications as compared with stents or angioplasties for patients with coronary artery disease following the results of the COURAGE trial, which showed that drugs were basically as effective as angioplasty or stents for many such individuals. We found that a substantial percentage of patients were not receiving the recommended medical therapy before getting stents. As a result, we are now systematically tracking the diffusion and impact of research findings from comparative effectiveness research (CER) in order to better understand how to make medicine more evidence-based. Although this is critically important, the main problem remains that there is still not enough CER being done to inform and influence care in a major way, and some of the CER that is out there is not solid and convincing enough to bring about change.

How do you think comparative effectiveness research can be improved?

First, we need more and better CER. It's more than a lack of funding and lack of research opportunities that is the problem. We also need better methods, study designs and statistical techniques to carry out this kind of research.

We need to find feasible alternatives and complements to randomized controlled trials (RCTs) for the evaluation of new drugs, devices or approaches in medicine. While RCTs are recognized as producing the most reliable data, they can be very expensive to conduct and take a long time to produce results, and in some situations it may not be possible or ethical to do them. We need to learn how to use observational data sets (i.e. electronic health records, registries, hospital data and administrative data) for these evaluations. Innovations in study design and statistics, as well as better methods of record-keeping, could make existing data the keys to important medical research in the future. Significant progress along these lines, mostly through electronic medical records, has been made in the last several years, but we need to do even more. There is still too much skepticism about our ability to inform clinical practices from such observational studies. That must change; however, even the best evidence will not alter behavior until we have better strategies to influence thinking and to change health care systems — that will always require a mix of science and politics.

Why is outcomes research so important to health care today?

The ACA has its aim to make high quality health care available and accessible to all. Therefore, determining the most effective, efficient and cost-effective care is essential. Developing and refining methods to make CER truly credible and capable of influencing clinical practice and health policy is of the utmost importance. We need to accumulate a sizable and robust research portfolio of studies to demonstrate that CER can deliver and improve the quality and efficiency of medical care. We should not underestimate the challenge that this represents or lose track of this important dimension as we proceed over the next few years.

Why is outcomes research integral to the ACA?

The goal of the ACA is to enhance access to quality medical care for all Americans. For this to become a reality, we must find ways to inform the practice of medicine with practical information about which interventions work best in medical care, and thereby to use our resources most effectively to enhance the health of our patients. This is the purpose of patient-centered outcomes research, the words that form the name of this institute. Also envisioned in the ACA are changes to the ways we insure and finance medical care that shift the incentives generally toward these same goals. However, unless we, as physicians and patients, have the information to make optimal decisions, the financial incentives alone will not assure the results we all want. Outcomes and comparative effectiveness research are essential to advance the goals of the ACA. I can't see any way that our country would be able to proceed along this path without some way of encouraging and enhancing this type of research. I also think that, by doing so, we are reestablishing our lead in the world in the quality and delivery of medical care.

How do you see the panel contributing going forward?

The Institute of Medicine and Department of Health and Human Services have already released priority lists of general topics for CER. The new panels established by PCORI will play a significant role in advising which specific CER projects should be encouraged and funded. Of course, we all think that as long as studies include health-related outcomes that CER will be useful and have importance to patients. But really understanding patients' concerns and the elements of care that are critical to them and to their physicians, and how these can be incorporated into priority setting for research funding, is new territory. I anticipate that the panel will give the inclusion of the patient perspective and the likelihood that research will influence clinical decisions significant emphasis in its work and that the priorities it develops will thereby break new ground and be of real importance for medical research, writ large, going forward.

In New England Journal of Medicine, Weill Cornell Researchers Advocate the Development and Implementation of Criteria for Elective Procedures, with Joint Replacement Surgery as an Example

NEW YORK (Dec. 26, 2012) — Many of the most common inpatient surgeries in the United States are performed electively. These surgeries are expected to significantly increase with the enactment of the Affordable Care Act. In a new perspectives article, published in the Dec. 27 edition of The New England Journal of Medicine, a team of Weill Cornell Medical College researchers are recommending the nation's health care leaders and medical community join forces to establish evidence-based appropriateness criteria to determine which patients are most in need of elective procedures, such as joint replacement surgery, to slow the projected surge in demand and rising costs. Currently, there are no appropriateness criteria for most of the common elective procedures.

Total joint replacement surgeries — such as hip and knee replacements — are among the most common inpatient surgeries in the United States and are used as a prime example of elective surgeries that could benefit from implementing appropriateness criteria. Patients requesting joint replacement surgery vary from those disabled by their joint arthritis to those who do so to maintain an active lifestyle without pain. Total joint replacement surgeries are expected to quadruple over the next two decades in the United States, contributing to the rise in health care costs and increasing the risk of medical complications.

"The purpose behind establishing criteria is to use evidence-based metrics to prioritize patients most in need," says lead author Dr. Hassan M.K. Ghomrawi, assistant professor of public health at Weill Cornell and an outcomes research scientist at Hospital for Special Surgery. "We don't want to sacrifice necessary care when thinking of cost-containment."

There were more than 1 million total joint replacement procedures performed in 2009. Experts predict that the number of these surgeries will grow drastically, exceeding 4 million by 2030, with more than half the patients younger than 65. The growing obesity epidemic, coupled with an aging population, is projected to fuel increased demand for total joint replacement surgery. These projections don't reflect the increase in the number of patients who will gain health insurance coverage under federal health care reform when the Affordable Care Act is fully implemented in 2014.

Current cost-containment proposals focus primarily on payment reforms, such as pay-for-performance and bundled payments. But in their perspective, titled "Appropriateness Criteria and Elective Procedures — Total Joint Arthroplasty," the authors posit that developing and implementing evidence-supported criteria that identifies the appropriate patients who are most likely to benefit from surgery will also slow the growing costs of these procedures.

"Identifying patients who are likely to benefit the most from these procedures could help to combat increasing health care costs while enhancing access and quality," says senior author Dr. Alvin I. Mushlin, the Nanette Laitman Distinguished Professor and chairman of the Department of Public Health and professor of medicine at Weill Cornell and public health physician-in-chief at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. "We believe that the case of total joint arthroplasty offers a prime example of the opportunities and challenges for appropriateness criteria."

"Although implementing appropriateness criteria for total joint arthroplasty has not succeeded in the past, there are reasons why it is more likely to work now," says co-author Dr. Bruce R. Schackman, chief of the Division of Health Policy and associate professor of public health at Weill Cornell. "Opinion leaders in the U.S. orthopedics community recognize the importance of such criteria, and health information technology has developed to allow more sophisticated appropriateness criteria to be integrated into decision-support tools."

According to the researchers, criteria will enable physicians to determine which patients' surgeries are medically necessary, which ones are elective, and which ones are inappropriate, and then tie reimbursement to the analysis. Procedures deemed truly inappropriate would then not be reimbursed by health insurers. The researchers believe this would decrease the number of inappropriate procedures performed, as only a minority of patients would be willing or able to pay out of pocket for them. A secondary, but just as important, result of appropriateness criteria is the potential to enhance the overall quality of care by increasing access to the procedure for those most in need and by preventing complications that might have occurred in operations that were inappropriate to begin with.

In order for the criteria to be successful and credible to physicians and patients and not limit necessary care, clinical opinion leaders and patient representatives must be involved in developing the guidelines, the researchers say. Also, although integrating appropriateness criteria into the reimbursement and care delivery systems could help "bend the cost curve," achieving savings will depend on acceptance of the criteria by physicians and patients. The researchers believe criteria generated for total joint replacement surgery could lead the way for other elective procedures, reducing their cost and enhancing quality of care.

"Evidence-based criteria, if applied wisely and fairly, may be the most powerful tool for controlling the cost and enhancing the quality of elective procedures," says Dr. Ghomrawi.

Weill Cornell Medical College

Weill Cornell Medical College, Cornell University's medical school located in New York City, is committed to excellence in research, teaching, patient care and the advancement of the art and science of medicine, locally, nationally and globally. Physicians and scientists of Weill Cornell Medical College are engaged in cutting-edge research from bench to bedside, aimed at unlocking mysteries of the human body in health and sickness and toward developing new treatments and prevention strategies. In its commitment to global health and education, Weill Cornell has a strong presence in places such as Qatar, Tanzania, Haiti, Brazil, Austria and Turkey. Through the historic Weill Cornell Medical College in Qatar, Cornell University is the first in the U.S. to offer a M.D. degree overseas. Weill Cornell is the birthplace of many medical advances — including the development of the Pap test for cervical cancer, the synthesis of penicillin, the first successful embryo-biopsy pregnancy and birth in the U.S., the first clinical trial of gene therapy for Parkinson's disease, and most recently, the world's first successful use of deep brain stimulation to treat a minimally conscious brain-injured patient. Weill Cornell Medical College is affiliated with NewYork-Presbyterian Hospital, where its faculty provides comprehensive patient care at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. The Medical College is also affiliated with the Methodist Hospital in Houston. For more information, visit weill.cornell.edu.

Weill Cornel Medical College-Qatar Students Honor Teachers

A dozen faculty members from Weill Cornell Medical College in Qatar and Weill Cornell Medical College were recognized by their students for making the greatest difference in their education.

The winners of the annual Medical Education Faculty Teaching Awards were announced during a ceremony in June.

"It would, of course, be nice to be able to honor every one of our teachers," said Dr. Javaid Sheikh, dean of Weill Cornell Medical College in Qatar who handed out the awards. "We have a faculty to be proud of at WCMC-Q who place their students first in everything they do. However, there have to be winners, and it is a privilege to see the esteem that these faculty members are held in by their students."

Winners

Pre-Clinical Curriculum
Molecules, Genes and Cells
Dr. Moncef Ladjimi

Human Structure and Function
Dr. Rachel Koshi

Host Defenses
Dr. Ali Sultan

Medicine, Patients and Society I
Dr. Ziyad Mahfoud

Brain and Mind
Dr. Leopold Streletz

Basis of Disease
Dr. Gerardo Guiter

Medicine, Patients and Society II
Dr. Ziad Kronfol

Clinical Curriculum

Clinical Clerkships and all 4th year courses (4 awards)
Dr. Thurayya Arayssi
Dr. Hassan Al-Amin
Dr. Marcellina Mian
Dr. Basim Uthman

WCMC-NY Visiting Teaching Faculty

1st Year
Dr. Estomih Mtui (HSF)

2nd Year
Dr. Estomih Mtui (BAM)

Clinical Years
Dr. Mark Pecker (Medicine Clerkship)

Additional awards and honors:

Dr. Jonathan Avery, Dr. Anna Dickerman and Dr. Alexander Harris, residents in the Department of Psychiatry, are members of this year's Cornell Mind Games. Mind Games is a resident competition in psychiatry, similar to Jeopardy, which took place at the annual meeting of the American Psychiatric Association on May 8. The 2012 team finalists were from NewYork-Presbyterian Hospital/Weill Cornell Medical Center, NewYork-Presbyterian/ Columbia University Medical Center and the University of Texas at Houston.

Dr. Madelon Finkel, professor of clinical public health, is co-hosted a conference on cervical cancer screening Aug. 18 in Chennai, India. Dr. Finkel is currently working with colleagues Dr. Rita Isaac of the Christian Medical College in Vellore India and Dr. Lyndal Trevena of the University of Sydney School of Medicine on a program to instruct local practitioners how to screen for cervical cancer. Anysley Duncan, a second-year Weill Cornell medical student, spent eight weeks in Vellore working on the cervical cancer screening project and helped organize the conference.

Dr. Judith Fontana, a postdoc in the laboratory of Dr. Mirella Salvatore, was awarded a Stony Wold-Herbert Fund fellowship and travel grant to attend the American Society for Virology meeting scheduled July 21-25 in Madison, Wis. The Fund is a privately-endowed nonprofit dedicated to assisting in the fight against all forms of pulmonary disease throughout greater New York. Stony Wold provides funding through research grants and fellowships to physicians and other health care professionals active in the pulmonary field.

Rev. Curtis Hart, lecturer in public health, psychiatry and medicine, has been invited to give the annual Heberden Lecture in the History of Medicine at the New York Academy of Medicine in September entitled "Franklin Delano Roosevelt: A Famous Patient." The lecture will focus upon President Roosevelt's therapeutic relationship with his doctor, Dr. George Draper, who treated his polio, as well as how the illness affected Roosevelt's character and leadership as president.

Dr. Mary Katherine Hayes, associate professor of clinical radiation oncology, was named president of the NY Metropolitan Breast Cancer Group in July for the 2012-2013 term. A multidisciplinary society whose members come from hospitals and medical schools in the tri-state area, the Group provides a forum for discussion and exchange of ideas on how to best promote and improve the quality of breast cancer care.

Dr. Yan Ma, assistant professor of biostatistics in public health, gave an invited talk in June entitled, "Recent developments in multivariate meta-analysis and a robust approach based on the theory of U-statistic" at the Applied Statistical Symposium in Boston. The International Chinese Statistical Association is a non-profit organization dedicated to educational, charitable, and scientific purposes.

Dr. Alvin Mushlin, chairman of the Department of Public Health, the Nanette Laitman Distinguished Professor of Public Health, professor of medicine and professor of public health; Dr. Yan Ma, assistant professor of biostatistics in public health; and Dr. Stephen Lyman, associate professor of public health, were invited to serve as grant reviewers for the Patient-Centered Outcomes Research Institute, which is authorized by Congress to conduct research to provide information about the best available evidence to help patients and their health care providers make more informed decisions. Its research is intended to give patients a better understanding of the prevention, treatment and care options available, and the science that supports those options.

Dr. Sandra Hurtado Rua, a postdoctoral associate in the Division of Biostatistics and Epidemiology in the Department of Public Health, was awarded a scholarship for expenses to attend the workshop, "Developing Statistical Methods for NeuroImaging," hosted July 24-26 at the University of California at Irvine. The scholarship comes from the National Science Foundation's Division of Mathematical Sciences, which supports a wide range of projects aimed at developing and exploring the properties and applications of mathematical structures. The goal o the workshop was to identify open problems in statistical research that emerge from current challenges in neuroimaging.

Dr. Mirella Salvatore, assistant professor of public health and assistant professor of medicine, was awarded the Feldstein Medical Foundation Research Grant, effective July 1, for the project titled, "Targeted vector delivery for rapid protection from infectious diseases?" The Foundation is a private foundation, created to promote and advance previously neglected areas of medical research.

Dr. Art Sedrakyan, associate professor of public health, presented at the U.S. Food and Drug Administration's advisory panel hearings June 27-28 to help doctors find ways to better monitor the risks posed by metal-on-metal hip replacements. Once lauded by industry and doctors as a groundbreaking orthopedic innovation, these devices have failed prematurely in thousands of cases, causing crippling injuries or requiring repeat surgeries.

Dr. Genevieve Yuen, a fellow in geriatric psychiatry at Payne Whitney in Westchester, was selected by the American College of Psychiatrists as one of this year's Laughlin Fellows. Each year, The College selects 10 third, fourth and fifth-year residents from the United States and Canada and pays for them to attend its annual meeting. The Laughlin Fellows are chosen from an elite pool of applicants deemed likely to make a significant contribution to the field of psychiatry.

Submit your awards and honors to WCMCAwards@med.cornell.edu.