Al-Refaie Leads Multidisciplinary Research Team

(Oct. 5, 2017) — Early next year, construction will begin on a new medical/surgical pavilion at MedStar Georgetown University Hospital, enabling Georgetown University Medical Center faculty and students to pursue cutting-edge research and education in state-of-the-art facilities.

The medical-surgical pavilion is symbolic of the relationship that GUMC and MedStar Georgetown have been building over time, encouraging collaborations between researchers and physicians. One of these collaborations has been led by Waddah Al-Refaie, MD, FACS.

As chief of surgical oncology at MedStar Georgetown University Hospital and Georgetown Lombardi Comprehensive Cancer Center’s surgeon-in-chief, Al-Refaie has deep expertise in cancer surgery care. However, to answer the research questions he was interested in addressing, he required a team of researchers knowledgeable in biostatistics, health finance and economics, public policy and law.

He was able to find those experts at Georgetown. Together, they have produced two publications on cancer care and health disparities with additional publications on the way, demonstrating the power and potential of team science and cross-campus collaboration.

“We have a wealth of intellectual capital here that can lead to fantastic research work,” Al-Refaie said. “I feel extremely blessed and fortunate to benefit from capable researchers who can answer these questions in a scientific manner.”

Building a Team

Before Al-Refaie even started working at Georgetown in 2013, he began identifying and connecting with researchers with whom he was interested in collaborating, including Thomas DeLeire, PhD, a professor in Georgetown’s McCourt School of Public Policy who has focused his research on health economics.

“This all started with a cup of coffee with Dr. DeLeire,” said Al-Refaie, who also serves as director of the MedStar-Georgetown Surgical Outcomes Research Center and the John S. Dillon Chair in Surgical Oncology at Georgetown. “We bounced some ideas about his areas of expertise and our areas of interest and where are the gaps of cancer surgery care.”

“I was delighted to meet Dr. Al-Refaie and to learn about his interest in forming a collaborative cross-campus research team to address some of today’s most pressing health policy questions,” DeLeire said.

Al-Refaie also spoke about collaboration opportunities with Nawar Shara, PhD, director of the department of biostatistics and biomedical informatics at MedStar Health Research Institute, associate professor of medicine and director of the biostatistics core at Georgetown-Howard Universities Center for Clinical and Translational Science.

Each of the team members brought their unique combination of experience, skills and subject matter knowledge to the collaboration, laying the groundwork for the research to follow. "The different backgrounds brought a lot of breadth and depth to the research," Shara said.

Developing Methodology

After brainstorming with the other research team members, Al-Refaie decided to study whether the Affordable Care Act would increase access to cancer surgery for minority patients. “Research is all about finding out whether initial results can be verified and whether there are unintended consequences,” Shara said. “We hypothesize that the Affordable Care Act might improve access but we don't know yet.”

Knowing that data showing the effects of the Affordable Care Act would not be available for years, the researchers looked at the 2001 expansion of Medicaid in New York. It was useful to study because the target population — nondisabled adults without dependent children — was similar to the population policymakers were trying to reach with the Affordable Care Act and it was one of the largest expansions of Medicaid before the Affordable Care Act in the country.

There are downsides to extrapolating potential effects of the Affordable Care Act based on data from the New York Medicaid expansion. Since the expansion took place 15 years ago, it’s difficult to tell what other factors may have had an impact on the data. It would also be challenging to determine whether patients may have simply sought care in neighboring states.

Additionally, since the Affordable Care Act also increased access to care through its subsidized health care exchanges, the effects of expanded Medicaid coverage on access to care could be different today than they were following the New York expansion. However, both of the populations affected by the New York Medicaid expansion and the Affordable Care Act are demographically and geographically diverse, increasing the relevance of the research.

Surprising Results

Using the New York State Inpatient Database, Al-Refaie and his colleagues studied the periods five years before and after the Medicaid expansion.

In a recent paper, the researchers studied how the New York Medicaid expansion affected access to high-quality hospitals. They found that the disparity in access to high-volume hospitals between patients with private insurance compared to patients with Medicaid and patients without insurance dropped 20 percentage points in the 21-month period after the expansion.

However, in the same time frame, racial disparity between African-Americans and non-white Hispanic patients, regardless of their insurance type, increased 18 percentage points at high-volume hospitals. “Low-income non-Hispanic whites may have been better able to obtain or take advantage of the benefits of Medicaid coverage when obtaining complex surgical cancer care,” the paper said.

In a previous paper, the researchers found that after the Medicaid expansion, the proportion of cancer surgeries paid for with Medicaid increased from 8.9 percent to 15.1 percent. Yet the researchers were surprised to find that the ethnic composition of patients who received cancer surgeries after the Medicaid expansion did not change. “This observation is of concern, because expansion of insurance for the poor should, in theory, benefit disadvantaged groups more than other groups and contribute to reducing disparities in health care access,” the paper said.

Both papers suggest that factors other than a patient’s insurance status may be responsible for racial disparities in surgical cancer care. “Increasing health insurance coverage — while increasing access to care overall — is clearly not sufficient for reducing disparities in access to care,” DeLeire said.

Future publications will address whether increased access to surgical oncology led to better outcomes for patients. “The overarching goal is to understand the impact of the Affordable Care Act and Medicaid expansion on cancer surgery care,” Al-Refaie said.

Secrets of Success

Several factors have contributed to the researchers’ successful collaboration. Team members meet and communicate frequently, prepare for meetings ahead of time and share goals, Al-Refaie said. They are also realistic about what they can and cannot accomplish, and know when to seek outside help.

“I believe interdisciplinary work, while challenging, is particularly important when addressing health policy questions,” DeLeire said. “Collaborating with Drs. Al-Refaie and Shara has been particularly successful because I believe we all have been able to learn from one another while also staying focused on our goals.”

When researchers from different fields come together, they should feel comfortable asking lots of questions, Shara said. “It’s okay to say, ‘I don’t understand,’ ” she said. “Once we get to that point, then the relationship will take off.”

In her role, Shara collaborates with colleagues frequently and adds that her experience working with Al-Refaie has been especially satisfying. “This is how I would envision a successful collaboration,” she said. “I predict that this collaborative model will be translated to other disciplines given how efficient and highly productive this collaboration is to all the parties involved.”

“Critical research questions can only be answered through team science,” Al-Refaie said.

Kat Zambon
GUMC Communications