By Rebecca Moragne, TuftScope Research-Highlights Editor
Dr. Keren Ladin is an assistant professor in the Tufts University Department of Occupational Therapy and the Department of Public Health and Community Medicine. She teaches classes in health policy, public health and medical ethics, health disparities, and research methods. Additionally, she is the director for the Research on Ethics, Aging, and Community Health Lab (REACH), where she carries out research focused on disparities in health policy. The REACH lab is currently pursuing several studies. The research is hoping to give a voice and support to those who are vulnerable in the health care system and close such disparities. Dr. Ladin’s passion for closing the health care gap is inspiring and the REACH lab is making incredible strides towards that goal. Below is an interview with Dr. Ladin regarding her research. The lab is bringing to light very important information that will certainly impact health care, particularly organ transplants. According to Dr. Ladin, any research is important research and that most definitely applies to her lab.
What kind of research are you doing right now?
“In the REACH lab we do research that is essentially at the intersection of ethics and health policy. And it is mainly related to question about how people make complex medical decisions and how resources are allocated with concern to vulnerable populations."
"So the topical areas in the studies that we have going now, one looks at transplantation and resource allocation in transplantation where organs are scarce and we have to make some rationing decisions. So what we are looking at is actually the impact of the social support criteria. In the United States, people cannot be listed for transplantation without adequate social support. It is a CMS [Centers for Medicare and Medicaid Services] guideline but CMS does not offer any guidance on how to evaluate social support or define it or how much weight it should be given on the transplant listing. There is a lot of variation between centers. Some centers exclude over 25% of their patients and some have never excluded anybody. And the patients that it affects also vary a lot. They tend to be of lower social economic status, patients with more dependence, and more limited resources. Our work has to do with looking at the efficiency of that criteria and why do we use it to begin with. Our research has demonstrated that it is really inefficient and not predictive of outcomes. And so it should not bear much weight on the listing decision. We have a national survey of clinicians that looks at the procedures… What we think of as procedural and distributive justice considerations. Procedural justice being how evenly is it affecting people across the different centers. If you were to look for a transplant in Massachusetts versus Texas, what is the likelihood that you would have similar treatment? And the second is a distributive concern. If you are affluent in this country or not, what is the likelihood that you would actually get listed? So we demonstrate that there is a significant variation based on those two factors. And we also look at the legitimacy. So we assess kind of to what extent do transplant providers feel that this is a fair consideration, to what extent do they feel this is discriminatory, and why do they use it. So that is some of the work that we are doing now and it is you know, mixed methods and part national survey and part a large qualitative project with in-depth interviewing of clinicians. So that is one area where we are doing a lot of work."
"Another area is looking at low-value care around end of life. In particular we are looking at older patients who have end-stage or advanced kidney disease. And we are looking at their choices to start dialysis. So for older populations, especially many with co-morbidities, dialysis is a marginal benefit, meaning that you could start dialysis or you could just manage yourself with medication and your survival would not be significantly different after age 75. Other countries outside of the U.S. do not actually dialyze people over 75 on the most part, but in the U.S. we dialyze people in to their 80s, 90s, and 100s routinely. And there are a lot of financial incentives associated with the dialysis systems, the companies, and surgical procedures in all of this. For patients, there have been many studies recently that have significant regret amongst patients for patients on dialysis because it is a life changing procedure. Basically three days out of each week they are dialyzed for about four hours a day. And many have fatigue associated with it and other kinds of burdens. So our research in that area is to look at patient perspective and also provider perspective in what is successful in the decision making process. So what do patients need to know when they are making these decisions? How do they end up on dialysis? If their preference is not to be on dialysis, are they being asked? How autonomous are they in the decision making process? How engaged? And with providers we are really looking at what incentives and what are their perspectives with success… We assume that most health care providers are well intentioned, they want to serve a patient but there are some question about how are they viewing success in this encounter, if their outcomes are contradicting patient preferences? So we study that. One qualitative study on that and a randomized control trial downtown, which is looking at the effectiveness of a decision aid on helping align people’s preferences with the treatment that they receive. So based on some of our research and research that others have done, identifying what factors and what types of information are important to people when they make these kinds of significant decisions. We have this decision aid, which they then engage and it should help them better align or ask more questions of their physician to better reflect their treatment. So we are testing that for the next year and a half at two centers: one here in downtown at Tufts and one in St. Elizabeth’s in Brighton.
We do some other work on social network analysis, looking at kind of how social networks and social connectedness affect people’s medical decision making. So we are looking at one study jointly with colleagues downtown looking at young-avid drug users and Hep-C medication readiness. Kind of who you know predicts where you will seek care, or if you seek care, or if you know about syringe exchange and things like that. That keeps us pretty busy… It is fun.”
What research are you most passionate about?
“It is hard to say, I think the research that you know I am passionate about is research where we feel like because of institutional factors or a variety of social factors certain voices have been silenced or certain communities have been disenfranchised. I think I am really passionate about research that can empower people to get the kind of care that they want and aligning people’s preferences, their goals of care, their treatment is really what motivates me. I think part of the disparity story that is so seldom discussed is the role of people’s social networks. We just do not think about it. We just think of all these individual level characteristics like you know your income, whether you are employed or educated, but we do not think of how people actually think of certain care. For most people, that has so much to do with who they know. And so that is kind of what motivates me is to really explore this hidden dimension of disadvantage.”
Is there research in your past that particularly stands out to you as particularly interesting or important?
“I think that really all research that I have done has fed in to this. I do not really believe in you know any kind of wasted research…I think the bigger question is are the research opportunities that you have teaching you a new skill or giving you a new perspective? I think as long as those are true than they are all worthwhile. For me, I think primarily my training as an undergrad… I had really interdisciplinary training in philosophy of science and medicine and neuroscience. And I think that that was really critical for me to be able to value and kind of understand the different types of data and argumentation that can come to bear on any of these issues. And then I did my doctorate work in network analysis, really like social networks. I am a real believer in interdisciplinary training, I think it is where the world is these days, and the more you get it at an undergraduate level, the better. And I came from a really disciplinary institution, University of Chicago. And it was one of the cross-cutting programs and it was really great, really really great.”
When you were an undergraduate student in college, did you see yourself where you are now?
“I do not know. I was always really interested in ethics and questions of what should be not just what is. And I think that was really you know motivating to me in terms of the organizations that I was involved in and the research and all of that. I think I was always slightly more worried about the pragmatics. So I do not know if I ever envisioned myself here, but I thought a lot about, you know, medical school or different types of science. I studied health economics and demography in graduate school. But I never let go of the ethics piece and I think I was lucky to wind up in a job that allows me continue to think about those things. I think these days it is a bigger niche than people realize.”
Moragne, R. Interview with Dr. Keren Ladin. January 31, 2017. Tufts University, Medford, MA.