Faculty Spotlight: Rita Redberg, MD
Although the US spends more per person on health care than any other country, Americans rank lower on life expectancy and other health measures than many other countries in the developed world.
"Much of that is because we spend a lot of money on very expensive technologies that don’t lead to better patient outcomes," said Dr. Rita Redberg, a cardiologist and health policy expert. "When I studied the issue more, I became convinced that some tests were not just wasteful, but also harmful, because they lead to unnecessary procedures where patients do not receive any benefit, but are only subject to harms."
Dr. Redberg grew up in modest circumstances in Brooklyn. Due to financial limitations, neither of her parents graduated from high school, and Dr. Redberg was the first in her family to attend college. "I was always taught not to waste things," she said. That early training helped her put herself through college and medical school, and has contributed to her longstanding interest in assessing value and waste in the health care system.
Dr. Redberg was always interested in math and science, and attended James Madison High School – alma mater of US Supreme Court Associate Justice Ruth Bader Ginsberg and Senator Bernie Sanders, among others. In her final semester, she was among the first students enrolled in City-as-School, an experiential learning high school that allowed students to have educational experiences all over New York City. "We got a bag of subway tokens every Monday morning, and one of the things I had chosen was to work at a hospital, shadowing doctors," recalled Dr. Redberg. "I decided medicine would be a great way to combine my interest in helping people with science."
She majored in biology at Cornell University in Ithaca, N.Y., then earned her medical degree from the University of Pennsylvania School of Medicine in Philadelphia. During medical school, she also earned a master’s degree from the London School of Economics, focusing on health policy and performing a cost-effectiveness analysis of heart transplant surgery in Great Britain and the US.
Her advisor in medical school, Dr. John Eisenberg, also had an interest in health policy. One of his research studies focused on whether he could change residents’ routine ordering of daily laboratory tests for hospitalized patients. "That really changed the way I looked at medicine," said Dr. Redberg. "Before then, I had never questioned whether someone who above me was ordering tests that might not always be necessary. You get information from any test, but is it meaningful, and does it actually change the way you manage that patient and lead to better outcomes?"
Dr. Redberg completed her internal medicine residency at Columbia-Presbyterian Medical Center in New York, and was applying to be a Robert Wood Johnson Clinical Scholar to pursue health policy. At the last minute, a cardiology fellowship position opened up at Columbia, and her professors encouraged her to take it.
"I said, ‘I like cardiology, but I am going to pursue health policy,’ and they said, ‘You can do health policy and cardiology!’" said Dr. Redberg. Because cardiology is a technology-intensive specialty, it was a good fit for her interest in technology assessment – evaluating how new technology is used in health care. "Some things you plan, and some things happen," she said. "Cardiology happened."
She completed advanced fellowship training in non-invasive cardiology at Mount Sinai Medical Center in New York and the UCSF Cardiovascular Research Center, joining the UCSF faculty in 1991.
Learning the Legislative Ropes
In 2003, Dr. Redberg spent a year in Washington, D.C. as a Robert Wood Johnson Health Policy Fellow. She and the other fellows spent several months meeting with key health care leaders in Washington and around the country, visiting the Centers for Disease Control and Prevention, the National Institutes of Health, state governments, private think tanks, and the Centers for Medicare and Medicaid Services. "It was a great year," said Dr. Redberg. "In my continued policy work in the last 15 years, often the people I meet are those I first met as a Robert Wood Johnson fellow."
As part of her fellowship, in January 2004 she began working as a health policy staff member for Senator Orrin Hatch of Utah, who was the chair of the Senate Judiciary Committee and a senior member of the Senate Finance Committee, which oversees Medicare. Among other issues, she helped research and develop legislation related to the US Food and Drug Administration (FDA), implementation of the recently passed Medicare Modernization Act, and stem cell research.
"I learned a lot about how the sausage is made," said Dr. Redberg. "One of the most educational but disappointing things was realizing that many patient advocacy groups weren’t representing patients. One of the first questions I always would ask is where their funding came from, and so often it came from industry."
She also learned the nitty-gritty of how legislation works, including the processes of rulemaking, appropriations and effective lobbying. For example, an FDA guidance is non-binding, whereas a requirement is compulsory. Understanding those nuances has proven invaluable to her later work in national policy, such as serving as a member of the Medicare Payment Advisory Commission, chairing the Medicare Evidence Development and Coverage Advisory Committee, and advising the FDA.
Dr. Redberg has a longstanding interest in policy around women and heart disease, which is the leading killer of women. Often, studies enroll few women, and investigators extrapolate their findings about drugs or devices from clinical trials that have mostly studied men. (The FDA currently has a guidance encouraging the inclusion of women in clinical trials, but not a requirement.) Yet women sometimes experience different side effects and outcomes in response to various drugs, and tend to bleed more from procedures and medications. She recalled one Medicare advisory committee meeting which was reviewing possible expansion of criteria for defibrillator placement.
"I noticed that the trial that was being presented as the basis for expansion had only 15 percent women, and it did not show any statistically significant benefit in women," said Dr. Redberg. "When I asked the principal investigator why there weren’t more women, he told me that women didn’t get heart failure. That was a real shame, because the Medicare population is over 60 percent women, but we were being asked to approve this device on the basis of a study that had been done in mostly middle-aged men."
Safety and Medical Devices
When Dr. Redberg returned from her Robert Wood Johnson Health Policy Fellowship, she focused much of her subsequent research on technology assessment and the evidence base and regulatory pathway for medical devices. "Because I’m an academic, I have a very strong belief that the best way to weigh risks and benefits is to have good evidence," said Dr. Redberg. "I have learned that we are often approving high-risk devices on the basis of little and sometimes no clinical data."
Along with colleagues and the medical students and residents she mentors, Dr. Redberg has published extensively on this subject. "We need stricter requirements for high quality data for safety and effectiveness of medical devices and drugs before they hit the market, and we also need to collect post-market data," she said. The bar needs to be even higher for implantable devices which cannot be easily removed from patients without risk, she noted.
"I hear the word ‘innovation’ thrown around a lot, but you can’t really know if something is innovative unless you’ve done clinical testing," said Dr. Redberg. She and former UCSF resident Dr. Sanket Dhruva, who is now a Robert Wood Johnson Clinical Scholar at Yale University, co-wrote a New York Times op-ed piece critiquing the 21st Century Cures Act, a Congressional bill which would further weaken FDA oversight of new medical devices. That bill passed the House, and is currently in the Senate.
In another area of research, Dr. Redberg serves as principal investigator of the FAMRI Bland Lane Center of Excellence on Second Hand Smoke, which studies the long-term effects of secondhand smoke on non-smoking flight attendants. It is supported by the Flight Attendant Medical Research Institute. She and her colleagues have collected more than a decade of data about this group, which includes about 400 flight attendants who used to work in smoke-filled airplane cabins. Study participants fill out an online survey, and can also come in to the Mission Bay clinic to undergo pulmonary testing.
Advancing the Conversation
In 2009, Dr. Redberg became editor of JAMA Internal Medicine (formerly the Archives of Internal Medicine). That year, the US Preventive Services Task Force released new guidelines on mammography screening, recommending that women ages 50 to 74 have biennial screening, replacing its earlier guidelines recommending that women have mammograms every one to two years starting at age 40.
The new guidelines sought to minimize the large number of false positives which can lead to unnecessary biopsies and other invasive procedures, while maintaining the same benefits of regular screening. (Conducting mammograms every other year has been shown to produce the same benefit as screening annually in patients without a family history of breast cancer or other additional risk factors.) The new guidelines were controversial, and set off unfounded accusations of health care rationing.
That backlash inspired a long conversation between Dr. Redberg and Dr. Deborah Grady, associate dean for Clinical and Translational Research. "We talked about how the reaction to that very scientific and evidence-based announcement was negative, and how we needed a whole public re-education process," said Dr. Redberg. "Right now, people think that if a little health care is good, then more health care is better, which is not always the case."
The two developed the idea for "Less is More," an ongoing series in JAMA Internal Medicine; Dr. Grady serves as section editor. The articles highlight areas of health care with no known benefit, and definite harm. Several articles have prompted the FDA to issue warnings about faulty drugs and devices described in the series.
One article by UCSF radiologist Dr. Rebecca Smith-Bindman found that radiation doses for the same diagnostic test varied widely at four different Bay Area hospitals, and even within the same hospital on different days. "That suggested that there was a lot of room for quality control, because everyone should be getting the lowest dose of radiation possible," said Dr. Redberg.
In the same issue, JAMA Internal Medicine published a study by researchers at the National Cancer Institute finding that from the computed tomography (CT) scans conducted in 2007, over the coming decades there will be about 29,000 excess cancers and 14,500 excess cancer deaths caused by the CT scans themselves. "And that’s just from the CT scans done in 2007," said Dr. Redberg. "While certainly some of these scans are life-saving, there are a huge number of deaths from medical radiation. A lot of those CT scans probably didn’t need to be ordered." Dr. Smith-Bindman testified in Congressional hearings held in response to the articles that JAMA Internal Medicine published on the subject.
In 2014, JAMA Internal Medicine also launched a series of perspectives called Teachable Moments, featuring articles by trainees that bring attention to the harms that can result from medical overuse, as well as from underuse of needed medical interventions.
"When we launched ‘Less is More,’ there were very few journals that were talking about the harms of medical care," said Dr. Redberg. "All of our editors share a vision of moving the conversation forward. We select only the highest quality science, and appreciate being able to publish articles that get people thinking and talking."
In addition to her role as editor and her own extensive publications in scientific journals, Dr. Redberg is interviewed frequently by the lay press, and serves on a panel of health care experts for the Wall Street Journal, for which she regularly contributes blog posts. Some of her New York Times op-ed pieces have been that publication’s most frequently emailed articles for days, and have generated hundreds of reader comments.
Training the Next Generation
Dr. Redberg has been a leader in encouraging more women to become cardiologists. In 1994, she and Dr. Michael Crawford co-founded an American Heart Association committee to increase the number of women entering the field, as well as the number of women in leadership positions.
She has mentored many trainees, and shares a few key pieces of advice with them. "It’s good to have a plan in mind, but to also be open to other ideas and opportunities that may come up," said Dr. Redberg. "Also, always publish what you’ve done – it’s important to write and express your ideas."
She and her husband, attorney David Larson, have two grown daughters, Anna and Rebecca. Dr. Redberg enjoys running and hiking, and does a wine country century bicycle ride each spring with her husband.
– Elizabeth Chur