D E P A R T M E N T 0 F H E A L T H@ E D U C A T I 0 N A N D W E L F A R E National Institutes of Health Division of Regional Medical Programs National Advisory Council on Regional Medical Programs Minutes of Meeting February 26-27, 1968 National Institutes of Health Conference Room 4 Building 31 DEPARTMENT OF HEALTH, EDUCATION AND WELFARE PUBLIC HEALTH SERVICE NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS Minutes of Eleventh Meeting 1/ I/ The National Advisory Council on Regional Medical Programs convened for its eleventh meeting at 8:35 a.m. on Monday, February 26, 19689 in Conference Room 4, Building 310.-National Institutes of Health, Bethesda, Maryland. Dr. Robert Q. Marston, Associate Director, NIH, and Director, Division of Regional Medical Programs$ presided for Dr. William H. Stewart, Surgeon General, who was unable to be present for all of the meeting. The Council members present were: Dr. Edwin t.Crosby Dr. James T. Howell Dr. Michael E. DeBkkey Dr. Clark H. Millikan Dr. Helen G. Edmonds Dr. George E. Moore (2/26 only) Di. Bruce W. Everist Dr. Edmund D4 Pellegrino Dr. John R. Hogness (2/26 only) Dr. Alfred M. popma Dr. mack I. Shanholtz Liaison members attending: Dr. Sidney Farber, NCI Council (2/26 only) Dr. J. Willis Hurst, MHI Council (2/26 only) Dr. A. Earl Walker, NINDB Council (2/26 only) 1/ Proceedings of meetings are restricted unless cleared by the Office of the Surgeon General. The restriction relates to all material subm"@tted for discussion at the meetings, the agenda for the meetings, the supplemental material, and All other official documents. 2/ For the record, it is noted that members absent themselves from the meeting when the Council is discussing applications. (a) from their respective institutions, or (b) in which a conflict of interest might occur. This procedure does not, of courses apply 6n bloc actions--only when the application is under individual discussion. -2- PUBLIC HEALTH SER7JICE MEMBERS ATTENDING Dr. Ernest Allen - Office of the Surgeon General Dr. R. G. BAsalyga - National Center for Chronic Diseases Dr. B. Hi Cole - Office of the Surgeon General Dr, Samuel Fox III - National Center for Chronic Diseases Dr. Joseph Gallsigher- Bureau of Health Manpower Dr. K. Kasuga - Bureau of Health Services Dr. E. P. Offutt - Office of the Surgeon General Mr. John L. Pendleton - National Center for Chronic Diseases Dr. William H. Stewart - Surgeon General Di. Francis Weld - National Center for Chronic Diseases OTHERS ATTENDING Dr. Lionel Bernstein - Veterans Administration Dr. J.H.U. Brown - NIH/NIGMS Dr. M. Bi Domald miss Pauline L. Stephan - NIH/NCI DRMP STAFF ATTENDING Mr. Stephan Ackerman - Associate Director for Planning and Evaluation Mr. James Beattie, Chief, Grants Management Officer Mr. Mick Cavatocchi Financial Management Officer Di. Burnet Davis - Assistant to the Director for Special Studies Mr. E. M. Friedlander - Associate Director for Communications and Public Information Dr. Louis S. Gerber Medical Consultant Mrs. Eva M. Handal C iit-t-ee Management Officer Mr. Charles Hilsenroth - Executive Officer Dr. Richard Manegold - Associate Director for Program Development and Research Mr. Maurice Odoroff Assistant to the Director for Health Data Mr. R. L. Peterson Chief., Planning Branch Mrs. Martha Phillips - Chief, Grants Review Branch Dr. A. M. Schmidt Chief, Continuing Education and Training Branch Dr. Margaret Sloan Associate Director for Organizational Lisiaon Dr. Richard Stephenson - Associate Director for Operations Mr. Karl Yordy - Deputy Director, DRMP Mr, Ira Alpert - Office of the Associate Director for Operations Mr. Robert Anderson - Office of the Associate Director for Operations Miss Sheila Beach - C-1, ittee Management Office Dr. Thomas Bodenheimer Office of the Associate Director for Operations Mr. Cleveland Chambliss Assistant Associate Director for Operations Mr. Peter Clepper - Grants Review Branch Dr. Veronica Conley Continuing Education and Training Branch Miss Cecelia Conrath Continuing Education and Training Branch Dr. Vo J. Coroilo - Office of the Associate Director for Operations Mr. Arthur Curry - Grants Management Branch Mrs, Elizabeth Fuller - Office of the Director Dr4 David Golde - Continuing Education and Training Branch Mr. LeRoy Goldman - Office of the Director -3- Mr. Robert Jones - Grants Review Branch Dr. John Hamilton - Officeof the Associate Director for Operations Mr. Loren Hellickson - Office of the Associate Director for Planning and Eva,14ation Mr. Arthur Hiatt - Office of the Associate Director for Planning and Eva:luation Mr. George Hinkle - Grants Management Office Dto Philip Klieger - Office of the Associate Director for Operations Mri Robert E. Lee - office of the Director Mrs. Patricia McDonald - Grants Review Branch Mr. T.J. McNiff - Grants Management Branch Miss M.J. Morrill - Continuing Education and Training Branch Miss E.J, Nelson Continuing Education and Training Branch Dr. R. M. O'Bryan - Office of the Associate Director for Operations Mrs. Suzanne Paul - Office of the Associate Director for Planning and Evattlation Miss Leah Resnick - Office of the Associate Director for Planning and Evaluation Mrs. Rebecca Sadin - Continuing Education and Training Branch i,irs. Jesse Salazar - Grants Review Branch Mrs. Judy Silsbee - Continuing Education and Training Branch Miss Jane Shouse Office of the Associate Director for Planning and Evaluation Mr, James Suter Continuing Education and Training Branch Mr. Lee Teets - Grants Management Office Mrs. Mary A. Teller - Office of the Associate Director for Planning and Evaluation Miss Charlotte Turner Continuing Education and Training Branch Mrs. Virginia Waller Office of the Associate Director for Operations Mr. Stepbhn Walsh - Office of the Associate Director for Planning And Evaluation I. CALL TO ORDER AND OPENING REMARKS Doctor Marston called the meeting to order at 8:35 a.m. II, ANNOUNCEMENTS Doctor Marston made general announcements about the Service Desk, and called attention to the statements on, "Conflict of Interest, " and "donfidentiality of Meetings.1' He also mentioned that the DRMP Conference Workshop, which was held on January 17-19, 1968, was a success. Dr. Helen G. Edmonds, Dean, Graduate School, North Carolina College, Durham, North Carolina, was welcomed as a new Council member. Dr. J. Willis Hurst, Professor and Chairman, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia$ a former RMP Council member, was also welcomed. Doctor Hurst is now the liaison member from the Heart Council, III. CONSIDERATION OF FL?FME 14EETING DATES The Council reaffirmed the following dates for future meetings: May 27-28, 1966 (All of these will be held in August 26-279 1968 Conference Room 4, Building 31, November 25-26, 1968 beginning at 8:30 a.m.) -4- IV. CONSIDERATION OF MINUTES OF NOVEMBER 1967 COUNCIL MEETING The Council unanimously recommended approval of the Minutes of the November 20-21, 1967, meeting as written. V. COMMNTS FPOYI LIAISON IIENBERS None of the liaison members had comments to make, VI. EXTENSION OF P.L. 89-239 The Bill requesting a five-year extension of this legislation has not yet been introduced in the Congress. We would anticipate that t is will occur shortly after the President's Health Message is sent to the Congress, and that Hearings will take place quite rapidly thereafter. The Draft Bill is still essentially as it was in our previous discussions and is based on recommendations in the Surgeon Generalls Report to the President and the Congress. This Bill contains an amendment with regard to the Veterans Administration participation in the Regional Medical Program; it does not contain provisions for construction authority* Copies of this will be sent the Council as soon as they are available* Representatives from many groups such as the APIA are in favor of supporting the Bill. VII. DISCUSSION OF DRAFT GUIDELINES The draft Guidelines have been forwarded for clearance. Mr. Robert Lindee, Assistant Dean Stanford University. has worked with us in the development of this revision, and the Council sub-Coxmiittee met in December in Chicago to discuss revisions. The draft Guidelines now constitute a faitly Iextensive reorganization of existing materials that were in the previous one. These were distributed to the 800 persons who attended our Conference Workshop in January, and a few minor comments have been received. They seem to have been accepted quite well by the regions. Discussion ensued concerning the sentence on page 28, item c. of the Guidelines, i.e., "Physician and dentist trainees may be reimbursed at a rate not to exceed $50.00 per day." It was further recommended that the words, "Stipend" and, "reimburse" be eliminated# Other questions to consider have to do with the amount of stipends to be payed and whether the specific dollar figure should be included, It was suggested that this be changed to, "For all health personnel there may be compensation in accordance with the maintenance with income which would have the effect..*" There is A new adrbss-the-board training policy which may or may not have an effect on this* VIII. INVOLVEMENT OF VETERANS ADI,@IINISTRATIONS HOSPITAL IN REGIONAL MEDICAL PROGRAM Dri Lionel Bernstein, Director of Research Servic6s, Department o Medicine and Surgery, Veterans Administration$ Washington, D.C. discussed certain provisions of recently acquired Veterans Administration authority under Public Law 89-7'05. This broadened authority permits the Veterans Administration to cooperate and coordinate its programs with other programs such as Regional Medical Programs in waye',which were previously precluded. Accordingly, the Chief Medical Dire-eV= of the Veterans Administration through the "Directorts Letter" (copy attached) intends to apprise the Veterans Administration hospitals, Domiciliary, and Outpatient Clinics of these facts and encourage them to further coordinate their programs with Regional Medical Programs. Mr. Yordy, Deputy Director, Division of Regional Medical Programs$, then discussed the rationale for and implications of section 107(b) of the bill which would, if enacted, extend the authorization for Regional Medical Programs. Section 107(b) would Authorize the use of Regional Medical Program grant funds in meeting the costs of participation in a Regional Medical Program by any Federal hospital. Mr. Yordy explained that while the effect of this section would in some ways be duplicative of the Veterans Administration authority under Public Law 0'9-785 it was necessary in that Federal hospitals,; other than those within the Veterans Administration be permitted to participate actively in Regional Medical Programs. IX. CONSIDERATION OF GRANT APPLICATIONS (a) New Applications 3 G02 R14 00013-02S2, Western New York (Buffalo) The Council recommends approval in the amount of $174,,909 for one year, as requested, plus appropriate indirect costs. Council was cognizant of the imediate need to further augment current program staff so as to assure maximum capability to meet present obligations, as well as future requirements in the area of program development. It was felt that adequate justification for additional staff was presented in the application and that the results of the site visit on February 5-6, reinforced this identified need. 3 G02 RM 00028-02SI, Alabama The Council recommends disapproval because this diffuse, poorly organized, document failed to describe objectives or project an impact on regional health care. Lack of approval by the Regional Advisory Grouplis a further major drawback. A major planning activity involves 10 sub-proj6ctg in veterans hospitals, including a heavy investment in equipment. It is hoped that involvement of VA Hospitals will continue, but in a way more in keeping with health activities for the entire regional population. Council agreed on the recommendation for disapproval after deciding that the application is not suitable for revision. Disapproval, however, should be construed as an encouragement to examine goals and priorities more closely, and to present them more clearly in an entirely new proposal. -6- 3 G02 RM 00031-02Sl and 5 G02 RM 00031-02,-Metropolitan Washington.D.C. The Council recommends approval in the time and amount requested of $256,089 for one year,, plus appropriate indirect costs, The Council felt that experience during the first planning year has demonstrated that the original projection of staff needs was unrealistic, The Council believes that coordinators are needed in each of the participating universities, the Health Department of the District of Columbia, and the Hospital Council of the National Capital Area. The Council also approved the staff recommendation that the second year planning grant be increased by $35,163. These funds ,will support a stroke project director, coordinating personnel at the D.C. Health Department, and Consultant services* 3 G02 RM 00044-02Sl, Maryland RIIP The Council recommends approval in the time and amount requested, less funds for renovation. The epidemiology And statistics center, as well as the stroke components of this application, were felt to hold particular promise as RMP activities. The amount requested was: $328,700 direct costs, plus appropriate indirect costs. 3 G02 RM 00045-02SI, West Virginia RMP The Council recommends conditional approval subject to a site visit for purpose of clarification of issues and to assist an encourage the region in its transition to the operational phase. Even though Council believed the proposals to be diffuse, they also f4Lt that the objectives are desirable even though the methods proposed are somewhat unusual. Certainly there was no doubt that this region is making a sincere effort to come to grips with its many problems, and it needs encouragement and assistance, The amounts requested were: $127,632, first year and $58,992, secon( year, plus appropriate indirect costs. 3 G02 RM 00046-02Sl, Georgia RMP The Council recommends conditional approval in the amount of $208,031 for one year as requested. Request for additional personnel is reasonable and consistent with staffing requirements for an actiire region about to Asam operational status. The Council condittAMe its recommendation upon assurance from the RMP that involvement of minority leaders and predominately Negro institutions is taking place,, and that the program being planned will include projects to benefit minority groups. -7- The Council also appro@d the use of $89,000 of funds unexpelided in the first year for a further necessary supplementto the core staff. I G03 RM 00006-01, North Carolina The Council recommends approval in the time and amount requested, conditioned upon reduction of the amount of compensation to be allowed for physician trainees in-the Continuation Education in Internal Medicine project to stipends of $1,500 per month. It was agreed that this was a well-conceived application which would consolidate planning activities and operational projects into one grant. Although several of the proposals are not directly related to the categorical diseases, they reflect regionwide cooperation in meeting locally developed priorities for health care resources, The amounts requested were: $l,2OOi9l6, first year; $1,317*129, second year; and $1.4164,203, third year, plus appropriate indirect costs. Doctor Edmonds absented herself. Two Council members disapproved. .1 G03 Fl-I 00012-01, Or@on The Council recommends approval in the time and amount requested with advice to the Region that assistance be sought from the College of Education of the University of Oregon for designing better evaluation of the project. The Oregon program has demonstrated impressive progress and is sufficiently developed to move into an operating program and the project is appropriate for support by PI-IP. The amounts requested were: $179,242, first year; $166,706, second year; and $174,204, third year, plus appropriate indirect costs. .1 G03 RM 00031-01, Wikshington, D.C. The Council recommends conditional approval for approximately $343,000. Projects one and two are to be supported for the time and in the amount requested of $276,098 for the first year; project three to be supported for two years only at a reduced level of approximately $66,902. No funds to be calculated in the award for project four. The projects included in the application are: 1. Freedmen's Hospital Stroke Station 2 Zer-ebrovascular Disease Follow-up and Surveillance System 3: Training Program for Cardiovascular Technicians 4. Home Telecasts of Medical-Suritical Conferences I The amounts requested were: $599,476, first year; $296,315, second year; and $158,447, third year, plus appropriate indirect costs. 1 G03 RM 00032-01, WICHE RMP The Council rec nds approval in the amount and time requested. The region is well organized and eager to focus on the solution of their problems. The staffing of intensive coronary care centers in small hospitals was identified by the region As of first priority and the region has approached its development in a competent manner, The University of Washington Medical Center @-hrough its consultants to the WICHE region, will continue to encourage and strengthen the program. The amounts requested were: $175,287, first year; $150,666, second year; and $153,3060, third year, plus appropriate indirect costs. 3 G03 RM 00002-OlSl, Kansas The Council recommends conditional approval of all five components of this application subject to a Council site visit to obtain further clarification and determine the amount to be awarded. The Council expressed interest in the over-all development of this program. The Council felt that this was a well planned group of projects which are worthy of support. The amounts requested were: $397,710 first year; $270,923, second year; and $248.,887, third year, plus appropriate indirect costs. 13 G03 RM 00009-OlS3. Missouri. The Council recommends deferral, pending a site visit, with return to the Review Committee and Council for final recommendation. Council members believe that both projects in this application need a site visit in order to clarify project objectives, local capability for accomplishing the proposals, and appropriateness of the requested budgets. Project development has apparently been successful in fostering cooperation between M.D.'s and D.O.'s in the stroke project. It seems likely that the proposed Cooperative Tumor Registry would expand a registry already in operation. In that case, the present functioning and utility of the registry should be described. The amounts requested were: $841,155, first year; $596,834, second year; and $610,962, third year, plus appropriate indirect costs. IX. CONSIDERATION OF GRANT APPLICATIONS (CON'_P-l (b) Request for Program Expansion in Non-Competing Applications Program expansion by using unexpended funds in the second year of the planning grant was included in the Metropolitan Washington, D.C., and the Georgia application shown above. In addition, the Council recommended -9- approval of the use of unexpended funds for the following based on the recommendation of the DRMP staff: 5 G02 RM 00043-02, Indiana The Program Coordinator has stated that an additional $23,500 will be essential to carry out the Flanner House studies. This will pay for personnel, equipment, and cost of laboratory tests. 5 G02 RM 00021-02, Northlands (Minnesota) The Region requested an expansion in thelevel of support in order to cover both the planning studies and the core staff which is now available, and will receive $81,200 to do so. 5 G02 RM 00048-02, Ohio Valley (Lexington, Kentupky) Based on recent discussion with the Region, the Program Coordinator.'s expressed need for an additional $40,000 was recommended for approval to support several additional positions for which candidates are now available. IX. CONSIDERATION OF GRANT APPLICATIONS (CON'D) (c) Report on, "Earmarked Funds" The Council Sub-Ci -littee met on February 25 and reviewed 2$ projects for earmarked funds. Upon presentation to the full Council, the following recommendations were made: CORONARY CARE Mobile Coronary care Units and Extension of the,_"State of Franklin"-_ North Carolina RMP. 1 G03 RM 00006-OlSl The Council recommends approval in the time and amount requested of $25,455 for one year, plus appropriate indirect costs. in recommending approval of this application the Council recognized the specific relationship to two other projects being undertaken by the region - coronary care units in small rural hospitals and training of coronary care unit managers - and to their over-all approach to regional- ization. Council emphasized their hope that some answers would come out of these projects which would help assessthe value of provision of specialized coronary care in very small hospitals widely separated throughout rural areas. Doctor Edmonds absented herself during the deliberation. -10- Western New York (Buffalo) RMP, 3 G03 RM 00013-OlSl The Council concurs with the Sub-Comitteels recommendation of deferral for Approval of this Mobile Coronary Care Unit because of the absence of approval by the Regional Advisory Group. North Carolina RMP, I G03 Rli 00006-01 The Council concurs with the Sub-Committee's recommendation of the following: Approval for one year of the Training of Unit Managers ($65,823), and Small Hospital Coronary Care Units ($93,019) plus appropriate indirect costs. Provisional approval was given for the Mobile Coronary Units ($16,985). In reconmnding approval of these three proposals,the Council recognized the relationships of these projects to ongoing programs and the rate of development within the Region. The cooperative arrangements and interrelationships between the projects were noted. It was also emphasized that mobile coronary care units and coronary care units in very small hospitals have not had sufficient study to prove their feasibility and that this was the proper time and program for such feasibility to be determined. Doctor Edmonds absented herself. Mobile Coronary Care Units, Ohio State RMP, 3 G02 RM 00022-OlS2 The Council concurs with the majority recommendation of the Sub- Committee for conditional approval in the time and amount requested pending complete local approval of the project by the Ohio State Regional Medical Program for $154,242 first year, plus appropriate indirect costs. In recommending this mobile coronary care unit project for provisional approval, the Council was aware that it had not yet received Regional Advisory Group approval. They recognized that this project was consistent with the intent of Congress regarding earmarked funds and Regional Medical Program goals. It was noted that the planning and evaluation techniques were not as sophisticated as those of another region and that this region and all regions withmnbile coronary care unit projects should work together and develop interrelationships. They believed that these suggestions would accomplish more effective programs for determining the feasibility of such projects and that the capabilities and expertise were available in this region to successfully undertake this project and overcome the project's shortcomings. One Council member opposed. Intermountain RMP, 00015 The Council concurs with the gub-Committee's rec(x=endations for disapproval under earmarked funds and that the projects listed below should be resubmitted for review with the other proposals in the complete applications: 1. Small Hospital Coronary Care Unit; 2. Mobile Coronary Care Unit. In disapproving these two projects the Council recognized their merit and suggested that they undergo the normal review process of the Regional Medical Program. They felt that these proposals were important to the over-all regional program and the continuity of the program would be best served by keeping all of the projects together for review. They were also concerned that the evaluation process 'was weak and would probably not measure the stated objectives. Rochester RMP, 3 G03 RM 00025-OlSl The Council concurred with the Sub-Committee's recommendation for approval in the time and amount requested pending submission of formal approval of the project by the local Regional Advisory Group for $73,676 first year plus appropriate indirect costs. This project is for training nurses as coronary care unit managers. The Council was satisfied-that this project was consistent with Congressional intent for earmarked funds and Regional Medical Program goals. Also, it was impressed that this project would satisfy the stated needs of the region, and that the necessary planning and expertise were available to accomplish the objectives. Iowa RMP-, 3 C02 Rm 00027-02SI, Training Unit Managers The Council concurs with the Sub-Cuumittee's recomendation for approval in the amount requested of $132,263 for one year, plus appropriate indirect costs. The Council believed this to be a well defined physician and nurse training course in coronary care techniques and unit management and to be relevant to regional development. The Council was impressed that this project would satisfy the stated needs of the region and that the necessary planning and expertise are available to accomplish the objectives. Albany RMP, Herkimer Hospital Coronary Care Project The Council concurs with the Sub-C itteels recommendation for approval for one year in the amount requested of $50,000. The Council was impressed that this project would satisfy the stated needs of the region and that Sufficient capability was available to accomplish the objectives. Doctor Moore absented himself. -12- California RMP The Council concurs with the Sub-Committee's recommendation for approval for one year in the amount requested of$42,393. In recommending approval of this proposal it was agreed that this physician-training program in coronary care is of high quality and would satisfy the stated needs of the region. WICHE RMP, I G03 RM 00032-01 Council concurs with the Sub-C- ittee's recommendation of approval of one year in the amounts requested as follows-. $175i287 - lst year $150,666 - 2nd year $153,306 - 3d year, plus appropriate indirect costs. The staffing of intensive coronary care centers in small hospitals, to which this project is addressed)was identified by the region as of first priority. The region has approached its development in a competent manner, The association of St. Patrick's Hospital with the Western Montana Medical Clinic is an asset, as are the physicians who will direct the activities of the training center. The Council was confident that the University of Washington Medical Center, through its consultants to the WICHE region will continue to encourage and strengthen the program. STROKE Missouri RMP, University of Missouri Intensive Care Unit The Council concurs with the Sub-C,li ittee's recommendation of deferral for site visit and then submission to Review C ittee and Council. This proposal will be considered in the "Missouri package" already under consideration (3 G03 RM 00009-OlS3). The following quest ons were raised: 1. What is the research-training-demonstration of patient care mix?; 2. Is the budget too high for what is proposed?; 3. What will be the real regional impact of this proposal? Cerebrovascular Disease Workshop, University of Minnesota The Council concurs with the Sub-Ce=ittees opinion regarding the project's high quality. The Northland Regional Medical Program had not expressed intent to support the project however and, therefore, recommendation for approval was precluded. It was ;uggested that the proposal be returned to NINDB. -13- Missouri RMP, Western Missouri Cerebrovascular Diagnostic Center The Sub-C@ littee believes this proposal to be only a slight revision.. of a similar proposal rejected by the Council one year ago. However, the Sub-C ittee felt that Kansas City needed some support, and, therefore, an attempt should be made to fund the project. It was recommended that the project be approved conditionally on the approval of, and in the amount decided by a site visit team, The Council questioned whether the site visit team should be given final authority to make a decision on this project, which was really a research oriented proposal rather than a primarily patient-care program. After some debate, the Council reccxmended that a site visit be made, and that the project, with the site visit reports be submitted to the Council for mail vote. California RMP.(San Francisco), 3 G02 RM 00019-02Sl The Council recommends deferral for additional clarification and information. The Council felt that it should recommend deferral until the local Regional Medical Program can conduct a full review of the proposal. The Council recognized the merits of the proposal but was concerned that the proposed fit into the over-all San Francisco planning process. Specific questions concerning the large items for renovation and the relationships of the NINDB grant were raised. North Carolina RMP, Comprehensive Stro@ Program It was felt that this proposal was vague* and that is showed little indication of fulfilling its stated objectives# The Council cnncurs with the Sub-C-r-iitteels recommendation of disapproval. Doctor Edmonds absented herself. Northeastern Missouri RMP (Kirksville) The Council concurs with the Sub-C@ittee's recommendation of deferral for site visit and then submission to Review Committee and Cauncil. This suggested, in order to obtain more information, and define more realistic program funding for the Region. The specific items which need further elaboration that were asked by the Council are: 1. The neurological capabilities in the project were not adequately demonstrated; 2. Is there a relationship to the Missouri Regional Medical Program and can the University of Missouri be a source of consultation for the Northeast Missouri Project. There was questions as to the amount of time the Project Director w@ld spend for the project and the 10% listing was not considered -14-A adequate for the over-all scope of the eroject. Another question was the low budget in the light of various comprehensive projects included within the grant application. Metropolitan D.C, RMP, George I,-Tashington University Comprehensive Hos2ital and Home Care of the Stroke Patient The Council concurs with the Sub-cr itteels recommendation of deferral until the next meeting of the Sub-Ccnmiii-ttee. This was necessary because the Sub-Committee had not had the opportunity to study this proposal before its meeting. 1,4etrop@itan. D.C., RI-4P Preedmen's Hospital Ftroke Stati2n The Council ctmcurs with the Sub-Committee's recommendation for approval in the amounts requested of $188,851, first years $126,379 second year, plus appropriate indirect costs. Metropolitan D.C. RMP, Comprehensive Stroke Care Program The Council concurs with the 8ub-Committee's recommendation of deferral until the next meeting because there had not been an opport- unity to study this proposal before the meeting. Mississippi RMP, Stroke Intensive Care Unit The Council concurs with the recommendation of the Sub-Committee that this Project was worthy of support because of the great need for improved stroke care in Mississippi. However, funding of the $'93,000 budgeted for hospitalization costs was disapproved because the members fslt that this would create a dangerous and expensive precedent. Illinois RMP (Chicago), 3 C02 Pll 00061-02 The Council recommends deferral for additional clarification and information until the local Regional Medical Program could cmnduct a full review of the proposal. The Council remarked on the attractiveness of the concept of involving several community hospitals in a stroke project. Reservations were expressed about the single focus of rehabilitation of the project and its relationship to the over-all stroke program of Illinois PIIP. A specific question concerning the details of the support of the various stroke committees was asked. Mississippi Palip.-Comprehensive Stroke Detection and Treatmeni The Council concurs with the Sub-Committee's recommendation of approval for two years in the amounts requested of $278,039 first year; and $174,432 second year, with the deletion of funds for hospitalization of $134,,964 first year, plus appropriate indirect costs. The Sub-Committee for Earmarked Funds agreed that this is a reasonable appreach to a very great need in the Mississippi region. It is recognized as a straightforward service program for admission and referral, but appears to have a strong training aspect. The project is an extension of the presently funded feasibility study and will serve as a strong base for operational projects for stroke control in the area. Doctor Crosby abstained from voting. Texas RMP, Stroke Detection and Treatment, 3 G02 RM 00007-02Sl The Council concurs with the Sub-CoL=itteels recommendation for approval for one year in a reduced amount of $240,499, plus appropriate indirect costs. All were favorably impressed by this project. They were, however, unanimous in their opinion that the bed costs should not be supported from Regional Medical Program funds. There was discussion of other grant support to this institution for activities relating to, this project and staff was directed to check with other granting agencies to be reassured that there is no duplication of program or of funding. Doctor DeBakey absented himself. X. APPLICATIONS WHICH WERE CONSIDERED AT THE NOVMER COUNCIL MEETING AWARDED APPLICATION NUMBER REGION I G02 R-@l. 00063-01 Northwestern Ohio (Toledd) 1 C02 R:@, 00064-01 NortheAstern Ohio (Cleveland) 2 G02 R-@@ 00035-02 South Carolina 3 G02 RY 00013-02Sl Western New York (Buffalo) 3 Cr,2 RI,,! r)0023-02SI Oklahoma I C03 RI-I 00018-01 Tennessee Mid-South 1 ('@03 P14 00025-01 Rochester, New York 1 G03 RM 0003'0-OIR Washington-Alaska 3 G03 RM 00015-OIS2 (Project 2) Intemountain DISAPPROVED 3 G03 RM 00009-OIS2 Missotivi 3 G03 RM 00015-OlS2 (Project 1) Intermountain XI. CONTRACT FOR HEART STUDY--PROGRESS REPORT ON IMPLEMENTATION OF SECTION 9,,J7 The Division of Regional Medical Programs has the responsibility for implementing Section 907 of P.L. 89-239, which states that: "Th6 Surgeon General shall establish, and maintain on a current basis, a list or lists of facilities in the United States 6quipped and staffed to provide the most advanced methods and techniques in the diagnosis and treatment of heart disease, cancer, or stroke, together with such related information, including the availability of advanced specialty training in such facilities, as he deems useful, and shall make such list or lists and related information readily available to licensed practitioners and other persons requiring,such information. To the end of making such list,or lists and.'other,,information most useful, the PuZ&eon General *hall from tire to: time colxsu-lt wit4t .intr,rmted. national professional organizations. To carry out this responsibility in the field of cancer, discussions were held with experts in the diagnosis and treatment of cancer, with officers of interested professional organizations and with the Director of the NCI. Acting on their advice, the Division negotiated a contract with the American College of Surgeons whose C4ncer Commission includes, in its recently expanded membership, representatives of those professional organizations which could make a significant contribution. Under this contract, the American College of Surgeons has conducted a study to determine how the requirements of Section 907 can best be carried out in the field of cancer. They have established an expert committee composed of representatives of the professional organizations represented on the Cancer Commission, with the addition of appropriate additional societies and associations, and have pursuaded Dr.- arren Cole to serve as Chairman. That committee on the basis of its collective experience and the detailed study of a number of different types of hospitals and cancer institutes, is preparing to make recommendations to the Division of RMP concerning the requirements for staffing, equipment, and organizations which are needed in a medical facility if it is to provide the highest quality of diagnosis and treatment (including rehabilitation) in the field of cancer. While no decision can be made on the use of such recommendations until they have been studied, a primary goal will be to make such information Available to the hospitals and Ri4P staffs in each region as a guide to the improvement of their facilities. We now are contacting national organizations such as the American Heart Association, the American College of Cardiology, the American College of Surgeons, the American College of Physicians, the American Academy of Pediatrics, the American Medical Associatian, the American Hospital Association and others to determine whether they would be willing to participate in a joint effort to advise the Division as to the most how the requirements appropriate response to Section 907 in the field of heart disease--and shortly, will initial similar negotiations in the field of stroke. A follow-up report will be presented at the May 27-28, 1963, Council meeting. XII. DEVEkOP14ENT OF THE HEALTH POLICY RESEARCH CONTRACTUAL PROGRAM At the February Council meeting Mr. Ackerman discussed the nature of the proposed Health Policy Research Contract being developed by the Division. The basic policy of the study is to determine, through an assessment of the program's activities, RM.Pls actual and potential impact on the Nation's health care system. -17 - The specifications that were sent to the five firms selected to receive requests for proposals were divided into five general study areas which the Division Contracts Cr, 'ittee felt were of primary importance to the program at this stage of its development. The five areas were: (1) Regional Medical Programs as an Instrument for Regionalization of Health Care; (2) Evaluation of RMP in terms of the Accomplishment of the Purposes of P.L. 89-239; (3) Evaluating RMP in terms of the Ultimate Goal of Improved Patient Care; (4) the Economics of Regional Medical Programs; and (5) Division of Regional Medical Programs--Regional Relationships, This delineation of topics was made with the knowledge that there would be overlapping aspects of these areas, and that each area of study was of relatively equal importance. In addition, they are not meant as the definitive boundaries of the study, but are the core to the development of the study. For these reasons then, it is clear that one contractor would undertake the entire contract. The pvoposed contract period is to run two years because the complexity of the problems posed in the specifications and the description of work does not admit to a realistically shorter project period. The Council expressed some concern lest the study involve the evaluation of individual Regional Programs by an outside group rather than providing the Division and Council with information ' insights, methodology, and possible criteria for their evaluation of the progress of Regional Medical Programs. It was agreed thatthe Division would keep the Council informed as to the further development of the contract, which it is anticipated will be awarded around the first of June. XIII. ADJOURNMENT The meeting was a4journed on February 27, 1968, at 10:30 a.m. ARTAC I hereby certify that, to the best of my knowledge, the foregoing minutes and attachments are accurate and complete. Robert Q. Marston, M.D. Associate Director, NIH, and Director, Division of Regional Medical Programs Eva M. Handal Committee Management Officer, DRMP NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS Edwin L. Crosby,, M.D. (71) James T. Howell, M.D. (68) Director Executive Director American Hospital Association Henry Ford Hospital Chicago, Illinois 60611 Detroit, Michigan 48202 Michael E. DeBakey, M.D. (68) Clark H. Millikan, M.D. (68) Professor and Chairman Consultant in Neurology Department of Surgery Mayo Clinic College of Medicine Rochester, Minnesota 55902 Baylor University Houston, Texas 77025 George E. Moore, M.D., Ph.D. (68) Director, Public Health Research Uelen G. Edmonds, Ph.D. (71) New York State Department of Health Dean, Graduate School Roswell Park Memorial Institute torth Carolina College 666 Elm Street Durham, North Carolina 27707 Buffalo, New York 14203 MAILING ADDRESS Edmund D. Pellegrino, M.D. (70) Director of the Medical Center P.O. Box 432 State University of New York Durham, North Carolina 27707 Stony Brookp New York 11790 Bruce W. Everist, M.D. (71) Alfred M. Popma, M.D. (70) Chief of Pediatrics Regiona Director Green Clinic Regional Medical Program 709 South Vienna Street 525 West Jefferson Street Ruston, Louisiana 71270 Boise, Idaho 83702 John R. Hogness, M.D. (70) Mack 1. Shanholtz, M.D. (70) Dean, School of Medicine State Health Commissioner University of Washington State Department of Health Seattle, Washington 98105 Richmondg Virginia 23219 EX OFFICIO MEMBER Dr. William H. Stewart (Chairman) Surgeon General Public Health Service 9000 Rockville Pike Bethesda, Maryland 20014 May 1968 c 0 p y VETERANS ADMINISTRATION Department of Medicine and Surgery WASHINGTON, D.C. 20420 Your File Reference: In Reply Refer To: 15 CHIEF MEDICAL DIRECTOR'S LETTER NO. TO Directors of Hospitals, Domiciliary, and VA Outpatient Clinics, and Managers of Regional Offices with Outpatient Clinics SUBJ: To clarify relationships between the Veterans Administration and the Regional Medical Programs of the Public Health Service, and to provide guidelines for implementation of VA participation in those Programs 1. The General Counsel's Office of the Department of Health, Education and Welfare has recently offered an opinion regarding the degree of participation of Federal facilities in Regional Medical Programs which now allows clarification of potential VA involvement in those programs. Title IX of the Public Health Service Act, "Education,, Research, Training and Demonstrations in the fields of Heart Disease, Cancer, Stroke, and Related Diseases," (PiL. 89-239), is the basis for the establishment of the Regional Medical Programs (RMP). The purposes of the RMP will be effected via the grant mechanism. RMP grants are to encourage and assist in the establishment of regional cooperative arrangements among medical schools, research institutions, hospitals, and other medical institutions and agencies -- to make available the latest advances in the diagnosis and treatment of these diseases. Grant funds will supports through these cooperative arrangements, research, training (including continuing medical education) and related demonstrations of the highest standards of patient care. Through these means the Programs are intended to improve generally the health manpower and facilities of the Nation.* 2. The Regional Medical Programs have an important role in effecting cooperation among essential elements of health resources in a region to overcome fragmentation and insularity and thereby obtain the beat use of complex, specialized, expensive and rare resources required for pat@t care, education and training, P.L. 89-785,, section 203 authorizes the Administrator of Veterans Affairs and the Secretary of Health, Educat on and Welfare to coordinate to the maximum extent practicable programs carried out under the Heart Disease, Cancer and Stroke Amendments of 1965 (Title IX of the Public Health Service Act). Involvement of VA hospitals in the Regional Medical Programs can contribute to the missions of bothi The described goals of the Regional Medical Programs can be considered as an expanded version of similar goals toward which the VA hospital system has moved during the last 20 years. Via affiliation with medical and dental schools the VA has sought to extend the highest quality of the See Guidelines, Regional Medical Programs, DHEW, PHS, NIH, June 1967. -2- c 0 p y interrelated research,, education and patient care activities of academic centers into its hospitals. The recent extension of the VA mission via the exchange of medical information section of P.L. 89-785, emphasizes the need to extend these medical center qualities into the remote unaffiliated VA hospitals as well. The many comon goals of the VA and the RMP warrant closely related programs. 3. Discussions with the Division of Regional Medical Programs have clarified the potential of relationships with the VA$ and have allowed development of the following guidelines: a. An eligible grantee (the grant recd.@10-attat a non-VA institution under an approved Title IX operational grant, may include in his proposal (and budget) activities in which local VA hospitals might be utilized and receive appropriate reimbursement for those activities. utilization of such funds must be for cooperative activities for whose performance the VA has authority. b. The authority for the VA to enter into cooperative sharing and exchange of use agreements has been clearly delineated (see Circulars 10-67-86; 10-67-145; and the Chief Medical Director's Letter No. 67-61). Because appropriate use of such agreements to reach full utilization of VA specialized medical resources will result in significant improvements in the DM&S patient-care mission, VA Central Office policy has been to encourage their Implementation (CMD's Letter No.68- ). Exchange of use agreements allow both the VA hospital and the non-VA institution to provide better care for their respective patients. Such agreements also provide the VA and other institutions with means deliberately to plan location of various specialized medical resources within the institutions so as best to meet the needs of all. c. It must be recognized that the contribution of RMP funds to VA installations must be demonstrated to result in benefits to the Regional Medical Programs separate from and/or in addition to those to VA missions. At the local planning and operational levelss the provision of RMP funds for VA equipment, supplies minor improvements,, personnel, etc*, must be accompanied by a clear flow into components of the RMP of an additional output which otherwise would not have occurred, i.e., the use of specialized VA facilities by the RMP for patient care demonstrations, for research,, or training of individuals at levels beyond those which would have resulted from VA funding alone. Demonstrations of patient care using non-veteran patients could be provided in VA facilities via agreements for sharing of incompletely used VA resources (Circular 10-67-86), agreements for exchange of use of specialized medical resources (Circular 10-67-145). or by contract with the RMP grantee, Via these mechanisms,, RMP funds may be provided to VA institutions (in accordance with existing VA regulations) for investigators' or trainees' salaries, equipment, supplies, minor alterations and renovations, and indirect costs pursuant to the general rules and regulations of the PHS. -3- c 0 p y ,d, For specific participation of a VA hospital in a Regional Medical Program application for funds would be made to the grantee institution. The professional, administrative, and fiscal responsibilities for RMP funds used in VA facilities will lie with the RMP grantee institution, in this same fashion as for other components of a Regional Medical Program. The administrative details for the reimbursement to the VA of such funds is the subject of a forthcoming budget letter. The individual Regional Medical Program with the VA Hospital Director and Deans C- ittee must negotiate potential agreements which provide mutually acceptable benefits to their respective programs. Details of planned VA participation in a Regional Medical Program will be submitted by the Hospital Director to the Chief Medical Director for approval. H. M. ENGLE, M.D. Chief Medical Director ASSIGNMENT SHEET AND INDEX NATIONAL ADVISORY COUNCIL ON REGIONAL MEDICAL PROGRAMS February 26-27, 1968 Application Number Region Planning Supplement: Dr. Hogness Western New York Dr. Shgnholtz 3 G02 RM 00013-02S2 (Buffalo) Dr. Howell rosby 3 G02 RM 00028-02SI Alabama Dr. Hogness Dr. DeBakey Dr. Millikan 3 G02 RM 00031-02Sl Metropolitan WashingtOr4 Dr. Crosby D.C. Dr. Edmonds Dr. Everist 3 G02 RM 00044-02SI Maryland Dr. Edmonds Dr. Shanholtz 0 Dr >4 3 G02 RM 00045-02Sl West Virginia Dr. Millikan Dr. Everist Dr. Moore 3 G02 RM 00046-02Sl Georgia Dr. Popma Dr. Hogness New Operational: Dr. Shanholtz North Carolina Dr. Hogness I G03 RM 00006-01 Dr. Everist Dr. Popma 1 G03 RM 00012-01 Oregon Dr. DeBakey Dr. Pellegrino Dr. Millikan I G03 RM 00031-01 Metropolitan Washington, Dr. Crosby Dr. Edmonds D.C. Dr. DeBakey I G03 RM 00032-01 W.I.C.H.E. Dr. Ever at Dr. Moore Dr. Howell Operational Supplem6nt. Kansas Dr. Moore 3 G03 RM 00002-01SI Dr. Popma Dr. Pellegrino 3 G03 RM 00009-OlS3 Missouri Dr. Howell r. Crosby 2/12/68