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Randall W. Rupper

Rupper

Randall W. Rupper, MD, MPH
randall.rupper@hsc.utah.edu

Cancer Center Bio


Selected Achievements

Development of multiple module caregiver vignettes for dementia caregivers

Multi-year funded shared care planning/ care coordination project

Governor Appointee to the Utah Digital Health Services Commission

My early interest in science was reinforced by a series of research experiences working under the mentorship of successful bench scientists through college.  When I arrived at medical school, I was ambivalent about whether I ever wanted to work directly with patients. The culmination of my laboratory experience came as I applied for and received a grant from the American Heart Association to work in the immunology group led by Dale Umetsu at Stanford. Creating and using fusion proteins to modify immunologic responses was fulfilling work. However, during my final two years of medical school I became even more intrigued by the narratives I was hearing from patients in my clerkships, and I decided to pursue an internal medicine residency. 

As a resident, I felt compelled to understand the contradictions I saw in our medical system. I was especially influenced by my rotations at Harborview in Seattle. This medical center is both a level-one trauma center and a county hospital, bursting with the latest life-saving technologies, but filled past capacity by people who are hospitalized because they lack access to basic primary care. I was fortunate to interact with clinicians who were also health services researchers studying these issues. They steered me to the Robert Wood Johnson Clinical Scholars Program at the University of North Carolina, where I also spent two years completing an MPH at the School of Public Health. This training was transformational. In addition to meeting my goal of learning new methodologies and techniques, I also learned that accomplished health services researchers used hypothesis driven experimental approaches similar to my basic science mentors.

At North Carolina I deepened my interest in access to care, including barriers to access faced in rural communities.  Collaborating with Dan Blazer at Duke, I analyzed a large epidemiological data set that had tracked community dwelling elders for ten years. We focused on self-reports of decisions to seek care and determined the longitudinal connections of these decisions to health outcomes. Because of intentional sampling, these results were stratified according to a relatively equal representation of urban and rural elders.

The major finding of this analysis was unexpected and it has strongly influenced both my continuing interest and evolving conceptual models. Elderly patients’ reports of delayed care did not predict adverse outcomes. In fact, in many models, patients who reported that they did not receive timely care actually had improved survival. This finding persisted even after adjustment for the presence of chronic diseases that increased both adverse outcomes and reports of delayed care.

Our findings point toward two possible explanations:  1) At a community level, timeliness of seeking care may not have a positive impact on mortality or functional decline in elderly patients and/or 2) Self-reported assessment of the timeliness of seeking care may not accurately reflect the actual timeliness of care-seeking. Our data did not allow us to differentiate between these possibilities, but I was compelled to consider the dynamic process of deciding to seek care. For instance, before an elderly individual can report that care was delayed, they must first decide that care from a physician is needed.  Our results could be explained if patients struggle at the level of assessing their need for medical attention.

Since that time, my focus has been on developing models of care that support aging rural patients and their families in deciding the best strategies for assessing and addressing care needs in their own homes and communities. At HCI, this work has involved using lay patient navigators, working within their own rural communities in the Intermountain West, to improve the ability of older Native Americans to access cancer screening, diagnosis, and treatment.