Research

Health Policy Research Institute is dedicated to reducing disparities in the quality of care for chronic diseases. Among the projects the UC Irvine institute’s faculty and staff are involved in are:

Coached Care Intervention Studies »

An area of study pioneered by Drs. Sherrie H. Kaplan and Sheldon Greenfield is the improvement of patient health outcomes by increasing patient participation in treatment decisions for chronic diseases.

Kaplan and Greenfield, along with two HPRI health services researchers, Dr. Dara Sorkin and Dr. John Billimek, are testing whether Vietnamese and Hispanic community-based “coaches” with diabetes can be trained to administer an intervention that would help patients from their communities participate more effectively during office visits with their physicians.

This innovative research is being conducted at six Irvine outpatient clinics, and represents a potentially cost-effective approach to changing physician-patient interactions as a vehicle for improving patients’ effective management of their disease.

Relying on the creation of a partnership between patient, provider and community-based peer coaches to co-manage chronic disease in a culturally appropriate manner, this research has the potential for reducing the well-described disparities in the quality of diabetes care.

Originally funded by a $1.8-million grant from the Novo Nordisk Foundation, the research was recently awarded 5-year, $2.2-million grant from the National Institute of Diabetes, Digestive and Kidney Diseases.

Preliminary findings suggest that the coached care intervention, compared to the control group, appears to be effective in reducing and maintaining sugar control.  Multiple exportable products will result from this research, including training materials, in appropriate languages, for the coaches and audio tape confirmation of the effectiveness of the coach training.

Heterogeneity of Treatment Effects »

As the population ages, more patients have more than one chronic condition, often more than four such conditions.  To manage healthcare effectively for these patients, physicians, particularly those providing primary care for such patients, must often focus their efforts on the most severe or poorly controlled of these conditions.

Minority patients, who have more barriers to access healthcare services in general, are more at risk for suboptimal quality of care when having these complex constellations of chronic conditions.

Drs. Sheldon Greenfield and Sherrie H. Kaplan have been extensively involved in two aspects of the evaluation of complex patients and the impact of complexity on treatment outcomes:

  • assessing heterogeneity responses to specific treatments among patients with single and multiple chronic conditions in addition to the condition being studied
  • developing approaches to this complexity and its impact on treatment decisions

The first aspect was the subject of several publications and a  national symposium sponsored by HPRI, producing an April 2007 publication in the “Institute of Medicine Roundtable” (The Learning Healthcare System: Workshop Summary, Roundtable on Evidence-Based Medicine, Olsen, LA, Aisner D, McGinnis JM, Editors).

Kaplan and Greenfield also published a paper on comorbidity in “Diabetes in Annals of Internal Medicine,” showing widely diverse outcomes among patients with varying comorbidity, based on the Total Illness Burden Illness.

The second aspect was the subject of research on the impact of the Total Illness Burden Index (TIBI), a summary measure of complexity of multiple chronic conditions, on the decision to treat men with prostate cancer aggressively in the face of potential mortality from other conditions.  This study was conducted by a multidisciplinary team from HPRI in collaboration with clinical and health services research colleagues from UCLA, the RAND Corporation and UC San Francisco and was published in "Cancer" ( Litwin et al.)

Quality of Life Disparities »

Dr. Wenzel has over 20 years of experience developing health-related quality of life endpoints in national gynecologic cancer clinical trials.  The overall goal of Dr. Wenzel’s cancer control research program is to improve health outcomes and quality of life (QOL) for cancer survivors, and those at high risk for cancer.   To accomplish these goals, Dr. Wenzel’s team has successfully developed and tested the efficacy of biobehavioral interventions which have improved quality of life, psychosocial outcomes, and neuroendocrine and immune parameters for cervical cancer survivors, a particularly vulnerable cancer survivor population. 

In addition to this project, Dr. Wenzel also received a $1.9 million award from the Patient-Centered Outcomes Research Institute (PCORI) to create and study the use of a new, personalized approach to shared treatment decision-making for newly diagnosed ovarian cancer patients. Her team designed and is now testing a new, personalized approach to shared treatment decision-making for newly diagnosed advanced stage ovarian cancer patients. 

Dr. Wenzel is also working on a project to characterize the genomic, biologic and biobehavioral basis for long-term (LT) survivors of ovarian cancer, in order to assess the distinct features that distinguish LT survivors from short-term (ST) survivors.  This project will help determine the extent to which health-related QOL measures, additional patient-reported outcomes (PROs), and key CTCAE criteria predict LT ovarian cancer survival. The project will also assess the potential relationship between health-related QOL, PROs, and key CTCAE criteria with genomic features predicting disease recurrence. We hypothesize that LT survivors of OC have distinct features that distinguish them from ST survivors.

Improving the Performance of Individual Physicians in Chronic Disease Care »

Dr. Sherrie H.  Kaplan, a national leader in chronic disease care, is addressing the issue of creating reliable and valid approaches to the assessment of individual physician performance.

In a recently completed grant from the Commonwealth Fund, Kaplan developed an approach that combines evidence-based medicine with psychometric and statistical analytic techniques in a national diabetes quality-of-care database to yield an aggregate performance score that is highly reliable and can be used to discriminate between high, average and low performing physicians.

This study, described in the April 2009 issue of Medical Care, uses at least 25 patients per physician and data from more than 200 physicians in a nationwide sample. Kaplan has created an aggregate, evidence-based physician performance measure for quality of diabetes care.

In the successful conduct of this study, Kaplan formed a highly multidisciplinary team of statisticians, expert in cluster and latent variable analysis, clinicians, expert in evidence based medicine and quality measurement, stakeholders, from national medical societies and quality-of-care assessment organizations, and policy makers, including representatives of organizations involved in "pay-for-performance."

Her approach is currently being used by national accrediting and credentialing societies, including the American Board of Internal Medicine, to which she is providing assistance to generate appropriate recertification methods.

Locally, in collaboration with the UC Irvine Healthcare Quality of Care Office, this approach is being applied to provide UC Irvine physicians with individualized data in order to improve the quality of care they provide.  The diabetes registry, created as a product of the research described above, reflects Kaplan and Greenfield’s commitment to amplifying the value of research conducted at HPRI to UC Irvine, both in service and to create databases for research training in the new graduate programs in public health and clinical sciences.

Variations in the Quality of Care at the Five University of California Hospitals »

Dr. Sheldon Greenfield is the UC Irvine principal investigator for a project designed to evaluate and compare the quality, costs and outcomes of care for the five University of California hospitals.

Collaborating with investigators from UCLA, UC San Francisco, UC Davis, and UC San Diego, the investigators have set up statewide standardized data collection mechanisms for studying and establishing benchmarks for lowest cost, highest quality of care for congestive heart failure.

This study has compared the five hospitals’ care to these benchmarks and proposed organizational changes based on study results, in order to decrease variations and improve quality of care. It was published in the journal Circulation earlier this year.

Epidemiology and Infection Prevention »

Dr. Susan Huang’s research focuses on the clinical epidemiology of highly antibiotic-resistant organisms including estimating the risk for infection and assessing practical means for prevention.

Huang’s work involves studying the risks of healthcare-associated transmission of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE)  due to these pathogens within and beyond the hospital stay. Her scope of research also includes an evaluation of inter-facility spread and containment of these pathogens, including the intersection of preventative measures on hospital networks, affiliated nursing homes, and surrounding communities.

She has evaluated several strategies to mitigate transmission and disease, including active surveillance and institution of contact precautions, enhanced environmental cleaning, and, most recently, is leading a large national cluster randomized trial of three ICU strategies to reduce MRSA infection.

Huang has also built a population laboratory in a large metropolitan county in Southern California (Orange County, CA), the only one of its kind in the nation. She has performed detailed data collection across all hospitals and nursing homes in this county, including extensive details on inter-facility patient sharing, infection control practices, and ICUs, non-ICUs, and nursing homes estimates of pathogen burden in this county.  These detailed population data are the foundation for a dynamic transmission model of Orange County facilities and communities built through the National Institutes of Health's Models of Infectious Disease Agent Study (MIDAS) collaborative. This model will allow simulation of intervention strategies as well as prediction of future trends in transmission and disease burden for MRSA and other pathogens.

Beyond MRSA, Huang is broadly interested in the measurement and prevention of healthcare associated infections. She has evaluated more efficient ways to look at relative hospital rankings using administrative data, and has balanced this with rigorous in depth assessments related to accuracy and completeness of reporting.  She has specific interests in the use of automated hospital and claims data to assess pathogen clusters and surgical site infections.

Her work also includes the study of antibiotic resistance in streptococcus pneumoniae, and how serotype distribution and antibiotic resistance have been impacted by the licensure of the heptavalent conjugated pneumococcal vaccine.  She has recently characterized community level variables (e.g. population size, community antibiotic prescribing, and poverty) that predict the prevalence of pneumococcal carriage and penicillin-resistance over and above individual risk factors such as age, daycare, and recent antibiotic use.

Huang’s intent is to apply epidemiologic, statistical, and mathematical modeling methods to impact the way we monitor and intervene in the spread of bacterial infectious diseases and promote a career studying the spread and containment of antimicrobial resistant pathogens in healthcare and community settings.