Research

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.

For more information on the Coached Care Project >>

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:

• The assessment of 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 just 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.)

Dr. Lari Wenzel is studying the differential effects of gynecologic cancer disease and treatment on minority patients’ health and quality of life outcomes.

Her research is focused on a newly recognized period of heightened policy relevance, following initial cancer treatment (see the Institute of Medicine’s report, Lost in Transition), and on gynecologic cancers with certain tumor types that are more prevalent among racial and ethnic minorities (e.g., cervical cancer). 

As effective cancer treatments lead to increasing cohorts of ‘survivors’, cancer has begun to resemble a chronic disease in its management, requiring effective follow-up and long-term monitoring for recurrence as well as treatment.

Wenzel’s research has been instrumental in demonstrating the need to understand the differential impact of disease and treatment on minority cancer survivors, particularly as it creates physical, psychological, and social stress that places these patients potentially at risk for further negative health consequences. 

Her research has driven the emerging field of study to link quality of life with access, quality and costs of care, in order to obtain a more complete and comprehensive elucidation of cancer survivorship among underserved survivors. 

Her work on the incorporation of patient-reported outcomes into the design of clinical trials has gained national and international recognition. Her recent National Cancer Institute-funded award, a five-year, $3.2-million grant, is designed to test the efficacy of a novel telephone counseling intervention in order to improve the quality of life of cervical cancer survivors throughout Southern California. 

Dr. Dara Sorkin is a research psychologist and associate adjunct professor of Medicine at HPRI.  In addition to her work with Drs. Sherrie H. Kaplan, Sheldon Greenfield and Ngo-Metzger, Dr. Sorkin is studying the differences in the nature of social support networks among Vietnamese and Hispanic patients seen at UC Irvine Medical Center outpatient clinics, and studying the relationship of those differences to effective disease management for diabetes. 

Her novel approach, which included the primary care physician as part of the social network, is a direct product of her close collaborations with clinical investigators at HPRI.

As part of this work, Dr. Sorkin is examining whether or not patients who lack key social ties (such as a spouse) are as effective in their ability to manage their chronic illness as those who do not.  Part of this work involves understanding the ways in which spouses may be uniquely positioned to influence patients and promote effective self-management. 

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

In a recently completed grant from the Commonwealth Fund, she 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. Dr. Kaplan has created an aggregate, evidence-based physician performance measure for quality of diabetes care. 

In the successful conduct of this study, Dr. 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.

Dr. Dana Mukamel has been studying racial disparities in access and quality of cardiac surgery, specifically coronary artery bypass graft or CABG.  With funding from the National Institute on Aging, the National Center for Minority Health and Health Disparities, and The Commonwealth Fund, Mukamel was the first to show that African Americans in New York State received cardiac care from lower quality surgeons. 

These findings persisted after adjustment for insurance coverage were observed for individuals enrolled in managed care as well as Medicare.  Mukamel has shown that these disparities can be attributed to two causes: 

• African-Americans were more likely to receive care from cardiologists whose referral network is of lower quality; and
• African-Americans are referred to different surgeons than non-Hispanic white patients by the same cardiologist.  Most recently, she has also identified capacity constraints among the high quality surgeons as a potential cause for disparities.

Mukamel’s research has also shown that when report cards on quality of care, such as the New York State Cardiac Surgery Reports, are published, they improve the access of racial minorities to the higher quality providers.  This is attributed to improved access to information about quality by minorities that the public dissemination of quality information provides. 

Mukamel’s work is also identifying a disturbing change in the nature of disparities in access to care.  Her studies suggest that increased access of racial minorities to high-quality providers may result in “crowding out” low-education patients, who are less likely to have access to the information in published report cards, and may consequently be displaced to lower-quality surgeons.  Her findings raise concerns about replacing one vulnerable population with another. 

Currently, she and colleagues are extending this line of research to another vulnerable population.  Their most recent research suggests that individuals with mental illness face similar barriers to high-quality care as those observed for African-Americans.   They have recently been awarded a new research grant by National Institute of Health to examine the causes and mechanisms for these disparities.

As the population ages, more patients are living to advanced years and require non-acute care to manage their multiple chronic diseases.  Dr. Dana Mukamel, professor of medicine and senior research scientist at HPRI, is a national and international expert in the assessment of quality of nursing home care at the regional and national level.

Mukamel has a history of continuous NIH support for the past decade for her research studying the organizational, staffing and patient characteristics that contribute to disparities in the quality nursing home care and community-based long-term care.  Her research constitutes a body of sentinel work that has had considerable national impact, especially at the organizational level. With funding from the National Institute on Aging and the Veteran’s Administration, Dr. Mukamel has studied organizational and market characteristics that contribute to the provision of high-quality care in long-term care settings. 

Her work focused on evaluations of the Program of All Inclusive Care for the Elderly (PACE), designed to provide community based alternatives to nursing homes for acute, chronic and long-term care for the elderly, and  assessment of the impact of the CMS web-based Nursing Home Compare quality report card on nursing home behavior and quality of nursing homes. 

Mukamel was the first to develop quality measures for long-term care settings based on risk adjusted health outcomes.  These methods have now been employed to assess quality of care in the community-ased VA and in the PACE program nursing homes. 

Since this seminal work, Dr. Mukamel has used these measures to study quality of care and the factors that contribute to high-quality care for the elderly.  In recent work, she has shown that PACE enrollees have better risk-adjusted health outcomes in programs with better teams and more geriatric-specific training.  Her studies have produced evidence that higher quality is associated with lower costs in nursing home care. 

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, UCSF, UC Davis, and UCSD, 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.

Dr. Dana Mukamel recently received a grant from the National Institutes of Aging, to study the impact of State regulations of nursing homes on quality of care and patient outcomes.  This work will rely on the quality measures developed by Dr. Mukamel to assess the quality of care provided to the elderly by nursing homes and will examine whether stricter state policies and enforcement of those policies lead to better quality of nursing home care.

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 NIH 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.

Dr. Huang’s 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.