CHAS 2006-2007 Seed-Grant Awards

William Dale, MD

Anxiety and Rising PSA in Prostate Cancer: Initiating Androgen Deprivation Early

This research project focuses on the influence of patient anxiety about prostate cancer on their decision to initiate hormone therapy which has quality-of-life affecting side-effects and unclear mortality benefits. Men with an asymptomatic recurrence of prostate cancer following primary therapy, evidenced by an elevated and rising prostate specific antigen (PSA) level in the blood, must decide when to start androgen deprivation therapy (ADT). ADT is associated with many side effects including osteoporosis, fatigue, hot flashes, muscle weakness, and cognitive impairment. Furthermore, evidence that ADT provides survival benefits for older men is unclear, and it is very expensive. Despite these drawbacks, many men start ADT immediately after a PSA rise. We are testing the hypothesis that men with higher anxiety levels will start therapy earlier and at lower PSA levels, even after controlling for clinical predictors of disease spread. If proven true, such results would provide reason for an anxiety-reducing patient intervention for these currently asymptomatic patients.

Robert Daum, MD

Reminder-recall from birth to increase immunizations in an underserved population

As the urban measles outbreaks in the U.S. in 1989-1990 underscored, the importance of achieving and maintaing high rates of immunization among children is crucial. Although immunization rates on a national level are improving and approaching 90%, there remain major pockets of underimmunized children. One such pocket is African American children in the city of Chicago. The Pediatric Immunization Program seeks to find barriers to on-time immunizations which create such disparities and addresses them. This study is a cost-analysis of an ongoing intervention of providing immunization education at birth combined with ongoing reminder-recall. This project was designed to increase immunization rates in under-served children on the south side of Chicago. Using a two-tier intervention involving hepatitis B vaccine and immunization education at birth combined with reminder-recall, including home visits as necessary, the aim is to increase up-to-date immunization rates to over 90% for children ages 19-35 months. This is especially important in the primarily African-American population served by the University of Chicago Hospitals because these children are known to have lower up-to-date rates at all ages prior to school entry. This project continues to tie immunization receipt with well-child care thereby increasing contact with primary health care providers as well. A major component of the next phase of this project is to conduct a cost analysis to find exactly how much it costs to keep a child up-to-date with this intervention. Thus far the program has proven successful with over 95% of children in the first pilot study currently up-to-date with all immunizations. Now a cost-analysis is necessary to demonstrate that it is financially feasible to expand this intervention to a larger population both.

John M. Hickner, MD

Patient-Centeredness in a Pay for Performance Environment: A Pilot Study Exploring Patient Expectations and Experience of Acute, Chronic Disease and Preventive Care in Access Community Health Network

Pay-for-performance (P4P) programs have emerged as a significant response to government, private payors and consumers demand that health plans and physician groups improve the quality and safety of health care. The fundamental rationale for P4P programs is to reward healthcare organizations and individual providers for providing high quality health services consistent with evidence-based national guidelines (e.g., US Preventive Services Task Force guidelines). While P4P programs may achieve their intended goals, there may be unintended negative consequences, especially when physicians and other clinicians are provided direct financial incentives for certain types of care but not for others. P4P plans usually stress preventive and chronic illness services. As physicians strive to provide these services, they may inadvertently deemphasize services that may be more important and urgent to patients, such as addressing acute medical and psychosocial issues. We have two goals for this pilot study. First, we will develop and test methods for studying patient’s perceptions of and satisfaction with their care for acute problems, chronic problems, and preventive care during office visits with primary care physicians. Second, we will gain insight into how patients’ pressing health care needs are met or not met in Access Community Health Network health centers, where the physicians participate in a performance based compensation program that directly compensates physicians for chronic disease care and preventive care but not for care of acute and urgent problems.

Elbert Huang, MD

The Quality of Care of Medicaid-Medicare Dual Eleigibles with Diabetes

Access to quality health care is considered a critical foundation for eliminating health disparities and increasing the quality and years of healthy life for all persons in the United States. Two major policy options for improving access to quality of care include insurance expansion at the federal or state level. Patients who are enrolled in both Medicare and Medicaid, dual eligibles (DE), are a group of vulnerable individuals who have already been granted expanded access to health care. DEs are elderly or disabled, atypical of the general Medicaid population, and have lower socioeconomic status than the average elderly Medicare beneficiary. Despite the unique characteristics of DE patients, most studies of access to health care have misclassified DE patients as either Medicare or Medicaid patients. We propose to specifically examine the quality of care of the DEs with diabetes with comparison to other Medicare patients, using a nationally representative, claim-linked survey data. We will compare the health, functional status, a comprehensive set of process of care measures, and resource utilization of Medicare-Medicaid DEs with diabetes with other diabetic patients enrolled in Medicare. Knowledge gained through this research will provide valuable information about the quality of care of DEs and potentially the effect of insurance expansion on care.

Thomas Keller, PhD

Parent Involvement in a Mentoring Program Promoting Health for Vulnerable Youth

Many individual-level services designed to promote health among adolescents must negotiate models of communication and collaboration with parents to ensure youth participation the programs and support for the intervention within the family context. This study will investigate the role of parent involvement in a youth mentoring program specifically designed to promote health-related outcomes for early adolescent females in socio-economically disadvantaged urban settings. A systemic model of mentoring interventions suggests the parent may help or hinder participation in the program and development of the mentoring relationship. Likewise, the mentoring intervention may demonstrate indirect effects by influencing the parent-child relationship. The innovative mentoring program being investigated incorporates several strategies to inform and engage parents in support of the health-related lessons being conveyed. The specific aims of the research are to explore how parents contribute to the health-focused mentoring intervention, how program participation may alter parent-child interaction regarding health-related issues, how program practices to enhance parent involvement are implemented and utilized by parents, and to derive preliminary estimates of program effects on measures of parent-child relationships and communication and health-related outcomes. This examination of issues pertaining to parent involvement represents an extension and elaboration of an ongoing randomized control evaluation of the health-focused mentoring program. In addition to analysis of measures incorporated into evaluation surveys, the research will include in-depth qualitative interviews with open-ended questions as well as data regarding program implementation and utilization.

Tamara R. Konetzka, PhD

Dementia, Deterrence, and Malpractice Litigation in Nursing Homes

Nursing home quality has been an area of policy concern for decades. The majority of nursing home residents suffer from moderate or severe dementia or other cognitive impairment, leaving them particularly vulnerable to negligent care when family members or friends do not monitor care closely. Malpractice litigation is viewed as one mechanism for ensuring that providers have a stake in maintaining quality. Consumer groups laud increased litigation as a vehicle for compensating victims of bad care and as a deterrent that encourages facilities to provide better quality care. Nursing home industry representatives, on the other hand, complain that the costs of malpractice litigation and liability insurance when it is available at all threaten the financial viability of nursing facilities and the quality of care they are able to provide. Little research is available to support or refute the effects under debate, other than limited survey research and expert opinion. We intend to fill that gap and inform the policy debate by assessing the deterrence effect of malpractice litigation in the nursing home sector and assessing the role of dementia in these cases. Both quantitative and qualitative methods will be used.

Korok Ray , PhD

Hospital Pricing and Access to Medical Care: Theory and Evidence

U.S. hospitals face a mix of publicly insured and privately insured patients. The specific aim of this study is to explore how hospitals set prices for and determine access to medical care, given the twin revenue sources of public and private money. This is especially relevant given the last ten years of federally mandated cuts in Medicare spending as well as the $35 billion cuts in Medicare spending proposed by the current Bush administration. We hope to answer the following specific questions: a) Whether hospitals respond to Medicare cuts by increasing prices charged to private insurers, b) Whether hospitals internally allocate costs from publicly insured patients to privately insured patients, c) Whether non-profit and for-profit hospitals react differently to government spending cuts, d) How hospital decisions change with respect to the level of competition in the marketplace, e) Whether hospitals select long-term investment decisions based on their payer mix, and whether the hospital resides in the poor neighborhood. Our goal is to develop microeconomic models of hospital decision making, and to test these propositions empirically.

Stacy Lindau , MD

Analysis of Survey Data to Expand a Cancer Survior Subcohort for the Second Wave (2008) of the National Social Live, Health and Aging Project

An unprecedented shift in the age of the population combined with advances in detection, diagnosis, and treatment of cancer in the U.S., has resulted in a growing population of people living with cancer. The number of cancer survivors in the United States reached nearly 10 million in 2001; nearly 70% of these are women, many of whom are affected by gynecologic or breast cancer. Such cancers directly invade and destroy female sexual organs, involve interventions such as surgical removal and/or radiation of the sexual organs, require therapies that interfere with normal sex hormone function, and may render the breasts and/or genitalia of women visibly disfigured. Yet, little is known about the impact of such cancers on the quality of sexual health of affected women, particularly those surviving cancer beyond one to five years. Likewise, little evidence exists regarding the quality or effect of health services for cancer care on sexual health of cancer survivors. Using primary data collected from a 2005 survey of gynecologic cancer survivors, this study aims to inform efforts to improve the quality of sexual health and related clinical interventions and services for women with gynecologic cancer, many of whom are older and physically disabled due to cancer and its treatments.

R. Parker Ward , MD

Cardiology Quality of Care Study

Quality of care for all patients is quickly becoming a foremost priority not only for physicians, but also for the Centers for Medicare and Medicaid Services (CMS), which has instituted a national quality measure reporting system and is piloting a pay-for-performance financial incentive program linked to those quality measures. Special attention must be paid not only to whether such new policies are beneficial, but whether they are beneficial to all groups. Programs like the CMS initiatives may very well benefit the vast majority of patients, however, precisely because such policies aim at the majority of patients, they may fail to help those vulnerable individuals who fall outside the mainstream, exacerbating discrepancies of care that stem from socioeconomic or functional factors. The relevance of this research to public health lies in the potential for identifying risk factors that patients with congestive heart failure or myocardial infarction have for not receiving quality care. Recognition of these characteristics could lead to interventions that specifically address the vulnerable populations and help to minimize disparities in quality of care.

Chad T. Whelan, MD

Pain Control in Vulnerable Hospitalized Patients: Experience Sampling Method Study

Elderly patients who are hospitalized often suffer with pain during their hospital stay. Despite increased awareness of the need for improved pain management in these patients, there are still important opportunities for improvement. This pilot project is to test the feasability of using automatic telephone surveys for elderly patients in the hospital to assess their pain and pain management. In addition to obtaining "real-time" pain assessments, this project is also designed to begin looking at non-medical factors that may contribute to or alleviate the pain experience. These factors of interest include if the patient is alone or with family or with members of the health care team. Using information learned from this pilot study, we will be able to design a larger study that will help us better measure and manage elderly patients pain.