Faculty Research Spotlight: Amal Trivedi
Health services research has been defined as “the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health and well-being. Its research domains are individuals, families, organizations, institutions, communities, and populations.” (Association for Health Services Research).
Faculty in the Department of Health Services, Policy and Practice (HSPP) engage in a broad range of health services research. Total research funding for departmental faculty in 2013, including both the Center for Gerontology and Healthcare Research and the Center for Evidence Based Medicine, was approximately $8M. Department investigators have collaborations with a broad range of groups including other academic departments at Brown University, Rhode Island state government agencies, the Veterans Administration Medical Center and other Brown affiliated hospitals.
AREAS OF RESEARCH EXPERTISE
Research centers in HSPP
There are two Centers that are closely associated with the Department of HSPP: the Center for Gerontology & Healthcare Research (CGHCR, Established in 1986) and the Center for Evidence-Based Medicine (CEBM, established in 2012). Centers in the School of Public Health are intentionally designed to facilitate collaboration with other Centers.
Areas of substantive expertise
There are 10 broad areas of faculty expertise in HSPP. These areas are presented here in brief, narrative form, and a number of them have substantial overlap.
- Aging/Gerontology. The CGHCR is nearly 30 years old, and is the home a wide variety of both aging/gerontology and non-gerontology health care research. The CGHCR is the home of Vincent Mor’s NIH Program Project Grant, Changing Long-Term Care in America: Policies, Markets, Strategies and Outcomes, which was recently renewed, and many other aging/gerontology focused research and education projects. Vincent Mor is also PI of two T32’s to train pre- and post-doctoral students in aging and HSR related areas. It is also the home of important educational initiatives. Richard Besdine, the Director of the CGHCR, is the PI of the Reynolds Project that teaches aging/gerontology content to undergraduate and post-graduate medical curricula.
- Medicare and Medicaid policy research. Much of the work of Vincent Mor’s PPG, and also of the work of Joan Teno (now at the University of Washington), Susan Miller, Amal Trivedi, Pedro Gozalo and others uses Medicare and Medicaid claims data to examine policy issues such as variations, disparities, costs, and quality, with a particular focus on post-acute and long term care.
- End of life and palliative care research. Joan Teno's work has focused on measuring and evaluating interventions to improve the quality of medical care for seriously ill and dying patients. She created the Brown University Family Evaluation of Hospice Care that is currently being used by hospice across the nation and internationally to examine the quality of hospice care, and Joan Teno and Pedro Gozalo are working with CMS to redesign hospice payment policy. Susan Miller is an expert on hospice care in nursing homes and she and colleagues are now conducting the first comparative study of palliative care consults in nursing homes.
- Nursing home care quality. CGHCR researchers helped to develop the Minimum Dataset (MDS), which has been in use by CMS since 1990. The Minimum Data Set (MDS) is a federally mandated assessment tool for all residents in Medicare- or Medicaid-certified facilities. Federal regulations require nursing homes to complete MDS assessments for each resident at admission and quarterly thereafter, for as long as a resident remains in the nursing home. The MDS, now in its third version (MDS 3.0) includes over 400 variables which contain detailed information about residents’ health conditions, such as individual cognitive functioning status (e.g. cognitive performance scale), behavior patterns, physical functioning status (e.g. activities of daily living), and disease diagnoses, and is used by CGHCR researchers for many projects. Susan Miller is leading scholarship of culture change practices in U.S. nursing homes and she and colleagues have studied how the prevalence of culture change practices vary in relation to a state's long term care policies as well as how practices are related to quality outcomes.
- Evidence synthesis and meta-analysis. Investigators in the CEBM, led by Tom Trikalinos, conduct multidisciplinary research in, and teach the principles of, research synthesis (by means of systematic review, meta-analysis) and evidence contextualization (by means of decision or economic modeling) with a focus on comparing the effectiveness of interventions, tests and processes in clinical medicine. Their research agenda includes optimizing the processes of research synthesis in healthcare and beyond by extending existing methods and tools, or developing new ones.
- Pharmacoepidemiology. Multiple HSPP researchers, including Ira. Wilson, Amal Trivedi, and Vincent Mor use pharmacoepidemiologic methods and have active projects that focus on quality and cost questions related to prescription medications. Theresa Shireman, a pharmacist with a PhD in Pharmacy-Economics, Preventive Medicine and Public Policy, will be joining the Department in the fall of 2015. Dr. Shireman has an active pharmacoepidemiology research program.
- Physician-patient communication, shared decision-making, and stakeholder engagement. Ira Wilson and Bart Laws have studied physician-patient communication in HIV care for the last decade, and have a PCORI Methods grant that focuses on methods to study shared decision making in cardiac and renal disease care.
- Conditional economic incentives and behavioral economics. Omar Galárraga conducts intervention studies in Mexico that use conditional economic incentives to improve prevention and treatment with HIV care in men who have sex with men and male sex workers. Ira Wilson is interested in how to use “nudges” to improve physician-patient communication and the use of clinical pharmacists in primary care settings.
- HIV. Ira Wilson, Bart Laws, and Omar Galárraga all work on HIV related topics, including HIV the use of conditional economic incentives, as described above; measuring, monitoring, and improving adherence with HIV antiretroviral therapy (ART), and interventions to improve physician-patient ART communication. Dr. Wilson was recently awarded a new R01 grant on HIV, aging, and comorbid conditions that involves Drs. Miller, Rahman, and Galárraga.
- Disparities. A focus on disparities in care delivery is a theme that cuts across many of the areas described above. Amal Trivedi is a leading disparities researcher, Ira Wilson works on disparities in HIV care, and Vincent Mor and others have published numerous papers on disparities in post-acute and nursing home care.
Brown University Departments and Teaching Hospitals
Over the years the extensive collaborative relationships between Community Health and campus based and hospital based Departments have resulted in a number of faculty from other Departments having joint appointments in what is now the Department of HSPP. In the Department of Economics Professor Andrew Foster was the first to have a joint appointment in Community Health followed by Professor Anna Aizer and most recently Professor Kenneth Chay. In the Department of Sociology Professor Mary Fennell has held a joint appointment in Community Health since she was recruited to Brown and Professor John Logan has collaborated extensively with Community Health investigators. Several faculty in the Department of Medicine have joint appointments in Community Health and serve as investigators and Co-PI’s on Community Health faculty funded research. We have long-standing and strong relationships with investigators in the Division of Infectious Diseases at Lifespan and extensive collaborations with the Lifespan/Tufts/Brown Center for AIDS Research. Professor Wilson was Co-Director of the Biostatistics and Outcomes Core from 1998 to 2010, and has been Co-Director of the Developmental Core since 2010 to the present.
RI State Agencies
Long standing relationships with RI State Agencies, including the Department of Health and the Medicaid Program, as well as the Office of the Lt. Governor and the Commissioner of Health Insurance have provided opportunities for conducting research, informing policy and giving students internship experiences. For example, Terrie Wetle chaired the State’s legislatively mandated Coordinated Health Planning Advisory Council, and the former Health Insurance Commissioner regularly teaches for the Department. Dr. Wilson was Co-Chair of a 2015 effort ordered by Governor Raimondo called “Reinventing Medicaid” (http://reinventingmedicaid.ri.gov/), and is a member of a new effort ordered by the Governor called “Working Group for Healthcare Innovation” (http://www.governor.ri.gov/initiatives/healthcare/).
Providence Veterans Administration (VA) Medical Center
HSPP has a strong relationship with investigators at the Providence VA, with six faculty members who have VA appointments and two others who have funding through VA contracts. Investigators at the Providence VA have been highly productive and are nationally recognized, particularly for their expertise in post-acute care, an area in which the VA has great interest. HSPP faculty member investigators lead two large and highly competitive VA Center grants based at the Providence VA.
- CREATE (Director Vince Mor). The VA's Office of Research and Development Health Services Research and Development Service (HSR&D) developed an innovative funding initiative titled, "Collaborative Research to Enhance and Advance Transformation and Excellence (CREATE)," which encourages HSR&D investigators to collaborate with VA partners in conducting research on high-priority issues that affect the health and healthcare of Veterans. The goal of CREATE is to conduct research that will provide the tools, evidence, and evaluation information necessary for Geriatric and Extended Care (GEC) policymakers and staff in VHA to transform the spectrum of LTC services.
- COIN (Director James Rudolph, Co-Director David Dosa). The VA's Health Services Research and Development Service (HSR&D) has funded 19 new Centers of Innovation (COINs) effective October 1, 2013, and the Providence VA won one of these prestigious awards. The vision for the Providence VA COIN is to stimulate and develop research that will enhance the implementation of programs to support the mission of the VA's Geriatrics and Extended Care Service in maximizing Veterans' social participation and quality of life in the least restrictive setting possible. This Center will use the World Health Organization's International Classification of Functioning, Disability and Health conceptual framework as a guide. This model is particularly suitable for its primary research agenda in long-term services and supports (LTSS), given the VA's emphasis on community-based LTSS in the least restrictive settings possible. This conceptual framework also will be useful in guiding work in outside areas, including long-term services and supports delivered to homeless and disabled veterans.
In 2015, Brown University established a partnership with OptumLabs (https://www.optum.com/optumlabs.html). OptumLabs is an open and collaborative research center created to facilitate the use of observational datasets to improve health care. This partnership will allow Brown researchers access to large, robust, national de-identified data sets; access to new technologies to analyze these datasets; and the opportunity to participate in research “constellations” such as a Big Data Research Initiative to Fight Alzheimer’s Disease and a Health Care Big Data Methods Constellation.
To compare the productivity of HSPP faculty to other similar departments across the country we used metrics provided by Academic Analytics. Using the Academic Analytics “Custom Index,” Brown ranks #5 out of 45, behind two Harvard Departments, the University of Florida, and Johns Hopkins, and ahead of the University of Pittsburgh, University of North Carolina, Chapel Hill, the University of Michigan, and the University of Washington.
Using the Academic Analytics “Productivity Radar,” HSPP’s productivity can be examined in a number of ways, including citations, articles, grant funding, awards, and books.
- For citations there are six measures, and Brown is in the top quartile in all six. For the percent of authors with a citation, and the percent of the faculty with a citation we rank #1 nationally.
- For articles, we were in the top 30th percentile on all five measures, and #1 for the percent of faculty with an article.
- For grant funding we are in the top 20th percentile for six of seven measures, including being in the top 10th percentile for total grants, the percent of faculty with a grant, grants per faculty, and total grant dollars.
- For awards we were in the top 40th percentile on all four measures.
H-Index as a measure of performance
The H-index is a commonly used measure of imperfect measure of the impact of publications. In 2014, five HSPP faculty had H-indexes of 40 or above, led by Dr. Lau with an H-index of 105. Four other faculty had H-indexes above 20.