Research

Research Background

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 Synthesis in Health, 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 Substantive Expertise:

The Center for Gerontology and Healthcare Research (CGHCR) is nearly 30 years old and is the home of a wide variety of both aging/gerontology and non-gerontology health care research. The CGHCR is the home of important educational initiatives and 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 and is the director of the Center for Long-Term Care Quality & InnovationRichard Besdine, the CGHCR Director, is the PI of the Reynolds Project that teaches aging/gerontology content to undergraduate and post-graduate medical curricula. 

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.

Department faculty study access to and use of hospice and other palliative care services provided in the community and across diverse care settings. They also study how quality and costs may be affected by the use of hospice and palliative care services. Pedro Gozalo has studied the overall cost to Medicare of hospice care in nursing homes, and he and colleagues are working with CMS to redesign hospice payment policy. Susan Miller is an expert on palliative care in nursing homes, and as such, she and colleagues have studied whether nursing home hospice enrollment is associated with lower acute care use and better care processes (such as pain management). Dr. Miller is also conducting the first comparative study of palliative care consults in nursing homes. Dr. Vincent Morin a co-principal investigator on a nursing home cluster randomized trial of video-assisted advanced care planning in 2 nursing home systems. Center investigators also examine palliative care in the Veteran’s Administration system; Dr. Mor is studying whether newly diagnosed lung cancer patients treated in VA Medical Centers that use hospice/palliative care more receive less aggressive end of life care.

Investigators in the Center for Evidence Synthesis in Health (CESH), 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.

Pharmaceutical health services research is the application of the principles of epidemiology to study the use and effects of medications and other medical devices, generally in large populations.  Most studies examine the adverse events or therapeutic benefits of drugs or medical devices after products have been launched (post-marketing).  Such work is critical to overcoming the inherent limitations of pre-marketing studies and for supporting the most appropriate use of medications/devices with respect to safety and effectiveness.  

Multiple HSPP researchers, including Ira Wilson, Amal Trivedi and Vincent Moruse 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, joined the Department in the fall of 2015. Dr. Shireman has an active pharmacoepidemiology research program

    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 WilsonBart Laws, and Omar Galárraga all work on HIV-related topics, including HIV, the use of conditional economic incentives, measuring, monitoring, and improving adherence with HIV antiretroviral therapy (ART), the illness experience and HIV-related knowledge of people living with HIV, and psychological factors and beliefs as correlates of ARV adherence and successful self-management, 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. MillerRahmanShiremanand Galárraga. He has a second, related, R01 that is focused on understanding the quality of care that persons with HIV receive in nursing homes nationally. Galárraga, a health economist by training, has NIH-funded research on HIV, including projects in Ghana, Mexico, Kenya, South Africa and USA related to impact of social health insurance /health reform, cost-effectiveness analyses, and conditional economic incentives for HIV prevention and treatment.

     


    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.

     


    Disparities

    A focus on disparities in care delivery is a theme that cuts across many areas. Amal Trivedi is a leading disparities researcher and is currently working on several related projects. One NIH-funded R01 examines the impact of the Affordable Care Act on racial and socioeconomic disparities among patients with end stage renal disease.  Another project, funded by the VA, focuses on the implications of risk-adjusting clinical performance measures for socioeconomic status. Maricruz Rivera-Hernandez is currently working on a NIA-funded project assessing racial and ethnic disparities in quality of post-acute care in skilled nursing facilities in the Medicare advantage and traditional Medicare population. 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.

    Much of the work of Vincent Mor’s PPG, and also of the work of Joan Teno (now at the University of Washington), Susan MillerAmal TrivediPedro 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.