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Center Newsby Joan DeClaire
People and ProgramsUW awarded grant to study improvements in health care access and quality at Group Health The University of Washington (UW) School of Public Health and Community Medicine has received a two-year, $656,000 grant from The Robert Wood Johnson Foundation to evaluate the impact of Group Health Cooperative’s recent innovations to improve access and quality of care for its members. Group Health is a Seattle-based, nonprofit healthcare system that coordinates care and coverage for nearly 540,000 people in Washington and Idaho. Recent changes at Group Health, collectively called "the access initiative," include:
"We know from the Institute of Medicine’s 2001 Crossing the Quality Chasm report that improving the quality and safety of health care is going to require more than focusing on individual clinicians—it’s going to require changing entire systems of care," said David Grembowski, PhD, UW professor of health services and the study’s principal investigator. "Group Health’s innovations provide a ‘natural experiment’ of such system-wide, interrelated innovations," he explained. "Very few health care delivery systems in the United States have put together this type of integrated package of change." To conduct the study, Grembowski and his colleagues from UW and Group Health Center for Health Studies will use Group Health’s automated databases, member and physician satisfaction surveys, patients visit surveys, and in-depth interviews with care providers. Based on this data, they will determine how the access initiative is affecting factors such as cost, utilization of services, quality of care, member enrollment, and patient and provider satisfaction. "Our findings will be relevant to all people interested in issues of quality and access, regardless what model of health care they represent," said Eric B. Larson, MD, MPH, director of Group Health Center for Health Studies and a co-investigator on the study. "This is a seminal observation opportunity. Group Health’s Web based initiatives are being used by more than 66,000 patients—one of the largest groups in the world to have access to such services" Other UW researchers contributing to study will be Douglas A. Conrad, PhD and Diane P. Martin, PhD. Other CHS researchers on the project are Paul Fishman, PhD and James Ralston, MD, MPH. The Robert Wood Johnson Foundation, based in Princeton, NJ, is the nation’s largest philanthropy devoted exclusively to health and health care. It concentrates its grant making in four goal areas: to assure that all Americans have access to quality health care at reasonable cost; to improve the quality of care and support for people with chronic health conditions; to promote healthy communities and lifestyles; and to reduce the personal, social, and economic harm caused by substance abuse—tobacco, alcohol, and illicit drugs. Gastroenterology teams win the Birnbaum Award Group Health Cooperative’s Central and Eastside Gastroenterology (GI) Teams have been selected by Group Health Center for Health Studies (CHS) faculty to receive the 2004 Birnbaum Award for Supporting Research that Benefits Group Health Patients. CHS Director Eric B. Larson, MD, MPH, presented the award to Andrew Feld, MD, of the Central GI team, and Tom Ylvisaker, MD, of the Eastside GI Team, during the Fifth Annual Birnbaum Lecture and Luncheon at the Seattle Sheraton on November 18. The award is given each year to the Group Health work team that has made extraordinary contributions to research at the Cooperative. "This award recognizes that the GI teams have played a central role in the success of cancer prevention and cancer control research at Group Health over the past eight years," said Larson. He noted that the teams have facilitated a number of studies led by faculty from Group Health Center for Health Studies, the Fred Hutchinson Cancer Research Center, and Memorial Sloan-Kettering Cancer Center—including most recently:
The teams were nominated to receive the award by CHS investigators Margaret Mandelson, PhD, and Katherine Newton, PhD. "We wish to acknowledge the team members’ collaborative and gracious attitudes in working with the Center study teams on these projects. They have greatly contributed to the success of colorectal cancer research by scheduling research procedures, suggesting protocol and operational modifications, encouraging recruitment, and providing crucial information and data that improves study design," Mandelson and Newton wrote. Mandelson added that CHS staff members are looking forward to continued collaboration with the GI teams as the Center begins a major research program in pancreatic cancer. "This ongoing effort exemplifies how Group Health Center for Health Studies and the Group Health delivery system work together to achieve meaningful results that benefit Group Health members and the general public," said Mandelson. Previous winners of the Birnbaum Award were the Group Health Breast Cancer Screening Program nurses in 2002 and the Group Health Information Systems Department in 2003. Absence of screening mammograms accounts for most late-stage cancer, study finds What puts women in integrated health plans at greatest risk for late-stage breast cancer? Not having screening mammograms even though they have access to this test, according to a new study in the October 20, 2004 issue of the Journal of the National Cancer Institute. The study also found that older, unmarried, less educated, and lower income women are less likely to be screened. The study was conducted by scientists at Group Health Cooperative and six other organized health plans in the Cancer Research Network—a consortium of healthcare organizations nationwide that studies the effectiveness of cancer-control interventions. "This study tells us that in order to achieve the largest reduction in late-stage breast cancers, our highest priority should be reaching those unscreened women and encouraging them to have mammograms," said Stephen Taplin, MD, MPH, who led the research in his role as senior investigator with Group Health Center for Health Studies. Taplin is now a member of the National Cancer Institute’s Division of Cancer Control and Population Sciences. "Screening is a process, not just a test," Taplin added. "Our goal was to learn where that process needs improvement so that more women can achieve complete screening. For example, we wondered if women with positive tests were not being evaluated." To find out where the screening process breaks down and where changes in care might have the greatest impact, the researchers examined data from 2,694 women aged 50 years and older who had breast cancer and were members of integrated health plans that provide both primary and specialty care. They compared women who had been diagnosed with late-stage breast cancer with those who had been diagnosed with early-stage breast cancer and, on the basis of their care between three years and one year prior to their diagnosis, categorized the women into one of three groups: 1) absence of screening (no mammogram existed), 2) absence of detection (the earliest screening mammogram was negative), or 3) potential breakdown in follow-up (a screening mammogram was positive, but the diagnosis occurred more than a year later). The researchers found that 52 percent of the late-stage breast cancer cases were associated with an absence of screening, 39 percent with an absence of detection, and 8 percent with a potential breakdown in follow-up. They also found that the odds of having late-stage cancer were nearly doubled among women with an absence of screening. Among women diagnosed with late-stage cancer, women were more likely to be in the absence-of-screening group if they were aged 75 years or older, unmarried, or did not have a family history of breast cancer. In addition, women who had less education or lower income were more likely to have been in the absence-of-screening group. "For women, this study emphasizes the importance of getting screened regularly and within the appropriate time frame," said Taplin. "For doctors, it tells us that we need to identify the women in our practices who are not coming in even though they’re receiving reminders, to listen to them, and to find ways to encourage them to come. And for health care systems, it means considering reminder systems to reach those women who may not be seeing their providers for care." In addition, more research needs to be done to improve the use of current technology and to develop better tools for detecting cancer, Taplin said. About the Cancer Research Network The Cancer Research Network (CRN) is a consortium of 11 health care organizations that collaborate on studies of cancer epidemiology, prevention, early detection, and control in the context of health care delivery systems. Together, the participating organizations have access to health care data on 9 million people, or 3.5 percent of the U.S. population. The CRN is supported by grants from the National Cancer Institute. Group Health Center for Health Studies provides scientific and administrative leadership for the network. "This study was only possible through collaboration with scientists from across the CRN," Taplin noted. CRN scientists who contributed to this study of late-stage breast cancer are:
Study shows new model of asthma care reduces kids’ symptoms A "planned-care method" of providing primary care for children with asthma can significantly reduce their symptoms and need for emergency medications, according to a study published in the September 2004 issue of Archives of Pediatrics and Adolescent Medicine. The method involves providing regularly scheduled visits with specially trained nurses to help families learn how to manage symptoms. In addition, physicians received extra education in asthma management. "Our research shows that we can improve children’s asthma by doing a better job of organizing their routine care," said pediatrician Paula Lozano, MD, MPH, lead author of the study and a scientific investigator at Group Health Center for Health Studies. "Pediatricians generally do a great job with well-child care, scheduling check-ups and shots at two weeks, two months, four months, and so on. This research shows the benefits of organizing care for chronic conditions like asthma in much the same way." Using the planned-care method, nurses in the study had regularly scheduled calls and office visits to find out how the children were doing with their medications and self-management of symptoms. This information was conveyed to the children’s doctors. Then after the visits, the nurses met with families to set goals for better management, and to help families identify and solve problems that might be getting in the way of preventing symptoms. After two years, the researchers found that, compared to children in usual care, the children in the planned-care practices:
"Our profession has developed some great evidence-based guidelines for asthma care and we know that if we follow them, children have improved outcomes," Lozano explained. "But the fact is, a busy primary care doctor cannot possibly provide all the guidance that’s needed. But if we reorganize our practice teams, we can do it." To conduct the study, researchers followed 638 children ages 3 to 17 (average age 9.4 years) as they got care for more than two years. The team randomly assigned patients to one of three different groups, each one offering a different method for educating families and their doctors about asthma. The three methods were:
The study included children enrolled in Group Health Cooperative in Seattle, the Rush Prudential Health Plan in Chicago, and 16 practices in eastern Massachusetts—each affiliated with several insurers, including Harvard Pilgrim Health Care and Blue Cross Blue Shield of Massachusetts. The study was funded by a four-year, $6 million grant from the Agency for Healthcare Research and Quality, which is part of the federal Department of Health and Human Services, and the National Heart Lung and Blood Institute at the NIH. Kevin B. Weiss, MD, MPH, at the Hines VA Hospital and Northwestern University, Chicago, Illinois is the principal investigator. The study team is now analyzing the cost effectiveness of the planned-care model and hopes to publish these results soon. The cost-effectiveness analyses are being led by Sean Sullivan, PhD, at the University of Washington’s School of Pharmacy. "We don’t have to invent expensive new technologies or drugs to make these improvements," said Lozano. "It’s just a matter of being more thoughtful about collecting information, sharing it with the doctor, and talking with the patient. These changes are eminently doable." The Centers for Disease Control and Prevention estimates that asthma affects about 9 percent of all children. Most children with asthma get their treatment from primary care providers, Lozano explained. In addition to Lozano, authors of the study are Jonathan A. Finkelstein, MD, MPH, Vincent J. Carey, PhD, Anne L. Fuhlbrigge, MD, MS, Stephen B. Soumerai, ScD, and Scott T. Weiss, MD, MS, of Harvard Medical School; Ed Wagner, MD, MPH, of Group Health Cooperative; Thomas S. Inui, MD, of Regenstrief Institution for Heath Care; Sean Sullivan, PhD, of the University of Washington; and Kevin B. Weiss, MD, of Hines VA Hospital and Northwestern University Feinberg School of Medicine. How families and health care teams can work together for better asthma care Group Health Cooperative researchers and their colleagues have discovered that when families and primary care teams work together in planning asthma care, kids have better outcomes. Here are a few tips for parents:
JAMA: Phone-based psychotherapy plus outreach work well for depression, Group Health study finds A phone-based program combining outreach and psychotherapy can significantly improve symptoms of depression and satisfaction with care for patients beginning antidepressant treatment, according to a Group Health Cooperative study published in the August 25, 2004 issue of the Journal of the American Medical Association (JAMA). "Our research shows that providing structured psychotherapy for depression over the telephone works," said Greg Simon, MD, MPH, a Group Health psychiatrist, researcher, and the lead author of the study. "Equally important, it shows that providing vigorous outreach can help depressed people who would otherwise not be served by therapy at all." Previous research shows that antidepressant medication and structured psychotherapy are helpful for depression, but less than one-third of people with depressive disorders receive effective levels of either treatment. Barriers include feelings of discouragement, social stigma, and time constraints. Also, patients often need to be persistent to get the type and level of medication they need, and the benefits of treatment may not be apparent for several weeks. "Depression is a condition defined by being easily discouraged, pessimistic, or fatigued—that’s the nature of it," said Simon. "So we designed an outreach program that’s really persistent in order to overcome that natural discouragement patients feel." The study enrolled 600 Group Health patients with depression who were randomly assigned to receive:
The care-management program was provided by bachelors- or masters-prepared mental health clinicians who assessed patients’ symptoms, antidepressant medication use, and side-effects. They also coordinated doctor-patient communication and referred patients to mental health specialty care, if needed. The psychotherapy was provided by masters-prepared psychotherapists who provided eight, 30-40 minute sessions of structured cognitive-behavioral counseling. The study excluded people who were already seeing a therapist or
intending to see a therapist. "We were very interested in studying
people who were not seeking that kind of treatment at all—people who
would not be served otherwise," said Simon. Using a standard measure of depression (SCL depression score), the researchers also found that improvement was greatest in the phone-therapy group, intermediate in the care-management group, and least in the usual-care group. Satisfaction with treatment followed a similar pattern. Telephone-based treatment lacks the "richness" of in-person therapy, Simon said. "But in most large mental health systems, about 20 to 25 percent of the people who call to request an appointment don’t show up. And of people who make one visit, about 20 to 25 percent of people never make a second visit. So although telephone treatment may not be as powerful as seeing someone in person, it’s more effective than not getting help at all." The researchers acknowledge that efforts to improve management of depression "must consider resource limitations and pressures to control costs." They estimate that providing phone therapy would cost less than $50 per session. Simon also points out that fee-for-service health care systems are not currently equipped to reimburse providers for telephone-based care-management and psychotherapy. Simon and his colleagues are now planning a study to compare the telephone-based treatment and outreach program to conventional psychotherapy visits. In addition to Simon, authors of the study were Group Health researchers Evette Ludman, PhD, Belinda Operskalski, MPH, Michael Von Korff, ScD, and Steve Tutty, MA. The study was funded by grants from the National Institute of Mental Health. Harkness fellow begins year-long visit Group Health Center for Health Studies welcomes Rhiannon Tudor Edwards, PhD, a Commonwealth Fund Harkness fellow who will be working during the coming year with CHS Director Eric Larson, MD, MPH, and MacColl Institute Director Ed Wagner, MD, MPH. Edwards will pursue scholarship and research in the general area of "the business case" for quality, including an examination of recent developments in physicians’ "pay for performance"—a trend that’s coincidentally gaining ground in the U.K. National Health Service and in the United States. Edwards is founding director of the Centre for Economics of Health at the University of Wales, where she also provides health policy support to the Welsh Assembly Government. Her research interests have included economic evaluation of clinical trials and the impact of political devolution on health policy. Manager for Clinical Research named Kathy Tietje, PhD, has accepted the position of manager for clinical research at Group Health Center for Health Studies. Tietje comes to CHS from the Fred Hutchison Cancer Research Center, where she served a dual role as program administrator for the Cancer Prevention Research Program and information technology administrator for the Public Health Sciences Division. Tietje has a doctorate in pharmacology, experience managing a large NCI-funded program project, and broad high-level expertise in research administration. In her new job at CHS, Tietje’s responsibilities will include oversight of the CHS research clinic, liaison with the Group Health delivery system, and consultation with CHS project teams around the design and implementation of clinical studies that take place in the CHS research clinic or the delivery system. Research HighlightsThe overall prevalence of hormone therapy (HT) use declined 38 percent in the five months following the June 2002 release of results from the Women’s Health Initiative’s trial of these drugs, according to a study led by CHS Assistant Investigator Diana Buist, PhD. Published in the November 2004 issue of the journal Obstetrics & Gynecology, the study is based on pharmacy records from nearly 170,000 women enrolled in five health plans nationwide. Unlike previous investigations that relied on sales or mammography records, this pharmacy record-based study allowed the researchers to determine the effect of age on the initiation, discontinuation, and prevalence of use, looking specifically at the type and dose of HT used. The researchers found that the use of estrogen-plus-progestin dropped 46 percent, while use of estrogen-only dropped 28 percent. Other CHS co-authors of the study are Katherine Newton, PhD, Diana Miglioretti, PhD, and Kevin Beverly, MA. Postmenopausal women had an 80 percent higher risk of blood clots in their veins if they were taking conjugated equine estrogen (Premarin) rather than estrified estrogen (soy-based Menest), according to a University of Washington/Group Health Cooperative study published in the October 6, 2004 issue of the Journal of the American Medical Association. The study, based on Group Health medical records, was led by Nicholas Smith, MD, MPH, an epidemiologist in the Cardiovascular Health Research Unit (CHRU) at the UW School of Medicine. CHS Director Eric B. Larson, MD, MPH, was a study co-author. Other co-authors included two CHRU scientists who are affiliate investigators for CHS, Susan Heckbert, MD, PhD, and Bruce Psaty, MD, PhD. Depressed patients with diabetes are more likely to be obese, have poorly controlled diabetes, suffer more complications such as heart disease, and use more medical services than non-depressed patients, according to a study of 4,463 Group Health diabetes patients published in the September 2004 issue of the journal Diabetes Care. The depressed patients in the study—which was led by CHS Affiliate Investigator Elizabeth Lin, MD, MPH—also ate fewer fruits and vegetables, exercised less, and showed less adherence to prescribed regimens. Patients in the study completed questionnaires that assessed self-care, diabetes monitoring, and depression. Automated diagnostic, laboratory, and pharmacy data were used to assess glycemic control, medication adherence, and preventive services. Other authors were CHS’ Michael Von Korff, ScD, Carolyn Rutter, PhD, Greg Simon, MD, MPH, Malia Oliver, Evette Ludman, PhD, and Terry Bush, PhD; UW’s Wayne Katon, MD, MPH, and Paul Ciechanowski, MD, MPH; and Bessie Young, MD, of Veteran’s Administration Hospital. There’s a strong link between depression and cigarette smoking in kids aged 10 to 12, according to a study by researchers from CHS and Kaiser Permanente Northwest’s Center for Health Research. Also, preteens with depressed parents are more than twice as likely to experiment with cigarettes as preteens whose parents aren’t depressed, the researchers found. Their study, which appears in the September 2004 issue of Psychology of Addictive Behaviors, is based on a randomized controlled trial testing a family-based smoking-prevention program among more than 4,000 Group Health and Kaiser families. CHS’ Lou Grothaus, MA, Terry Bush, PhD, and Evette Ludman, PhD, were co-authors of the study, along with The Center for Health Promotion’s Tim McAfee, MD, MPH, and former CHS Director Sue Curry, PhD, now at the University of Illinois at Chicago. Kaiser’s Michael R. Polen, PhD, was the lead author of the study. Primary care doctors can boost enrollment in Head Start by facilitating their patients’ initial contact in this federally funded early childhood development program, according to a study in the August 25, 2004 issue of the Journal of the American Medical Association. David Grossman, MD, MPH, CHS senior investigator and director of Group Health’s Department of Preventive Care, is a co-author of the study, which was conducted at four Seattle community health centers in 2003. The researchers showed that kids whose doctors’ offices used the study intervention were more than twice as likely to be enrolled in or on the waiting list for Head Start compared to kids who received usual care. The intervention consisted of a referral packet and computer-generated documents mailed directly to Head Start by study personnel. What differentiates between heart-failure disease-management programs that improve outcomes and those that do not? The target population, the quality of usual care, and program design, according to an editorial by MacColl Institute Director Ed Wagner, MD, MPH, in the October 19, 2004 issue of Annals of Internal Medicine. Wagner’s editorial was written in response to a Kaiser Permanente study of a telephone-based, nurse-directed care-management program for patients with congestive heart failure in the same issue that found no measurable benefit of disease management over usual care. Citing a wide range of additional research on this topic, Wagner concluded that policymakers should "question the rush to telephone-only disease management programs. But they shouldn’t…deter further dissemination of multidisciplinary programs with some post-discharge, face-to-face patient contact, for which the evidence base is stronger." Nicotine dependence—what it is, why it occurs, how it is measured, and how it can be effectively treated—is the subject of an article in the November 2004 issue of Medical Clinics of North America. Susan M. Zbikowski, PhD, a researcher with The Center for Health Promotion and an affiliate investigator with CHS, is the lead author. CHS Assistant Investigator Jennifer McClure, PhD, and Gary E. Swan of Stanford Research Institute International are co-authors. More new fundingThe following grants are among several projects recently funded at CHS. Coordinated Clinical Studies Network: The National Institutes of Health (NIH) recently awarded CHS a three-year, $3.5 million contract to establish a Coordinated Clinical Studies Network (CCSN) among 13 integrated health systems in the HMO Research Network. Part of NIH’s initiative to "re-engineer the clinical research process," this contract seeks to develop interoperable information systems that will enhance the productivity and efficiency of clinical research in the United States. Led by CHS, the network will establish a powerful, shared informatics platform, supporting clinical research into a defined population of 13 million people, or 4 percent of the U.S. population. The goal of CCSN will be to conduct "translational research,"—i.e., answering questions about the way health care innovations work in real practice among large populations. CHS Director Eric B. Larson, MD, MPH, will serve as principal investigator of the project. Paul Fishman, PhD, James Ralston, MD, MPH, Denise Boudreau, PhD, and Sarah Greene, MPH, are co-investigators. Multi-Center Study of Pancreatic Cancer Etiology: A five-year, $5.6 million grant from the National Cancer Institute will fund a case-control study to investigate environmental and genetic factors related to pancreatic cancer. This study will enroll 745 newly diagnosed cases and 1,041 controls from two large health plan populations. The CHS lead investigator is Margaret T. Mandelson, PhD. Population Genetics Analysis Program: Genetic Risk for Myocarditis Related to Smallpox Vaccine: A five-year, $340,000 grant from the National Institute of Allergy and Infectious Diseases will fund a study to identify genetic differences that increase the risk for a major adverse event associated with smallpox vaccination—myocarditis (inflammation of the muscle tissue of the heart)—and to determine the mechanism by which these genetic differences confer risk. The CHS lead investigator is Robert L. Davis, MD, MPH. Patient-Provider Electronic Messaging And Chronic Illness Care: A one-year, $100,000 grant from the Agency for Healthcare Research and Quality will be used to evaluate the potential role of secure electronic messaging (SM) between patients with chronic medical conditions and their health care providers. Specifically, the study will describe the evolving use of online SM among patients with chronic medical conditions and evaluate the potential association of SM use with safer and more effective care of patients with diabetes. To address these goals, the research team will conduct a retrospective analysis of a large and uniform SM application at Group Health Cooperative. The principal investigator is CHS’ James D. Ralston, MD, MPH. Treatment of Nicotine Dependence in an HMO Setting: A five-year, $480,000 grant from the National Cancer Institute will fund a randomized clinical trial to examine the most effective and cost-effective combination of behavioral counseling and bupropion sustained release (SR) (Zyban) for smoking cessation. The specific aims are: 1) to determine the relative effectiveness of three different forms of the Free & Clear behavioral treatment program (telephonic, Web-based, and combined telephonic and Web-based) used with bupropion SR; 2) to evaluate treatment adherence and determine group and individual differences associated with non-adherence to the treatment regimens; 3) to examine heterogeneity in responsiveness to the three treatments; 4) to determine the cost-effectiveness of the different treatments; and 5) to disseminate the results of the trial to physicians, consumers, and policy makers at Group Health Cooperative and to other managed care organizations and health plans. The CHS lead investigator is Jennifer B. McClure, PhD. Genetic Changes as they Relate to Breast Cancer Survival: A five-year, $210,000 grant from the National Cancer Institute will fund CHS’ collaboration on a study of the way genetic changes in breast cells are related to differences in breast cancer survival between African-American and white women. This project brings together an interdisciplinary team skilled in genomics, pathology, epidemiology, biostatistics, and clinical research. This study will use a new method to identify duplicated or deleted chromosomal regions in a previously identified population of breast cancer patients from Atlanta, GA. The identification of altered chromosomal regions in breast tumors and their relation to breast cancer risk factors and tumor growth characteristics is an important step toward understanding the underlying biology and clinical behavior of the disease in African-American and white women. The principal investigator is Peggy Porter, MD of the Fred Hutchinson Cancer Research Center. The CHS lead investigator is Diana S. M. Buist, PhD with co-lead Erin Aiello, MPH. Medications and Colorectal Cancer Risk: A two-year, $160,000 grant from the National Cancer Institute will be used to investigate the relationship between commonly prescribed medications, prevalent diseases, and colorectal cancer risk among men and women age 40 years and older. The principal investigator is CHS’ Denise M. Boudreau, PhD. Understanding Variability in Community Mammography: A five-year, $1 million grant from the National Cancer Institute will seek to improve breast cancer detection by enhancing community mammography practice. The study will identify specific reasons for radiologist variability in the interpretation of mammograms and provide valuable data on improving the performance of mammography in the United States. This work will lead to development and testing of interactive Web-based educational material to assist radiologists in examining their diagnostic performance and to provide a system to facilitate radiologists’ monitoring of their performance over time. The CHS lead investigator is Diana L. Miglioretti, PhD. |
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