Better Effectiveness After Transitions for Heart Failure (BEAT-HF) 
Principal Investigator: Patrick Romano, M.D., M.P.H. 
Source of Support: Agency for Healthcare Research and Quality (AHRQ)

Reducing readmission rates, including the resulting variation in hospital resource use, is a key target for saving money and improving outcomes for patients with heart failure.  Previous studies have shown that intensive post-discharge follow-up with multiple home visits by a nurse reduces readmission rates; however, this type of intervention has not been widely implemented due to cost concerns.  Previous studies have also found that remote monitoring alone does not reduce readmission rates after hospital discharge. Small studies have demonstrated improvement in hospital readmission rates when remote monitoring was paired with telephone follow-up by call cetner nurses, but this model has not been studied on a large scale in a randomized, controlled trial. 

This comparative effectveness study places remote monitoring within a large and diverse clinical care system (comprised of six participating medical centers) and compares the effectiveness of remote monitoring in combination with structured telephone follow-up against usual care for middle-aged and elderly patients with heart failure. 

Values and Options in Cancer Care (VOICE)
Principal Investigator: Richard L. Kravitz, M.D., M.S.P.H.
Source of Support: National Cancer Institute (NCI)

This is an investigator-initiated two-site (University of Rochester and UC Davis) behavioral cluster randomized controlled trial (RCT) designed to improve communication about prognosis and treatment choices in advanced cancer patients. This RCT is the first rigorous test of a communication intervention that targets physicians, patients with advanced cancer, and their caregivers. This study involves two phases: Phase I involves preparation, physician recruitment, piloting and pre-randomization data collection of physicians' communcation behaviors.  Phase II is the cluster RCT; physicians are the unit of randimization and are randomly assigned to the intervention or control condition.  Intervention physicians will receive two in-office communication sessions with Standardized Patient Instructors (SPIs) using media, role-play and feedback on key communication skills.  Intervention patients and their caregivers will receive a booklet with common questions and concerns and individual coaching prior to their schedule office visit.  Control physicians and patients will receive usual care. 

Promoting Patient-Centered Counseling to Reduce Inappropriate Diagnostic Tests
Principal Investigator: Joshua J. Fenton, M.D., M.P.H.
Source of Support: Patient-Centered Outcomes Research Institute
Total Costs: $687,729

Enhancing the value of health services is an urgent national health priority.  Enhancing value entails reducing inappropriate or unnecessary care while maintaining or improving healthcare quality and safety.  While many factors may contribute to inappropriate care delivery in the U.S., patient requests have been shown to influence clinical decision-making regarding inappropriate services.  Patient-centered communication, however, can potentially avert inappropriate care while maintaining a trustful patient-doctor relationship.  Tools to enhance patient-centered communication may therefore play a critical role in reducing inappropriate care and enhancing healthcare value and safety.  

In response to the PCORI’s interest in “the development, refinement, and testing of interventions to enhance patient-centered care,” we propose to develop and to evaluate a novel intervention using standardized patients (SPs) -- or actors playing the roles of patients -- to enhance physicians’ patient-centered counseling skills regarding two frequently overused, potentially inappropriate services in primary care: magnetic resonance imaging (MRI) for acute low back pain and bone densitometry in women at low-risk for osteoporosis.  We will further evaluate whether intervention effects on physician patient-centeredness generalize to counseling regarding other costly, unnecessary diagnostic tests.  Specific aims are:

            1) To use stakeholder focus groups to develop an educational intervention for primary care physicians based upon simulated office visits with standardized patients (SPs) requesting two commonly overused services.

            2) To evaluate in a randomized trial the effectiveness of the intervention in enhancing physician patient-centered counseling behavior and reducing inappropriate or unnecessary test ordering. 

            3) To explore the durability of intervention effects and whether effects generalize to the delivery of other unnecessary primary care services.

Variations in Care:  Comparing Heart Failure Care Transition Intervention Effects
Principal Investigator: Michael Ong, M.D. (UCLA) / UCD Lead Investigator:  Patrick Romano, M.D., M.P.H. 

This comparative effectiveness project compares with concurrent controls the effectiveness of implementing care transition interventions on reducing variation in readmissions among hospitalized elderly patients with heart failure at six medical centers (5 UCs and Cedars-Sinai) over an 18 month period.  The project compares an adaptation of existing care transition interventions, the Transition Coach and Re-Engineering Discharge Programs, designed to reduce the implementation costs for the hospitals.  The study intervention uses a centralized call center, staffed by nurses and supporting all six medical centers, to provide post-discharge structured telephone moitoring of patients, in conjunction with wireless remote monitoring. 

AHRQ Quality Indicators Emergency Preparedness Measures
Principal Investigator: Patrick Romano, MD, MPH.
Source of Support: Batelle Memorial Institute
Approved/Proposed Dates: 1/1/08- (contract extensions and modifications ongoing)
Total Costs: $980,672

The intent of this contract modification is to provide the necessary analytic and technical support to the Agency for Healthcare Research and Quality (AHRQ) for the purpose of 1) developing a template for a State Data Profile on Emergency Preparedness; and 2) developing evidence-based measures of emergency preparedness for use in a report to Congress. The support shall include providing technical and subject matter expertise in the area of emergency preparedness, measure development, evidence reviews, analytic and statistical support, database management, computer programming, user support, and technical assistance with analysis activities as requested by the Project Officer.
The proposal has separate tasks (1-3) for “base” and “optional” measures. Optional measures are those determined after initial evaluation and consultation with AHRQ and ASPR staff to be considered important for capturing an accurate representation of emergency preparedness, but that require more resource intensive development and validation and therefore are outside of the scope of the current technical proposal (e.g. measures that require the development of novel exercises or substantial site visits for validation and accurate data collection).

Targeted and Tailored Messages to Enhance Depression Care and Reduce Stigma
Principal Investigator: Richard Kravitz, MD, MSPH
Source of Support: National Institutes of Mental Health
Approved/Proposed Dates: 9/27/07-7/31/12
Total Costs: $2,934,256

Surveys of patients and physicians show that direct-to-consumer advertising (DTCA) of prescription drugs influences public attitudes and patient behaviors. In a recent randomized controlled trial (RCT) (MH64683), we showed that patients’ requests for antidepressants increase depression-related history-taking, inquiry about suicidal thoughts, and delivery of appropriate initial treatment. Two important questions follow.  First, can messages designed to encourage patient participation reduce stigma and overcome barriers to optimal depression care in the clinic and beyond?  Second, what is the comparative effectiveness of communication strategies based on targeting vs. tailoring? In this application, we propose a two-phase study to enhance delivery of initial treatment for depression. First, using approaches informed respectively by market research and psychological theory, we will develop two communication interventions aimed at working age adults at risk for depression: (1) demographically targeted Public Service Announcements (PSAs) and (2) a social-psychologically tailored interactive multimedia computer program (IMCP). Second, we will conduct an RCT in primary care offices to compare the two interventions with each other and with an “attention control” (video on sleep hygiene). This proposal comports with dissemination and implementation goals as articulated in the NIMH report Bridging Science and Service and in PAR-07-086.