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UC Davis Medicine

UC Davis Medicine

Influencing national health reform

Expanding the national reach of UC Davis

Expanding the national reach of UC DavisThe Institute of Medicine looks to experts in academia, including many from UC DAvis Health System, for recommendations on shaping the future of health care. Read more

Serving the nation

UC Davis Health System's reputation and influence is advanced through faculty, staff and student memberships in professional organizations. Read more

UC Davis in the News

The national news media frequently covers stories about UC Davis Health System, UC Davis Medical Center, the School of Medicine and the Betty Irene Moore School of Nursing. Here is a sampling of coverage over the last six months. Read more

Leadership Appointments

Kizer heads new institute

Kenneth W. KizerKenneth W. Kizer

New Pathology chair

Lydia Pleotis HowellLydia Pleotis Howell

Diversity associate vice chancellor

Shelton J. DuruisseauShelton J. Duruisseau

New chief financial officer

Timothy MauriceTimothy Maurice

Joy MelnikowHealth-care reform is now on the top of the national agenda, but at UC Davis Health System, researchers have been contributing provocative and impactful work to improve health care in America for nearly two decades.

As the nation struggles to keep health-care costs down and as policymakers, insurance companies and health-care providers grapple with the new Affordable Care Act, UC Davis researchers continue forging new ground to transform health-care delivery. An examination of wage disparities among physician specialties, the role of nurses in health-care reform efforts, cost-effectiveness of cancer screenings and creation of better health-care quality measures are among the ongoing projects.

UC Davis faculty, for example, are charting the future of health care for women and the field of nursing, through their work with the influential Institute of Medicine.

"The core of [CHPR’s] mission advances the information needs for health-care reform."

Likewise, members of the UC Davis Center for Healthcare Policy and Research (CHPR) are bringing their groundbreaking work and expertise to bear on efforts to improve health-care access, delivery, cost-effectiveness and outcomes.

"The mission of our center is to enhance research and education around quality and outcomes of health care," says Joy Melnikow, director of CHPR and a UC Davis professor of family and community medicine. "There is no question that the center is contributing to and informing national health-care reform."

The center’s charge has been to help lead work in comparative effectiveness research, which involves the direct comparison of existing health-care interventions to determine which treatments work best, for whom, and under what circumstances.

President Obama has said that evidence-based medicine is key to making sure Americans get the best care while keeping the cost of care affordable. That includes standardizing care, based on the results of comparative effectiveness research.

Comparative effectiveness research is now a focus in the national debate, but CHPR members have been doing this type of work since 1994.

"The findings of this kind of research are the building blocks for decision-making to develop reforms that will lead us to health care that has increased benefits, reduced harms and controlled costs," Melnikow says. "The core of our mission advances the information needs for health-care reform."

Identifying best practices

Melnikow’s work has examined the costs and benefits of standard preventive interventions – primarily for breast and cervical cancer.

"In other countries, you’ll find that more than half the doctors are primary-care physicians. In the United States, we have fewer than 40 percent who are
primary-care physicians."

In 1996, she was one of a team of researchers who showed that most women at high risk for breast cancer do not increase their life expectancy by taking the drug tamoxifen. The findings were controversial at the time, but today tamoxifen is primarily used to prevent the recurrence of breast cancer in women already diagnosed with the disease.

In November, Melnikow was the lead author of a study of the options for reducing cancer incidence and mortality among women who have been treated for precancerous cervical lesions. The study, the first comprehensive one of its kind, revealed that an annual conventional Pap smear is a cost-effective strategy for these women.

"This is a large and growing pool of women who need follow-up after treatment," Melnikow said in a press release. "But we’ve had few studies on which to base recommendations for follow-up."

Wage disparity

One reason the cost of care is rising is the disproportionate number of specialist physicians practicing in the U.S. says CHPR researcher J. Paul Leigh.

"In other countries, you’ll find that more than half the doctors are primary-care physicians," says Leigh, a UC Davis professor of public health. "In the United States, we have fewer than 40 percent who are primary care physicians."

In November, he and a team of center researchers sparked national interest with their study showing that specialists make 36 percent to 50 percent more money on average than their primary-care physician counterparts.

"That’s a difference of $2 million to $3 million dollars over a lifetime," explains Leigh. "That’s a huge incentive for people to choose a specialty."

Addressing the wage disparity is a complex challenge, Leigh says. "The first thing we need to do is to document the disparity, and that’s what we’ve done."

Eliminating the wage disparity would help with recruitment and retention of primary-care physicians, and could be part of the solution as the health-care system becomes more focused on primary care, says CHPR investigator Richard Kravitz, senior author of the study.

"With primary-care physicians already overburdened, we need to figure out how we are going to protect, preserve and improve the quality of primary care as patient volumes increase," says Kravitz.

Harnessing patient choice

Groundbreaking work by Kravitz suggests that influencing patient behavior might be the key.

"My work has been about the patient’s role in averting under-use and diminishing overutilization of physicians," Kravitz says, adding that patients have a surprising influence on the kinds and numbers of tests ordered, prescriptions written and eventual diagnoses.

"Over the years, we have found that physicians’ perceptions of patients’ expectations and patients’ explicit requests have had a profound influence."

Richard Kravitz"Our work has highlighted
the importance of educating, engaging and activating patients in their own care."

In 2005, Kravitz and his colleagues captured the attention of the health-care community with a study in which they described using trained actors who were able to influence the way physicians treated symptoms of depression.

"Patients who made specific requests were much more likely to get the drug they asked for whether they had major depressive symptoms or not," Kravitz says.

These results might seem worrisome, but Kravitz takes a different view. "Our work has highlighted the importance of educating, engaging and activating patients in their own care."

Kravitz is currently leading a randomized trial of patient-centered interventions to encourage patients with depressive symptoms to discuss those symptoms with their primary-care physician.

"Most depressed patients are seen in primary care, yet it is still under-diagnosed."

Kravitz and his colleagues are testing interventions in which patients with symptoms of depression are presented with either short public service announcements viewed on a computer in the doctor’s office or an interactive multimedia computer program that tailors the information presented to the patients’ answers to questions. The third group does not receive any intervention prior to their appointment with their doctor.

"At the end of the study, we’ll compare each group according to whether they talked to their physician about their condition."

Kravitz anticipates that these ongoing studies and others will inform health-care reform now and in the decades to come.

"We have a real opportunity to improve the quality of care and at the same time bring down the cost of care."

Measuring quality

The quality of health care in America can only improve if the accurate quality measures are used to guide policy and practice. That’s where CHPR’s Patrick Romano plays a role. He is working side-by-side with the U.S. Agency for Healthcare Research and Quality (AHRQ) to ensure quality measures actually reveal what works and what does not.

Patrick Romano"We have to assess the quality of our measures and make sure that they make sense to clinicians, make sure providers can act upon them and that we account for variation in how sick the patients are."

Romano, a UC Davis professor of medicine and pediatrics, is an expert in the science of quality measurement, studying how to evaluate, compare and improve the quality of care that doctors and hospitals provide. Quality indicators are agreed-upon ways to measure whether medical procedures and interventions are having the desired outcomes. Romano’s work focuses on whether these indicators are valid and reliable.

"We have to assess the quality of our measures and make sure that they make sense to clinicians, make sure providers can act upon them and that we account for variation in how sick the patients are," he says.

He and his colleagues worked with state officials for 15 years on the technical methods behind report cards on hospital performance.

"We have lots of experience developing, testing and validating the methodology for these kinds of reports."

Romano has served as the clinical lead for the AHRQ’s national Quality Indicators program for the past eight years. During that time, he has evaluated the effectiveness of quality indicators, helping refine those that help health-care providers improve care delivery and making cases for eliminating those that do not.

Ultimately, better indicators mean more reliable information on which to base health-care policy decisions, Romano says.

"The cost of health care is increasing faster than we can afford. Resources are limited, and we need to be sensible about identifying and rewarding value in health care."

Evaluating proposed legislation

Melnikow was recently named the vice chair for public health of the California Health Benefits Review Program (CHBRP). The program provides independent analysis of the medical, financial and public health impacts of proposed health insurance benefit mandates and repeals to the California State Legislature.

"The cost of health care is increasing faster than we can afford. Resources are limited, and we need to be sensible about identifying and rewarding value in health care."

Representatives from the University of California, Loma Linda University, University of Southern California and Stanford University are members of CHBRP and work closely with a small analytic staff from the University of California’s Office of the President to analyze bills being considered by the Legislature.

The program provides law-makers with a three-part report detailing the medical, financial and public health impacts of the legislation within 60 days of a legislator’s request.

The state established the program in 2002 and is funded by an annual assessment of health plans and insurers.

UC Davis is in charge of generating the public health portion of the program’s reports to legislators.

Melnikow describes the program as unparalleled in its extent and rigor: "It is a model that could be picked up by other states and maybe even implemented at the federal level."

 UC Davis Health > Spring 2011 > Features
UC Davis Health

Spring 2011

Influencing national health reform

Joy Melnikow, director of CHPR and a UC Davis professor of family and community medicine