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Center for Healthcare Policy and Research

Center for Healthcare Policy and Research

The vast majority of injuries and illnesses in agriculture are not counted

(SACRAMENTO, Calif.) — April 8, 2014

Federal agencies responsible for tracking workplace hazards fail to report 77 percent of the injuries and illnesses of U.S. agricultural workers and farmers, new research from UC Davis has found. The lack of complete data greatly reduces the chances that safety and health risks for the nation’s food suppliers will be corrected.

Paul Leigh © UC Regents Paul Leigh © UC Regents

Published in the April issue of the Annals of Epidemiology and led by J. Paul Leigh, professor of public health sciences and researcher with the UC Davis Center for Healthcare Policy and Research, the study confirms the long-held belief that government reports dramatically and routinely undercount agricultural injuries and illnesses, ranging from chemical exposures to musculoskeletal injuries.

“Whatever anyone might have assumed about gaps in government statistics for agriculture, our study shows that the problem is actually about three times bigger than previously suspected,” said Leigh.

According to Leigh, the primary reasons for the discrepancy are the government’s focus on mid- to large-sized farming enterprises, which represent less than 50 percent of employment in the agricultural industry, along with the part-time nature of farm work and undisclosed information about injuries.

(Full Article)

 

 

New insights into controlling pediatric obesity

(SACRAMENTO, Calif.) — January 29, 2014

Childhood obesity is a growing epidemic. Almost one-third of children in this country are overweight or obese, but how can we stem the tide? One idea is to use electronic health records (EHRs) to help clinicians intervene more aggressively. Programmed alerts could spur caregivers to order key tests and educate patients and families. But how does this approach work in the real world?

Ulfat Shaikh © UC Regents Ulfat Shaikh © UC Regents

In a study published earlier this month in the American Journal of Medical Quality, researchers at UC Davis found mixed results. While EHR alerts definitely changed physician behavior when treating overweight and obese children, they are no magic bullet. The authors believe EHRs must be incorporated into a more comprehensive strategy to help patients overcome their weight issues.

“The alerts led to significant but not dramatic improvements,” said Ulfat Shaikh, lead researcher, pediatrician and director of Healthcare Quality at the UC Davis School of Medicine. “We believe any electronic record intervention must be combined with other approaches.”

To measure whether EHRs enhance practice, the researchers added obesity-related alerts to health records at the UC Davis Health System’s outpatient clinic, which cares for about 12,000 children each year. The alert — highlighted in bright yellow on the screen — warned physicians when a patient’s weight hit the 85th percentile, which is considered "overweight."

The EHR alert guided physicians through a series of steps to address weight issues. They were encouraged to educate patients and families about diet, exercise, screen time and other behaviors associated with obesity, as well as to document these discussions, order lab tests, refer patients to dietitians and schedule follow-ups.

The alerts had a positive impact, increasing the proportion of children diagnosed as overweight or obese from 40 percent in the pre-alert group to 57 percent in the alert group. Lab tests for diabetes and dyslipidemia (abnormal cholesterol and fat levels in the blood) increased from 17 to 27 percent. Follow-up appointment scheduling went from 24 to 42 percent. However, referrals to dietitians remained static at 13 percent. (Full Article)

 

Health System IT team honored for state's first electronic referral for smoking cessation

(SACRAMENTO, Calif.) — November 25, 2013

The Sacramento County Tobacco Control Coalition has honored UC Davis Health System’s Electronic Medical Records (EMR) team for creating the first two-way e-referral with the California Smokers' Helpline (1-800-NO-BUTTS) in the state.

(Left to right) Willy Bansi and Dr. Hien Nguyen with the health system's recognition award from Tobacco Coalition chair Carolyn Martin (Left to right) Willy Bansi and Dr. Hien Nguyen with the health system's recognition award from Tobacco Coalition chair Carolyn Martin

The new electronic records’ process ensures that smokers are contacted within one to two business days by Helpline, whose free telephone counseling support doubles a smoker’s chances of quitting. An added benefit of the new feedback process is that clinical providers receive a results message back from Helpline staff about their encounters with smokers. 

“Since it can take multiple attempts before a smoker quits for good, this e-referral is an important systems change that provides cessation help at every clinical encounter," said Elisa Tong, associate professor of internal medicine and one of the champions of the new process.  “In six months, we have had more than 280 e-referrals from a variety of clinics and departments. Care providers say they noticed a real benefit from the Helpline’s results feedback and follow-up support.” 

The California Smokers’ Helpline is a free, statewide quit-smoking service operated by UC San Diego's Moores Cancer Center. The Helpline offers self-help materials, referral to local programs, and one-on-one telephone counseling.

Tong credited fellow internist Hien Nguyen, medical director of UC Davis’ EMR system, and Clinical Information Systems specialist Willy Bansi with much of the design work and implementation. She said Nguyen’s leadership helped prioritize development of the project, which has attracted state and national interest. Tong also noted that Anthony Mayoral, the Helpline's director of Data Management and Information Systems, developed the underlying e-referral interface.

“Automated reminders and reliable follow-up information are among the great advantages of electronic medical records,” added Tong. “It’s a high-tech tool that helps improve quality of care. And when it comes to helping a smoker to quit, health-care providers need every possible tool in their medical kit."

Funding from the Affordable Care Act supported the development of UC Davis’ e-referral project. A UC Center for Health Quality and Innovation fellowship grant also supports Tong’s work in developing and promoting tobacco-cessation tools. Tong says the UC Davis team is planning to assist the other UC medical center campuses in launching similar e-referral programs. 

UC Davis Health System is improving lives and transforming health care by providing excellent patient care, conducting groundbreaking research, fostering innovative, interprofessional education, and creating dynamic, productive partnerships with the community. The academic health system includes one of the country's best medical schools, a 619-bed acute-care teaching hospital, a 1000-member physician's practice group and the new Betty Irene Moore School of Nursing. It is home to a National Cancer Institute-designated comprehensive cancer center, an international neurodevelopmental institute, a stem cell institute and a comprehensive children's hospital. Other nationally prominent centers focus on advancing telemedicine, improving vascular care, eliminating health disparities and translating research findings into new treatments for patients. Together, they make UC Davis a hub of innovation that is transforming health for all. For more information, visit healthsystem.ucdavis.edu.

Telemedicine reduces pediatric medication errors in rural emergency departments

(SACRAMENTO, Calif.) — November 25, 2013

A new study from researchers at UC Davis has shown that telemedicine consultations from pediatric specialists reduced the number of drug errors in eight rural emergency departments. Published today in the journal Pediatrics, the study is the latest in research from UC Davis which demonstrates that telemedicine consultations can improve quality of care in rural settings.

“We wanted to look at medication errors and see how telemedicine consultations impacted those rates, compared to telephone consultations or no consultations at all.” said Madan Dharmar, assistant research professor in the Pediatric Telemedicine Program. “We know that having a specialist treat children lowers the risk of medication errors. However, no one had ever studied whether specialists could use telemedicine to have the same effect.”

Rural physicians face distinct disadvantages when providing critical care for severely ill or injured pediatric patients. In addition to lacking pediatric specialty training and experience treating children, emergency physicians in small rural hospitals often lack access to electronic medical records, computerized order entry and 24-hour pharmacist coverage. Previous studies have confirmed that children are at greater risk when treated in rural emergency rooms.

“In children, there’s a higher risk of medication errors because the drug doses are based on weight,” said Dharmar. “Because many of these physicians are not specialists in the treatment of children, there tends to be more errors.”

The study looked at the care provided to 234 patients. In 73 cases (31 percent), a pediatric critical care specialist conferred, over a secure connection, with an emergency physician, the patient, a nurse and a parent or guardian (when available). In 85 cases (36 percent), the specialty consultations were conducted by telephone. In 76 cases (32 percent), the emergency department team received no specialist consult.

The results highlight how well these telemedicine consultations reduce medication errors. The error rate for the telemedicine group was 3.4 percent compared to 10.8 percent for telephone consultations and 12.5 percent when there were no consults. The most common errors were incorrect doses. Telemedicine patients had far fewer dosage errors.

“Our results clearly show that using telemedicine to increase specialist presence lowers the risk of medication errors among seriously ill children,” said Dharmar.

In particular, the contrast between the telemedicine and telephone error rates seems to indicate that visual interaction is a key component to improving care.

The eight rural hospitals were provided telemedicine services, high-resolution monitors and secure power supplies to facilitate the consultations. In addition, UC Davis made pediatric critical care specialists available around-the-clock to provide these consults.

To determine the error rates, researchers looked at charts from the eight hospitals. Patients were older than one day and younger than 17 years and were chosen based on their high level of illness or injury. Emergency department physicians made their own decisions on whether to take advantage of the telemedicine tools.

These findings could have a significant impact on care for all patients. According to the Institute of Medicine, hospital medical errors cause 98,000 preventable deaths each year.

“It’s a win-win for both the specialist, who can see the patients and provide better assessments and care,” said Dharmar, “and for the rural provider, who can deliver a higher level of care right there in their community.”

Other researchers in the study included Nathan Kuppermann, Patrick S. Romano, Nikki H. Yang, Thomas S. Nesbitt, Jennifer Phan and James P. Marcin from UC Davis, Cynthia Nguyen from UC San Francisco and Kourosh Parsapour from UC Irvine.

This research was funded by grants from Agency for Healthcare Research and Quality, Emergency Medical Services for Children, Office for the Advancement of Telehealth, the California Healthcare Foundation and the William Randolph Hearst Foundations. 

Health insurance increases preventive care but not risky behaviors

(SACRAMENTO, Calif.) — November 22, 2013

People with health insurance are more likely to use preventive services such as flu shots and health screenings to reduce their risk of serious illness, but they are no more likely than people without health insurance to engage in risky health behaviors such as smoking or gaining weight, researchers at UC Davis and University of Rochester have found.

New research from physician Anthony Jerant shows that having health insurance increases the use of important services such as cancer screenings, but changes in coverage do not tend to alter health behaviors. New research from physician Anthony Jerant shows that having health insurance increases the use of important services such as cancer screenings, but changes in coverage do not tend to alter health behaviors.

The findings, published in the November-December issue of the Journal of the American Board of Family Medicine, contradict the common concern that expanding health-care coverage may encourage behaviors that increase utilization and costs.

“The notion that people with insurance will exhibit riskier behavior is referred to by economists as ‘ex ante moral hazard’ and has its roots in the early days of the property insurance industry,” said Anthony Jerant, professor of family and community medicine at UC Davis and lead author of the study. “After buying fire insurance, some people wouldn’t manage fire hazards on their property. But health care is different. Someone might not care if their insured warehouse burns down, but most people want desperately to avoid illness.”

Jerant and his colleagues evaluated respondents in the Medical Expenditure Panel Survey, a source of national data on the costs and uses of health care. They included adults who entered the survey between 2000 and 2008, participated for two years and had insurance at least once during those two years of participation. The team then compared data on 96,021 respondents while they were insured to data on them while they were uninsured.

Specifically, the team compared health behaviors that are often detrimental to health such as smoking, seat belt use and weight gain. They also focused on use of preventive care services that are intended to protect health, including flu vaccinations, colorectal cancer screenings, mammography, pap smears and PSA (prostate-specific antigen) tests. In addition, the researchers examined numbers of office visits, prescriptions and other expenditure metrics.

The results showed that changes in health insurance status were closely linked to preventive care, which increased with coverage and decreased without it. The gain or loss of coverage, however, had no significant relationship to changes in health behaviors. This contradicts a belief long-held by some health economists that mandating the purchase of health insurance coverage may increase risky behavior. While this belief is at odds with the experiences of many physicians, this is the first time the relationship has been vigorously investigated in a national sample of adults of all ages.

“There has been a concern that people would say, ‘Hey, I have insurance now, I don’t have to worry about my diet. If I get heavy and develop a problem, I can just go to a doctor and have it treated,’” said Jerant. “Empirically, we find that’s not the case. Health insurance coverage did not worsen the health habits we studied.”

“These results do show that having health insurance affects the likelihood of receiving important preventive services that can potentially reduce the chance of an influenza-related hospitalization or death and prevent or detect colorectal or cervical cancer,” said co-author Kevin Fiscella, professor of family medicine at the University of Rochester School of Medicine. “This is a critical message, as many states continue to debate whether to expand Medicaid.”

While the results of this study generally support the broad intent behind the Affordable Care Act (ACA) to expand insurance coverage as one means to encourage preventive care, Jerant urges caution.

“The people in our study voluntarily acquired health insurance, while the ACA is mandatory,” he said. “We will need to verify whether our findings apply to mandatory coverage. People may behave differently when coverage is mandated.”

In addition, the study does not address why gaining insurance improves receipt of preventive care but not health behaviors that can have profound health effects. The authors suggest that this may result from clinicians having a greater vested interest in preventive interventions, which are more directly under the clinicians’ control and easier to bring about than sustained lifestyle changes. The authors also point out that studies have found that clinical efforts to encourage weight control, seat belt use and smoking cessation have limited efficacy.

While preventive care increased for those with insurance, that increase was not uniform across different types of care. For example, insurance increased cancer screenings, such as colonoscopies, much more than flu shots. The authors hypothesize this may be due to differences in cost and access, as vaccines are relatively inexpensive for uninsured people to buy and are widely available in many workplaces, drugstores and other places — not just in health-care facilities

Ultimately, the study findings counter a theoretical barrier to health insurance expansion.

“Now we have empirical evidence that patients don’t change the health behaviors we studied as a consequence of changes in their health insurance alone, and we’ve confirmed that insurance encourages people to get vaccinations and cancer screenings,” Jerant said. “In other words, insurance works.”

In addition to Jerant and Fiscella, study authors were Daniel Tancredi and senior author Peter Franks of UC Davis. The research had no external funding. A copy of the study is available at http://jabfm.org/content/26/6/759.full.

UC Davis Health System improves lives by providing excellent patient care, conducting groundbreaking research, fostering innovative, interprofessional education and creating dynamic, productive community partnerships. It encompasses one of the country's best medical schools, a 619-bed acute-care teaching hospital, a 1,000-member physician practice group and the Betty Irene Moore School of Nursing. Together, they make UC Davis a hub of innovation that is transforming health for all. For information, visit www.healthsystem.ucdavis.edu.

CHPR Researchers Study Depression Interventions in Primary Care

(SACRAMENTO, Calif.) — November 6, 2013

Patients who used an interactive computer program about depression while waiting to see their primary-care doctor were nearly twice as likely to ask about the condition and significantly more likely to receive a recommendation for antidepressant drugs or a mental-health referral from their physician, according to a new study by researchers at UC Davis.

Anthony Jerant © UC Regents Anthony Jerant © UC Regents

The study, published online today in the Journal of the American Medical Association, was conducted to evaluate the effectiveness of a waiting-room intervention that encourages primary- care patients to discuss depression symptoms and care with their physician. While patients who received treatment or a referral for depression did not report improved mental health 12 weeks later, the study did show that providing information to patients about depression is an effective way to start the conversation in a primary-care setting about mental health.

“We have developed an easy-to-use tool to help people with depression identify the symptoms, feel more comfortable discussing it with a primary-care provider and accept treatment if it is needed,” said Anthony Jerant, professor of family and community medicine at UC Davis and senior author of the study. “This brief and relatively inexpensive intervention could be easily and widely implemented in a variety of health-care settings.”

Depression is an underrecognized and undertreated condition that can easily be overlooked during a typical primary-care visit. While calculating the number of people suffering from untreated depression is difficult, the Centers for Disease Control estimates that nationally 1-in-10 adults has reported symptoms of depression. The National Institute of Mental Health has said that major depressive disorders affect approximately 14.8 million American adults, or about 6.7 percent of the U.S. population age 18 and older in a given year. When left untreated, depression poses high costs to society, jeopardizing relationships and employment, decreasing quality of life, prompting alcohol and drug abuse and, in some cases, leading to the higher risk of suicide.

Three waiting-room interventions tested

The new study involved nearly 900 patients and 135 primary-care clinicians at seven Northern California health-care sites. Prior to their medical appointments, patients were screened for depression. All patients were then randomized to view one of three interventions:

  • - A video – similar to a public-service announcement – focused on recognizing depression and talking with doctors about symptoms;
  • - An interactive multimedia computer program that provided patients with instant feedback and information tailored to different levels of depressive symptoms and treatment preferences;
  • - A non-depression-related video on healthy sleep.

The clinicians did not know which intervention their patients viewed. Immediately after the patients’ appointments, the researchers determined if the patients discussed depression with their clinicians and whether they left with prescriptions for medications to treat depression and if they received a referral for mental-health services.

Help for the most depressed

The results showed that patients with baseline depression who either watched the informational video or used the computer program were nearly twice as likely as control subjects to request information about depression during their appointment. Those who used the interactive computer program were significantly more likely to receive a prescription or referral for depression (26 percent) than were those who viewed either the depression video (17.5 percent) or the video on sleep (16.3 percent). The computer program had the greatest impact on patients who were most depressed, according to the baseline screening.

Richard Kravitz
Richard Kravitz

The investigators also studied the effects of the interventions on people who were not likely to be depressed according to the baseline screening. Among these patients, rates of prescribing and referral were low (about 5 percent) and did not differ by intervention group. According to Richard Kravitz, UC Davis professor of internal medicine and lead author of the study, it is important for public-health interventions to avoid inadvertently expanding unnecessary treatments that can do more harm than good and waste health-care resources. 

“We were concerned that the interventions could lead to treatment for depression for those who do not actually have it,” said Kravitz. “Our interactive computer program, however, increased help for those who needed it the most without increasing treatment for those who didn’t.”

According to Jerant, this study is the largest to compare “targeted” versus “tailored” interventions for stimulating people with depression to seek and accept treatment. Targeted interventions, such as the informational video used in the study, use terms and images most likely to resonate with the target audience, based on specific demographic factors. Four different versions were used in this study, targeted toward gender and income levels. The video took about three minutes to watch.

Tailored interventions, such as the study’s interactive computer program, integrate patient-specific answers to deliver information and guidance. The program used in the study, developed by the study investigators, prompted users to answer questions about symptoms of depression, informed users as to whether or not they were likely to be depressed, and provided guidance depending on the users’ specific needs and interests. Patients assigned to the computer program spent about two to 15 minutes on it, with a median of five minutes.

Kravitz speculated that the informational video did not work as well because, like a television commercial advertising a medication, it may require multiple repetitions to be effective. In contrast, the interactive computer program quickly provided a high level of personalization, which may account for its higher degree of effectiveness with a single use.

The UC Davis investigators intend to further refine and study the interactive computer model to identify patients who need to receive more extensive treatment for their depression.

"As reflected in the author list, this paper was a team effort by a group of very talented CHPR faculty and staff,"  said lead author Kravitz.  "We think the results have important implications for the development of patient engagement interventions and for improving the quality of care for depression in primary care.”

Other CHPR faculty researchers involved in the conduct of this research are UC Davis faculty Peter Franks, a professor of Family and Community Medicine; assistant professor-in-residence Daniel J. Tancredi of the CHPR and the Department of Pediatrics; Robert A. Bell, professor, Department of Communication; Debora A. Paterniti, adjunct associate professor, Departments of Internal Medicine and Sociology and Anthony Jerant, professor, Department of Family and Community Medicine.  CHPR research staff Christina A. Slee and Camille Cipri are also listed as contributing authors. 

The study, titled “Patient Engagement Programs for Recognition and Initial Treatment of Depression in Primary Care,” was supported by grants from the National Institute of Mental Health (1R01MH079387, K24MH072756 and K24MH02712).

For full information, please view the paper at the JAMA website (link).

 

Summer - Fall 2013

NEWS | September 23, 2013

Breastfeeding fraught with early challenges for most first-time mothers

(SACRAMENTO, Calif.)

Breastfeeding problems are extremely common among first-time moms, often causing them to introduce formula or completely abandon breastfeeding within two months, report researchers at the University of California, Davis, and the Cincinnati Children’s Hospital Medical Center.

Mother and newborn infant © iStockphoto Mother and newborn infant © iStockphoto

Strategies should be developed for evaluating infant breastfeeding and alleviating the concerns of the new, breastfeeding mothers soon after birth, recommend the researchers, who report their findings online this week in the journal Pediatrics.

“Findings from our study indicate that certain breastfeeding problems or concerns are experienced almost universally by first-time mothers, and some of those problems greatly increase the chances they will stop breastfeeding earlier than they planned,” said study co-author Caroline Chantry, a pediatrician at the UC Davis Medical Center, where the research with the first-time mothers was based.

“If we can enable mothers to achieve their breastfeeding goals, we will have a healthier nation,” Chantry said. She noted that although 75 percent of mothers in the United States initiate breastfeeding, only 13 percent of those women ultimately breastfeed exclusively for the recommended first six months of the child’s life.

The new study, based on a sample of 532 first-time mothers, included interviews while the women were pregnant and at six other times between birth and 60 days after the babies were born.

Ninety-two percent of the new moms reported at least one breastfeeding concern three days after birth. The most predominant concern was that the infants were not feeding well at the breast (52 percent), followed by breastfeeding pain (44 percent) and perceived lack of sufficient milk (40 percent).

The researchers collected reports of thousands of breastfeeding problems and concerns from the mothers. The concerns that were reported at interviews conducted at days three and seven after the baby’s birth were strongly associated with the moms’ subsequent decisions to supplement with formula or stop breastfeeding altogether.

“These interviews at three and seven days were conducted at a time when there may be a gap between hospital- and community-based lactation support resources,” said co-author Kathryn Dewey, a UC Davis nutrition professor and authority on maternal and infant nutrition. (More) 

 

NEWS | September 16, 2013

UC Davis study applies timely cost-effectiveness analysis to state breast cancer screening program

(SACRAMENTO, Calif.)

When public health budgets are constrained, mammography screening should begin later and occur less frequently, a cost-effectiveness analysis for California’s Every Woman Counts (EWC) program concludes.

Joy Melnikow © UC Regents Joy Melnikow © UC Regents

As outlined in a paper published in Value in Health, the analysis focused on several policy questions, including the effect on EWC program costs and outcomes of starting screening at age 50 years instead of 40 and of screening every two years instead of every year. The study was conducted in response to recent government funding cutbacks.

“This was not a clinical recommendation, but rather was intended to help a public health program use its resources to the greatest effectiveness,” said lead author Joy Melnikow, director of the UC Davis Center for Healthcare Policy and Research.

EWC, administered through the California Department of Public Health Cancer Detection Section, is one of the largest of 68 Centers for Disease Control and Prevention-funded programs across the country. It reimburses providers at Medi-Cal rates (Medi-Cal is the California version of Medicaid) for screening and diagnostic services for breast and cervical cancers. It provides services to women who are not eligible for Medi-Cal, who otherwise lack coverage for breast and cervical cancer screening, and whose income is less than 200 percent of the federal poverty threshold.

The study, conducted by UC Davis and EWC researchers, was based on a sophisticated microsimulation model that projected outcomes based on existing program data. It found that starting mammography screening biennially at age 50 was strongly supported by the model results, given that program funding did not allow screening of the full population of eligible women beginning at age 40.

“Because breast cancer incidence goes up with age, using program funds to screen all eligible women over age 50 will have a greater impact on reducing breast cancer deaths,” said Melnikow.  “The goal was to advise a public health program in a timeframe that could be helpful, given that cost-effectiveness analysis typically takes a long time to conduct — often too long to be of use in a quickly changing policy environment.”

The United States Preventive Services Task Force, a government medical task force, in 2009 recommended the same changes in breast cancer screening guidelines, suggesting that most women should not begin getting routine mammograms until age 50, and then only once every two years.

“The task force was asking a different question,” explains Melnikow, who became a member of the task force after the breast cancer screening recommendations vote. “In that case, cost-effectiveness and policy weren’t factors. Instead, the Task Force looked at recommendations for screening of women exclusively from a clinical point of view.”

Melnikow, a UC Davis professor of Family and Community medicine, points out that the EWC analysis has implications for other budget-constrained public programs around the country.

“This study is important for administrators who are doing their best to run public health programs with limited resources. We found that, although it can be challenging, it is by no means impossible to create carefully constructed cost-effectiveness analysis models quickly enough to be useful to programs and policy makers as they render important resource allocation decisions.”

Other study authors were Daniel J. Tancredi, Zhuo Yang, Dominique Ritley, Yun Jiang and Christina Slee, all of the UC Davis Center for Healthcare Policy and Research, UC Davis; and Svetlana Popova, Phillip Rylett, Kirsten Knutson and Sherie Smalley, of the Every Woman Counts program, Cancer Detection Section.

Funding for the study was provided by the California Program on Access to Care , UC Berkeley School of Public Health in cooperation with the UC Office of the President.

The Center for Health Policy Research conducts research on health-care access, delivery, costs, outcomes and related health policy to improve the organization, quality and effectiveness of the practice of medicine, especially primary care. The center is a resource for the university and health system on comparative effectiveness research. Center faculty conduct original research, offer consulting services to agencies in both public and private sectors, and provide research training to fellows, graduate students and junior faculty. Established as an interdisciplinary unit, the center includes more than 80 health-care researchers who represent disciplines ranging from business management and psychiatry to preventive medicine, epidemiology and statistics. For more information, visit https://www.ucdmc.ucdavis.edu/chpr.



"Incidental findings" rare but significant events in pediatric CT scans

Four percent of head-trauma scans have unexpected results that may need follow up

(SACRAMENTO, Calif.)

The largest study of computed tomographic (CT) scans taken in emergency departments across the country for children with head injuries describes the prevalence of “incidental findings” —  results that were not expected from the injury — and categorizes them by urgency. 

Nathan Kuppermann © UC Regents Nathan Kuppermann © UC Regents

The article, titled “Incidental findings in children with blunt head trauma evaluated with cranial CT scans,” was published in the August issue of Pediatrics, and provides a context for doctors in emergency departments who encounter these situations.

“Incidental findings are a rare but significant event,” said Nathan Kuppermann, professor and chair of emergency medicine at the UC Davis Medical Center and principal investigator of the study. “It is important for doctors to look for abnormalities other than what they expect to find and to be prepared to interpret and communicate these findings to families.” 

The study involved nearly 44,000 children seen for a head injury in 25 hospital emergency departments nationwide. Nearly 16,000 had CT scans to evaluate an injury, and about 4 percent of the scans revealed incidental findings ranging from enlarged tonsils to life-threatening cancers. Children with a known pre-existing brain abnormality were excluded from the analysis.

Researchers also stratified the incidental findings into three categories: those that needed immediate evaluation or treatment, those that needed appropriate timely outpatient follow up, and those that merited further investigation only if the problems were causing symptoms. Only 0.1 percent of the overall sample of CTs fell into the most serious category. (More)

UC Davis researchers receive $2.5 million grant to study telepsychiatry

Researchers at UC Davis have received a five-year, $2.5 million grant to study whether viewing videotaped interviews with patients to assess them and guide their mental-health treatment is more cost-effective and better for patient outcomes and satisfaction than real-time telepsychiatric evaluation.

Peter Yellowlees © UC Regents The study will involve videotaping interviews of patients and their providers in their primary-care clinic that later are viewed and evaluated by psychiatrists, who will make diagnostic evaluations and treatment plans that can be carried out by primary-care doctors and community therapists. This approach is called “store-and-forward,” or asynchronous telepsychiatry, because the patient is not being evaluated in real time.

The research will compare the effectiveness of this style of telepsychiatry to real-time, or synchronous telepsychiatry, in which a psychiatrist evaluates patients via live, interactive videoconferencing. In both approaches, the psychiatrist provides primary-care providers with assessments and treatment plans and is available for follow-up consultation by phone or email. (More)

 

School of Nursing professor named director of new center devoted to boost women's numbers in academia

Professor Mary Lou de Leon Siantz was recently appointed by UC Davis Chancellor Linda P.B. Katehi as director for the new Center for the Advancement of Multicultural Perspectives on Science (CAMPOS). The center is part of a new effort, led by Katehi, to increase the participation of women, especially Latinas, in academic science, technology, engineering and mathematics (STEM) careers.

Established by a grant of $3.725 million over five years from the National Science Foundation’s ADVANCE program, CAMPOS is a research center aimed at attracting women and Latina STEM scholars to UC Davis by providing an accessible and inclusive community of research collaborators and mentors throughout their careers.

CAMPOS is planned to be both a physical location for networking and exchanging ideas and a faculty-hiring initiative to increase diversity in key STEM fields. In making up to 16 new faculty hires, CAMPOS aims to build coalitions of STEM faculty who want to apply their research to serve underrepresented communities. (FULL STORY)

 

Reducing unnecessary and high-dose pediatric CT scans
could cut associated cancers by 62 percent

Diana Miglioretti A study examining trends in X-ray computed tomography (CT) use in children in the United States has found that reducing unnecessary scans and lowering the doses for the highest-dose scans could lower the overall lifetime risk of future imaging-related cancers by 62 percent. The research by a UC Davis Health System scientist is published online today in JAMA Pediatrics. It is accompanied by a journal editorial.

The 4 million CT scans of the most commonly imaged organs conducted in children each year could result in approximately 4,870 future cancers, the study found. Reducing the highest 25 percent of radiation doses could prevent 2,090 — or 43 percent — of these future cancers. By also eliminating unnecessary imaging, 3,020 — or 62 percent — of cancers could be prevented, said Diana Miglioretti, lead study author and Dean’s Professor in Biostatistics in the Department of Public Health Sciences at UC Davis Health System.

“There are potential harms from CT, meaning that there is a cancer risk, albeit very small in individual children, so it’s important to reduce this risk in two ways,” said Miglioretti, who is a member of the UC Davis Comprehensive Cancer Center. “The first is to only do a CT when it’s medically necessary, and use alternative imaging when possible. The second is to dose CT appropriately for children.” (FULL STORY)

 

Emergency medicine faculty honored at national meeting

Three members of the UC Davis Department of Emergency Medicine, including two members of the Center for Healthcare Policy and Research, were honored recently for their achievements and leadership at this year’s annual Society for Academic Emergency Medicine (SAEM) meeting in Atlanta.

Daniel Nishijima Daniel Nishijima, assistant professor of emergency medicine, received the society’s Young Investigator Award for his early career accomplishments in clinical research in emergency medicine. Nishijima, who came to UC Davis as a research fellow in 2008, is becoming known as an investigator with expertise in the evaluation and management of patients with blunt head trauma. One of his current projects is a cost-effectiveness analysis of using a decision rule for CT scanning in children with blunt head trauma versus routine care. Nishijima has published 18 manuscripts (including those in press), and has been the first author on 11 of those studies. He is currently an awardee of a competitive CTSC K12 career development award, and has been successful in obtaining highly competitive intramural grants as well as securing important extramural research funding.

James HolmesJames Holmes, professor of emergency medicine, was elected to the society’s board of directors. Holmes is well known for both his clinical-care expertise and research accomplishments. In addition to investigating various approaches to improving trauma care of both adults and children  in emergency departments, he is working with department Chair Nathan Kuppermann to oversee a five-year, NIH training grant for research education in emergency medicine, pediatric emergency medicine and associated disciplines.  His research is highly collaborative, frequently using multicenter research networks, and focuses on the care of adults and children with acute traumatic injuries. (FULL STORY)

 

2013 Outcomes Research Pilot Awards

The CHPR is proud to announce the recipients of the 2013 Outcomes Research Pilot Awards: 

Stephen G. Henry, M.D., M.Sc. (Department of Internal Medicine)
"Characterizing opioid dose escalation during early chronic opioid therapy for pain"

Caroline Chantry, M.D. (Department of Pediatrics)
"Delayed umbilical cord clamping for term infants: Evaluating the impact of adopting a hospital policy for vaginal delieveries and a pilot trial during Cesarean deliveries"

Garth Utter, M.D., M.Sc. (Department of Surgery)
"Anemia, transfusion and outcomes from traumatic brain injury"

Winter-Spring 2013

Three UC Davis recipients awarded fellowships from UC innovation center

January 28, 2013
(SACRAMENTO, Calif.) —Three UC Davis researchers, including CHPR Members James Marcin and Elisa Tong, are among the 10 new recipients of fellowships awarded by the University of California’s Center for Health Quality and Innovation. Representing five UC campuses, the recipients received the fellowships to support projects to improve the quality and value of care delivered by UC Health.  (more here)

Fall 2012

CHPR Researchers Receive New Awards Totaling $5.7M: Department Expands

From top left:  Kravitz, Jerant, Fenton, WaetjenUC Davis researchers afilliated with the Center for Healthcare Policy and Research (CHPR) have recently been awarded new funding for four separate projects totaling almost $6M.  All four project proposals were prepared by the CHPR in conjunction with the Principal Investigators and their research collaborators, and all four projects will be administered and housed at the Center for Healthcare Policy and research.

As a result of the new awards, the CHPR will expand to the first floor of the Grange Building.  They currently occupy the second floor of that building. 

Details about each of the four awards are listed below: 

"N-of-1 Trials Using mHealth in Chronic Pain"
Principal Investigator:
  Richard Kravitz, UC Davis Department of Internal Medicine
Funding Agency: National Institute of Health
Type: R01
Total Award: $3,905,813

Chronic musculoskeletal pain is an enormous problem, and treatments are often prescribed in a “trial and error” fashion. This project seeks to develop a mobile phone application (“app”) that allows patients and their health care providers to run rigorous, personalized experiments (“n-of-1 trials”) comparing two different pain treatments. Once the app is developed, the investigators will enroll 296 patients in a randomized study that looks at long term pain outcomes among patients assigned to undergo an n-of-1 trial using the app versus usual care. The project enlists mobile technology to help patients engage actively and collaboratively with their clinicians to identify the pain treatment that works best for them.

Other UC Davis researchers involved in this project are:

  • Barth Wilsey (Physical Medicine and Rehabilitation)
  • Debora Ward (Betty Irene Moore School of Nursing)
  • Joy Melnikow (Family and Community Medicine)
  • BK Yoo (Public Health Sciences)
  • Debora Paterniti (Internal Medicine, Bioethics)
  •  

    "Provider Training to Support Patient Self-efficacy for Depression Care"
    Principal Investigator:
      Anthony Jerant, UC Davis Department of Family and Community Medicine
    Funding Agency: National Institute of Mental Health
    Type: R34
    Total Award: $698,602

    This study will determine whether practicing primary care providers (PCPs) can be trained to support patient self-care of depression and co-existing diabetes during office visits, and begin to explore whether this might improve depression and diabetes outcomes. This is important because most patients with these conditions struggle with self-care and are seen in primary care, yet PCPs are seldom trained to support self-care.

    Other UC Davis researchers involved in this project are:

  • Peter Franks (Family and Community Medicine)
  • Richard L Kravitz (Internal Medicine)
  • Daniel Tancredi (Pediatrics)
  • Debora Paterniti (Internal Medicine, Bioethics)
  • Kurt Slapnik (UC Davis Medical Group)
  •  

    "Promoting Patient-centered Counseling to Reduce Inappropriate Diagnostic Tests"
    Principal Investigator:
      Joshua Fenton, UC Davis Department of Family and Community Medicine
    Funding Agency: Patient Centered Outcomes Research Institute (PCORI)
    Total Award: $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.

    Other UC Davis researchers involved in this project are:

  • Peter Franks, MD (Family and Community Medicine)
  • Richard L Kravitz, MD (Internal Medicine)
  • Anthony Jerant (Family and Community Medicine)
  • Debora Paterniti, PhD (Internal Medicine, Bioethics)
  • Heejung Bang (Public Health Sciences)
  •  

    "Exploring Disparities: Urinary Indontinence treatment seeking in mid-life women"
    Principal Investigator:
      Elaine Waetjen, UC Davis Department of Obstetrics and Gynecology
    Funding Agency: National Institute of Health
    Type: R21
    Total Award: $418,168

    Urinary incontinence (UI) is a frequent midlife problem that disproportionately affects women. While a number of effective treatments exist for UI, women can be inhibited in seeking care for this problem. This study proposes to explore racial/ethnic, socioeconomic, and educational level disparities in treatment seeking behavior for UI over time using 10 years of annual questionnaire and physical measures data from the Study of Women’s Health Across the Nation (SWAN), a multi-racial/ethnic, community-based, prospective cohort study of women transitioning through menopause.

    With longitudinal logistic regression and discrete proportional hazards statistical modeling, we will analyze the complex interplay between demographic characteristics and longitudinal changes in UI characteristics, economic, social psychological, and health factors that may affect: 1) not seeking UI treatment and reported reasons for not seeking treatment from health care providers, and 2) the types of treatments prescribed for and tried by community-dwelling midlife women who do seek UI care. With information from this study, public health educators can target messages to specific groups with bothersome UI symptoms at risk for not accessing UI care. For health care providers, a better understanding of what factors make a woman more or less likely to report UI to them and try their recommended treatments will allow them to improve and individualize assessment of and treatment plans for their incontinent patients.

    Other UC Davis researchers involved in this project are:

  • Joy Melnikow (Family and Community Medicine)
  • Ellen Gold (Public Health Sciences)
  • Guibo Xing (Center for Healthcare Policy and Research)
  •  

    CHPR Director Joy Melnikow Appointed to Let's Get Healthy California Task Force

    Sacramento – California Health and Human Services Agency Secretary, Diana S. Dooley announced today the members appointed to the Let’s Get Healthy California Task Force and the Expert Advisors charged with developing a 10-year plan to make Californians healthier. CHPR Director and professor of Family and Community Medicine Joy Melnikow is among the appointed members.  The appointments are made pursuant to Governor Edmund G. Brown, Jr.’s Executive Order.

    The Task Force will be Co-Chaired by Secretary Dooley and Don Berwick, MD MPP who is a senior fellow at the Center for American Progress (CAP), is the former president and CEO of the Institute for Healthcare Improvement and served by appointment of President Obama as the Administrator of the Centers for Medicare and Medicaid Services until December, 2011.

    “With the leadership of Dr. Don Berwick and California’s world-class talent in health, technology, education and research, it wasn’t hard to assemble this energetic group of leaders for our work ahead,” said Secretary Dooley. “With the knowledge, diversity and experience of these appointees and the support of so many others committed to our success, I look forward to receiving an innovative plan to reduce the burdens of chronic and preventable diseases and improve the health of all Californians.”

    The Task Force and the Expert Advisors will work together to gather, evaluate and prioritize the best ideas and practices and organize them into a 10-year plan to improve quality, control costs, promote personal responsibility for individual health, and advance health equity. The report will establish baselines for key health indicators, identify obstacles, inventory best practices, provide fiscally prudent recommendations and create a sensible framework for measuring improvements in key areas including:

    • Reducing diabetes, asthma, childhood obesity, hypertension, and sepsis-related mortality.
    • Reducing hospital readmissions with 30 days of discharge.
    • Increasing the number of children receiving recommended vaccines by age three.

    The first meeting of the Task Force will be held in Los Angeles on June 11, 2012. The plan will be presented by December 15, 2012.