IMPH Research in Healthcare Research

Health Literacy, Hospital Discharge, and Cardiovascular Outcomes 
The Quality of Care in Evaluating Patients Suspected of Having Bladder Cancer 
Trends in Surveillance for Localized Prostate Cancer and Barriers to Its Use

Health Literacy, Hospital Discharge, and Cardiovascular Outcomes

The period following hospital discharge is a vulnerable time for patients in which poorly coordinated care and medication mismanagement are common. Suboptimal care in the peri-discharge period contributes to preventable adverse events, hospital readmission, and higher mortality, particularly in high-risk conditions such as acute coronary syndromes (ACS). Low health literacy is a prevalent risk factor for poor processes and outcomes of care, but little research has been conducted on the role of health literacy in this high-risk setting. The goal of this research is to examine how health literacy and other patient characteristics affect the quality of hospital discharge and related outcomes after hospitalization. We will test a conceptual framework that includes patient-, provider-, and system-related factors as potential mediators and moderators of these relationships. The Specific Aims are to: 1) Determine the association of health literacy with the quality of hospital discharge, including the impact on communication, preparedness for discharge, and subsequent medication management. 2) Examine the effect of health literacy and hospital discharge quality on functional status, health- related quality of life, and unplanned health care utilization 30 and 90 days after hospital discharge. 3) Examine the effect of health literacy and hospital discharge quality on mortality after hospitalization. We will perform a prospective cohort study of 3,000 adults hospitalized for ACS and discharged to home. Data collection and analyses will be grounded in a conceptual framework that relates health literacy to processes and outcomes of care. During hospitalization, we will administer a robust set of validated sociodemographic, educational, cognitive, psychological, cultural, and behavioral measures. For Aim 1, we will interview patients by telephone 2-3 days after discharge to assess the quality of hospital discharge, including measures of patient-provider communication and preparedness for discharge. For Aim 2, we will review medical records and interview patients by telephone 30 and 90 days after discharge to assess changes in functional status, health-related quality of life, and unplanned health care utilization, including Emergency Department visits and rehospitalization. For Aim 3, we will ascertain mortality using the Social Security Administration Death Master File, following patients for up to 3.5 years after enrollment. We will use multivariable path analyses and survival analyses to model the direct and indirect relationships among health literacy, other measured factors, potential mediators or moderators, and each outcome of interest. This interdisciplinary research will greatly enhance our understanding of how health literacy affects hospital discharge processes and outcomes after hospitalization. Findings will enable us to better design interventions to improve services for patients with low health literacy, as well as other high-risk groups. Knowledge gained from this study may also help improve cardiovascular outcomes and reduce literacy-related health disparities. Read more.

Funding Source: NIH/NHLBI 
PI: Sunil Kripalani

The Quality of Care in Evaluating Patients Suspected of Having Bladder Cancer

The presence of blood in the urine, or "hematuria", may herald the presence of urologic malignancy such as bladder cancer or kidney cancer; benign urologic disease such as kidney stones (nephrolithiasis), urinary tract infection; or intrinsic renal disease, such as glomerulonephritis. The proper evaluation of patients with hematuria is essential to identify the 1 person in 10 who may have a life-threatening malignancy or other treatable condition. Chief among these conditions is bladder cancer (BC), because of its high incidence and lethality. Guidelines from the American Urological Associate (AUA) and the National Cancer Collaborative Network (NCCN) call for evaluation of persons presenting with suspicion for urothelial carcinoma using office cystoscopy (endoscopic evaluation of the bladder) to rule out BC and, in many instances, an imaging study of the kidneys and ureters to rule out other malignancies. There is some evidence of insufficient adherence to guidelines for surveillance of patients with BC, but there is a gap in the evidence with respect to the initial evaluation of those suspected of harboring BC. Delayed or incomplete evaluation indicates poor adherence to published guidelines, and could contribute to sub-optimal BC outcomes. In fact, one theory, which has yet to be tested, is that racial variation in adherence to evaluation guidelines could explain the racial paradox in BC: while BC is more common among Whites, African-American patients present with higher-stage disease, and have a higher likelihood of disease-specific mortality. We propose several approaches to determine the current quality of evaluation of patients with hematuria, to identify racial variation in the timely and complete evaluation of hematuria and to determine the underlying reasons for such variation. First, we will look broadly at the Medicare dataset to determine the frequency of use of cystoscopy and imaging for patients with hematuria, and investigate whether there are racial differences in their use on a national level. Second, we will use a well-characterized prospective cohort of over 86,000 economically disadvantaged and racially diverse persons in the Southeastern US (The Southern Community Cohort Study) in order to identify the factors that may underlie racial variation in the timely and complete workup of hematuria, such as socio-economic status, educational attainment, healthcare access indicators. The remaining unexplained variation may be amenable to educational interventions among primary care providers. The ultimate aim of the proposed study is to identify gaps in the quality of care for patients with hematuria, which will become targets in a planned interventional study through a multi-center quality collaborative in which we participate. Read more.

Funding Source: NIH/NCI
PI: Daniel Barocas

Trends in Surveillance for Localized Prostate Cancer and Barriers to Its Use

Observation of localized prostate cancer is often a reasonable alternative to immediate definitive treatment because many prostate cancers are non-lethal and have a protracted natural history. Active surveillance (AS) is associated with nearly 100% disease-specific survival in the management of low-risk clinically localized prostate cancer in prospective cohort studies and has been promoted in recent years as a means of stemming over-treatment of low-risk disease. However, AS seems to be an underutilized strategy in the management of prostate cancer, perhaps in part because of its association with the passive observation strategy known as watchful waiting (WW), which was more commonly recommended in elderly and infirmed men in past decades. Whereas AS seeks to identify signs of disease progression and offers definitive therapy (radiation or surgery) if progression is found WW is designed to allow prostate cancer to progress, assuming that the patient is more likely to die of other causes, and only palliative intervention is offered for symptom relief. Observation of prostate cancer has gained wider acceptance in Europe and Canada than it has in the US, where utilization remains at 10% or less among low-risk patients. In order to expand the acceptance of and adherence to AS for management of low-risk clinically localized prostate cancer, it may be necessary to distinguish it from WW in common clinical practice and to identify patient-level factors and physician communication styles that impact the decision to select AS. We propose using data from two large, community-based prospective cohort studies of men with localized prostate cancer with similar study designs (Prostate Cancer Outcomes Study [PCOS] and Comparative Effectiveness Analysis of Surgery And Radiation [CEASAR]), to compare the use of surveillance between two eras (1990s for PCOS and 2010s for CEASAR). Our aim is to determine whether the evidence demonstrating that AS is a safe alternative to active treatment has led to an increase in its use among men with low-risk disease and to increased use among younger, healthier men across the two eras (suggesting a transition from WW to AS). Secondly, we will use the CEASAR baseline questionnaire to determine the extent to which physician communication style influences the selection of AS in favor of other currently available treatments. The results of the proposed study will provide the foundation for a planned study of AS utilization within the Urological Surgery Quality Collaborative, a multi-institutional group of 7 urology practices throughout the Mid- West, Mid-Atlantic and Southeastern United States. Using an established quality assessment, quality improvement model, we aim to assess prospectively the physician and patient level barriers to AS; then perform an educational intervention with physicians in an effort to increase use of AS in appropriate clinical scenarios; then reassess to evaluate the effectiveness of the intervention. Because prostate cancer is the most commonly diagnosed cancer among men, the potential public health impact of increasing AS use is enormous. Read more.

Funding Source: NIH/NCI 
PI: Daniel Barocas