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Other Epidemiologic and Health Services Research

What Makes Medical Homes Work: Lessons for Implementation and Spread

PI: Jove Graham, PhD

Patients enrolled in the medical home program launched by Geisinger Health System receive higher-quality, more efficient care than those receiving care elsewhere.  There is now tremendous interest nationwide in understanding factors associated with successful spread of medical home models and identifying which features are most associated with greater efficiency. The project team is examining differences in how the medical home model was implemented in 26 sites to understand the factors associated with significant changes in hospital admissions, hospital readmissions, and total medical costs. Through interviews with primary care physicians, nurse case managers, other clinical staff, health plan officials, and system leaders, the project team will collect information on how the various components of the medical home were initially designed, and how they were practically implemented at each site.  We are using information from the interviews to identify structural characteristics of the practice (e.g., size of practice, geographic location and local resources, site ownership and staffing) and differences in implementation (e.g., staff roles, strategies, responses to site-specific challenges) that may account for variations in outcomes

Telemonitoring Systems Using Interactive Voice Response and Related Technology to Reduce 30-day Readmissions

PI: Jove Graham, PhD

Automated home monitoring systems have been used to coordinate care to improve patient outcomes and reduce rehospitalizations, but with little formal study of efficacy.  We have studied a home monitoring program for patients who are discharged from the hospital that includes nurse case manager follow-up and an interactive voice response system, and found evidence of a significant reduction in 30-day all-cause hospital readmissions when comparing patients using the system to a parallel comparison group and prior experience.  We are currently conducting similar investigations of readmission rates and cost outcomes for patients with congestive heart failure using home monitoring equipment including Bluetooth-equipped weight monitoring scales.

Breast Cancer in State of Pennsylvania

PI: Azadeh Stark, PhD

Pennsylvania ranks 21st among all states for breast cancer incidence with an age-adjusted annual incidence rate of 126.1 per 100,000.  However, Pennsylvania ranks 7th among all states in breast cancer mortality with an annual disease specific, age-adjusted, mortality rate of 27.5 per 100,000.  Stratification of breast cancer incidence and mortality data of the state by its counties, classifies a total of 11 counties as “Red Zone” or significantly above the national average. Six of these 11 counties are within the Geisinger Health System (GHS) service catchments.  These six “Red Zone” counties are geographically juxtaposed with counties that are at or below the national average for breast cancer incidence and mortality.  We have launched a study with the primary objective of discerning reasons for this disparity.  Currently, we are in the process of collecting clinical, demographic, pathologic, and mammography screening utilization data.  This study is in collaboration with Dr. James Evans, the Director of the Breast Clinic at the Geisinger Health System.

 

HPV infection and risk of cervical cancer in women with the confirmed diagnosis of systemic lupus

PI: Azadeh Stark, PhD

Lupus, a chronic, multi-system autoimmune disease, occurs predominantly in African-American and Asian women of childbearing age. Both autoimmunity and impaired immunity characterize this disease, and treatment consists of various types of immunosuppressive medications to halt the autoimmune process. Immunosuppression could foster an environment that facilitates neoplastic growth, particularly those related to infection. There is preliminary evidence that certain cancers are increased in lupus patients, particularly lymphomas.  In addition, recent studies suggest an increase in human papilloma virus (HPV)-related cervical malignancies and pre-malignant lesions in this population.  The reason(s) for this increase in cervical neoplasia in women with lupus has not been well defined, but is presumed to be due to infection by high risk HPV types. Cervical cancer arises from persistent infection of the cervical transformation zone by high risk HPV types.  Infection by HPV can be latent or produce squamous intraepithelial lesions that can progress to cervical cancer through integration of virus sequences into the host genome. Co-factors suggested to increase risk for cervical cancer include smoking, methylenetetrahydrofolate reductase (MTHFR) gene polymorphism(s), HPV variants, loss of fragile histidine triad (FHIT) gene expression, Chlamydia infection, and possible HLA class II allele associations.  These cofactors have been investigated in a limited fashion in non-lupus patients, but have not been studied in lupus patients with cervical dys-or neo-plasia.  The main objective of this project is to investigate the incidence, distribution and modifiers of cancer in systemic lupus patients and delineate the genetic mechanisms related to the development of female genital cancers in this population.    This study is in collaboration with Dr. Patricia Dhar at the Department of Internal Medicine, Wayne State University School of Medicine.

Treatment Seeking & Treatment Effectiveness following the World Trade Center  (WTC) Disaster

PI: Joseph Boscarino, PhD, MPH

The purpose of this study is to assess access to mental health care, delayed treatment seeking, and the effectiveness of brief mental health treatments following the WTC attack in New York City. The goal of this study is to identify risk prediction models for emergency mental interventions following traumatic event exposures. This study is based on a prospective cohort study of adults following exposure to the WTC attacks in New York City.

Natural History of Stress, Urge, and Mixed Urinary Incontinence in Women

PI: Xiaowei (Sherry) Yan, PhD

Urinary incontinence (UI) is a highly prevalent medical condition that affects the quality of life of millions of women of all ages in the United States.  This five-year, longitudinal study of nearly 12,000 women seeks to understand the natural history of urinary incontinence and how stress UI (i.e. loss of urine on exertion such as coughing, sneezing, lifting or laughing), urge UI (i.e. loss of urine with a strong desire to urinate) and mixed UI (stress and urge) are interrelated.  The first aim of the study is to understand the longitudinal relationship between stress, urge, and mixed UI by examining if the individual or composite effect of incidence and remission of UI subtypes results in a net accumulation of active mixed UI cases relative to stress or urge UI cases. A second aim is to determine if the presence of one UI subtype leads to the development of the other. Finally, the third aim of the project is to determine if risk factors common to both stress and urge UI (i.e. obesity, parity, prolapse, hormone replacement therapy, menopause, and diabetes) are consistent with excess co-occurrence of both UI subtypes. 

This project is supported by an R01 grant from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK).

Exposure to Trauma, PTSD & Health Outcomes after Trauma Treatment

PI: Joseph Boscarino, PhD, MPH

This study is assessing the risk for PTSD and mild traumatic brain injury among adults recently exposed to major traumatic events. The secondary purpose was to assess the post-discharge service needs among adult trauma patients in Pennsylvania. For this study, we recruited a sample of 250 patients who were treated at Geisinger’s Level-I Trauma Center. This study is funded by the Geisinger Clinic Research Fund Endowment.

Veterans Health Project

PI: Joseph Boscarino, PhD, MPH

The Geisinger Health System (GHS) has approximately 25,000 veterans from all eras who use GHS for health care services among approximately 350,000 active patients. Similar to the Department of Veteran Affairs, GHS has an Electronic Health Record (EHR) system for all its patients for the past decade. The purpose of this project is to enter veteran status information into the EHR at the patient encounter over the next 12 months. Once this has been achieved, the second phase is to undertake a descriptive study of health utilization and health problems experienced by different era veterans compared to non-veteran cohorts. Following this, the plan is to use these data in observational investigations, including case-control, cohort, retrospective, and prospective studies related to health outcomes. This study is funded by the Kline & Ditty Health Fund.

Developing PTSD Risk Assessment Tools Using the World Trade Center (WTC) Outcome Study

PI: Joseph Boscarino, PhD, MPH

The objective of this study is to differentiate trauma survivors who recover from those who develop enduring PTSD. Using an interdisciplinary team with expertise in psychology, epidemiology, neurology, medicine, and biostatistics, we are developing risk-factor models that predict PTSD outcomes among different populations, including resilient, remitted, delayed, and persistent PTSD. This study is currently funded by the National Institute of Mental Health.

Chronic Hepatitis B & C Longitudinal Cohort Study 

PI: Joseph Boscarino, PhD, MPH

This is a 5-year, multi-site longitudinal prospective study of chronic hepatitis B & C infection among patients seen within five sites of the National HMO Research Network. The purpose of this study is to study the epidemiology and health outcomes associated with chronic hepatitis infection. This study represents the largest the largest study ever done in this clinical area. This study is funded by the Centers for Disease Control Foundation.

Patterns of Utilization of DNA Testing in the Diagnosis of Polycythemia vera and Related Myeloproliferative Neoplasms

Site Co-I: Porat Erlich, PhD, MSc

Polycythemia vera (PV) is a member of a group of clonal hematologic malignancies termed myeloproliferative disorders, in which hematopoietic progenitor hypersensitivity to cytokines results in overproduction of blood cells that can lead to thrombosis, arthritis and other adverse health outcomes. In response to repeated complaints from residents of the Luzerne/Schuylkill/Carbon tricounty area of Northeast Pennsylvania, the Center for Disease Control (CDC) has launched an investigation into an apparent cluster of PV cases occurring in the tri-county area with an incidence that is significantly higher than the national average and a geographic overlap with several hazardous waste sites. Because the region of concern is part of Geisinger’s service area, the CDC has mandated this study to examine the practices used by Geisinger physicians to diagnose PV, specifically to ensure that novel genetic tests for PV recommended by the World Health Organization are being widely utilized. The results will contribute to the optimization of cancer diagnosis and care in the Geisinger Health System.