The mission of the Health Services Research Program is to create a scientific basis for ensuring the translation of treatments of proven efficacy - based on findings from clinical trials - into routine clinical care that thus benefits all persons with that chronic neurological disease. The Program's ongoing research includes development of tools to measure the quality of care in actual practice settings, and analysis of barriers to translating evidence-based treatments into routine clinical care and improved health in populations with neurologic diseases. Applying these measurement tools and new knowledge about barriers, investigators work collaboratively with healthcare systems and communities to design and test novel and sustainable healthcare interventions for their ability to improve quality and outcomes of neurologic disease care. Such interventions often involve "re-engineering" healthcare delivery systems and engaging providers, community agencies, and patients in new models of collaborative care. Investigators also study how to disseminate effective re-engineered care models to other healthcare settings and to policy-makers. This multi-disciplinary research agenda includes scientists in the areas of health services research, health economics, biostatistics, anthropology, survey research, geriatrics, psychology, and organizational behavior. Collaborating with core full-time faculty in the department are faculty and scientists from the UCLA School of Medicine, UCLA School of Public Health, the VA Center for the Study of Healthcare Provider Behavior, and RAND Corporation, a private, non-profit research institute focusing on research to inform public policy.
Ongoing and recent research studies in the Program are:
Stroke and Cardiovascular Disease Outcomes Research Center, Barbara Vickrey (Center Director; Jeffrey Saver [UCLA Stroke Program Director], Center Co-Director). UCLA is one of four centers funded across the US as part of a new, major Outcomes Research initiative of the American Heart Association and its Pharmaceutical Roundtable. These centers' research focuses on the end results, or outcomes, of healthcare for people with or at risk for stroke and heart disease. The UCLA Center's theme is to address racial/ethnic and socioeconomic disparities in care for and outcomes of stroke and cardiovascular disease among high-risk, underserved populations. The Center's two research studies will elucidate causes of these disparities, and will generate and test sustainable interventions to redress them at both the individual and community levels. One study will develop and test in a randomized controlled trial a new model for improving risk factor control in stroke survivors in the Los Angeles County public health system, a safety-net system for an ethnically diverse, indigent population (William Cunningham, PI). This study builds on pilot work on barriers to effective stroke prevention among stroke survivors, funded by the National Center on Minority Health and Health Disparities through the UCLA Project Export, Eric Cheng (PI), and on an ongoing Career Development Award to Dr. Cheng from NINDS to implement a novel stroke prevention care delivery model in several southern California VA facilities. The Center's second study (Arleen Brown, PI) will generate new knowledge about the impact and mechanisms of neighborhood socioeconomic disadvantage on stroke occurrence, stroke care, and post-stroke outcomes, through analysis of data from the Cardiovascular Health Study, a large, population-based, longitudinal study of coronary heart disease and stroke in elderly adults. The heart of the UCLA Center's fellowship training program is immersion of fellows in a stroke or cardiovascular disease outcomes research study that they design and execute under the principal supervision of a primary mentor; six post-doctoral (MD or PhD) fellows will be trained over the next four years. For further information on the fellowship and an application, see http://sites.google.com/site/uclaahaprtorc/.
Chronic Care Model-Based Collaborative Care Management for Alzheimer's Disease., With funding from the California Healthcare Foundation, the California Department of Aging, the California Department of Public Health, and the Archstone Foundation [Barbara Vickrey (PI)], researchers conducted a randomized controlled trial to improve the quality of care for Alzheimer's Disease at three healthcare organizations and three community agencies in the San Diego area . These organizations formed a collaboration that created a "virtual" care system spanning the medical system and community agencies, and engaged caregivers in this collaborative care model. Based on theoretical models of optimal chronic care delivery, we selectively re-designed and re-engineered the care delivery system through the incorporation and training of dementia care managers, and created a web-based care management system, to enable more efficient and effective care coordination. Relative to usual care, there were substantial and meaningful improvements in both processes of dementia care and in patient and caregiver outcomes among the 408 pairs of caregiver and persons with dementia enrolled in the trial and followed for 18 months. An economic analysis was just completed, and an analysis of how the intensity and frequency of various components of the intervention relates to improved quality and outcomes is underway (Joshua Chodosh, PI; funding from California Department of Public Health). This model is now being adapted and exported into other care settings in partnership with the Alzheimer's Association, including HealthCare Partners (in which UCLA is leading the evaluation), and medical groups in southern California affiliated with SCAN (Joshua Chodosh, PI).
Screening for Dementia in Hispanic Elders in Primary Care Settings, funded by the California Department of Health Services through the UCLA Alzheimer's Disease Research Center of California, Barbara Vickrey (PI). The extent of underdetection of cognitive impairment in the Hispanic elderly community is unknown. Using previously validated instruments and structured interviews, we implemented a procedure within a busy clinical setting to successfully screen for undiagnosed cognitive impairment among over 300 Hispanic elders attending outpatient general medicine clinics at a safety net facility in Los Angeles County. Over one in five screened positive for possible memory impairment, and following additional phone assessments, many were referred for further diagnostic evaluation in a memory clinic. Barriers to screening and to subsequent triage assessment and referral were analyzed and are being provided to both health planners and researchers about optimal ways to engage older Hispanic patients in cognitive screening, treatment, and research. Given that undiagnosed cognitive impairment is not uncommon, findings should motivate intervention studies to improve care quality in highly resource-constrained, safety net public healthcare settings.
Improving Quality and Outcomes of Care for Parkinson's Disease, funded by the Veteran's Health Administration through the Parkinson's Disease Research, Education, and Clinical Center at the Greater Los Angeles VA. Through a recent VA HSR&D award to Karen Connor (PI), researchers in the program have launched a one-year pilot study to develop the components of a multi-faceted care management intervention for Parkinson's Disease. The products of the pilot study will enable a subsequent large-scale randomized trial of the intervention in the VA. This initiative continues a stream of earlier research (Barbara Vickrey, PI; Eric Cheng, co-PI) to development tools to measure the quality of care of patients with Parkinson's disease (PD). In these earlier studies, a national workgroup of neurologists was engaged in a systematic process to identify quality indicators for care processes relevant to PD, employing a modified Delphi method. This approach identified 29 quality indicators as having high validity and potential value for quality improvement interventions. We applied these to investigate determinants of variations in levels of care quality for PD, based on explicit medical record review. Findings among a sample of over 400 veterans with PD were that movement disorder specialist involvement was associated with higher adherence to care quality indicators than general neurologist involvement and non-neurologist involvement for treatment of wearing-off and for assessments of falls, depression, and hallucinations. There were few disparities by race/ethnicity except for assessment of depression. We also found that a generic patient-reported outcome measure was better able to detect change over time than either of two widely-used PD-targeted measures.
Progression and Health Impacts of Parkinson's Disease Motor and Non-Motor Manifestations, funded by the National Institute of Neurological Disorders and Stroke, through the UCLA Udall Center; Barbara Vickrey (project PI), Beate Ritz (project co-PI). This study's goals are to assess whether and to what extent the development and rate of progression of motor and non-motor manifestations in Parkinson's Disease (PD) are influenced by environmental, behavioral, and social factors, and to determine the relative contributions of progression of motor and non-motor comorbidities to changes in health-related quality of life (HRQOL) over time. A representative sample of all newly-diagnosed PD patients in a three-county area of central California have been followed over time and undergone a comprehensive re-assessment including neurological and cognitive evaluations; these data are currently under analysis. A secondary goal of the research is the development of a state-of-the-science, dynamic HRQOL item bank that includes existing PD HRQOL measures and new items derived from focus groups and interviews with PD patients and caregivers.
Long-Term Outcomes of Childhood Onset Epilepsy, funded by NINDS through a subcontract to UCLA from Northern Illinois University, Anne Berg (PI), Barbara Vickrey (subcontract PI). This is a long-term follow-up study of risks and predictors of intractable epilepsy in a community-based cohort of children with newly diagnosed epilepsy at the time of enrollment. The focus of the UCLA component of this research is on assessment of patient-reported, health-related quality of life outcomes and predictors. Analyses to date reveal that parents report quality of life of their child with epilepsy as being much worse than that of a sibling without epilepsy, but children with epilepsy and their sibling report similar quality of life, findings that emphasize that the source of quality-of-life ratings should be weighed carefully when selecting and interpreting such measures in childhood epilepsy studies.
Development of Quality Indicators for Multiple Sclerosis, funded by the National Multiple Sclerosis Society, Barbara Vickrey (PI), Eric Cheng (co-PI). Multiple sclerosis (MS) is a complex neurological disorder that can cause a wide set of symptoms. There is currently no set of tools for measuring whether persons who have MS are receiving high-quality health care. A team of MS specialists, health services researchers, and social scientists are collaborating to analyze the medical evidence and gather data from key stakeholders, including patients, clinicians, insurers, and administrators, as to what constitutes high quality MS care. An initial stakeholder panel meeting was held in summer 2008, and findings guided development of a set of draft quality indicators that were rated by a second stakeholder, expert panel in summer 2009. The final set of MS quality indicators will be field tested in a wide range of practice settings, so that they can be ready for widespread use. Future applications include use of the indicators in studies to test new ways of delivering high-quality MS care, and to help clinicians and health care systems in evaluating the quality of the MS care they are providing.