CHPR Research | Evidence to Inform Clinical Care and Health Policy
The goal of CHPR’s work in evidence synthesis and policy analysis is to support the alignment of clinical practice, health policy, and healthcare reimbursement with evidence and value. To that end CHPR faculty conduct research and analysis designed to have relevance to clinical practice, specific healthcare policies, and healthcare costs.
CHPR faculty and staff have been analyzing the medical effectiveness of medical processes and interventions, their public health impacts, and their utilization costs for the California State Legislature through the California Health Benefits Review Program (CHBRP) for more than 15 years.
Conducting systematic and rapid evidence reviews, to inform cancer screening recommendations made by the United States Preventive Services Task Force (USPSTF), e.g., is another of CHPR’s specialties; the Center has an exceptionally skilled team of faculty and staff who have years of experience in conducting these valuable reviews.
CHPR analyses and economic models have also contributed to pricing recommendations for new medications coming into the market, most recently for two new drugs for treating amyloidosis.
Supported by the Agency for Healthcare Research and Quality (AHRQ) and CHPR staff with expertise in evidence synthesis, Drs. Melnikow and Fenton have led several systematic reviews, in collaboration with investigators at Kaiser Permanente, the Patient-Centered Outcomes Research Institute (PCORI) and RTI International, to inform national recommendations on disease prevention and treatment. These systematic reviews informed recommendations made by the United States Preventive Services Task Force (USPSTF). The 2016 USPSTF recommendation statement on breast cancer screening was based in part on a published CHPR systematic review of supplemental screening for women with dense breasts using ultrasound, MRI, and digital breast tomosynthesis. Dr. Melnikow also led a review published in JAMA on approaches to cervical cancer screening that informed the 2018 USPSTF recommendation on that topic. Dr. Fenton led a review published in JAMA of the available evidence on PSA testing for prostate cancer screening, which included evaluation of prostate cancer treatment and related harms and informed the 2018 USPSTF recommendation for shared decision-making on prostate cancer screening. Building on this work, Dr. Fenton has collaborated with colleagues at PCORI and RTI International to develop an evidence map to support clinicians and patients in shared decision-making about prostate cancer treatment options.
CHPR staff have also collaborated with colleagues at the Kaiser Permanente Evidence-Based Practice Center to conduct evidence reviews that have informed USPSTF recommendations on preventive interventions for perinatal depression; screening and behavioral interventions for unhealthy alcohol use in adolescents and adults; behavioral and pharmacotherapy interventions for tobacco cessation in adults; and hypertension screening in adults.
Dr. Hoch and his international team of colleagues analyzed the value of two new drugs for the treatment of Amyloidosis, a rare and devastating disease. Their economic model was used in a report for the Institute for Clinical and Economic Review (ICER), presented at the Midwest Comparative Effectiveness Public Advisory Council (Midwest CEPAC), and published in the scientific literature. The published findings were used in ICER’s recommendation on drug pricing to national healthcare payers.
During his post-doctoral fellowship at CHPR with Dr. Hoch, Dr. Logan Trenaman published a study reviewing ICER’s assessments and describing how cost-effectiveness, other benefits, and contextual considerations affect ICER Council members' assessments of value. Two case studies highlighted that factors beyond cost-effectiveness can lead to lower (e.g., tisagenlecleucel) or higher (e.g., voretigene neparvovec) assessments of a new drug’s value. Thus, Council members' judgments about the value of interventions were influenced by other benefits or disadvantages and contextual considerations but anchored by economic evaluation.
The California Health Benefits Review Program (CHBRP), a UC-wide collaboration, has a direct impact on state policy through rapid evidence reviews and impact analyses of health legislation proposed during the legislative process. CHPR faculty and staff have conducted rapid reviews and analyses of the medical effectiveness of various medical processes and interventions, their public health impacts, and their utilization costs, contributing to nearly 80 CHBRP reports since 2005. Over the last decade CHPR has conducted analyses (on public health or medical effectiveness) for 5-9 legislative bills per year, each produced within a 60-day timeframe to meet deadlines established by the Legislature’s policy committee. Topics analyzed for these health-related bills range from broad (equivalent coverage for telehealth services) to narrow (coverage for applied behavioral analysis for individuals with Autism Spectrum Disorder).
The Personalized Research for Monitoring Pain Treatment (PREEMPT) study, led by Dr. Kravitz and funded by the National Institute of Nursing Research and the National Center for Advancing Translational Sciences, developed a smartphone app to allow chronic pain patients and their clinicians to run personalized experiments (n-of-1 trials) comparing two different pain treatments. This effort to support patient-clinician collaboration on identifying the best pain treatment resulted in reductions in use of analgesics (less so with opioids) without concomitant increase in pain. These findings have implications for engaging patients directly to improve management of chronic pain.
In 2018 a CHPR team led by Dr. Melnikow summarized the history of Medi-Cal managed care in Sacramento County and described the challenges faced by patients due to the complex system and frequently shifting contracts with providers. Recommendations for improvement were reported in a brief posted on the CHPR website and presented to stakeholders. A team led by Dr. Melnikow used simulated patient calls to document significant differences in access to primary care for Medi-Cal beneficiaries between counties in the region.