Supporting the alignment of clinical practice, health policy and healthcare reimbursement with evidence and value.
We are a key contributor to the California Health Benefits Review Program. This program responds to requests from the California State Legislature to provide independent analysis of the medical, financial and public health impacts of proposed health insurance benefit mandates and repeals. The CHPR team has contributed medical effectiveness and public health impact analyses for over 15 years.
Supported by the Agency for Healthcare Research and Quality (AHRQ) and CHPR staff with expertise in evidence synthesis, CHPR researchers Joy Melnikow and Joshua 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). For example, the 2016 USPSTF recommendation statement on breast cancer screening was based in part on their published CHPR systematic review of published reports of supplemental screening for women with dense breasts using ultrasound, MRI, and digital breast tomosynthesis. Melnikow also led a systematic review (published in JAMA) on approaches to cervical cancer screening that informed the 2018 USPSTF recommendation on that topic. And Fenton led the systematic 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, 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.
CHPR Associate Director Jeffrey 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 Associate Director Jeffrey Hoch, 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.
CHPR researcher Richard Kravitz led the Personalized Research for Monitoring Pain Treatment (PREEMPT) study, funded by the National Institute of Nursing Research and the National Center for Advancing Translational Sciences. The PREEMPT researchers 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.
A CHPR team led by Joy 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 CHPR brief and presented to stakeholders. In a subsequent study, Melnikow et al. used simulated patient calls to document significant differences in access to primary care for Medi-Cal beneficiaries between counties in Northern California the region.