The Department of Population Medicine focuses on improving health care delivery and population health through innovative research and teaching. This is a brief overview of a few research and public health surveillance projects conducted by our faculty and staff. Please visit the individual research group pages for an in depth look at our research programs.
Advanced Breast Imaging: Trends and Outcomes Associated with Recent Breast Density Reporting Legislation
PI: Natasha Stout, PhD
Since 2009, 30 states have mandated women be notified if they have dense breasts at the time of their screening mammogram and are encouraged to obtain supplemental screening. Supplemental breast cancer screening tests such as ultrasound may improve early detection of breast cancer for these women; however, they may also increase the chance that a woman without breast cancer will undergo additional diagnostic testing and unnecessary biopsies due to false positive findings. Using rigorous analytic methods, this NCI-funded research study will use two large national databases to examine the impact of this state-specific legislation on the supplemental screening use and breast cancer detection rates in the United States and serve to guide future density notification policies, both in the remaining 20 states and at the federal level.
Age-Dependent Pharmacogenomics of Asthma Treatment (ADAPT)
PI: Ann Wu, MD, MPH
Applications of the genetic knowledge resulting from the Human Genome Project are not yet available for asthma despite the immense potential that pharmacogenomics demonstrates for improving asthma care. This research will link genetic variants to therapeutic responses with additional information from genomics and metabolomics to provide insight into the biologic pathways that may be activated in an age-dependent method. This study will elucidate response to the two most commonly used medications for asthma, inhaled steroids and β2-agonists. This research employs existing genetic, genomic, and metabolomics data from clinical trial and real-life populations. The ability to link genetic variants to the therapeutic responses with additional information from genomics and metabolomics will provide insight into the biologic pathways that may be activated. By integrating and accounting for the interplay between genetics, genomics, and metabolomics, we will develop a comprehensive signature that predicts response to inhaled steroids and β2-agonists. Knowledge gained from this research will advance the field of personalized medicine for pediatric asthma.
PI: Alison Galbraith, MD, MPH
This project, funded by the Patient-Centered Outcomes Research Institute (PCORI), is evaluating the impact of high-deductible health plans and preventive drug lists on medication use and clinical outcomes for adults and children with asthma. Preventive drug lists exempt certain chronic medications from the deductible to promote adherence. The project incorporates patient and stakeholder perspectives through a collaboration with the Asthma and Allergy Foundation of America, with the goal of providing evidence to help patients, families, employers, and health plans make decisions about health insurance that promote high-value health care, reduce adverse health outcomes, and reduce the financial burden for families.
CDC Eastern Massachusetts Prevention Epicenter III: Promoting new ways to address problems such as reducing the burden of healthcare-associated infections and antibiotic resistance
PI: Richard Platt, MD, MSc
The Epicenter III project evaluates five strategies for preventing healthcare associated infections. These strategies target common, high morbidity, and high cost complications of medical care, including infections caused by methicillin-resistant Staphylococcus aureus, ventilator associated pneumonia, and hospital-based outbreaks caused by many different kinds of pathogens. We have developed an extensive network of partners in academic and community hospitals, nursing homes, outpatient clinics, and microbiology laboratory data systems that represent local, regional, and national collaborations to address both current and future research needs to reduce healthcare associated infections.
Decision Making Challenges and Needs for Health Insurance Exchange Enrollees (also known as U-PIC: Understanding Preferences for Insurance Coverage)
PI: Alison Galbraith, MD, MPH
Health insurance exchanges created as part of health care reform have the potential to assist consumers in navigating the complex array of options for purchasing coverage on their own in the non-group health insurance market. This AHRQ-funded project will study the experiences of Harvard Pilgrim members who enroll in insurance plans in and outside exchanges in three states. In this project, we will examine how exchange enrollees differ from other non-group enrollees; explore whether use of particular tools during enrollment is associated with type of plan chosen and better downstream health care outcomes; identify enrollees who prove to be at highest risk for adverse downstream outcomes; and identify challenges enrollees face choosing and using insurance benefits and the types of information and tools needed during and after enrollment.
PI:Emily Oken, MD, MPH
To advance understanding the effects of environmental exposures on child health and development, NIH has launched the seven-year ECHO initiative. ECHO will support multiple, synergistic, longitudinal studies using existing cohorts to investigate environmental exposures on child health and development. The studies will focus on four key pediatric outcomes that have a high public health impact: upper and lower airway, obesity, pre-, peri-, and postnatal outcomes, and neurodevelopment. Project Viva is one of 35 US pediatric cohorts that received an ECHO award and will focus on addressing the question: “What environmental exposures from conception to age 5, singly and as mixtures, influence the separate and co-evolution of obesity, asthma and related dysfunctions?”
Genomics-based health care is complex, rapidly evolving, and highly relevant to public health because of its potential use in assessing risk, diagnosing disease, and developing treatment plans. Access to genomic tests often depends on cost and coverage of services by the health plan. Drs. Lu and Wu are leading the current investigation to systematically examine access and reimbursement issues relating to guideline-recommended pharmacogenomics tests and implications of barriers to access and/or differential access for patients, providers, and society. Understanding access barriers in current practice and decision-making processes will allow policy makers to develop coverage policies to optimize affordable and equitable access to guideline-recommended genomics-based technologies in order to improve population health.
PI: Frank Wharam, MB, BCh, BAO, MPH
This study seeks to assess the impact of high-deductible health plans on breast cancer diagnostic testing, treatment, and outcomes in a nationally representative population. Measures of diagnostic testing include diagnostic mammography, breast ultrasound, and breast biopsy. We also assess changes in surgical tumor resection and adjuvant hormonal therapy use. The study draws from a 15-year rolling sample of members from a large national health insurer whose employers mandated a switch from traditional to high-deductible health plans. We use employer- and member-level propensity score matching to minimize selection bias. The study employs strong quasi-experimental designs including interrupted time-series with comparison series and Kaplan-Meier survival curves to examine outcomes of interest. This project will be the first to examine these research questions on a national scale. Policy makers will be able to use results to design value-based insurance plans that optimize breast cancer care.
PI: Dennis Ross-Degnan, ScD
High-deductible health plans that require patients to pay up to $1000-$6000 out-of-pocket per year are rapidly replacing low cost-sharing insurance plans. Employers can tailor the most rapidly-emerging type of high-deductible health plan – those linked to a Health Savings Account – by purchasing additional coverage to make key preventive medicines free to patients and by depositing generous annual contributions to their savings accounts to offset out-of-pocket costs. This study seeks to improve outcomes in diabetes by determining the impacts of these designs on the health care utilization and health outcomes of diabetes patients.
MDPHnet: Development of an open source software application that uses EHR data to identify notifiable disease cases and automatically submits identifiable case reports to state health departments
PI: Michael Klompas, MD, MPH, FRCPC
In 2006, Massachusetts Department of Public Health, the Harvard Medical School/Harvard Pilgrim Health Care Institute Department of Population Medicine (DPM/HPHCI), and the Boston Children's Hospital Informatics Program established a Center of Excellence in Public Health Informatics funded by the U.S. Centers for Disease Control and Prevention (CDC). This collaboration developed Electronic medical record Support for Public Health (ESP), an open source software application that uses EHR data to identify notifiable disease cases and automatically submit identifiable case reports using secure protocols to state health departments. The timeliness, granularity, completeness, and accuracy of ESP reports are a tremendous benefit to health departments and will be useful to local boards of health in case investigation and response. They enable resource-strapped departments to rapidly identify the handful of highly actionable, high yield cases from amongst the thousands of undifferentiated cases routinely reported by ELR systems and clinicians.
PIs: Richard Platt, MD, MSc; Adrian Hernandez, MD, MHS; Sharon Terry, MA
PCORnet, the National Patient-Centered Clinical Research Network, is an innovative initiative of the Patient-Centered Outcomes Research Institute (PCORI). The goal of PCORnet is to improve the nation's capacity to conduct clinical research by creating a large, highly representative network that directly involves patients in the development and execution of research. PCORnet is made up of 33 partner networks - 13 Clinical Data Research Networks (CDRNs), based in healthcare systems such as hospitals, integrated delivery systems, and federally qualified health centers, and 20 Patient-Powered Research Networks (PPRNs), operated and governed by groups of patients and their partners focused on one or more specific conditions or communities, and interested in sharing health information and participating in research. Initially, these networks will be focused on more than 150 specific conditions and communities of interest. Over time, the intent is for PCORnet to serve as a platform for rigorous research on an even broader array of topics. The scientific expertise, large population size, and diversity of PCORnet make it a unique resource for both observational and interventional studies in these and other areas.
PI: Ann Wu, MD, MPH
Our research goal is to develop and apply a detailed simulation we are calling the Precision Medicine Treatment (PreEMT) Model, a sophisticated computer model capable of simulating short- and long-term clinical benefits and estimating the cost-effectiveness of integrating different genome screening strategies into clinical care for healthy or high-risk newborns for a wide variety of heritable conditions. With this model, we will synthesize the best available clinical, epidemiologic, and economic data on genetic variants present at birth for a wide variety of genetically-driven childhood conditions to project health outcomes, and provide a dynamic tool to evaluate evolving knowledge in the area of genomics and precision medicine in the United States over the next decade.
PI: Emily Oken, MD, MPH
Project Viva is a ground breaking longitudinal research study of mother-child pairs. The goal of Project Viva is to find ways to improve the health of mothers and their children by looking at the effects of mother's diet as well as other factors during pregnancy and after birth on child health outcomes. For example, the information we collect enables us to investigate the effects of diet on child development and obesity, and how diet and the environment influence the development of asthma and allergies in children.
Between 1999 and 2002, 2,128 mothers delivered babies and were officially enrolled in our study. Today, over a decade and a half later, approximately 1,700 mother and child pairs are still involved in Project Viva. For more information about Project Viva and the Project Viva cohort, please refer to the Project Viva Cohort Profile led by Principal Investigator Emily Oken. Project Viva also has a record on ClinicalTrial.gov (record ID NCT02820402).
PI: Richard Platt, MD, MSc
Sentinel is an active surveillance system sponsored by the U.S. Food and Drug Administration (FDA) to monitor the safety of regulated medical products using pre-existing electronic healthcare data from multiple sources. The Sentinel System is part of the FDA's Sentinel Initiative, a long-term effort to improve the FDA's ability to identify and access medical product safety issues. The Sentinel Initiative began in 2008 as a multi-year effort to create a national electronic system for monitoring the performance of FDA-regulated medical products. The Initiative is the FDA's response to the Food and Drug Administration Amendments Act (FDAAA) requirement that the FDA work with public, academic, and private entities to develop a system to obtain information from existing electronic health care data from multiple sources to assess the safety of approved medical products. Sentinel's work focuses on drugs, vaccines, and other biologics (such as blood products).
PI: Dennis Ross-Degnan, ScD
The Uganda Health Supply Chain (UHSC) project aims to improve the health status of the Ugandan population by increasing the availability, accessibility and appropriate use of essential medicines and health supplies (EMHS), including reproductive, maternal, newborn and child health (RMNCH) commodities. The objective will be achieved through three main intermediate results: 1) national policies and strategies to support cost-effective, equitable and transparent use of available EMHS resources; 2) country capacity strengthened for effective management and utilization of EMHS; and 3) increased availability of and access to EMHS for priority populations. Examples of key activities during the second year of this five-year project include: evaluating the long-term impact of regular supervisory visits and an indicator-based system for assessing health facility performance in prescribing, dispensing, and management of medicines; implementing an intervention to increase use of rapid diagnostic test results in treatment for pediatric malaria; strengthening the performance of hospital Medicines and Therapeutics Committees; transforming pharmaceutical supply in lower level health facilities from a centrally-controlled kit-based system to a decentralized order-driven system; and improving financial performance and equity of private wings in public hospitals.
Understanding pathways of fetal metabolic programming to stop the transgenerational risk of diabetes (GEN3G)
PI: Marie-France Hivert, MD, MMSc
Gen3G is a prospective cohort study of mother-child pairs followed from 1st trimester to childhood aimed at identifying which epigenetic adaptations across the human genome are implicated in pathways linking maternal glycemia in utero exposure and fetal metabolic programming of future type 2 diabetes (T2D) risk. This study uses recent technological advances to investigate epigenetic markers across the human genome in an agnostic manner and reveal novel biologic pathways implicated in T2D etiology. Placenta and cord blood samples were collected in 725 newborns. DNA methylation will be estimated using the epigenome-wide array Illumina HumanMethylation450 and analyzed with rigorous methods. Revealing etiologic T2D pathways might help development of early life preventive interventions to reduce rates of diabetes in future generations.