CarPE Current Research

Developing a Model for a Joint Provider-Payer Strategy to Increase Use of Home-based Palliative Care
Harvard Medical School/Ariadne Labs
PI: Anita Wagner, PharmD, MPH, DrPH

This initiative will develop, in two phases, a novel payer-provider collaboration that will ensure rapid targeting of eligible patients, as well as address barriers to generalize this initiative among payers and physicians.

Oral Targeted Anticancer Medication Trends and Modifiable Use Predictors
American Cancer Society
PI: Anita Wagner, PharmD, MPH, DrPH

The goal of this study is to investigate how pharmaceutical benefit policies affect oral molecularly-targeted anticancer medications utilization and spending, and to identify patient- and provider-related factors associated with treatment access.

A Conversation Aid to support Shared Decision Making between Women Aged 75 and Older and their Clinicians on Mammography
NIA/Beth Israel Deaconess Medical Center
PIs: Mara A. Schonberg, MD, MPH and Natasha Stout
, PhD

The goal of this project is for an interdisciplinary team of geriatricians, internists, computer programmers, decision analysts and communications researchers, the American College of Physicians (ACP), and the NCI-funded Cancer Intervention and Surveillance Network (CISNET) to collaborate to develop an innovative multi-level web-based decision support tool for clinicians and women >75 years to use during an office visit to improve shared decision making around mammography screening.

Patients’ and Providers’ Perspectives on Value-Focused Frameworks for Cancer Treatment
Department of Population Medicine Faculty Grant
PI: Anita Wagner, PharmD, MPH, DrPH

Explore the awareness, acceptability and potential use of value-focused frameworks among HPHC-contracted hematologists and HPHC members with chronic lymphocytic leukemia (CLL).

Addressing payers' challenges in managing novel cancer therapy coverage
Department of Population Medicine Faculty Grant
PI: Anita Wagner, PharmD, MPH, DrPH

This project focuses on estimating the economic impact of mandated coverage of off-label use of cancer therapies in Massachusetts.

Advanced Breast Imaging: Trends and Outcomes Associated with Recent Breast Density Reporting Legislation
NIH/NCI R01CA207373
PI: Natasha Stout, PhD

This research study will evaluate the impact of state-specific density notification legislation on the use of breast imaging and downstream clinical and economic outcomes including breast cancer incidence. Investigators will use a combination of observational data including one of the largest, geographically diverse observational datasets of more than 18 million commercially-insured adult women in the US from 2001 through 2018 and state cancer registry data from 2001-2018.

Comparative Modeling: Informing Breast Cancer Control Practice and Policy
NIH/NCI U01CA199218
HPHCI Site PI: Natasha Stout, PhD
Study PI: Jeanne Mandelblatt, MD, MPH (Georgetown University) 

The Cancer Intervention and Surveillance Network (CISNET) Breast Working Group proposes innovative modeling research focused on challenges in early detection and clinical management that are expected to re-define breast cancer control best practices. The specific aims of this research are to: 1) evaluate the population impact of using polygenic risk to inform screening strategies; 2) assess use of emerging new imaging technologies for population screening; 3) evaluate use of active surveillance for the clinical management of screen-detected DCIS; 4) evaluate the impact of new molecular pathway- and genomic-targeted treatment paradigms in the adjuvant and recurrence settings; and 5) synthesize the methods to quantify the relative contributions of these new paradigms for screening and clinical management on US mortality trends for the general population and risk-stratified subpopulations.

Risk-Based Breast Cancer Screening in Community Settings and Surveillance in Community Practice
NIH/NCI P01CA154292
HPCHI Site PI/Co-Lead of the Comparative Effectiveness Core: Natasha Stout, PhD
Study PIs: Diana Miglioretti, PhD (University of California Davis); Karla Kerlikowske, MD (University of California San Francisco); Anna Tosteson, ScD (Dartmouth)

A renewal of  P01CA154292, this research conducted by members of the Breast Cancer Surveillance Consortium, consists of three projects supported by two cores that will identify tomosynthesis and multi-modality screening outcomes by examining women, radiologist, and facility factors. Project 2 takes an innovative approach to risk assessment by focusing on identifying subgroups of women who warrant consideration of more or less intensive strategies than biennial mammography screening due to low or high risk of screening failure or false alarms (false-positive results). Project 3 focuses on developing tailored approaches to surveillance imaging of women with a personal history of breast cancer.

Comparative Effectiveness of Breast Cancer Screening, Diagnosis, and Management in Community Practice
PCORI PCS-1504-30370
HPHCI Site PI: Natasha Stout, PhD
Study PI: Diana Miglioretti, PhD (University of California Davis)

The major goals of this project are to: (1) provide information on the benefits and harms of screening modalities tailored according to extent of breast density by comparing clinical outcomes and PROs for women who receive digital mammography with vs. without 3 different approaches for supplemental screening by the extent of breast density. (2) Provide information to providers and women with DCIS and early stage breast about the comparative effectiveness of preoperative breast imaging with MRI (vs. no MRI) by breast density so that they can make more informed and individualized decisions about the evaluation of their cancer.

Risk of Pediatric and Adolescent Cancer Associated with Medical Imaging
NIH/NCI R01CA185687
HPHCI Site PI: Natasha Stout, PhD
Study PI: Rebecca Smith-Bindman, MD (University of California San Francisco)

The goal of this grant is to use a retrospective, stratified nested case-control study with counter-matching to evaluate patterns of medical imaging, cumulative exposure to radiation, and subsequent risk of pediatric cancers. Investigators will study 7.3 million children and their mothers enrolled in four integrated health care delivery systems, spanning 1996 to 2017, with the primary outcome of interest for exposure from pediatric imaging being leukemia.

High Deductible Insurance: Impact on Breast Cancer Care and Outcomes
NIH/NCI R01CA172639-04
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.

Genomics-based Technologies: Access and Reimbursement Issues
PIs: Christine Lu, MSc, PhD; Ann Wu, MD, MPH

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 pharmacogenomic 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.

Implementing Universal Lynch Syndrome Screening Across Multiple Health Care Systems: Identifying Strategies To Facilitate And Maintain Programs In Different Organizational Contexts
HPHCI Site PI: Christine Lu, PhD
Study PI: Alanna Rahm, PhD (Geisinger Clinic)

The overarching goal of this project is to create an organization-level toolkit for implementing, maintaining and improving Lynch syndrome (LS) screening by using tools from implementation science to describe, explain, and compare decision making and other variations in LS screening implementation across multiple healthcare systems. We will accomplish this through analyzing variation in LS screening implementation across diverse healthcare systems, estimating costs of different protocols by healthcare system, synthesizing this information into an organizational implementation toolkit, and testing the toolkit within the healthcare systems. This model will enable more effective and efficient implementation of LS screening; ultimately preventing needless suffering of patients and their family members from preventable cancers, decreasing waste in healthcare system costs, and informing strategies to facilitate the promise of precision medicine.