CHER Research Studies

Evaluation of Hospital-at-Home in Response to COVID-19 Pandemic

During the COVID-19 pandemic, there is an increased need to rapidly develop new models of inpatient care to address the demand for hospital beds during surge episodes. Standing up freestanding inpatient units outside of hospitals has been met with limited success, and in general can only accommodate low acuity patients, with minimal mild disease and limited monitoring and assistance. Providing inpatient level care in one’s house (hospital-at-home) to a subset of patients has been a concept recently developed and demonstrated to be effective and safe in several small randomized trials, but has not had the necessary stakeholder buy in by patients, their families, or their providers to expand to broader use or for more high acuity cases. Given the current interest on the part of patients to receive as much care as possible locally, due to fears of COVID19, this is an ideal opportunity to evaluate the implementation of hospital-at-home for high acuity inpatient care. Tufts Medical Center has partnered with a company, Medically Home, to provide hospital at home high acuity (levels II and III) inpatient level care to qualifying patients from either the emergency department or the inpatient service. This program was launched on March 31, 2020 with a small but sustained transition of patients to this model of care. The COVID-19 pandemic offers the opportunity to conduct a formal implementation evaluation of a hospital-at-home program. This includes evaluation of outcomes of care and complications of care, and implementation facilitators and barriers. We propose a pilot analysis of the findings from patients at Tufts Medical Center to inform a larger multi-site analysis of this hospital-at-home program.

Disparities in Testing and Diagnosis of COVID-19 among Tufts Medical Center Employees

The COVID-19 pandemic is shining a powerful spotlight on pre-existing health disparities. Black and Latinx people in the United States are overrepresented in COVID-19 diagnoses and deaths. The increased mortality in minority communities is a result of decades of structural racism. Racist policies and practices have led to disinvestment in community infrastructure and public health for people of color. The long-term consequences have resulted in higher prevalence of chronic illnesses like obesity and diabetes, less access to healthcare, increased reliance on public transportation, and higher rates of employment at hourly-waged jobs. At the natural interface between the hospital and community, healthcare workers are particularly high risk for transmission of COVID-19 infection.  Tufts Medical Center represents a socioeconomic microcosm, with a hierarchical mapping of higher salaries for predominantly-white physicians, nurses and administrators, and lower salaries for a population of racially and socioeconomically diverse people who work in various jobs integral to the function of the hospital, including but not limited to technicians, administrative staff, food services, housekeeping and transportation. Tufts MC was one of the first hospitals in Boston to offer in house rapid COVID-19 testing, and one of the only hospitals in Boston to make testing available to all staff. There are still unanswered questions about the relative role that socioeconomic status plays in exposure to the disease. The cohort of Tufts MC and Tufts MC Physicians Organization (Tufts MC PO) employees thereby provides unique opportunity to interrogate the impact of sociodemographic impact on COVID-related care for front-line healthcare workers with access to COVID-19 testing.

Translating Research into Practice (TRIP)

African American women with breast cancer face disparities in time-to-treatment, quality of treatment, and delayed follow up to abnormal tests. According to the Centers for Disease Control and Prevention, African American women have a 40 percent higher chance of dying from breast cancer than white women.

In partnership with the Boston Breast Cancer Equity Coalition, the TRIP researchers found three evidence-based strategies known to reduce delays in care that have failed to make it into practice as a result of persistent patient and health system barriers:

• A navigator for every vulnerable patient to solve problems and provide support and guidance through the complex health care system
• A regional registry to help providers and navigators track their patients
• Resources to help navigators identify social determinants of health (e.g., food and housing insecurity) 
   

Translating Research into Practice (TRIP) is being carried out at six clinical sites from the Boston area with the goal of assisting 1100 women who are seeking breast cancer care over the next five years. Investigators from Boston University Clinical and Translation Science Institute (CTSI), Tufts CTSI, Brigham and Women’s Hospital, Harvard Catalyst (the Harvard Clinical and Translational Science), and the University of Massachusetts Center for Clinical and Translational Science (CCTS) are testing a coordination of care approach for vulnerable populations experiencing breast cancer disparities.

TRIP integrates these strategies into a cohesive package. If successful, TRIP will be able to be adapted to any disease in other communities impacted by disparities.

Cancer Health Disparities Network (CDRN) Cohort

The aim of this study is to evaluate the feasibility of recruiting, collecting survey and biospecimen data, and following a cohort of 450 diverse individuals from underserved populations from various geographic areas of the United States.  This study proposes to establish the Cancer Disparity Research Network (CDRN) Cohort, a resource for studies of factors related to cancer incidence among underserved populations. The CDRN Cohort will pool data and initiate new studies not previously undertaken in underserved populations. Targeted underserved populations that will compose the CDRN cohort will be recruited by research teams from the following study sites:

• The Ohio State University Comprehensive Cancer Center (100 residents of Appalachia)
• University of Illinois at Chicago (100 Hispanics)
• Fox Chase Cancer Center (Philadelphia, PA) (100 African Americans)
• University of Pennsylvania (50 African Americans)
• Tufts Medical Center (100 Asians)

The Ohio State University Comprehensive Cancer Center is the Coordinating Center for the CDRN cohort feasibility study. 

The goals of the Tufts study site are to:

• Recruit 100 Asians to the CDRN cohort
• Collaborate with the CDRN Coordinating Center to refine study procedures, forms, questionnaires, and process for collecting and mailing biospecimen data.
• Interact with the other cohorts/study sites to conduct two pilot studies: 

1. Determine the impact of the Affordable Care Act (ACA) on cancer prevention and screening behaviors; and
2. Explore the response to chronic stress (telomere length and Tumor Necrosis Factor (TNF) and C-reactive protein (CRP) concentrations) with the characteristics of cancer risk profiles for each of the populations and the cohort as a whole.

Insurance Instability and Disparities in Chronic Disease Outcomes

Racial and ethnic health disparities in the processes and outcomes of chronic disease care are pervasive, well documented, and consistently linked to health insurance coverage.  Insurance instability (the frequency of switches in insurance coverage or gaps without coverage), may contribute to disparities in outcomes of chronic disease care.  With the explicit goal of reducing disparities, Massachusetts (MA) Health Insurance Reform has now extended comprehensive health insurance coverage to 98% of the state’s residents, with disproportionately greater gains in coverage among racial/ethnic minorities and the poor.  

• To examine if MA insurance reform has lessened health disparities through increased insurance stability, our specific aims are:
• To examine changes in insurance instability pre- and post-reform, overall and comparing racial/ethnic specific minority populations to whites.  We hypothesize that (a) Insurance instability decreased in the post-reform period and (c) Insurance instability decreased more for racial/ethnic minorities.
• To examine whether patients receiving care post-insurance reform had better processes of chronic disease management and improved health outcomes, compared with patients receiving care pre-insurance reform, and whether such patterns vary by race/ethnicity.  We hypothesize that improvements in processes and outcomes of chronic disease management were greater among racial/ethnic minorities who benefited the most from insurance reform, resulting in reduced disparities.
• To assess whether patients with more favorable insurance stability had better processes of chronic disease care and improved health outcomes compared to patients with less favorable insurance stability, and whether racial/ethnic minority patients experienced disproportionately greater gains. We hypothesize that greater insurance stability will be associated with improved processes and outcomes of chronic disease management, resulting in reduced disparities. 
   

We will assess the processes and outcomes of care for six highly prevalent, chronic conditions before and after the implementation of MA Health Insurance Reform: diabetes, hypertension, hyperlipidemia, congestive heart failure, asthma, and chronic obstructive pulmonary disease.  We will utilize existing electronic medical records on over 110,000 subjects from Boston Medical Center and eight of its affiliated federally qualified Community Health Centers, the largest safety net institution in New England that serves African American and Hispanic communities, and Tufts Medical Center, which serves a large Asian American community in Boston’s Chinatown.  When the study is completed, we will provide empiric data on the direct impact of insurance reform and insurance instability on health disparities in multiple populations.

Partners on this project include Multi- Principal Investigator Dr. Nancy Kressin (Boston Medical Center), Dr. Amresh Hanchate, co-Investigator (Boston University School of Medicine), Dr. Norma Terrin, co-Investigator (Tufts Research Design Center/Biostatistics Research Center), and Dr. Tracy Battaglia, co-Investigator (Boston Medical Center).  This work is supported by the National Institute on Minority Health and Health Disparities.

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Screening for Social Determinants of Health in Massachusetts

Health Centers are nonprofit organizations that provide health and other related services to residents in medically underserved areas. Social Determinants of Health (SDH) are defined as the circumstances, in which people are born, grow up, live, and work. There is a well-documented relationship between SDH and health outcome. Despite the prevalence of unmet social needs that disproportionately impact health when compared to other aspects of medical care, we understand relatively little about how best to recognize and address such needs. Even less is known about the landscape of current SDH screening practices. Our proposed study will address this gap by characterizing SDH screening practices in health centers throughout Massachusetts. By understanding and comparing current practices across all health centers in the state, we can identify heterogeneity in screening, which can facilitate targeted improvement in practices across the state.

30-Day Readmissions at Tufts Medical Center

This is a qualitative study to examine the medical and socioeconomic factors contributing to 30-day readmissions. The data collection for adults is currently complete. We are now piloting this study with the pediatric department to understand unique factors in the pediatric patient populations.

CTSA Consortium SRC pilot study

This NCATS funded study assesses the implementation and use of in the recommended Scientific Review Committee (SRC) process developed by the SRC Working Group. Scientific review is distinct but complementary to IRB review. The goal of the SRC is to review studies for scientific merit and feasibility. This pilot study is attempting to implement this review process at 10 CTSA hubs and assess the barriers and facilitators to its implementation and use.

Stakeholder and Community Engagement (SCE) in Early Stage (T1) Translational Science

Four CTSA hubs have come together to develop a framework for stakeholder engagement in the early stages of translational science.

Together for Child Wellness

With support from the Deborah Munroe Noonan Memorial Research Fund, this study aims to understand the barriers and facilitators to diagnosis and treatment of Autism Spectrum Disorder (ASD) in children from Chinese immigrant families. Chinese children with ASD tend to be diagnosed later than their non-Chinese peers and experience significant delays in linking to care. By understanding the perspectives of both parents and providers we hope to inform an intervention to address these delays in a culturally competent and relevant manner. 

Longitudinal Follow-up to the National Faculty Survey

In 1995, over 1,900 academic faculty from 24 medical school completed the National Faculty Survey (NFS).  Under the leadership of Phyllis Carr MD as PI, the NFS collected information about demographics, professional goals, academic environment, perceptions of bias, discrimination, and harassment, compensation, and work/life balance.  The original survey provided seminal data on recruitment, promotion and retention of women and underrepresented minority faculty in academic medicine.

In 2011- 2012, we invited 1,300 faculty members from the original survey to complete a follow up survey.  The data serves as the first longitudinal follow up of a nationally representative sample of faculty in medical schools.  The specific aims of the project are:

• To measure longitudinal career outcomes for women compared with men, and under-represented minority women faculty compared with majority women, along the following domains:
  • Satisfaction with academic career
  • Compensation
  • Productivity, including grants and publications
  • Academic rank
  • Retention
• Identify how individual (e.g., hours of work, family responsibilities), institutional environment (e.g., support, work environment) and factors that intersect the individual and institution (e.g., racial discrimination, sexual harassment) are associated with career advancement outcomes form women compared with me, and for under-represented minority women compared with majority women.

We also conducted key informant interviews with administrative faculty at the medical schools to collect information regarding institutional policies and practices that differentially facilitate or impede faculty advancement based on gender or under-represented racial/ethnic minority status.

Partners on this project include Multi- Principal Investigator Dr. Phyllis Carr (Massachusetts General Hospital), Dr. Norma Terrin, co-Investigator (Research Design Center/Biostatistics Research Center), Dr. Samantha Kaplan, co-Investigator (Boston University), and Dr. Anita Raj, co-Investigator (University of California, San Diego).  Dr. Carr was the Principal Investigator of the 1995 survey.  This work is supported by the National Institute of General Medical Sciences.

The National Patient Navigation Research Program

Dr. Freund serves as Chair of the Design and Analysis Committee of the National Patient Navigation Research Program (PNRP), an NCI funded cooperative group to conduct a controlled trial on the impact of patient navigation on timely cancer care in vulnerable populations.   The PNRP looks at the impact of patient navigation interventions to reduce or eliminate cancer health disparities. The Avon Foundation provides additional support for the secondary analyses of the Patient Navigation Research Program (PNRP). Current research questions addressed through this initiative include:

• The impact of comorbidities on cancer care and patient navigation
• The influence of household size and composition on delays in cancer care, and the ability of navigation to ameliorate their impact
• Whether patient navigators with personal experience with cancer care are more effective in their position than navigators without cancer treatment experience
• Understanding which tasks that navigators perform are associated with best practices and more timely care for their patients
• The impact of patient navigation on the quality of breast cancer treatement
• The impact of patient navigation for patients with abnormal Pap tests.
• The impact of patient navigation in women with abnormal breast cancer screening

Patient Navigation Research Program Database

The national Patient Navigation Research Program recruited nearly 10,000 subjects with abnormal cancer screening, and over 2000 subjects with incident cancer and precancerous lesions into a controlled trial of patient navigation compared with the control of usual care.  Subjects were predominantly from under-insured and minority populations.  Subjects were recruited from nine centers (comprised of 21 local community health centers or ambulatory care sites).  We collected clinical and patient navigation information for eligible participants 18 years and older who had an abnormal breast, cervical, colorectal, or prostate concerning screening result.  Clinical information included type of screening abnormality, type and stage of cancer, dates and types of clinical services, and clinical outcomes.  Patient navigation information barriers identified as part of the care delivery process, activities to address the barriers, and services provided are also in the database.  Other information included race/ethnicity, gender, primary language, and health insurance coverage.