Delivering High-Quality HIV Care in the South: System-Level Policy Alternatives

Principal Investigator: April D. Kimmel, Ph.D.

Funding Source: National Institute on Minority Health and Health Disparities

Project Summary:

While clinical care for HIV has made tremendous advances, the majority of persons living with HIV in the US do not receive the evidence-based care that will allow them to fully extend life and improve health. Lack of effective HIV care is particularly problematic in the Southern region, the epicenter of the US HIV epidemic and where poverty, uninsurance, rurality, and a constrained health workforce further threaten effective care. Research suggests that system-level factors, or the structural and policy-related aspects of health care delivery, have the potential to improve quality of care and health outcomes. But little is known about their role in the context of HIV care delivery, quality of care, and health outcomes. The proposed research will study how two modifiable system-level factors—geographic accessibility to care and physician payment policies—affect quality of HIV care and population outcomes, including new HIV infections, along the HIV care continuum in the US South. Because racial and ethnic minorities face increased barriers to HIV care, we pay special attention to how these system-level factors may contribute to disparities in quality of HIV care and population outcomes along the HIV care continuum. The research involves developing a novel database that combines multiple data sources, including Medicaid administrative claims files, HIV surveillance data, and county and state characteristics from national datasets. Our approach will rely on state-of-the-art spatial network analysis and data visualization (mapping), statistical tests using econometric methods, and systems science forecasting techniques that have been used to study quality of care and population health outcomes. The work moves beyond examination of core quality of HIV care measures to include HIV-related preventive care measures that collectively are critical to reducing HIV morbidity and mortality. In investigating these factors, the study will answer a number of important questions. How do geographic accessibility, measured in travel time to receive care, and physician payment for services affect quality of HIV care in the South? Are these effects different among racial and ethnic minorities? Do improvements in geographic accessibility or increased physician payments reduce new HIV infections and racial and ethnic disparities along the HIV care continuum? The proposed study will address these questions and others. By quantifying the role of system-level factors in quality of HIV care and population health along the HIV care continuum, as well as understanding disparities in these effects, the research will provide valuable information to state and federal policy makers who seek to address systemic challenges to effective HIV care, efficiently allocate scarce resources, and improve public health.

Central Africa International Epidemiologic Database to Evaluate AIDS (IeDEA)

Site Principal Investigator: April D. Kimmel, Ph.D.

Funding Source: National Institutes of Health: National Cancer Institute, National Institute of Allergy and Infectious Diseases, Eunice Kennedy Shriver National Institute of Child Health and Human Development, and National Institute on Drug Abuse.

Project Summary:

Elimination of HIV infection as a cause of human illness and death, and achieving "zero HIV transmission" have been embraced by the AIDS research and treatment communities as achievable. As HIV care and treatment programs are implemented throughout Africa, critical advances in research and policy are needed, so that care and treatment resources can be deployed to optimal benefit: decreasing both new HIV transmissions and HIV-related morbidity and mortality. Among the most important challenges to maximizing the public health benefits of HIV care and treatment programs are late diagnosis of HIV-infection, low rates of linkage to care, and high rates of late ART initiation which in turn ar associated with high rates of mortality, more costly clinical management and continued HIV transmission. In addition there remain unanswered clinical questions for persons living with HIV (PLWH) even with optimal ART. For PLWH in SubSaharan Africa (SSA), ART has been highly effective in decreasing HIV-related morbidity (and mortality), but the association of HIV with metabolic diseases and other conditions of aging (e.g. cancers), and the impact of under- or over-nutrition are not well defined. Newly funded as CA-IeDEA four years ago, we have built a new Central Africa IeDEA (CA- IeDEA), and have 1.) Compiled and managed secondary source patient-level data on ~52,000 patients through both extraction from existing electronic data and new on-the-ground systems for efficient capture of clinical data in low-resource clinical settings; 2.) Been highly productive scientifically with >20 publications even while data collection was in development, and 3.) have continued to foster African leadership and build local research capacity. We propose now to increase the database modestly (to ~80,000 patients) to increase the representativeness of HIV in the region geographically and in service delivery strategies and success and to expand our implementation science approaches to optimize short- and long-term HIV care outcomes both in Central Africa and globally, continue to investigate epidemiologic questions with clinical impact, with a focus on the comorbidities of aging and women's reproductive health.

Disparities in Cancer Screening: The Role of Medicaid Policy

Site Principal Investigator: Bassam A. Dahman, Ph.D.

Funding Source: National Cancer Institute and the Office of Behavioral and Social Science Research / University of Pittsburgh

Background

There are substantial disparities in breast and cervical cancer diagnosis, treatment and outcomes in the U.S. by race, ethnicity, socio-economic and insurance status. While mortality rates have fallen over recent decades due to improved screening and treatment, these benefits are not distributed equally across the population.

Despite the existence of programs aimed at screening underserved women (e.g., the National Breast and Cervical Cancer Early Detection Program), many eligible women are not reached, and research shows that significant disparities in screening remain. Medicaid coverage for low-income women may play an important role in ensuring access to screening, though supporting evidence is limited and does not address recently enacted and proposed changes in patient eligibility, physician payment and patient cost sharing.

Study design

The study examines how existing and new policies that affect the generosity of state Medicaid programs correlate with breast and cervical cancer screening and related health outcomes among low-income women. The study will consider the effect of pre- and post-healthcare reform variation in eligibility between and within states, as well as the effect of physician payment and patient cost sharing on screening. It will also assess how the variation in Medicaid generosity across states and over time is related to outcomes including cancer incidence and stage at diagnosis.

The project brings together complementary secondary data from a number of sources. Nationally representative survey data from the Behavioral Risk Factor Surveillance System will be used to study the effects of Medicaid eligibility on breast and cervical cancer screening among low-income populations.

Medicaid administrative claims and utilization data will allow us to consider the effects of changes in eligibility as well as physician payment and patient cost sharing on screening among Medicaid enrollees. Surveillance, epidemiology and end-results cancer registry data will be used to estimate the effects of changes in Medicaid generosity on cancer incidence and stage at diagnosis.

Intended policy outcomes

Findings from this study will provide evidence about the impact of public policies on cancer screening for underserved populations. The study will be the first to explore the effects of recent Medicaid policies on breast and cervical cancer screening and diagnosis among low-income women. The outcomes considered will also serve as an indicator of the effect of health reform on prevention and women’s health.

African American Cancer Clinical Trial Decisions: Testing Tailored Messages

Principal Investigator: Richard Brown, Ph.D.

Funding Source: American Cancer Society Research Scholar Grant

The purpose of this study is to demonstrate the efficacy of an established method, tailored health messaging, to aid African American (AA) cancer patients’ decision-making about joining a therapeutic clinical trial. This study moves the field forward as it is the first to utilize tailored heath messages to directly intervene in the physician – AA patient clinical trial consultation communication process to increase patient activation in the consultation and thus, potentially improve a range of relevant patient outcomes associated with AA barriers to accrual. We propose to conduct a randomized controlled trial to assess the differential impact on consultation communication of two different levels of tailored messages, (deep vs shallow tailoring) and the additional impact of either providing or not providing the patient’s oncologist with a summary of the tailored messages prior to the trial consultation.

 

Minority Based NCI Community Oncology Research Program

Principal Investigator: Andrew J. Barnes, Ph.D.

Funding Source: National Cancer Institute Grant No. 1UG1CA189869-01

Massey Cancer Center (MCC) will serve as the primary component site for an NCORP Minority/Underserved Community Site award in partnership with nine collaborating community component sites. The overall objectives of this partnership are to extend novel, innovative, and effective minority recruitment approaches to an expanded base of community component sites, increase opportunities for minority and medically underserved individuals to participate in Cancer Clinical Trial Research (CCTR), and to integrate Cancer Care Delivery Research (CCDR) into the overall MB-NCORP. Accordingly, the specific aims of this proposal are to (1) establish a research infrastructure that will further enable community component sites to conduct CCTR with an emphasis on trials relevant to minority and medically underserved populations, (2) conduct NCI-approved CCTR at the MCC primary component site and throughout the community component sites, and (3) integrate Cancer Care Delivery Research (CCDR) into the overall MB-NCORP.

The research design of the MB-NCORP offers a full menu of cancer studies including those in cancer prevention and control, screening, treatment, imaging, and CCDR. The proposed research is relevant to the mission of the NCI as MCC and the community component sites will bring cancer clinical trials and research to low-income, minority, and medically underserved individuals who otherwise would not have access to such studies. These studies will address many diverse factors from patient, provider, organizational, and policy perspectives that contribute to known disparities in cancer detection, treatment, and outcomes. Targeting the minority/underserved populations in their communities is a critical step toward alleviating the cancer care disparities prevalent in these populations.

Incentives to Encourage Primary Care Use: A Randomized Controlled Trial in Safety Net

Principal Investigator: Maria Thomson, Ph.D.

Funding Source: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services. Grant No. R01HS022534

The study supports a randomized controlled trial of incentives for an initial primary care visit within six months of enrollment in a healthcare coverage program. The lack of healthcare coverage leads to poor health and inappropriate healthcare use among the uninsured. Medicaid expansions to the uninsured adult population are a means of improving access to primary care. However, the evidence from these expansions on reducing hospitalizations and emergency department use is mixed, suggesting that barriers to primary care remain, in spite of coverage.

Interventions, such as incentives (also known as conditional cash transfers), may be a means to steer patients toward a model of care that emphasizes prevention, primary care for nonemergent needs and primary care chronic disease management. Cash incentives may generate a desired behavioral response for a relatively small price.

Preventing and Controlling Obesity and Chronic Disease through Evidence-Based Programming

Principal Investigator: Jessica LaRose, Ph.D.

Funding Source: Virginia Department of Health, Richmond City Health District

The goal of this initiative is to implement environmental and school-based strategies to improve nutrition access, dietary choices and reduce obesity risk among children in Richmond Public Schools. A central goal of this work involves a systematic evaluation of these efforts to determine the impact on key outcomes of interest.

Improving Adolescent Obesity Treatment: Exploring the Role of Parents

Co-Investigator: Jessica LaRose, Ph.D.

Funding Source: National Institutes of Health

There is an urgent need for innovative approaches to obesity prevention and treatment, particularly among African Americans (AA), a population at increased risk of obesity and its associated morbidity and mortality. Research and clinical practice guidelines consistently recommend that parents should be included in their children’s obesity treatment, yet the most effective strategy to engage parents in adolescent obesity treatment is unclear. The adolescent period presents substantial challenges to family-based care, as youth experience increased desire for independence and autonomy, contributing to resistance to authority figures; yet they still rely on parents for many needs. Given these challenges, it is not surprising that research investigating specific clinical paradigms for involving parents in adolescent obesity treatments is inconsistent. To that end, the current application pilots two distinct approaches for involving parents in their adolescents’ obesity treatment. TEENS (Teaching, Encouragement, Exercise, Nutrition, Support) is a family-based, multidisciplinary behavioral treatment program targeting primarily AA, obese adolescents. This investigative team previously demonstrated that participation in the TEENS intervention is associated with significant reductions in body mass index (BMI) at 6 months. In TEENS, parents were included in monthly groups to support their adolescent’s weight management. Although parent weight was not targeted, a significant correlation between parent and adolescent BMI change was found. These findings highlight the importance of parental involvement and suggest that parent weight management might be an important intervention target. Indeed, directly targeting parent weight loss within adolescent treatment might be associated with even greater adolescent BMI reductions, as parents engaged in concurrent weight management might make greater changes to the shared environment and serve as powerful role models, given their common goals. Towards that end and building on our previous work, we developed TEENS+, a family-based adolescent obesity intervention. This application proposes a randomized controlled pilot to determine the feasibility and preliminary efficacy of two parent treatments within TEENS+ among 96 overweight or obese adolescents (BMI>85th percentile) and parent(s) (BMI>25 kg/m2). Families will be randomized to one of two 4-month treatments: 1) TEENS+Parents as Coaches (PAC), engaging parents as helpers in their child’s weight management, or 2) TEENS+Parent Weight Loss (PWL), engaging parents in their own weight management. All adolescents will participate in the TEENS+ protocol, which includes nutrition education with dietary goals, supervised physical activity, and behavioral support, and integrates motivational interviewing to enhance treatment engagement. Assessments will be completed at 0, 4, and 7 months. Results of this investigation will inform a subsequent larger trial investigating the role of parents in adolescent obesity treatment, targeting predominately African American families. 

Communication and Communication Outcomes for Cancer Survivors

Principal Investigator: Maria Thomson, Ph.D.

Funding Source: National Institutes of Health/National Cancer Institute 

This study will examine whether families and patients with blood cancers communicate well with each other about treatment and care decisions. These cancers can disrupt patient and caregivers’ lives and can cause patients and caregivers stress and make it difficult from them to continue to work or meet their family obligations. This study will examine whether and how their communication is associated with these outcomes and how we can intervene in the future to improve their quality of life and is important because a growing number of people are affected by these diseases, many of whom are working age adults. 

Red Flag Campaign Outcome Evaluation

Co-Director of Research and Evaluation: Kellie E. Carlyle, Ph.D., M.P.H.

Funding Source: Community-Engagement Grant and Avon Foundation

Summary: http://www.ivpp.vcu.edu/programs/empower/index.html

Oral Health Disparities, Community Engagement Plan

Principal Investigator: Maghboeba Mosavel, Ph.D.

Funding Source: DentaQuest Foundation/Fiscal Agent Pathways

The DentaQuest Foundation funded the Petersburg Wellness Consortium (Team Lead: Dr. Mosavel) to explore the oral health landscape in Petersburg using various community engaged research strategies. The Foundation’s current campaign – Oral Health 2020 – is mobilizing a national network across the grassroots, grassmiddles and grasstops to increase awareness of health equity and racial justice in the understanding of oral health disparities.  The PWC and VCU will conduct community engaged research to assess how 1) oral health can be integrated into education and other services, 2) to optimize oral health literacy, 3) to build a strong community prevention and care infrastructure. Laypersons will be engaged in all aspects of the research.