Center for Health Systems Research Investigators and Projects
Improving the care, experience, and health of patients, clinicians, and communities through innovative research, development, and analytics.
Kristen Azar, RN, MSN, MPH
- Clinical experience: preventive cardiology nurse
- Expert in developing innovative interventions for prevention and management of chronic disease
- Evaluates clinical programs leveraging EHR data
- Promotes health equity within Sutter and the communities it serves
Improving Early Detection and Treatment of Depression
Project Lead: Kristen Azar, RN, MSN/MPH, CHSR Principal Investigator, East Campus
The Challenge: Depression threatens the well-being of patients and their families, and is a significant cause of disability in the U.S. It is the most common mental health condition, but screening rates remain extremely low.
CHSR Approach: Leverage Sutter Health electronic health record (EHR) data to improve screening practices and ensure vulnerable patients receive timely care. CHSR researchers are using EHR data to better understand the real-world care practices of primary care providers around detection of depression during primary care visits, follow-up care, and treatment. The team will compare screened versus non-screened patients, and identify follow-up care in patients with depression. This study will be completed by December 2019.
The Impact: Results of this work will help improve the detection and treatment of depression in primary care. Early identification of depression may increase the effectiveness of treatment and reduce long-term effects on patient wellbeing and healthcare costs.
Project Team: Kristen Azar, RN, MSN/MPH, Shruti Vaidya, MS, Ivelina Popova, Jinnan Li, PhD, MPH, Andrew Hudnut, MD, Alice Pressman, PhD, MS.
Funding Sources: Takeda, Lundbeck
- Measuring Health Equity for Ambulatory Care Sensitive Conditions in a Large Integrated Healthcare System: the development of an index. Pressman A, Lockhart S, Petersen J, Robinson S, Moreno M, Azar KMJ. Health Equity 2019; 3.1. DOIL 10.1089/heq.2018.0092
- Current Science on Consumer Use of Mobile Health for Cardiovascular Disease Prevention: A Scientific Statement From the American Heart Association. Burke LE, Ma J, Azar KM, et al. Circulation 2015;132:1157-213.
- Virtual small groups for weight management: an innovative delivery mechanism for evidence-based lifestyle interventions among obese men. Azar KM, Aurora M, Wang EJ, Muzaffar A, Pressman A, Palaniappan LP. Transl Behav Med 2015;5:37-44.
Ellis Dillon, PhD
- PhD in sociology
- Leads initiatives to assess and improve physician/clinician wellbeing
- Conducts mixed methods research integrating data to improve care practices
- Proven expertise improving care delivery and experience in serious illness and mental healthcare
Joy of Work: Improving Physician Wellbeing
Project Lead: Ellis Dillon, PhD, Principal Investigator, West Campus
The Challenge: Over 50% of U.S. physicians report symptoms of burnout including depersonalization and/or emotional exhaustion.
CHSR Approach: Evaluate and understand factors comprising physician burnout, and support strategies to foster physician wellbeing across Sutter Health. Our team surveyed physicians from six Sutter-affiliated medical groups and explored changes over time. In 2018, 1,035 physicians (65%) completed the survey, and 842 commented on workplace changes that would significantly improve wellbeing.
We merged wellbeing survey responses from individual physicians with administrative data and data from electronic health records. We used statistical analyses to identify the factors significantly associated with burnout: having adequate support staff, finding work meaningful, feeling highly valued, and number of Epic in-basket messages received weekly.
Physicians’ written comments indicated they desired improved staff support, in-basket message support, decreased workload/improved work-life balance, progress note/documentation support, and improved leadership.e Impact: We are collaborating with Robert Nordgren, MD, Chief Executive Officer, Palo Alto Foundation Medical Group (PAFMG), and Suzanne Pertsch, MD, Director, PAFMG Office of Physician Wellness, to disseminate the findings and support efforts to enhance wellbeing.
The Impact: We are collaborating with Robert Nordgren, MD, Chief Executive Officer, Palo Alto Foundation Medical Group (PAFMG), and Suzanne Pertsch, MD, Director, PAFMG Office of Physician Wellness, to disseminate the findings and support efforts to enhance wellbeing.
Ongoing studies will compare physician and staff burnout, and assess the relationship between staffing levels and physician and staff wellbeing.
Project Team: Ellis Dillon, PhD, Amy Meehan, MPH, Yan Yang, PhD, Veronique Martin, Jinnan Li, PhD, MPH, Martina Li, MPH, Nina Szwerinski, and Dominick Frosch, PhD.
Funding Sources: Sutter Health and Palo Alto Foundation Medical Group
- Provider Perspectives on Advance Care Planning Documentation in the Electronic Health Record: The Experience of Primary Care Providers and Specialists Using Advance Health Care Directives and Physician Orders for Life Sustaining Treatment. Dillon, E., Chuang, J., Gupta, A., Tapper, S., Lai, S., Yu, P., Ritchie, C., Tai-Seale, M. American Journal of Hospice and Palliative Medicine®. PMID: 28196448. doi: 10.1177/1049909117693578. Epub 2017 Feb 15.
- An evaluation of two interventions to enhance patient-physician communication using the observer OPTION5 measure of shared decision making. Dillon, EC, Stults CD, Wilson C, Chuang J, Meehan A, Li M, Elwyn G, Frosch DL, Yu E, Tai-Seale M. Patient Education and Counseling. 2017; 100(10):1910-1917. PMID: 28532861 DOI: 10.1016/j.pec.2017.04.020
- Community-based palliative care and advance care planning documentation: Evidence from a multispecialty group. Tai-Seale M, Yang Y, Dillon E, et al.Journal of the American Geriatrics Society. 2017: doi: 10.1111/jgs.15145. [Epub ahead of print].
- Measuring the impact of patient-engaged research: How a methods workshop identified critical outcomes of research engagement. Dillon EC, Tuzzio L, Madrid S, Olden H, Greenlee RT. J Patient Cent Res Rev. 2017;4(4):237-246. doi: 10.17294/2330-0698.1458
- Using unlicensed health coaches to improve care for insured patients with diabetes and hypertension: patient and physician perspectives on recruitment and uptake. Dillon E, Panattoni L, Meehan A, Chuang J, Wilson C, Tai-Seale M. Population Health Management. Oct 2016;19(5):332-340. PMID: 26674597. doi: 10.1089/pop.2015.0095. Epub 2015 Dec 16.
Dominick Frosch, PhD
- PhD in clinical psychology; Co-Director of CHSR
- Leverages data to transform healthcare
- Leads research to advance patient engagement and patient-centered care
- Proven expertise in randomized efficacy and effectiveness trials, implementation science, measurement and qualitative methods
Dorothy Hung, PhD, MA, MPH
- PhD in Health Services and Policy Analysis, MA in Political Science, Master's degree in Public Health
- Expert in the evaluation of Lean techniques for improving value in healthcare
- Helps lead organizational approaches to achieving high-quality, high-value care delivered in ambulatory and hospital settings
Lean Management in Primary Care
Project Lead: Dorothy Hung, PhD, MA, MPH, Principal Investigator, West Campus
The Challenge: ‘Lean’ design — a change strategy with roots in continuous quality improvement — is a powerful tool to transform healthcare delivery and increase efficiency. But there are few studies assessing its impact on delivery system performance over time, particularly in ambulatory settings.
CHSR Approach: We launched ‘The Impact of Lean Management on Primary Care Efficiency, Affordability, and the Patient Experience’ to examine performance metrics after Lean redesign was implemented in 46 primary care departments at the Palo Alto Medical Foundation.
We used statistical modeling to estimate Lean impacts on performance metrics including: workflow efficiency, physician productivity, operating expenses, clinical quality, and satisfaction among patients, physicians, and staff. We leveraged EPIC® electronic health record (EHR) access log data to track physician time spent daily on direct and indirect patient care activities.
The Impact: Lean redesigns benefited primary care patients, physicians, and staff. (See Appendix for full results.)
- For patients: increased satisfaction with care and handling of personal issues.
- For physicians: increased workflow efficiency and less time spent on indirect patient care and administrative tasks.
- For staff: improved engagement, connection to purpose, and enhanced relationships with peers and physicians.
Study results helped support healthcare delivery system leaders to innovate using Lean techniques and may further enhance support for Lean learning among public and private payers.
Project Team: Dorothy Hung, PhD, MA, MPH, Hal Luft, PhD, Quan Truong, Su-Ying Liang, PhD, Anqi Jin.
Funding Sources: Agency for Healthcare Research and Quality, Palo Alto Medical Foundation
- Scaling Lean in Primary Care: Impacts on System Performance. Hung DY, Martinez M, Harrison M, Luft H. American Journal of Managed Care. 2017;23(3):161-168. PMID: 28385026.
- Ready for Change? The Role of Physician and Staff Engagement, Burnout, and Workplace Attributes. Hung DY, Chen P. Journal of Ambulatory Care Management. 2016;40(2):150-157. PMID: 27893517. doi: 10.1097/JAC.159.
- Implementing a Transitional Care Program to Reduce Hospital Readmissions Among Older Adults. Hung D, Leidig R. Journal of Nursing Care Quality. 2015;30(2):121-129. PMID: 25485791. doi:10.1097/NCQ.91.
- What’s in a Setting? Influence of Organizational Culture on Provider Adherence to Clinical Guidelines for Treating Tobacco Use. Hung DY, Leidig R, Shelley D. Health Care Management Review. 2014;39(2):154-63. PMID: 23636103. doi: 10.1097/HMR.0b013e3182914d11.
- Rethinking Prevention: Applying the Chronic Care Model to Address Health Risk Behaviors. Hung, DY, Rundall, TG, Tallia, AF, Cohen, DJ, Halpin, HA, and Crabtree, BF. Milbank Quarterly. 2007;85(1):69-91. PMC2690311.
- Lean redesign significantly increased workflow efficiency, including proportions of office visit chart closures (29.8%) and telephone encounter resolutions (22.2%), and moderately increased prescription refills (2.8%). These changes were sustained several years after Lean redesigns were introduced in each clinic location. We also found a 5% increase in physician productivity with no adverse effects on clinical quality.
- Overall, patient satisfaction increased from 49.1% to 63.2% following Lean redesigns. Specifically, patient perceptions of access to care via appointments, phone calls, online messages, and referrals increased by 48.4%. Patient satisfaction with the handling of personal issues regarding safety, privacy, and exam room cleanliness also improved by nearly 8%; however, patient satisfaction with interactions with care providers decreased by approximately 11.6%.
- Annual staff and physician satisfaction scores increased, particularly among early adopters of Lean redesign, with key improvements in employee engagement, connection to purpose, relationships with staff, and physician time spent working. Based on time-stamped EHR records of physician work time, we found a 6.6% decrease in hours that physicians spent in the EHR each day, beyond the time spent interacting directly with patients during office visits. Additionally, there was a 7.4% reduction in the amount of time that physicians spent working, specifically after the last patient visit daily.
- Finally, there was a small but significant decrease in the trend of total daily work hours. These decreases were observed immediately following Lean redesigns, and were sustained over a continuous 3-4 year period. We found no change in number of hours that physicians spent caring for patients in face-to face time during scheduled office visits.
J.B. Jones, PhD, MBA
- PhD in health services research
- Directs Sutter’s Digital Healthcare Solutions Team
- Leverages EHRs to improve healthcare processes
- Develops digital health tools
Shining Light on Multiple Sclerosis With Precision Medicine: Floodlight Mobile
Project Lead: J.B. Jones, PhD, MBA, CHSR Principal Investigator, East Campus
The Challenge: Multiple sclerosis (MS) is a potentially disabling immunologic disease of the central nervous system. More than 2.3 million people have MS worldwide, including over 450,000 people in the U.S. Despite new research, the specific immunologic cause remains unknown and the disease has no cure. Most people with MS manage a relapsing-remitting course of the illness with disease-modifying therapies to slow disease progression. People with a less common form of the illness, called primary progressive MS, steadily decline in function.
Most neurologists see their MS patients once every six to 12 months. In each visit, it’s unlikely patients can convey a summary of their daily mobility experience and secondary symptoms with the precision needed to guide treatment decision making. So neurologists lack comprehensive data to deliver precise care.
CHSR Approach: We launched Floodlight™, a mobile application to leverage patient-generated data for new insights on MS progression in individual patients. Developed by Roche and pilot tested by Sutter Health, Floodlight™ collects patient data through digital questionnaires and online sensors that assess cognition, coordination and motor skills, mood, gait, and mobility in MS patients. We are collaborating with Sutter clinicians to design displays of the data that are clinically informative and actionable.
Approximately 100 Sutter Health patients will be recruited to test the mobile application; ongoing refinements through Summer 2019 will help ensure its use and validity in real-world settings.
The Impact: Floodlight™ will give neurologists meaningful, actionable patient data to help them provide more precise, personalized treatment to MS patients with varying disease subtypes.
Project Team: J.B. Jones, PhD, MBA, Iva Popova, Diamonne Mitchell, Jackie Liu, Gil Flamino, Frank Velasco, Jerry Chen, Jennifer Pearce.
Funding Sources: Sutter Health, Roche Diagnostics, and the California Initiative to Advance Precision Medicine
The Wired Patient: Patterns of “Web Portal” Use Among Patients With Caridac Disease or Diabetes. Jones JB, Weiner JP, Jones JW, Shah NR, Stewart WF. J Med Int Res. 2015 Feb 20;17(2):e42.
The Preference-Based Care Tool: Using HIT to Integrate Patient Choice Into Primary Care CVD Management. Jones JB, Bruce CA, Shah NR, Steward WF. Translational Behavioral Medicine. 2011 March; 1(1); 123-133.
Meaningful Use of EHRs by Incorporating Quantitative Patient-Specific Risk Information During Routine Primary Care. Jones JB, Shah NR, Bruce CA, Stewart WF. Am J Prev Med. 2011 May;40(5 Suppl 2):S179-86.
Measuring Adherence and Outcomes in the Treatment of Patients With Multiple Sclerosis. Hao J, Pitcavage J, Jones J, Hoegerl C, Graham J. J Am Osteopath Assoc2017;117(12):737–747. doi: 10.7556/jaoa.2017.145.
CM-SHARE: Development, Integration, and Adoption of an Electronic Health Record–Linked Digital Health Solution to Support Care for Diabetes in Primary Care. Jones JB, Liang S, Husby HM, Delatorre-Reimer JK, Mosser CA, Hudnut AG, Knobel K, MacDonald K, Yan XS. Clinical Diabetes 2019 May; cd180057. https://doi.org/10.2337/cd18-0057
Jiang Li, PhD, MPH
- PhD and MPH in health behavior
- Leads research to improve cancer screening, smoking cessation, patient-physician communication, and digital health tools
- Collaborates in research to improve health equity in underserved populations
- Expert in preventive medicine
Improving Early Detection of Lung Cancer
Project Lead: Jiang Li, PhD, MPH, CHSR Principal Investigator, West Campus
The Challenge: Lung cancer is the leading cause of cancer-related deaths in the U.S. Annual screening with low-dose computed tomography (LDCT-LCS) is recommended for heavy smokers and people at high risk for lung cancer.* Despite national guidelines on lung cancer screening, there is little data on the adoption of LDCT-LCS in large U.S. healthcare systems.
CHSR Approach: We launched the three-year Multilevel Study of Lung Cancer Screening Implementation (MUST) study. MUST filled critical knowledge gaps in the implementation of lung cancer screening and smoking cessation interventions, and identified multilevel barriers among patients and providers.
We compiled Sutter-wide electronic health record data from patients aged 55-80 years with no history of lung cancer who visited a primary care provider between 2010 and 2017. We studied implementation of LDCT-LCS and smoking cessation interventions, and multilevel factors associated with receiving a medical order of screening and counseling.
- Documentation of smoking history, smoking cessation interventions, and LDCT-LCS referrals increased since the U.S. Preventive Services Task Force recommended LDCT screening for lung cancer.
- Even after the policy implementation, only 7% of LCS-eligible patients were referred for LDCT-LCS.
- Lung cancer screening practice varied across primary care providers.
- Eligible patients seeing their regular primary care provider were significantly more likely to receive lung cancer screening referrals. Older, former smokers who had severe or moderate major comorbidities were significantly less likely to receive lung cancer screening referrals.
We are conducting in-depth interviews with patients and providers. Insights from our interviews will advance knowledge of patient and provider motivations and barriers for implementing LDCT-LCS and smoking cessation interventions.
*The National Lung Screening Trial demonstrated that, among individuals with a high risk of lung cancer, a 20% relative reduction in lung cancer mortality was observed with low-dose computed tomography for lung cancer screening (LDCT-LCS) compared to chest X-ray. In 2013, the U.S. Preventive Services Task Force (USPSTF) recommended annual screening for lung cancer with LDCT -LCS for heavy smokers aged 55-80 years. The guidelines included tobacco cessation interventions in parallel with LDCT-LCS. Despite these recommendations, there is little data on the adoption of LDCT-LCS in healthcare systems.
Project Team: Jiang Li, PhD, MPH, Sukyung Chung, PhD, Dorothy Hung, PhD, PhD, MA, MPH, Meghan Martinez, Edward Yu, MD, Alan Chausow, MD.
Funding Sources: The Tobacco-Related Disease Research Program
- Promoting men's health within barbershops: barber/owner survey results and implications for intervention planning. Li J, Linnan LA, Rose J, Hooker E, Boswell M, D’Angelo H, Harrington C. Preventive Medicine, 2011; 53(3):207-208. DOI: 10.1016/j.ypmed.2011.06.001.
- Knowledge and Perceptions of Overweight Employees about Lifestyle-Related Health Benefit Changes. Li J, Linnan LA, Finkelstein EA, Tate DF, Naseer C, Evenson KR. North Carolina Medical Journal, 2011; 72(3): 183-190. PMCID: PMC5082972.
- Access and health services utilization among Koreans in Los Angeles: the mediating role of acculturation. Li J, Maxwell AE, Glenn BA, Herrmann AK, Chang LC, Crespi CM, Bastani R. Int J Soc Sci Res. 2016;4(1):83-97. PMCID: PMC5647155.
- Implementing Smoking Cessation Counseling for Lung Cancer Screening-Eligible Patients. Li J, Chung S, Luft H. Abstracts from the 24th annual Health Care Systems Research Network Conference; April 2018; Minneapolis, MN. J Patient Cent Res Rev. 2017; 5:109. doi: 10.17294/2330-0698.1630.
- New recommendation and coverage of lung cancer screening (LCS) by low dose computed tomography (LDCT): uptake increased but is still dismally low. Li J, Chung S, Wei EK, Luft H. BMC Health Serv Res. 2018;18(1):525. PMCID: PMC6034213.
Su-ying Liang, PhD
- PhD in economics
- Applies health economics and quantitative methods to improve healthcare delivery
- Research interests in medical care utilization, personalized medicine, genetic testing, and women’s health
Improving Lynch Syndrome Screening
Project Lead: Su-Ying Liang, PhD, CHSR Principal Investigator, West Campus
CHSR Approach: We launched a collaborative, multi-site study to understand and compare decision making in Lynch syndrome screening across healthcare systems. The study includes clinical sites with diverse patient populations in various stages of implementing Lynch syndrome screening. Participating sites are: Sutter Health (Palo Alto Medical Foundation), Geisinger, Kaiser Permanente (Colorado, Northwest), Meyers Primary Care Institute, HealthPartners, Harvard Pilgrim Health Care, and Catholic Health Initiatives.
We interviewed patients and providers and used qualitative comparative analyses to identify barriers and facilitators of Lynch syndrome screening. Economic evaluation models were applied to investigate how contextual factors impact organization costs and program success. The five-year study is nearing completion of its second year (8/1/2017 – 7/31/2022).
The Impact: Study findings will advance understanding of how contextual factors impact Lynch syndrome screening across healthcare systems.
Project Team: Su-Ying Liang, PhD, Martina Li, MPH, and Tony Chen.
Funding Sources: National Institutes of Health/National Cancer Institute
- Implementing universal Lynch syndrome screening (IMPULSS): protocol for a multi-site study to identify strategies to implement, adapt, and sustain genomic medicine programs in different organizational contexts. Rahm AK, Cragun D, Hunter JE, Epstein MM, Lowery J, Lu CY, Pawloski PA, Sharaf RN, Liang SY, Burnett-Hartman AN, Gudgeon JM, Hao J, Snyder S, Gogoi R, Ladd I, Williams MS. BMC Health Serv Res. 2018 Oct 30;18(1):824. doi: 10.1186/s12913-018-3636-2.
- The Healthcare Systems Research Network (HCSRN) as an Environment for Dissemination and Implementation Research: A Case Study of Developing a Multi-Site Research Study in Precision Medicine. Rahm AK, Ladd I, Burnett-Hartman AN, Epstein MM, Lowery JT, Lu CY, Pawloski PA, Sharaf RN, Liang SY, Hunter JE. EGEMS (Wash DC). 2019 Apr 12;7(1):16. doi: 10.5334/egems.283.
Hal Luft, PhD
- PhD in economics
- Expert in health policy studies, medical care utilization, quality and outcomes of hospital care
- Leads postdoctoral training programs in healthcare research and quality
- Conducts research to improve clinical care, enhance value for patients and providers, and leverage EHR data for optimal health outcomes
New Insights Into Primary Care Counseling Approaches
Project Lead: Hal Luft, PhD, Senior Scientist, West Campus
The Challenge: Primary care physicians (PCPs) have differing approaches to handle workload pressures. Some address only the patient’s main healthcare concern during acute care visits; others also address patients’ chronic conditions, thereby potentially avoiding subsequent patient visits. Those PCPs are “max-packers” because they pack the maximum possible care into a visit. The published literature does not indicate which counseling style is better.
CHSR Approach: We leveraged data from patients’ electronic health records (EHRs), patient experience of care surveys, quality metrics, and EHR access logs, to understand differing approaches to acute primary care visits.
We examined patients of 285 PCPs over 2011-2013 and contrasted the one third behaving as max-packers with the one third who focused on patients’ main concerns.
Relative to the patients of the focused PCPs, those of the max-packers had better clinical quality, comparable patient experience scores (except waiting time), and lower annual costs. The difference in cost was attributable to less specialty care. Max-packing PCPs had fewer (but longer) patient visits daily, and more non-face-to-face contacts with patients before and after visits. Traditional fee-for-service payment under-compensates max-packers because they spend more time with EHR/communications.
Results of the 2011-2013 study will be submitted for publication and updated with data through 2018 to confirm earlier findings.
The Impact: Max-packing is better for patients and lowers resource use, so alternative compensation approaches and more flexible appointment scheduling may facilitate this counseling style.
Project Team: Hal Luft, PhD, and Su-Ying Liang, PhD.
Funding Sources: Agency for Healthcare Research and Quality, National Institutes of Health, Robert Wood Johnson Foundation
- Preventive visit among older adults with Medicare's introduction of Annual Wellness Visit: closing gaps in underutilization. Chung S, Romanelli RJ, Stults C, Luft H. Prev Med. 2018 Aug 23 https://doi.org/10.1016/j.ypmed.2018.08.018
- Is good enough for our peers good enough for policy makers? Luft H. Health Serv Res. doi: 10.1111/1475-6773.12750. [Epub ahead of print] 2017 Sep 4.
- Five decades of HSR-by words and figures. Luft HS. Health Serv Res. 52(3):908-918. doi: 10.1111/1475-6773.12717. 2017 Jun 1.
- Electronic health record logs indicate that physicians split time evenly between seeing patients and desktop medicine. Tai-Seale M, Olson CW, Li J, Chan AS, Morikawa C, Durbin M, Wang W, Luft HS. Health Aff. 36:655-662; doi:10.1377/hlthaff.2016.0811. 2017 Apr 1.
Alice Pressman, PhD, MS
- PhD in epidemiology, MS in statistics
- Co-Director of CHSR
- National expert in clinical trials methods, health disparities, and chronic pain research
- Leads Sutter’s Evaluation as a Service program
Improving Migraine Management with Mindfulness: A Pilot Trial
Project Lead: Alice Pressman, PhD, MS, CHSR Co-Director, Principal Investigator, East Campus
The Challenge: Migraine headache is one of the most common neurological disorders and a leading cause of disability worldwide. Medications are typically the standard therapy, but are only moderately effective and cause side effects; newer, more effective medications are expensive.
CHSR Approach: We investigated the effectiveness of Mindfulness-Based Stress Reduction (MBSR) in patients with moderate-to-severe migraine. MBSR has demonstrated clinically meaningful benefit in several chronic-pain syndromes and has shown promising results for migraine therapy in small case series and pilot studies.
We conducted a pragmatic* two-arm randomized controlled pilot trial of MBSR for the treatment of moderate-to-severe migraine. Our recruitment goal was approximately 60 participants with moderate-to-severe episodic migraine. The feasibility outcomes included ability and time required to recruit, adherence to the MBSR treatment, and demonstrated ability to measure outcomes. The active intervention consisted of an eight-week community-based mindfulness-based stress reduction (MBSR) class plus usual care, and the wait-list control group was usual care alone.
We recruited 66 participants; seven (11%) withdrew before the intervention began (six in the MBSR arm). Adherence to MBSR was high. Of the 28 who registered for MBSR, 26 (93%) attended at least five classes. We measured headache days and collected four-month questionnaire data on 50 (76%). We are analyzing the questionnaire data to understand participant experience with MBSR to help design the fully-powered trial.
The Impact: To our knowledge, this is the first pragmatic trial of MBSR for migraine in the U.S. It provided an excellent background for the design and implementation of fully-powered trials to determine the effectiveness of MBSR for reducing headache frequency in patients with moderate-to-severe migraine. The results will help us design and conduct a fully-powered, multi-center trial at Sutter Health in collaboration with Kaiser, UC San Francisco, and Stanford.
*Pragmatic trial in this case is defined as a trial that is designed to evaluate the effectiveness of an intervention under real-life routine practice conditions, as opposed to an explanatory trial which aims to test whether an intervention works under optimal conditions. In this case, the intervention was a broadly-available community MBSR class.
Project Team: Alice Pressman, PhD, MS, Heather Law, MA, Sylvia Sudat, PhD, Alice Jacobson, MS, Alex Scott, MA(Edin), Lisa Dean, MS, MBA, Nina Szwerinski, MSc, Angelica Obillo, and Michelle Goodreau, MPH, and two external co-investigators: Andy Avins, MD, MPH from Kaiser Permanente Northern California, and Bob Stahl, PhD from Insight Santa Cruz a Buddhist Meditation Community.
Funding Sources: National Center for Complementary and Integrative Health (1R01AT009081)
- Conducting a pilot randomized controlled trial of community-based mindfulness-based stress reduction versus usual care for moderate-to-severe migraine: protocol for the Mindfulness and Migraine Study. (M&M) Pressman A, Law H, Stahl R, Scott A, Jacobson A, Dean L, Sudat S, Obillo A, Avins A. Trials 2019 May 6 20:257 https://doi.org/10.1186/s13063-019-3355-y
- Prevalence of migraine in a diverse community – electronic methods for migraine ascertainment in Kaiser Permanente, a large integrated health plan. Pressman AR, Jacobson A, Eguilos R, Gelfand A, Huynh C, Hamilton L, Avins A, Bakshi N, Merikangas K. Cephalalgia. 2016 Apr;36(4):325-34. https://doi.org/10.1177/0333102415590242
- Should we reconsider the routine use of placebo controls in clinical research? Avins AL, Cherkin DC, Sherman KJ, Goldberg H, Pressman A. Trials 2012 Apr 27;13:44 https://doi.org/10.1186/1745-6215-13-44
Robert Romanelli, PhD, MPH
- PhD in biomedical sciences, MPH in epidemiology and outcomes research
- Leads research in pharmacoepidemiology and health outcomes
- Expert in designing observational research studies and analyzing real-world healthcare data
- Develops initiatives to improve medication prescribing and drug utilization
Behavioral Lifestyle Change to Reduce Risk of Cardiovascular Disease and Diabetes
The Challenge: Nearly 70% of U.S. adults are overweight or obese, and are at high risk for developing diabetes and cardiovascular disease. Research suggests behavioral interventions that promote weight loss are effective; however, the impact of such interventions has not been widely tested.
CHSR Approach: We used electronic health record data to study the effectiveness of a group lifestyle change program. The program is a 12-month, Centers for Disease Control and Prevention recommended curriculum for weight loss in individuals with pre-diabetes, and cardiovascular/diabetes risk factors. It was implemented at Sutter Health in 2010.
The Impact: Program participants achieved modest weight loss after 12 months and sustained weight loss after 24 months. About one-quarter achieved clinically meaningful weight loss (5% reduction in body weight) regardless of underlying risk factors. Engagement with the program, evidenced by the number of sessions attended, led to even greater weight loss and improved blood pressure. Future studies will assess whether the program reduces participants’ risk of diabetes and cardiovascular disease, compared with Sutter patients who did not participate.
Project Team: Robert Romanelli, PhD, Kristen Azar, RN, MSN/MPH, Alice Pressman, PhD, Sylvia Sudat, PhD, Sukyung Chung, Meghan Halley, Catherine Nasrallah, MS, Nina Szwerinski, MS, Vidita Chopra, MPH, Claire Huang, MPH, Qiwen Huang, MS, Jack Petersen, BS.
Funding Sources: National Institute of Diabetes, Digestive and Kidney Diseases of the National Institutes of Health
- Improving diet, activity and wellness in adults at risk of diabetes: randomized controlled trial. Block G, Azar KM, Romanelli RJ, Block TJ, Palaniappan LP, Dolginsky M, Block CH. Nutr Diabetes. 2016 Sep 19;6(9):e231. doi: 10.1038/nutd.2016.42. PubMed PMID: 27643726; PubMed Central PMCID: PMC5048017.
- Comparative effectiveness of early versus delayed metformin in the treatment of type 2 diabetes. Romanelli RJ, Chung S, Pu J, Nimbal V, Zhao B, Palaniappan L. Diabetes Res Clin Pract. 2015 Apr;108(1):170-8. doi: 10.1016/j.diabres.2014.12.019. Epub 2015 Jan 21. PubMed PMID: 25661984; PubMed Central PMCID: PMC4388779.
- Patient-Reported Experiences in Discussing Prescribed Medications with a Health Care Provider: Evidence for Racial/Ethnic Disparities in a Large Health Care Delivery System. Chung S, Huang Q, LaMori J, Doshi D, Romanelli RJ. Popul Health Manag. 2019 Apr 23. doi: 0.1089/pop.2018.0206. [Epub ahead of print] PubMed PMID: 31013464.
Cheryl Stults, PhD, MA
- PhD and MA in sociology
- Proven expertise in qualitative and mixed-methods research
- Leads research to improve patient-centered communication in primary care
- Studies the evaluation of primary care redesign initiatives
Improving Patient-centered Communication in Primary Care
Project Lead: Cheryl Stults, PhD, Principal Investigator, West Campus
The Challenge: Research suggests patients rarely talk openly with care providers because they fear retribution or being labeled ‘difficult’. On the ‘flip side’, healthcare providers are sometimes unprepared to answer all questions posed by their patients.
CHSR Approach: We launched the Open and Ask study to improve patient-centered communication in primary care.* We compared three interventions that empower patients to communicate honestly and that enable physicians to respond effectively: Open Communication High Touch, Open Communication High Tech, and ASK. The interventions are being tested at the University of California at San Diego, Sutter Health, and Reliant Medical Group in Massachusetts.
The four-year study will conclude in March 2021.
The Impact: The interventions are randomized at the clinic level to one of three communication approaches:
- Open Communication High Touch — Patients use an electronic system (MyHealthOnline) to prepare for office visits and communicate with their doctors through a questionnaire assessing health concerns. Doctors receive in-person training on how to discuss what matters most to patients.
- Open Communication High Tech — Patients use the Open Communication High Touch approach. Doctors receive training via a mobile app, versus in person.
- ASK — Clinics place posters in exam rooms that encourage patients to ask their doctors “What are my options? What are the possible risks and benefits of each option? How likely are the benefits of each option to occur to me?”
* This study builds on a previous pilot study conducted at the Palo Alto Medical Foundation of an approach called Open Communication. The study showed that patients and doctors who used open communication had better communication than patients who received standard care.
Project Team: UC San Diego (Ming Tai-Seale), Reliant Medical Group (Kathy Mazor). Sutter Health Team: Cheryl Stults, PhD, Dominick Frosch, PhD, Albert Chan, MD, and Ed Yu, MD. Clinician Stakeholders: Dominique Quincy, MD, Peter Cheng, MD, Jimmy Hu, MD, ad Kelly Reilly, MD. Patient Stakeholders: Patricia Alexander and Erez Baron. Research Team Members: Amy Meehan, MPH, and Martina Li, MPH.
Funding Sources: Patient-Centered Outcomes Research Institute (PCORI)
- Enhancing shared decision making through carefully designed interventions that target patient and provider behavior. Tai-Seale M, Elwyn G, Wilson CJ, Stults C, Dillon EC, Li M, Chuang J, Meehan A, Frosch DL.Send to:, Health Aff (Millwood). 35(4):605-12. doi: 10.1377/hlthaff.2015.1398., 2016 Apr 01
- An evaluation of two interventions to enhance patient-physician communication using the observer OPTION5 measure of shared decision making. Dillon EC, Stults CD, Wilson C, Chuang J, Meehan A, Li M, Elwyn G, Frosch DL, Yu E, Tai-Seale M., Patient Educ Couns. pii: S0738-3991(17)30254-9. doi: 10.1016/j.pec.2017.04.020. [Epub ahead of print], 2017 May 01
- Using CollaboRATE, a brief patient-reported measure of shared decision making: results from three clinical settings in the United States. Forcino RC, Barr PJ, O'Malley AJ, Arend R, Castaldo MG, Ozanne EM, Percac-Lima S, Stults CD, Tai-Seale M, Thompson R1, Elwyn G., Health Expect. doi: 10.1111/hex.12588. [Epub ahead of print], 2017 Jul 05
- How do primary care physicians respond when patients cry during routine ambulatory visits? Stults CD, Elston Lafata J, Diamond L, MacLean L, Stone AL, Wunderlich T, Frankel RM, Tai-Seale M., J Comm Healthcare. 7(1):17-24. DOI: http://dx.doi.org/10.1179/1753807614Y.0000000044, 2014 Mar 01
Sylvia Sudat, PhD
- PhD in biostatistics
- Epic data and analytic expert
- Key partner in the Advanced Illness Management® program
- Proven expertise in risk prediction for palliative care and hospital readmissions
Machine Learning for Early Detection of Sepsis
Project Lead: Sylvia Sudat, PhD, CHSR Principal Investigator, East Campus
The Challenge: Sepsis — a potentially life-threatening condition caused by the body's response to an infection — is the leading cause of in-hospital mortality, and is associated with substantial healthcare costs. Early detection and treatment of sepsis is critical, yet its early symptoms are not easily detected.
CHSR Approach: We developed a predictive model identifying emerging sepsis using artificial intelligence and machine learning. This project leveraged in-hospital and ambulatory data from the Sutter Health electronic health record. The data will help summarize patients’ health at the time of hospital admission.
The Impact: Predictive modelling can help prevent sepsis-related complications and mortality among the 200,000 Northern California patients admitted to Sutter Health hospitals annually. Our project demonstrates how machine learning algorithms can be used to decrease U.S. healthcare costs and improve the care of patients nationwide.
Project Team: Sylvia Sudat, PhD, Alice Pressman, PhD, MS, Shruti Vaidya, MS, Ridhima Nerlekar, MS, Alexandra Scott, MA, Phillippe Boileau (intern).
Funding Sources: Greathouse Family Foundation, Sutter Health Philanthropy
- Predicting need for advanced illness or palliative care in a primary care population using electronic health record data. Jung K, Sudat SE, Kwon N, Stewart WF, Shah NH. J Biomed Inform. 2019 Apr; 92:103115. doi: 10.1016/j.jbi.2019.103115. Epub 2019 Feb 10. PubMed PMID: 30753951.
- Predicting all-cause risk of 30-day hospital readmission using artificial neural networks. Jamei M, Nisnevich A, Wetchler E, Sudat S, Liu E, Upadhyaya K. PLoS One. 2017 Jul 14; 12(7):e0181173. doi: 10.1371/journal.pone.0181173. eCollection 2017. PubMed PMID: 28708848; PubMed Central PMCID: PMC5510858.
Xiaowei (Sherry) Yan, PhD, MS
- PhD in statistics, MS in geophysics
- Expert in pragmatic trials design
- Develops predictive models to predict disease onset
Advancing Safe, Effective Opioid Prescription Stewardship
Project Lead: Sherry Yan, PhD, MS, Principal Investigator, East Campus
The Challenge: Addiction and deaths from opioid use pose an enormous public health burden across the U.S. Emergency departments (EDs) and urgent care clinics across Sutter Health face significant challenges to curb opioid over-prescribing.
CHSR Approach: We launched the Opioid Reduce Trial to promote opioid prescription stewardship. The randomized study will assess the change in opioid default pills count in electronic health records (EHRs), and the use of social comparison feedback to decrease opioid prescription pill burden in Sutter Health EDs and urgent care clinics.*
Opioid Reduce is a collaboration between Sutter’s Center for Health Systems Research, Sutter Information Services, William Isenberg, MD (Vice President, Office of Patient Safety, Sutter Health), and Howard Landa, MD (Vice President of Clinical Informatics and EHR, Sutter Health).
The Impact: Interventions (EHR default change and social comparison) in Opioid Reduce are designed to minimize interruption of clinicians’ workflow and represent real-world clinical settings. If we observe a successful intervention, we will scale it across Sutter Health, broadly disseminate findings, initiate further trials, and promote implementations nationwide.
*Default change describes an EHR function change where care providers set a default number of pills for medication.
Project Team: Sherry Yan, PhD, MS, Farah Refai, William Isenberg, MD, Howard Landa, MD, Barbara Bond, MD. University of Pennsylvania Team: Amol Navathe, MD, and Mitesh Patel, MD.
Funding Sources: Donaghue Foundation
- CM-SHARE: Development, Integration, and Adoption of an Electronic Health Record– Linked Digital Health Solution to Support Care for Diabetes in Primary Care. JB Jones, S Liang, HM Husby, JK Delatorre-Reimer, CA, Mosser, AG, Hudnut, K Knobel, K MacDonald, X Yan. Clinical Diabetes, 2019 (online published).
- Does transition of urinary incontinence from one subtype to another represent progression of the disease?. Minassian VA, Yan X, Pilzek AL, Platte R, Stewart WF. Int Urogynecol J. 2018 Aug;29(8):1179-1185. doi: 10.1007/s00192-018-3596-4. Epub 2018 Mar 13. PMID: 29536139.
- Using the PARAFAC2 Tensor Factorization on EHR Audit Data to Model Clinician Behavior. Perros I, Yan X, Jones JB, Sun J, Stewart WF. AMIA 2018 Informatics Summit.
- Recurrent neural networks for early detection of heart failure from longitudinal electronic health record data: implications for temporal modeling with respect to time before diagnosis, data density, data quantity and data type. R Chen, WF Stewart, J Sun, K Ng, X Yan. Circulation: Cardiovascular Quality and Outcomes, accepted, 2019.
- Primary Care Diabetes Bundle Management: Three-Year Outcomes for Macro- vascular and Micro-vascular Events. F. Bloom, X. Yan, T. R. Graf, T. Anderer, D. Davis, S. Pierdon, J. Pitcavage, W. F. Steward, G. Steele. 2014, 20(6), e175-e182; PMID: 25180500.