Health Services and Policy Research

Health disparities

the causes and effects of unequal access to pharmaceutical services and medications, as well as potential solutions

Bridging gaps in patient care, especially for the underserved, is a shared aim of the department. Research analyzes the extent of disparities in pharmaceutical care associated with differences in cultural and socioeconomic status, gender, and disease status. Department faculty members evaluate access to, insurance coverage for, cultural literacy about, and adherence to vital medications and disease prevention regimens.

Examples of our research include:

• Examining racial/ethnic differences in the use of antiretroviral therapy among women with HIV, and whether these differences were affected by insurance status or substance abuse
• Evaluating the association between enrollment of HIV-positive women in a publicly funded AIDS Drug Assistance Program and their use of antiretrovirals and anti-hypertensives
• Assessing the relationship between immigration status and the use of preventative and other health services among Latina women in the San Francisco Bay Area
• Systematic review of gender bias in safety and effectiveness data for high-risk cardiovascular devices that received premarket approval by the U.S. Food and Drug Administration
• Analyzing internal tobacco industry documents that reveal how cigarette companies have marketed their products to the homeless and seriously mentally ill

Health policy analyses

existing and proposed policies and campaigns to improve public health, including how to best convert research findings into public policy

Analyses in the department examine the effectiveness of a variety of health policies on public health and clinical outcomes for patients. These include assessment of policies affecting the distribution and use of medicines, as well as broader policies such as tobacco control.

Examples of our research include:

• Conducting research to support the creation of policies mandating smoking cessation therapy for patients in treatment for alcohol, drug, and mental disorders—a population twice as likely to smoke—as well as how to most effectively communicate the results to policy makers
• Systematically reviewing the effect of public health campaigns that seek to reduce smoking via “tobacco industry denormalization”—changing public attitudes toward cigarettes by focusing on their purveyors’ manipulative marketing

Pharmacoeconomics

economic analyses of pharmaceutical products

How can we reduce the cost of drug therapies? Can we decrease cost while also increasing effectiveness? How do we look at the cost of therapeutic interventions compared to the benefit the therapy produced, measured in the number of years lived in full health by a patient?

Department researchers assess the economics of:

• Pharmaceutical therapies
• Diagnostic tests (including the emerging realm of predictive pharmacogenomics)
• Public health policies (in terms of their efficacy in reducing disease and/or enhancing quality of life)

They use tools such as cost-benefit, cost minimization, and cost utility analyses that take into account factors such as the monetary costs for patients, health systems, and society of a given treatment, test, or policy, and their effect on quality-adjusted life years (QALYs)—a statistical measure that combines and seeks to balance additional life years gained with the burden of ongoing disease or adverse drug side effects.

The department is home to the Program for Outcomes, Pharmaceutical Economics, and Policy Studies (PrOPEPS), which focuses on determining the best use of pharmaceutical care resources in the management of disease in the current health care environment of scarce resources.

Department researchers are expert in assessing the economics of:

• Reductions in dietary salt, secondhand smoke, and antibiotic use
• Adoption of treatments to reduce HIV transmission during birth
• Combining risk-screening questions with blood serum testing to protect the blood supply from the parasite that causes Chagas disease

Examples of our research include:

• Analyzing the cost-effectiveness of testing patients diagnosed with colorectal cancer and their relatives for Lynch syndrome, a familial genetic condition conferring a high risk for several forms of cancer
• Analyzing data from a national disease registry to determine the cumulative costs of different prostate cancer treatments, including the costs of adverse events and disease recurrence

Personalized medicine and pharmacogenomics

the effective use of genetic testing to guide tailored drug choice and dosing, including issues around insurance coverage and applicability to diverse patient populations

Faculty members address the proper application of pharmacogenomic testing that allows for both personalized risk/benefit profiles—indicating who will benefit most, as well as those who might suffer adverse drug reactions from a given drug—and the most cost-effective use of medications.

As the opportunities for such testing expand, department researchers ask: How accurate and useful are the tests? Who should get them? Who will pay for them? Are tests results being correctly applied and acted upon?

The department-based Center for Translational and Policy Research on Precision Medicine (TRANSPERS) is a first-of-its-kind research center for the study of personalized medicine and its translation into clinical care and health policy.

The center assesses how new genetic testing of patients and disease types can be most beneficially and efficiently applied to improve health outcomes. Center research also evaluates the evidence for testing technologies to determine where gaps and uncertainties exist and how to best address them.

Examples of our research include:

• Analyzing clinical practice patterns to determine whether genetic testing for targeted breast cancer treatment is being done accurately and cost-effectively and whether results are effectively applied and acted upon
• Reviewing private and public insurance eligibility criteria for testing for and counseling on hereditary gene mutations (such as BRCA gene mutations) that significantly increase cancer risk
• Evaluating the effect of ethnicity on dosing of the blood thinner warfarin, and the accuracy of a pharmacogenetic dosing table included in the drug’s labeling
• Analyzing the association between breast cancer gene expression profiling (which helps predict the risk of recurrent disease) and the use of follow-up chemotherapy, its adverse effects, and costs of care for a year following diagnosis

Pharmacy practice models

new approaches to delivering pharmacy care to patients, including the education of health care providers and students

In the 1960s, the Department of Clinical Pharmacy, in collaboration with the Department of Pharmaceutical Services in UCSF Health, pioneered the practice of acute care clinical pharmacy, which is now an international standard.

Initially, this meant physically relocating pharmacists from a central hospital pharmacy to locations on specialized wards. More significantly, it signaled the evolution of pharmacists from medication compounders and dispensers to drug therapy experts who work with medical teams at the bedside, recommending drug treatments—including doses, timing, and forms of delivery—and monitoring patients’ drug responses.

Today, Department of Clinical Pharmacy faculty members continue to implement and evaluate innovative forms of pharmacy practice in a variety of settings—from hospital wards and ambulatory clinics to medical groups and retail pharmacies, and through community outreach events and video telepharmacy. They study the effects of education and training on pharmaceutical care topics with the goal of influencing clinical knowledge and behavior.

In an age of ever-tighter health care dollars, department research provides the evidence of efficacy and cost-effectiveness to support the wide adoption of new pharmacy practice models to meet current pharmacy care challenges.

In acute and ambulatory care settings, examples of our research include:

• Developing, implementing, and evaluating the effectiveness of a multi-site pharmacist-directed managed care outreach program (PRICE clinic: Pharmacist Review to Increase Cost Effectiveness) to aid low-income elderly patients in decreasing out-of-pocket drug expenses while improving access to needed medications and ensuring clinically appropriate, cost-effective drug regimens
• Assessing clinical outcomes for diabetic patients under care in a private medical practice, who receive integrated medication management by a pharmacist
• Comparing the effectiveness of a clinic team of nurses, dieticians, and pharmacists providing education and recommendations for diet, lifestyle, and medication modifications to diabetic patients versus routine care (specifically examining the model’s impact on achieving national benchmark cholesterol goals and thus, potentially, incentive payments to a medical group under a California pay-for-performance program)
• Developing, evaluating, and implementing a program to deploy trained and supervised hospital pharmacy technicians to check the accuracy of their colleagues in filling unit dose medication cassettes (specifically, conducting a study under a waiver of California regulations, which led to a change in state law that significantly freed up the time of hospital pharmacists to provide expanded clinical services)
• Reviewing randomized controlled trials, in community and ambulatory care settings, of the effect of pharmacist-provided care on patient outcomes and prescribing patterns in outpatient settings

Beyond traditional practice settings, examples of our research include:

• Developing, implementing, and evaluating the impact of a multi-site community-based outreach program to identify and aid vulnerable Medicare beneficiaries (low-income, limited English proficiency), in order to optimize their Medicare Part D prescription drug benefits, via one-on-one counseling by pharmacists and trained student pharmacists
• Assessing the impact of HIV-specialized pharmacists and services versus traditional pharmacies (both in a national retail chain) on patient adherence to and persistence with antiretroviral (ARV) regimens; on-going measurement, analysis, and innovation in determining and increasing the influence pharmacists can have on ARV adherence (a significant issue since ARV regimens can be complex and associated with major side effects, but their suboptimal use can lead to drug-resistant virus)
• Evaluating the comparative effectiveness of two intervention approaches for increasing pharmacy-based referrals to state-run telephone “tobacco quitlines”