Health Care Policy Decision Analysis and Technology Assessment

The Department of Health Care Policy was established in 1988. Harvard was the first medical school in the country to establish a department with a faculty that includes both physicians and social scientists, working in areas related to the financing and delivery of health care services. The School's rationale in establishing the Department was to link physicians who actually practice medicine with researchers who could help them develop accurate unbiased studies ultimately aimed at improving the system of care. Currently, the Department of Health Care Policy has a multi-disciplinary department of physicians, economists, medical sociologists and statisticians. It has 15 graduate students, 5 post-doctoral fellows and over 20 programmers/statisticians. Its offices are at 180 Longwood Avenue. The Department's teaching activities involve HMS undergraduates, doctoral students in the Harvard University-wide program in health policy, and post-doctoral fellows in statistics and medicine.

As major changes in the health care system occur, our goal as a department is to do the kind of fundamental work which will influence the direction of reform and its successful implementation. By providing good information about cost-effectiveness and accurate insights into patient outcomes, we hope to support rational and productive change. Our initial focus has been on measuring the quality of care, analyzing the economics of health care, examining differences in access to care, and improving methods of analysis. Projects associated with these objectives are well underway and others are being planned.

Patient Outcome Research Teams

Dr Barbara McNeil serves as the Principal Investigator of the second Patient Outcome Research Team (PORT) studying patients with a recent Acute Myocardial Infarction (AMI). This is a follow-up of the original PORT created to assess the benefits, risks and costs of the diagnostic and treatment strategies used for patients with AMI, or heart attack. The PORT's five-year research program focused clinically on the decisions to perform (1) coronary angiography and two follow-on revascularization procedures, coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty (PTCA); and (2) key medical therapies, including the use of thrombolytic agents, beta-blockers, calcium-channel blockers and other cardiac drugs.

Partially as a result of this work, the Health Care Financing Administration (HCFA) has "redesigned" the work of the Peer Review Organizations (PROs) in their efforts to improve quality of care for Medicare beneficiaries. This redesign effort was called the Cooperative Cardiovascular Project (CCP) and involves studying process and outcome measures for Medicare beneficiaries having an AMI. Using our experience with this area, Dr. McNeil and others in the Department of Health Care Policy have launched a comprehensive set of studies on quality of care for patients with an AMI, using not only detailed clinical data from the CCP but also billing data from Medicare. The major aim of the study will involve determining the extent to which outcomes are better for patients after an AMI depending upon whether or not they were treated according to national guidelines for aggressive management after an AMI; "aggressive" management means angiography followed by revascularization where appropriate. Two types of guidelines will be potentially studied -- those developed by the American College of Cardiology and the American Heart Association and those developed by the RAND Corporation and recently updated by us. In addition to evaluating the survival outcomes of these patients, we will look at outcomes related to patient satisfaction and quality of life. We will also study organizational characteristics of all hospitals caring for AMI patients and will determine to what extent these characteristics (staffing patterns, types of specialists involved, training programs, hospital size, etc.) impact outcomes. Finally, we will determine the extent to which physicians of various specialties believe in the recommendations of the guidelines. A second aim will involve determining the extent to which appropriate drug therapy is administered

RDOG

Since 1986 Dr McNeil has led a national activity, the Radiology Diagnostic Oncology Group (RDOG), in technology assessment under the sponsorship of the National Cancer Institute. The group has worked on several imaging modalities for several types of tumors (eg, lung, prostate, colo-rectal, musculoskeletal, ovarian, head and neck) and is currently comparing stereotactic biopsies of the breast with excisional biopsies for women with non-palpable masses. Currently, over 20 institutions led by two clinicians (Drs Etta Pisano and Laurie Fajardo) are working with us to determine whether fine needle biopsies or core needle biopsies can replace open surgical biopsies. A data safety and monitoring board is being led by Dr. Jay Harris of the BWH Division of Radiation Oncology. Preliminary results on the value of fine needle aspiration were recently published, and full results will be available in two years.

For more information, contact:

Barbara J McNeil, MD, PhD
Professor of Radiology, Harvard Medical School
Department of Health Care Policy
180 Longwood Avenue
Boston, MA 02115
Phone: (617) 432-1909
Fax: (617) 432-3503
Email: bmcneil@bwh.harvard.edu

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