Research / Quality Improvement Projects

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Center to Reduce Health Disparities
In October 2002, the National Institutes of Health, through its National Center on Minority Health and Health Disparities (NCMHD) awarded the Department of Health Policy a five-year, $6 million grant to develop a center whose mission is to improve the health of minority populations in East and Central Harlem. The grant will enhance research focused on reducing health disparities for individuals with many different conditions, create new training programs for minority health care providers in health services research, and foster community outreach and education. The grant is part of the NCMHD initiative for Excellence in Partnerships for Community Outreach, Research on Health Disparities and Training (Project EXPORT). Mark Chassin, M.D., M.P.P., M.P.H., is the Director, and Principal Investigator for the Center.

Although the Center is based in the Department of Health Policy, a number of partnerships are essential to achieving the goals of the Center. We are collaborating with many other departments within Mount Sinai, including Medicine, Neurology, Surgery, Pediatrics, Obstetrics and Gynecology, Community Medicine, Community Relations, and the Center for Multicultural and Community Affairs. We have established a special partnership with North General Hospital as the focus of our training activities and as the hub for several community outreach programs. Our long-standing research collaborations with Harlem and Metropolitan Hospital Centers and with Settlement Health and Boriken Neighborhood Health Center will also be a vital part of the Center’s activities. Specific areas of focus include reducing underuse of effective therapy for hypertension, stroke, breast cancer, and neonatal prematurity.

Improving the Delivery of Effective Care to Minorities (EXCEED) (4 Projects)

Project 1 - Improving Hypertension Control in East and Central Harlem
This project is evaluating strategies that it developed to target problems underlying lack of blood pressure control among treated hypertensive patients in East and Central Harlem. Along with the communities' 6 major health providers, we combined qualitative and quantitative methods to identify specific patient, provider, and system problems, and customized interventions to address them. We are conducting a randomized controlled trial of patients from these six sites to evaluate the effectiveness and cost-effectiveness of those interventions during a 9-month trial period. The project includes 3 study arms: usual care, blood pressure monitoring, and nurse management. Patients in the usual care arm continue to receive care from their regular clinicians. We provide blood pressure monitors to patients in the blood pressure monitor arm for self-measurement. Patients in the nurse management arm, who also receive a blood pressure monitor, meet with a nurse, who follows them for 9 months. We will assess differences in blood pressure changes among the 3 arms as the primary outcome and differences in quality of life, patient satisfaction, costs, and cost-effectiveness as secondary outcomes.

Project 2 – Preventing Recurrent Stroke in Minority Populations
This project seeks to determine the factors that contribute to the disparity of recurrent stroke in minority populations. Specifically it will focus on causes of underuse of stroke preventive measures demonstrated in randomized clinical trials to be efficacious, but not appropriately utilized in urban, minority populations.

Project 3 – Reducing Underuse of Early-Stage Breast Cancer Treatment in Minority Communities
This project will measure the extent of underuse of efficacious breast cancer treatments among patients of hospitals serving East and Central Harlem and other minority communities in lower Manhattan. This study will provide new knowledge about racial disparities in treatment for early-stage breast cancer; patient and physician reasons for underuse; and the effectiveness of a simple, sustainable intervention to improve rates of efficacious cancer treatment.

Project 4 – Assessing Variations in the Management of Prematurity
The purpose of this study is to measure underuse of three effective interventions (antenatal steroids, surfactant therapy, and maintenance of temperature) for the management of prematurity at three hospitals serving East and Central Harlem residents. We will assess whether rates of underuse differ by racial and ethnic groups among these hospitals.

Participating sites: The Mount Sinai Hospital, Maimonides Medical Center, Phelps Memorial Hospital, Hospital for Joint Diseases.

Hip Fracture
Improving functional outcomes after hip fracture.
This 5-year federal grant funded by the Agency for Health Care Policy and Research (AHCPR) seeks to develop quality indicators for care of patients with hip fracture. The project will measure risk-adjusted functional outcomes after hip fracture repair, assess the relationship between specific medical and surgical processes of care and those risk-adjusted outcomes, and develop interventions to improve the quality of care.

Carotid Endarterectomy
Improving quality of care for patients undergoing carotid endarterectomy.
This 5-year AHCPR funded study is creating evidence-based guidelines for appropriate patient selection for carotid endarterectomy, developing a risk-adjustment model for predicting perioperative stroke and death, and measuring the relationship between specific processes of care and risk-adjusted outcomes. In Phase 1, we will review the medical records of 2050 patients from 6 collaborating hospitals. In Phase 2, in conjunction with the New York (NY) Island Peer Review Organization, we will abstract the records of all 8000 Medicare beneficiaries undergoing carotid endarterectomy in NY in 1997. Phase 2 will also include quality improvement initiatives at the 6 collaborating hospitals.

Participating sites: The Mount Sinai Hospital, New York University Hospital, Maimonides Medical Center, Long Island Jewish Hospital, SUNY-Albany Medical Center, and Englewood Hospital.

Instability on hospital discharge
Outcomes of instability on discharge in urban hospitals.
This 3-year AHCPR-funded study aims to develop and validate generic and condition-specific measures of instability on discharge and examine the outcomes associated with premature hospital discharge in patients with hip fracture, pneumonia, and asthma. The goal is to produce quality indicators for assessing appropriateness for discharge.

Participating sites: hip fracture (Mount Sinai, Maimonides, Phelps, Hospital for Joint Diseases), pneumonia (Massachusetts General Hospital, University of Pittsburgh, St. Francis Hospital, Victoria General Hospital, Canada), and asthma (The Mount Sinai Hospital).

Delays in surgical treatment
Assessing the variability in time to treatment in surgery.
This AHCPR-funded study aims to understand the relationship between time to treatment and health outcomes by several delay-sensitive conditions (such as ectopic pregnancy, acute appendicitis, and intestinal obstruction).

Participating sites: The Mount Sinai Hospital, Harlem Hospital

Breast Cancer
Solving problems of underuse of effective interventions in patients with early-stage breast cancer.
This 4-year study is assessing the frequency of failure to provide proven effective interventions to patients with early-stage breast cancer in a group of 4 collaborating hospitals. It is designing, implementing, and evaluating interventions to ameliorate these problems.

Participating sites: The Mount Sinai Hospital, Cabrini Hospital, Maimonides Medical Center, and Englewood Hospital.

Tympanostomy Tubes
Improving the quality of care for children: reducing the inappropriate use of tympanostomy tubes.
This 3-year study funded by the Aetna Foundation is developing evidence-based guidelines for the appropriate selection of children for tympanostomy tube insertion, the most common surgical procedure in childhood. It will assess appropriateness in a group of collaborating hospitals and create, implement, and evaluate interventions to reduce the inappropriate use of this procedure.

Participating sites: Mount Sinai

Maternal Outcomes
Improving Functional Outcomes in Postpartum Women.
This AHRQ and RWJ funded study aims to learn how pregnancy and childbirth affect women's health and well being. Little research has explored women's physical and emotional health during pregnancy and the postpartum period. This project will determine how well prepared women are for the changes in functioning and well being they experience during and after their pregnancies. In addition, the study aims to determine the specific problems women encounter during this process and identify how they believe the care they receive could be altered to prevent these problems.

Participating sites: Mount Sinai Hospital

Diabetes
East Harlem Regional Center of Excellence and the Community Advances in Nutrition for Diabetes through Education and Empowerment (CANDEE) Project.
The New York State Department of Health funds both the Center and the CANDEE Project to measure and access to diabetes services and to improve the process and outcomes of diabetes care in East Harlem. Upcoming activities include: disseminating ADA diagnostic criteria; distributing and revising evidence-based guidelines for care; conducting a foods availability assessment in East Harlem; and completing a follow-up telephone survey of diabetes patients.

Participating sites: Mount Sinai, Boriken Health Center, Metropolitan Hospital, North General Hospital, and Settlement Health.

Congestive Heart Failure
Enhancing functioning in patients with congestive heart failure.
This 3-year study is measuring functional status in patients with moderate to severe congestive heart failure and identifying modifiable risk factors for worsened functioning. It will design, implement, and evaluate patient-centered interventions to alter these risk factors and improve functioning.

Participating sites: The Mount Sinai Hospital, Boriken Health Center, Metropolitan Hospital, North General Hospital, Settlement Health.

Myocardial infarction
Improving the quality of care for acute myocardial infarction.
The focus of this project is to evaluate the patterns of use of specific therapies that have been proven to have benefit in improving the health outcomes of patients with acute myocardial infarction (such as aspirin, beta-blockers, thrombolysis, among others).

Participating sites: Mount Sinai, Maimonides, Cabrini, and Phelps.

Community-acquired pneumonia
Evidence-based approach to patients hospitalized with pneumonia.
The purpose of this project was to develop and implement a guideline to improve the timely conversion from intravenous to oral antibiotics once patients are clinically stable. The study also assessed patients' understanding of their illnesses and treatments and developed educational materials to improve patient knowledge.

Participating sites: The Mount Sinai Hospital

Adverse drug events
Developing a computerized system for measuring adverse drug events.
This project, funded by the New York State Department of Health, will adapt computerized screening techniques used to detect suspected adverse drug events in hospitals with state-of-the-art computer systems (including electronic medical records) for use in a typical New York hospital with more modest pharmacy and laboratory results data systems. We aim to develop and implement an automated system for identifying potential medication safety problems as a first step in preventing iatrogenic injuries, improving quality, and reducing costs.

Participating sites: The Mount Sinai Hospital

Medication costs
Educating physicians about medication costs.
Using a written survey, this project assessed physicians' attitudes, knowledge, and beliefs about the cost of medications and insurance coverage of drugs. We surveyed general internal medicine housestaff and attending physicians.

Participating sites: The Mount Sinai Hospital, Elmhurst Hospital, James J. Peters VA Medical Center, Englewood Hospital