Improving the quality and cost effectiveness of medical care

This project examines the care provided to newly diagnosed children with attention-deficit/hyperactivity disorder (ADHD). DACP Investigators are analyzing data on the medical care received by children covered by Harvard Pilgrim Health Care who were diagnosed with ADHD at a Harvard Vanguard Medical Associates site between 1997 and 2003. We are investigating how children have used medication for ADHD, including stimulants (e.g. Ritalin) and antidepressants. Concerns about side effects that may be caused by these medications (cardiovascular events and suicidality, respectively) resulted in the Federal Drug Administration (FDA) investigating whether they appear to have injured patients. This study has been funded by a grant from the Harvard Pilgrim Health Care Foundation. Dr. Colin Sox leads the study and Jonathan Finkelstein and Ken Kleinman are DACP-based co-investigators.

The growth in the number of elderly people in the US has brought with it an increasing emphasis on how to best provide health care to older people and patients at the end of life. Elderly patients and their families and clinicians often have to make complicated and difficult decisions about medical care when health begins to fail or terminal illness strikes. DACP's Muriel Gillick, a geriatric physician, author, and researcher, has written extensively about issues related to care for the elderly, particularly advance care planning and the use of technology in geriatric care. For more information about Dr. Gillick's work and publications, click here.

Advance care planning: A critical questions for older patients is how much and what kind of medical care they should receive. What sorts of tests and treatments are too painful or too invasive or too prone to complications to be worthwhile? From the perspective of the individual patient, the best way to ensure that the medical care he/she receives is the care he/she wants is to plan in advance for the possibility of illness. Advance care planning is the process of establishing and prioritizing the goals of care and translating those goals into an approach to care. Research in advance care planning studies how best to help patients clarify their goals, how to convert goals into pathways of care, and how to implement such pathways at the time of acute illness.

The technological imperative and geriatric care: Technology can be a boon to older people, enabling them to live longer and to function better, or it can be a burden, offering the possibility of longer life in exchange for debility and dependence. From a societal perspective, technology creates expectations among patients and families, comes with a substantial price tag, and often leads to forgoing other potential goods. We have entered an era of accelerating growth in the development of new technology. Combined with the imminent growth of the population that most often uses this technology, older people, the technological growth spurt represents a major policy challenge. To respond to this challenge, we need to understand how technology for older patients is developed, adopted, and disseminated, taking into consideration new political, economic, industrial, and social forces that have arisen over the last 25 years. A nuanced understanding of the process of technological change is the prerequisite for developing policies that will allow us to mold health care policy to assure that older people will receive excellent medical care while simultaneously controlling costs.

The Joint Initiative in Vaccine Economics produces research to guide national policy decisions about new vaccines. The costs of routinely recommended vaccines have increased dramatically in the U.S. over the past two decades, due to more sophisticated biotechnology, improved safety, and market forces. The purpose of the JIVE Project is to conduct studies of the benefits, risks, and costs of new vaccines to inform decision-making by national, state, and local policymakers. The project is sponsored by the Centers for Disease Control and Prevention and is led by DACP in collaboration with the CDC and the Harvard School of Public Health. Recent studies have evaluated the cost-effectiveness of a new whooping cough vaccine for teenagers and adults (click here), global strategies for eradication of polio infection (click here), and the cost-effectiveness of influenza vaccination in children. Current studies are examining the cost-effectiveness of influenza vaccination for adults; patient preferences and values for a new vaccine against shingles in the elderly; global strategies for the elimination of polio via vaccination; and financing issues faced by states as new vaccines are introduced. The JIVE Project is led by Drs. Tracy Lieu, Lisa Prosser, and Grace Lee at DACP, and Dr. Kim Thompson at the Harvard School of Public Health.