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Featured Research Projects

Our work aims to make a difference, so that we can continuously improve outcomes in the prevention, treatment, and management of health conditions.  Our research is focused on the following areas:

  • Patient safety and quality improvement
  • Communication in healthcare
  • Healthcare delivery science
  • Healthcare policy
  • Epidemiology of chronic diseases
  • Pharmacoepidemiology and medication safety
  • Comparative effectiveness research

Below is a select overview of some of our projects that help shape the delivery of healthcare in our community, and beyond.

Developing a PRogram to Educate and Sensitize Caregivers to Reduce the Inappropriate Prescription Burden in Elderly with Alzheimer’s Disease Study (D-PRESCRIBE-AD)   

MHCI Investigators: Jerry Gurwitz, Sonal Singh, Kathy Mazor, Sybil Crawford, Mary Antonelli
Funding Agency: National Institute on Aging
Status: Ongoing

Project Overview: Potentially inappropriate prescribing includes the use of medications that may no longer be necessary or that may increase the risk of harm. Inappropriate prescribing is a “morbidity multiplier,” increasing overall symptom burden, and adversely affecting health-related quality of life and function. Inappropriate prescribing of certain drug categories such as sedative/hypnotics, antipsychotics, and highly anticholinergic agents poses particular risks for older adults, and may be more prevalent among those with Alzheimer’s disease and Alzheimer’s disease-related dementias (AD/ADRD) due to a higher prevalence of multimorbidity and associated polypharmacy. The Developing a PRogram to Educate and Sensitize Caregivers to Reduce the Inappropriate Prescription Burden in Elderly with Alzheimer’s Disease Study (D-PRESCRIBEAD) will test a health plan-based intervention leveraging the NIH Collaboratory's Distributed Research Network, which uses the Food and Drug Administration (FDA) Sentinel Initiative infrastructure. The overarching goal is to develop, implement, and evaluate the effect of a patient/caregiver-centered, multifaceted educational intervention on inappropriate prescribing in patients with AD/ADRD. The research hypothesis is that education on inappropriate prescribing among patients/caregivers and their providers can reduce medication-related morbidity in patients with AD/ADRD and lead to an improvement in medication safety for this vulnerable population. The study population will include community-dwelling patients with AD/ADRD, identified based on a diagnosis of AD/ADRD or use of a medication for Alzheimer’s Disease, who have evidence of inappropriate prescribing. We will evaluate the effect of educational interventions designed to stimulate patient/caregiver-provider communication about medication safety (versus usual care) on the proportion of patients with inappropriate prescribing, the primary outcome of this study. The trial will be health plan-based, conducted in two large, national health plans. The study design will be a prospective, cluster randomized, comparative effectiveness intervention trial with three arms: (1) a combined patient/caregiver and provider educational intervention; (2) a provider only educational intervention; and (3) usual care. A one-year R61 planning phase preceded a four-year R33 implementation phase. During the R33 phase we will sequentially implement two separate pragmatic trials, each enrolling over 11,000 patients, adapting the second trial based on the findings and experience gained in the first. The R33 aims are: (1) to assess the impact of the patient/caregiver educational intervention on inappropriate prescribing to AD/ADRD patients, employing a prospective, cluster randomized trial design with three arms; and (2) to create a plan for disseminating study findings to stakeholders who might implement the intervention or make decisions about its future use.

Trusted Messengers: Developing and Evaluating Materials to Support Physicians in Promoting COVID-19 Vaccination

MPCI Investigators: Kimberly Fisher, Kathleen Mazor, Sonal Singh
Funding Agency: National Institute on Minority Health and Health Disparities (NIMHD)
Status: Ongoing

Project Overview: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and associated coronavirus disease 2019 (COVID-19) pandemic have been devastating. In the United States (US), more than 25 million people have been infected, resulting in more than 700,000 deaths. The approval of multiple effective COVID-19 vaccines has raised hope that a return to “normal” life may be at hand. However, realizing the benefits of a vaccine requires widespread acceptance and vaccine uptake. Recent estimates suggest that as many as 90% of the population may need to be vaccinated to achieve herd immunity. Our work and that of others indicate a significant proportion of the US population are reluctant to be vaccinated. Overlap between factors associated with COVID-19 disease and COVID-19 vaccine hesitancy, including being of Black or Latino race/ethnicity, and socioeconomic disadvantage, threaten to severely exacerbate existing health disparities. The overall goal of this proposal is to refine and test strategies to overcome COVID-19 vaccine hesitancy, particularly among vulnerable populations, through a community-engaged approach. Our research hypothesis is that trusted messengers, such as primary care providers (PCPs) and community organizations, are essential to increasing uptake of the COVID-19 vaccine, particularly for the most hesitant groups. Building on strong community partnerships, we will refine, implement, and evaluate a multi-faceted intervention to support PCP outreach, and PCP and community organization dissemination of information to promote COVID-19 vaccination among vulnerable patients in and near Worcester, MA. The intervention will include: (1) a library of videos addressing common vaccine concerns to be disseminated by PCPs and local community organizations; (2) tools to implement PCP outreach and COVID-19 vaccine recommendation; and (3) educational materials for PCPs to support their conversations with patients about the COVID-19 vaccine. We will accomplish this via the following specific aims: 1) To refine and adapt tools to support effective PCP recommendations for COVID-19 vaccination and information dissemination by PCPs and community organizations to vulnerable patients; 2) To implement and assess the impact of the intervention on COVID-19 vaccine uptake; 3) To evaluate the intervention according to the RE-AIM framework.

Multimorbidity and Treatment-Related Outcomes in Older Heart Failure Patients

MHCI Investigators: Mayra Tisminetzky, Jerry Gurwitz
Funding Agency: National Institute on Aging
Status: Ongoing

Project Overview: Heart failure (HF) is the most common reason for hospitalization in older adults. Over 85% of all patients hospitalized with HF are 65 years of age or older. Multimorbidity, usually defined as the presence of two or more chronic conditions, greatly increases the risk of hospitalization and mortality among older HF patients. In addition, the presence of multiple chronic conditions can greatly complicate the management of HF, especially with regard to pharmacotherapeutic decision-making. While national guidelines exist for the care of patients with HF, it is widely recognized that caution is required in applying established clinical practice guidelines to the care of older adults with multimorbidity, as practitioners are faced with managing not just a single condition, but multiple conditions simultaneously. In the proposed study, we will examine treatment patterns and the net benefits versus harms of selected therapies in patients presenting with HF and multimorbidity. The source population included over 100,000 members from four participating healthcare delivery systems within the Cardiovascular Research Network. Sites included Kaiser Permanente Northern California, Kaiser Permanente Northwest, Kaiser Permanente Southern California, and Fallon Health in Massachusetts. In addition, we will build a bridge to the new era of use of electronic health record data through natural language processing (NLP) technology. As an important, new, and novel approach, we will use NLP systems that will extract key information on adverse outcomes related to the therapies of interest in patients with HF and multimorbidity.  Learn more about this study here.

Leveraging Evidence-Based Practices for Ambulatory VTE Patients to be Safe with Direct Oral Anticoagulants: LEAVE SAFE with DOACs

MHCI Investigators: Alok Kapoor, David McManus, Abir Kanaan, Kathleen Mazor, Jerry Gurwitz
Funding Agency: Agency for Healthcare Research and Quality (AHRQ) 
Status: Ongoing

Project Overview: Patients with new episodes of venous thromboembolism (VTE) are at an elevated risk for adverse drug events (ADEs). The ambulatory VTE population includes most patients with deep vein thrombosis (DVT) and many patients with pulmonary embolism. Unlike patients with atrial fibrillation, who typically receive follow-up with a cardiologist, or patients attending warfarin clinics, ambulatory VTE patients prescribed DOACs do not have established pathways for follow-up. They also do not typically have consultation by a clinical pharmacist as a hospitalized patient often does. Recently the Anticoagulation Forum, a multidisciplinary nonprofit organization focused on anticoagulation issues, published the DOAC Checklist for Optimal Care Transitions (DOAC Checklist) to elaborate the steps required to ensure a safe transition of care in patients prescribed DOACs for treatment of VTE. We propose operationalizing the items of the DOAC Checklist to create a comprehensive intervention delivered by clinical pharmacists with the goal of preventing DOAC-related clinically important medication errors which includes preventable ADEs, ameliorable ADEs (ADEs in which the severity or duration could have been reduced), and potential ADEs (medication errors with the potential to cause harm. Given the growth of the ambulatory VTE population prescribed DOACs, the associated risks with this class of medications, and the lack of defined pathways for these patients, our care transition intervention has the potential for enormous impact in preventing clinically important medication errors and improving the quality of care transition, patient knowledge, and medication adherence.

SAFEMED: Characterizing Opioid-Related Adverse Events in Older Adults After Hospital Discharge

MHCI Investigators: Alok Kapoor, Jerry Gurwitz
Funding Agency: Agency for Healthcare Research and Quality (AHRQ)
Status: Ongoing

Project Overview: Medications are a major cause of adverse events both during hospitalization and after discharge, and older patients are particularly susceptible to such events. Opioids are consistently identified as one of the top medication classes to cause adverse drug events (ADEs), and are prescribed to millions of older adults after hospital discharge each year. Although prior studies have examined the incidence and consequences of post-discharge ADEs globally, these studies did not focus on older adults and did not investigate opioid-related adverse event rates specifically. A better understanding of the patient- and prescribing-related factors that place patients at highest risk for opioid-related post-discharge ADEs is vital to inform improvements in healthcare systems to reduce the incidence and consequences of these potentially devastating events for older adults. Overall, our study aims to gather a better understanding of the specific nature of opioid-related patient harm after hospital discharge, identify factors that place patients at highest risk for such harm, and inform development of improvements in healthcare systems to reduce the incidence and consequences of these potentially devastating events for older adults.

Medication Use, Safety, and Evidence Project (MUSE)

MHCI Investigators: Susan Andrade, Robin Clark
Funding Agency: This project is being conducted as part of an FDA-required postmarketing study for extended-release and long-acting opioid analgesics being implemented by the Opioid Postmarketing Consortium (OPC) consisting of the following companies: Allergan; Collegium Pharmaceutical, Inc.; Daiichi Sankyo, Inc.; Depomed, Inc.; Egalet Corporation; Endo Pharmaceuticals, Inc.; Janssen Pharmaceuticals, Inc.; Mallinckrodt, Inc.; Pernix Therapeutics Holdings, Inc.; Pfizer, Inc.; Purdue Pharma, LP.; West-Ward Pharmaceuticals Corp.
Status: Ongoing

Project Overview: The MUSE study, a prospective investigation of the risks of opioid misuse, abuse, and addiction among patients treated with extended-release/long acting (ER/LA) opioids for the treatment of chronic pain.  The primary objective is to quantify the serious risks of misuse, abuse, and addiction associated with long-term use of opioid analgesics for management of chronic pain among patients newly prescribed ER/LA opioid products. This multi-site research study is comprised of both a prospective longitudinal study that will estimate the incidence of misuse, abuse and addiction associated with long-term use of ER/LA opioids for chronic pain, and a cross-sectional study that will estimate the prevalence of misuse, abuse and addition associated with long-term use of opioids.

Open Notes in COPD: A Study of the Effects of Inviting Patients with COPD to Read Their Clinic Notes

MHCI Investigators: Kimberly Fisher, Kathleen Mazor
Funding Agency: Robert Wood Johnson Foundation, Gordon and Betty Moore Foundation, and Peterson Center on Healthcare
Status: Complete

Project Overview: Patients report many benefits of access to their clinic notes (Open Notes) including increased patient activation and self-management, which are particularly important in chronic illnesses such as chronic obstructive pulmonary disease (COPD). Despite this promise and increasing numbers of patients being provided access to their clinic notes, little is known about how patients understand and react to the information in clinic notes. We conducted in-depth ‘think-aloud’ interviews with patients with COPD who had been provided a written copy of their most recent COPD-specific clinic note.

Main Findings: Patients reacted positively to statements in the notes suggesting the provider listened to them (“he’s got my thoughts in here, which…makes me feel good about the fact that he listened to me”), saw them as a person, and was attentive to details (“I don’t even realize that he does that.”); all of which fostered the relationship. Reading notes enabled patient self-management through motivation (“seeing it [smoking history] in black and white makes you think”). It also prompted patients to seek more health-related information and reminded them of action steps. Patients indicated notes facilitated information sharing with other providers and family members, served as a longitudinal record of care, and provided an opportunity for patients to learn details of their condition they had not gleaned from the visit (“I didn’t get all this from the doctor. I got this from reading.”) – each strengthening information exchange. Most patients reacted negatively to medical terminology, abbreviations, incorrect information, and wording that was perceived as disparaging (“he is an active smoker would’ve been fine, instead of putting abuse down there”). Sharing clinic notes with patients is a promising tool that can strengthen the patient-provider relationship and promote self-management and information exchange. As patients increasingly access their clinic notes, more research is needed to ensure notes are written in a way that optimizes communication with patients, while fulfilling other functions of clinical documentation.  Learn more here.

Strategies to Reduce Injuries and Develop Confidence in Elders Study (STRIDE)

MHCI Investigator: Jerry Gurwitz
Funding Agency: Grant award from the National Institute on Aging (NIA) in partnership with the Patient-Centered Outcomes Research Institute (PCORI), as part of the Falls Injuries Prevention Partnership of the organizations.
Status: Complete

Project Overview: The STRIDE (Strategies to Reduce Injuries and Develop Confidence in Elders) Study is supported by a The study’s approach differs from others in that it integrates proven falls reduction strategies into a cohesive intervention that can be adopted by many health care systems.The trial is led by Shalender Bhasin, M.D., Brigham and Women’s Hospital, Harvard Medical School, Boston; Thomas Gill, M.D., Yale School of Medicine, New Haven, Connecticut; and David Reuben, M.D., David Geffen School of Medicine at the University of California, Los Angeles. The team includes more than 100 researchers, stakeholders, patients and their representatives at ten clinical health system sites across the country.  Read more about this study here.

Valuing Treatments to Prevent and Effectively Treat Alzheimer's Disease

MHCI Investigators: Kouta Ito, Jerry Gurwitz
Funding Agency: National Institute on Aging
Status: Complete

Project Overview: No matter how desirable the availability of highly effective treatments for Alzheimer’s disease may be, the American health care sector is ill prepared to face the challenge of assessing and paying for these future treatments. To date, policy analyses of the challenge of valuing highly-effective treatments for chronic conditions have focused mainly on developing new ways to pay for the anticipated extremely high prices of treatments that provide the possibility of a lifetime of benefit for rare and ultra-rare diseases. Few have considered novel therapies for conditions with applicability to the care of large numbers of older patients, such as those with Alzheimer’s disease. The question remains: how should a fair, value-based price be determined? Evaluating different approaches to calculating and presenting suggested value-based prices will be essential to providing policymakers, payers, health care organizations, and the academic and manufacturer communities with a platform that can reward innovation while supporting a sustainable U.S. health care system. Importantly, this information will ultimately have direct relevance to the care of those with Alzheimer’s disease, particularly in relation to access to effective therapies and shared clinical decision-making efforts among clinicians, patients, and their families.  Read more about this research project here. 

Post-Hospital Discharge Adverse Events in the Nursing Home Setting

MHCI Investigators: Alok Kapoor, Terry Field, Kimberly Fisher, Sybil Crawford, Ning Zhang, Jerry Gurwitz
Funding Agency: Agency for Healthcare Research and Quality (AHRQ)
Status: Complete

Project Overview: In this project, we studied adverse events occurring among long-term care residents who transitioned from the nursing home setting to an acute care setting, and were then discharged back to the same facility.  The setting was a representative sample of 32 nursing homes drawn from across the six New England states. The specific aims of the study were to characterize the rates, types, severity, and preventability of adverse events that occur in the 45-day period post-hospital discharge among long-stay nursing home residents (long-stay = >100 days) who were hospitalized and returned to the same facility; to identify demographic, clinical, and functional resident characteristics associated with the occurrence of adverse events; to identify facility-level characteristics associated with the occurrence of adverse events; and to examine the impact of level of facility participation in the New England regional National Nursing Home Quality Care Collaborative on the occurrence of adverse events. Nurse abstractors collected data from resident charts at the 32 homes on a quarterly basis and four physician adjudicators evaluated the adverse events reported by the nurse abstractors.

Main Findings: 555 unique nursing home residents contributed data on 762 hospital discharges with return to the same facility.  Nearly 66% were female, and the mean age was 82.2 years. There were 379 adverse events identified.  Of those 379 events, 197(52.0%) were related to resident care, with pressure ulcers, skin tears, and falls with injury representing the most common types of events in this category.  Health care–acquired infections (108 [28.5%]) and adverse drug events (64 [16.9%]) were the next most common.  In terms of preventability, 267 (70.4%) adverse events were deemed preventable or ameliorable. Adverse events developed in nearly 4 of 10 of discharges from hospital back to LTC. Most were preventable or ameliorable. Standardized reporting of events and better coordination and information transfer across settings are potential ways to prevent adverse events in LTC residents. Read more about our findings here.

Detecting, Addressing, and Learning from Patient-Perceived Breakdowns in Care: We Want To Know (WWTK)

MHCI Investigators: Kathleen M. Mazor, Kimberly A. Fisher
Funding Agency: Agency for Healthcare Research and Quality (AHRQ)
Status: Complete

Project Overview: There is increasing recognition that patients have critical insights into care experiences, including about breakdowns in care. Harnessing patient perspectives for hospital improvement requires an in-depth understanding of the types of breakdowns patients identify and the impact of these events. The major goals of this project were to develop, implement, disseminate and evaluate a program for detecting, addressing and preventing patient-perceived breakdowns in care. Implementation included a unique, proactive multimodal We Want to Know campaign, encouraging patients to report if they perceive a breakdown in their care; a We Want to Know Specialist who coordinated real-time responses to these care breakdowns. Using the RE-AIM framework, we examined program reach, adoption, and implementation, of the WWTK program across the 10 hospitals within the MedStar Health organization.

Main Findings: When asked directly, almost 4 out of 10 hospitalized patients report a breakdown in their care. The most common reported breakdowns involve information exchange, medications, delays in admission, team communication, providers’ manner, and discharge. Of patients reporting a breakdown in care, more than 3 in 10 feel they have experienced harm related to the breakdown, such as distress, pain, damage to their relationship with providers, a prolonged hospital stay, or life disruption. Hospitals that effectively encourage patients and their family members to speak up about perceived breakdowns will identify many opportunities to address patient concerns, potentially leading to improved patient safety and experience. However, further work is needed to develop sustainable methods to overcome patients’ reluctance to report breakdowns in care.  Read more about our findings here.