Driving Change in Practice and Policy With Clinical Futures PolicyLab Pilot Grants

The Clinical Futures/PolicyLab Pilot Grant program supports investigators in their studies on clinical effectiveness and/or policy-oriented health services.

The year 2020 may have brought many uncertainties and surprises, but one thing that stays constant is our researchers’ pursuit to improve clinical effectiveness and policy-oriented health services. The Pilot Grant Program, a partnership between the Clinical Futures and PolicyLab at Children’s Hospital of Philadelphia, provides support to CHOP investigators working in these areas during the Spring and Fall of each year. We reached out to each award winner this year to learn about their projects and how, in their own words, they seek to drive change in policy and practice.

Fall 2019

Exploring Pharmacist-prescribed Contraceptive Access for Teens

Nadia Dowshen, MD, MSPH

Expanding access to contraceptives is one of the most effective approaches to reducing unintended pregnancies. In their Pilot Grant project, Nadia Dowshen, MD, MSHP, co-founder and co-director of CHOP’s Gender and Sexuality Development Clinic, Ava Skolnik, MPH, and Sarah Wood, MD, MSHP, attending physician in the Division of Adolescent Medicine, are developing and testing a telemedicine platform staffed by pharmacists to simulate an approach wherein pharmacists might prescribe contraception for teens.

Q: What makes your research project innovative?

A: We know that contraception is safe and effective in preventing pregnancy and improving health and wellbeing of adolescents. However, there are many barriers to youth accessing contraception. There is a move toward considering the option for pharmacists to provide the prescription directly without a physician visit. Our goal is to develop and pilot test a digital health platform to simulate pharmacist delivered contraception. We also aim to provide proof-of-concept that pharmacists would make the same decisions as physicians and know when to refer to physicians if there is any contraindication.

Q: How could results from your project lead to future research?

A: If our simulation is successful and acceptable to both teens and pharmacists, there will be many other potential opportunities. We will be able to apply for funds for a larger trial to determine whether this can increase uptake of contraception among adolescents and ultimately whether this type of access can prevent teen pregnancy, improve well-being, and decrease healthcare costs.

Addressing Disparities to Improve Chlamydia Screening

Sarah Wood, MD, MSHP

Chlamydia is now the most commonly reported bacterial infection in the U.S. Nevertheless, routine screenings for chlamydia remain low in primary care settings. With Pilot Grant support, Dr. Wood is working on another research project alongside Vicky Tam, MA, and Jungwon Min, PhD, MS, to identify patient, clinic, and geographic disparities in chlamydia screening for adolescent females, with the goal of improving current resources in the healthcare system.

Q: What makes your research project innovative?

A: Our research is innovative in several ways. First, we are using a near real-time data visualization platform to aggregate chlamydia screening and prevalence rates across the entire CHOP primary care network so we can better understand trends in screening over time. This platform not only allows us to rapidly collect data from the CHOP system, but to share it with clinic teams so we can better intervene on the clinic level.

Second, we are using a geospatial data analytic approach to better identify and visualize community-level disparities in screening throughout the region served by our primary care network. This approach will also help understand where CHOP clinics may be operating in "service deserts” — areas where there aren't other viable options for young women to get chlamydia screening.

Finally, we will be applying principles of improvement science to our findings to understand where interventions are most needed, what interventions may be most appropriate, and how to best leverage our findings to implement health system change.

Q: How could results from your project lead to future research?

A: Our project is designed to yield actionable results for our health system. While interventions to improve chlamydia screening will need to be applied broadly throughout our care network, by understanding the epidemiology of screening at individual clinics and geographic areas, the investigative team can target intensive resources at the sites with the greatest need for intervention.

Examining the Impact of Postoperative Antibiotic Prophylaxis

Leila Posch, MD

In this Pilot Grant project, Leila Posch, MD, fellow in the Division of Infectious Diseases, Jeffrey Gerber, MD, PhD, Associate Chief Clinical Research Officer, and Yun Li, PhD, are taking on the gap in pediatric studies about postoperative antibiotic prophylaxis, or the administration of antibiotics after performing surgery, and its impact on clinical outcomes such as infection.

Q: What makes your research project innovative?

A: Pediatric surgical patients are a vulnerable population with significant and highly variable prophylactic antibiotic use. There are a lack of pediatric studies assessing the impact of postoperative antibiotic prophylaxis on clinical outcomes including postoperative infection and antibiotic-associated adverse drug events in children. Furthermore, current best practice and antibiotic stewardship guidelines focus on pediatric inpatients and the operating room setting and not on ambulatory patients. Finally, there have been no studies assessing the impact of the revised 2017 CDC Surgical Site Infection Prevention Guideline in the pediatric surgical population.

Our study, therefore, which will look at the effect of this guideline, assess current practice around surgical antibiotic prophylaxis, and assess important outcomes in pediatric ambulatory surgery patients, will provide much needed data not only to inform current best practice in children but also to reduce unnecessary antibiotic use and improve clinical outcomes.

Q: How could results from your project lead to future research?

A: This project will provide much needed epidemiologic and outcomes data which will inform subsequent projects needed to guide our use of antibiotics to improve clinical care of pediatric surgery patients. It will lay the foundation for future studies which will utilize prospective data collection to better assess the association between antibiotic prophylaxis and pediatric outcomes after surgery. Results from this study also will provide the basis for development of quality improvement research initiatives that seek to implement evidence-based interventions to improve use of prophylactic antibiotics for pediatric surgery.

Building on the Successful PriCARE Parenting Intervention

Joanne Wood, MD, MSHP

Since 2014, the PriCARE program at CHOP provides caregivers and families with a parenting intervention designed to strengthen relationships with their child, improve child behaviors, and decrease parenting stress, all within a primary care setting. With support from Clinical Futures and PolicyLab, Joanne Wood, MD, MSHP, research director of Safe Place: Center for Child Protection and Health, alongside Linda McWhorter, Devon Kratchman, and Emily DePaul, are evaluating the module to study whether an additional offering, a four-session Positive Discipline Module for parents and caregivers who have completed the PriCARE program, can ultimately improve child behavioral problems.

Spring 2020

Studying the Impact of Immigration Policies on Children’s Health

Robin Ortiz, MD

Not much is known about how immigration policies influence children’s health, particularly whether sanctuary areas offer protective health benefits. Nevertheless, understanding the political determinants of health could help inform future local and national policies, and set an agenda for future research into the relationship between immigration policy and population health. In their Pilot Grant project, Robin Ortiz, MD, attending physician at CHOP and National Clinician Scholar at Penn, alongside Diana Montoya-Williams, MD, FAAP, neonatologist at CHOP; Katherine Yun, MD, MHS, faculty at PolicyLab and attending physician in the Division of General Pediatrics and the Refugee Health Program; Atheendar Venkataramani, MD, PhD, and Courtney Boen, PhD are mapping and describing sanctuary areas as they relate to the health variables of the Latinx population.

Q: What makes your research project innovative?

A: Our project brings together information from many different disciplines — public policy, public health, demographics — to better understand the ways in which sanctuary policies might influence immigrant family health. There is a growing body of work examining immigration policies in relation to health. Much of this work has focused on federal or state-level policies and rhetoric. Our study extends this research to local sanctuary policies, including policies that specifically call out health and well-being as important outcomes.

Q: How could results from your project lead to future research?

How do Low-income Parents Perceive the Philadelphia Beverage Tax?

Emma Edmondson, MD

Research that examines how food policies such as beverage taxes might influence healthier behaviors in individuals could help the development of equitable and effective future policies. With support from the Pilot Grant program, Emma Edmondson, MD, a fellow in the Academic General Pediatrics (AGP) Fellowship program and the Division of Pediatrics; Senbagam Virudachalam, MD, MSHP, faculty at PolicyLab and the Division of Pediatrics; and Emily Gregory, MD, MHS, also faculty at PolicyLab and the Division of Pediatrics, are studying how low-income parents perceive the fairness of the Philadelphia Beverage Tax.

Q: What makes your research project innovative?

A: In January 2017, Philadelphia became the largest U.S. city to enact a tax on sweetened beverages (SBs). This is the first qualitative study interviewing Philadelphians as SB consumers since the implementation of the tax. Furthermore, its is the first study focusing on perceptions of an SB tax after it has been in place for several years and has generated revenue, rather than imagining how one might feel about this type of tax if it were to be implemented.

While there have been quantitative studies describing SB sales and consumption trends since the implementation of the tax, there have been no qualitative studies assessing individuals’ perceived behavior change and reasons for behavior change in response to the tax. This study will help elucidate how food policies like SB taxes translate into healthier behaviors in individuals. Additionally, our focus on parents’ views is novel, as parents are a population not yet studied in this area.

Finally, the approach Philadelphia policymakers took to get the tax passed, framing it as a way to generate revenue for community programming rather than a public health initiative, was innovative in its own right. Thus, evaluating how the policy is now perceived will help add detail to this innovative approach, informing future cities that may employ a similar mechanism to pass SB tax policies.

Q: How could results from your project lead to future research?

A: The perceived fairness and effectiveness of a food policy by the population it affects directly informs their acceptance of the policy and its future success in achieving behavior change. The results from this qualitative study will complement future quantitative studies evaluating the impact of SB taxes on SB consumption and, ultimately, health outcomes, in people from different income levels and racial/ethnic backgrounds. These findings will help illuminate the differential impact food policies like SB taxes have across a population, with the ultimate goal of designing future policies that are both equitable and effective in achieving positive health behavior change.

Evaluating Platelet Levels After Acute Myeloid Leukemia Chemotherapy

William R. Otto, MD

With support from a Pilot Grant, William R. Otto, MD, fellow in the Division of Infectious Diseases, is leading innovative research into the association between platelet levels and the development of bacteremia, or the presence of bacteria in the blood, in children with acute myeloid leukemia (AML). Working with Brian T. Fisher, DO, MPH, MSCE, physician in the Division of Infectious Diseases; Richard Aplenc, MD, PhD, MSCE, assistant vice president and chief clinical officer at the Research Institute; and Yimei Lei, PhD, research biostatistician in the Division of Oncology, Dr. Otto aims to identify variability in platelet counts after pediatric patients receive AML chemotherapy and then evaluate how those variations might be related to subsequent risk of bacteremia over time.

Q: What makes your research project innovative?

A: Platelets are heavily involved in coagulation or clotting process, but recent laboratory research has shown that platelets are also involved in the immune response to infection. There has been no published literature specifically looking at the association of platelet levels with subsequent development of infection, so this project will hopefully contribute information regarding that association in a high-risk population. Secondly, this project will be using data from a unique database developed by my mentors (Dr. Fisher and Dr. Aplenc) and their research team. This database contains data acquired from the electronic medical record from multiple children's hospitals using an automated data extraction process. In this way, the research team is able to build large patient cohorts to explore research questions that might have been difficult to answer without significant chart review.

Q: How could results from your project lead to future research?

A: If we find that there is an association between platelet levels and the development of bloodstream infections, then further research can be performed to explore the causal impact of platelet level or what platelet level. Additionally, future studies could potentially include clinical trials to explore the impact of platelet transfusions on bacteremia risk.

Assessing Herpes Zoster Infections in Pediatric AI Disease

Beth Rutstein, MD

Beth Rutstein, MD, fellow in the Division of Rheumatology, is setting out to address a gap in knowledge when it comes to understanding and addressing the risk for Herpes Zoster (HZ) infection in children with autoimmune and/or autoinflammatory (AI) conditions. Herpes zoster, more commonly known as shingles, is caused by a reactivation of the virus that causes chickenpox. Though incidence of HZ in children is low, those with depressed immune systems have a greater risk and may experience more severe symptoms. Alongside Jeffrey Gerber, MD, PhD, associate chief clinical research officer; Sabrina Gmuca, MD, MSCE, physician in the Division of Rheumatology; and Alexis Ogdie-Beatty, MD, MSCE, associate professor of Medicine and Epidemiology at Penn, Dr. Rutstein’s project will be the first to focus on the at-risk pediatric AI population, in order to establish baseline risk of the infectious complication. Findings from the work has the potential to move the needle forward toward preventative measures.

Q: What makes your research project innovative?

A: It is no secret that many children with AI disease are at risk for opportunistic infections. In fact, the question of proper pathogen prophylaxis is one of the more common questions asked of our ID specialists when patients with AI disease are admitted to the hospital. However, asking two different ID team members often leaves us with two different answers. Because of this lack of standardization, we are time and time again left to treat infection after the fact, which can be quite tricky when also trying to balance the proper amount of immunosuppression. For the last three years, adults with similar autoimmune or autoinflammatory disease have benefited from an immunization against HZ. Whereas prior HZ vaccines were contraindicated in the immunosuppressed population, this new vaccine is safe for the vast majority of our patients, despite their underlying disease and/or medications. Little has been studied about the true burden of HZ within the pediatric AI community, and there is little push to expand the vaccination coverage guidelines.

Q: How could results from your project lead to future research?

A: Unfortunately, the vaccine in question is not yet approved in pediatric patients, and thus our patients are unable to benefit. With this project, we aim to prove the true burden of this opportunistic infection, such that we can eventually leverage the novel HZ vaccine to shift our infection treatment algorithm from reactionary to preventative. Additionally, with this study we call to light the importance of standardization of infectious prophylaxis guidelines across the pediatric AI world.

Learn more about the Clinical Futures/PolicyLab Pilot Grant Program.