Research

Faculty associated with the Department of Health Policy, Management and Evaluation (HPME) are involved in a broad range of research activities with a variety of organizations. Success of the HPME Knowledge Transfer initiative is dependent on presenting our stakeholders with a unified, clear image of the depth and breadth of Departmental expertise. To promote greater internal awareness of the knowledge developed through HPME, faculty research profiles will be included as a regular feature of this newsletter.

In this issue we feature research profiles from Wendy Ungar and Brian Feldman:

• Wendy Ungar is an Assistant Professor with HPME. She is also a Scientist with the Hospital for Sick Children Research Institute and an Adjunct Scientist with the Institute for Clinical Evaluative Sciences. Her research interests focus on pediatrics, pharmaceutical policy and economic evaluation methods.
  
  
• Brian Feldman is an Associate Professor in HPME. He holds the positions of Clinical Chief, Arthritis Program at Bloorview MacMillan Centre and Scientist, Hospital for Sick Children Research Institute while maintaining a clinical practice in Rheumatology at the Hospital for Sick Children. His research interests focus on pediatric rheumatic conditions and clinical trial design for rare diseases.

+ + PROFILES OF THE MONTH + +

Wendy Ungar, PhD

The provision of medications is a major component of health care not universally covered by provincial health programs. A major research interest focuses on the health consequences of medication cost-sharing borne by children and their families for the treatment of acute and chronic diseases. This work is particularly relevant as a model for understanding the relationship between user fees, with medication cost-sharing as a single example, and health outcomes. Given the evolution of our health care system and the intensifying debate surrounding the appropriate mix of privately- and publicly-funded health services, this avenue of research is of growing importance.

Education and Work Background

One might say I have always been interested in drugs. Following a BA cum laude in Biology from Brandeis University in Boston (and a successful NCAA swimming career), I completed an MSc in Pharmacology and Therapeutics at McGill University. My research career began in the private sector with managerial positions in clinical research at Bristol-Myers Pharmaceutical Group and Ciba Canada. During my eight years in the pharmaceutical industry, I participated in the development of significant novel treatments for a variety of disorders, including depression, AIDS, prostate cancer, breast cancer and asthma. I subsequently returned to university to complete a PhD in Health Administration at the University of Toronto with Dr. Peter Coyte as my thesis advisor. My doctoral dissertation focused on the development of a prospective model for assessing the cost of asthma at the patient level. Upon completion of my PhD, I conducted pharmacoeconomic analyses at Innovus Research Inc. before moving to my present position as Scientist, Population Health Sciences, at the Hospital for Sick Children (HSC) Research Institute and Assistant Professor, Department of Health Policy, Management and Evaluation, at the University of Toronto. Additional professional experience was obtained through affiliations with the Pharmacy Medication Monitoring Program and the Father Sean O'Sullivan Research Centre, both at McMaster University. Most recently, I was appointed as an Adjunct Scientist with the Institute for Clinical Evaluative Sciences. I still swim and I still like to study drugs.

Research Activities

A significant component of my research involves the study of the health impact of pharmaceutical policy on children with asthma. This CIHR-funded research program invokes quantitative and qualitative research methods to understand the relationship between medication cost-sharing and health outcomes. Another avenue of research involves studying challenges to the application of conventional health economic methods to the pediatric population. Funded by the Canadian Coordinating Office of Health Technology Assessment, the Pediatric Economic Database Evaluation (PEDE) Project includes a 787-record database of all pediatric economic evaluations published between 1980 to 1999. An analysis of trends over time with respect to analytic technique, disease, outcomes, and other characteristics is underway along with a quality appraisal of the published literature. In addition to this research, I collaborate with investigators at HSC, University of Toronto and McMaster University on health economic evaluations of treatments and services for asthma, fetal alcohol syndrome, cardiovascular disease and gastroesophageal disease. I aim to continue to support pediatric health services research as a member of the Standing Committee on Youth and Adolescents of the CIHR Institute of Human Development, Child and Youth Health.

Teaching and Supervisory Responsibilities

I enjoy co-teaching HAD 5730, Health Economics I, with Audrey Laporte. I also teach workshops in health economics and health services research within the HSC Research Institute. Students under my supervision include those pursuing Masters and PhD degrees, post-doctoral fellows and medical residents.

Future Research

Future research will include population-based studies examining medication and health services use of Ontario children with asthma using linked claims databases. This work will examine the health impact of medication cost-sharing and the relationship to indicators of socio-economic status. Additional work will study the prevalence and economic burden of fetal alcohol syndrome and will evaluate the cost-effectiveness of early diagnostic strategies.

Brian M. Feldman, MD, MSc, FRCPC

My research follows two broad areas. The first is developing and testing new methods for carrying out clinical trials for rare diseases. The pediatric rheumatic diseases are uncommon and accrual to clinical trials is difficult due to small numbers. New trial designs must be developed in order to overcome this difficulty. The second major area is applied therapeutic and outcome research in the field of childhood arthritis.

Education and Work Background

I obtained a medical degree from the University of Western Ontario in 1985 and then an MSc in Clinical Epidemiology from the University of Toronto in 1994. Additional expertise includes fellowships in Pediatrics (Toronto/Ottawa) and Rheumatology (Toronto). I have been the Clinical Chief of the Arthritis Program at Bloorview MacMillan Children's Centre since 1995 and Scientist, Hospital for Sick Children Research Institute since 1998. Academic affiliations include cross-appointments to HPME, Public Health Sciences and Pediatrics as Associate Professor. I also maintain a clinical practice at the Hospital for Sick Children in Rheumatology.

Research Activities

Using computer simulation I have developed a novel randomized trial design in which patients all receive the experimental therapy. Those who begin therapy sooner are expected to respond sooner to treatment.

Along with collaborators at the NIH/FDA and using computer simulation I helped to develop and test the validity and efficiency of a clinical trial design in which subjects begin in a standard randomized controlled trial and then move into a randomized withdrawal design. We found a substantial increase in efficiency with no increase in false positive results.

I am currently running three studies in which single subjects are studied by n-of-1 methods. Several subjects are then combined using a Bayesian statistical model. This method offers a way to develop a clinical trials registry for very rare diseases for which accrual, even amongst several centres, would be impossible.

I have just completed a pilot study of early treatment with methotrexate in juvenile dermatomyositis. My research fellow won the pediatric research award at the American College of Rheumatology for this paper. We found that early methotrexate use was safe, and effective as a steroid sparing agent.

Teaching and Supervisory Responsibilities

I am the Course Director for HAD 5301, Introduction to Clinical Epidemiology and Health Care Research, and currently supervise eight graduate students, three undergraduate students and six post-doctoral fellows.

Future Research

I am currently running a multi-centre clinical trial in which I am testing the efficacy and costs of a tailored approach to Factor VIII prophylaxis. Along with my collaborators in the hemophilia clinic, I plan to study this approach to prophylactic therapy applied to Factor IX deficiency (in a multi-national study) and as prophylaxis for older children with hemophilia.

I have just finished a clinical trial of fitness exercise used in the rehabilitation of juvenile rheumatoid arthritis which demonstrated that it was possible to train and test all but the most severely affected children and that exercise improved gait efficiency and function. A second study is being planned to extend these observations.

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