Introduction to practice based research
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INTRODUCTION TO PRACTICE BASED RESEARCH. Chet Fox MD UB Family Medicine. RESEARCH IS A TEAM SPORT. How many authors does it take to make a New England Journal article? Ans. A lot more than 1 Collaboration is the art of making abundance out of scarcity. Dr. Kurt Stange.

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INTRODUCTION TO PRACTICE BASED RESEARCH

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Introduction to practice based research

INTRODUCTION TO PRACTICE BASED RESEARCH

Chet Fox MD

UB Family Medicine


Research is a team sport

RESEARCH IS A TEAM SPORT

  • How many authors does it take to make a New England Journal article?

    • Ans. A lot more than 1

  • Collaboration is the art of making abundance out of scarcity.

    • Dr. Kurt Stange


Practice based research

PRACTICE BASED RESEARCH

  • REAL PROBLEMS, REAL QUESTIONS, REAL SOLUTIONS IN THE REAL WORLD

  • ONLY ONE PATIENT PER THOUSAND POPULATION ENDS UP IN AN ACADEMIC HEALTH CENTER; EVEN FEWER END UP IN CLINICAL TRIALS

  • IT TAKES AN AVERAGE OF 17 YEARS FROM THE TIME EVIDENCE IS CLEAR IN THE LITERATURE TO THE TIME IT IS COMMON PRACTICE (IOM REPORT- “CROSSING THE QUALITY CHASM”)


The ecology of medicine

For 1000 pts

800 have sx

253 will see any MD

113 PCP

13 ER

6 Hosp

1 Academic Health Center

THE ECOLOGY OF MEDICINE


Rationale for pbrns

RATIONALE FOR PBRNS

  • WHILE RANDOMIZED CONTROLLED TRIALS TELL US WHAT IS KNOWABLE

  • PBRNS TELL US WHAT IS DOABLE

  • TRANSLATE RESEARCH INTO PRACTICE

  • DISSEMINATE INNOVATION

  • BASICALLY, IT ANSWERS THE QUESTIONS THAT ARE IMPORTANT TO PRACTICING PHYSICIANS.

  • HOW CAN WE DO THINGS BETTER?

  • CONVERTS CLINICAL OBSERVATION TO SCIENTIFIC KNOWLEDGE


What is a practice based research network pbrn

WHAT IS A PRACTICE BASED RESEARCH NETWORK? (PBRN)

A Primary Care Practice Based Research Network (PBRN) is a collaborative of at least 4 practices that have come together to study issues of importance to primary care practice. They all have a representative governance structure that exists beyond the needs of a single study and will have completed at least one study.


What do pbrn s do

WHAT DO PBRN’S DO?

  • SEEK RESEARCH QUESTIONS FROM CLINICIANS

  • MAKE CLINICIANS PARTNERS IN RESEARCH

  • QUALITY IMPROVEMENT RESEARCH


Emerging methodologies

EMERGING METHODOLOGIES

  • BEST PRACTICES RESEARCH

  • PRACTICE ENHANCEMENT ASSISTANTS (PEAS)

  • TELEPHONIC CASE MANAGEMENT

  • CLAIMS DATA FOR CASE FINDING


Example the chronic kidney disease study

EXAMPLE: THE CHRONIC KIDNEY DISEASE STUDY


Making chronic kidney disease guidelines work in underserved practices

Making Chronic Kidney Disease Guidelines Work in Underserved Practices

Chet Fox MD

Linda Kahn PhD

Katheryn Glaser BS

UNYNET

AHRQ R03 H5016031


Pcp s are unaware of guidelines

PCP’S are Unaware of Guidelines

  • Only 10% of practices in UNYNET were aware of existence of CKD guidelines

  • A national study showed PCP unaware of CKD guidelines

  • AND HAVE COMPETING DEMANDS

    • 7.9 hours for screening

    • 3.5 hours chronic disease management


References

References

  • Fox, C. H., A. Brooks, et al. (2006). "Primary care physicians' knowledge and practice patterns in the treatment of chronic kidney disease: an Upstate New York Practice-based Research Network (UNYNET) study." Journal of the American Board of Family Medicine: JABFM 19(1): 54-61

  • Boulware, L. E., M. U. Troll, et al. (2006). "Identification and referral of patients with progressive CKD: a national study." American Journal of Kidney Diseases48(2): 192-204.

  • Ostbye, T., K. S. Yarnall, et al. (2005). "Is there time for management of patients with chronic diseases in primary care?" Annals of Family Medicine3(3): 209-14.

  • Yarnall, K. S., K. I. Pollak, et al. (2003). "Primary care: is there enough time for prevention?" American Journal of Public Health93(4): 635-41.


Testing a model to help pcp

Testing a model to help PCP

  • Combination of proven interventions

    • Practice Enhancement Assistants (PEA) to work with office staff on QI

    • Creation of Registries extracting a limited data set from chart to Access database

    • Evidence Based Computer Decision Support

    • Academic Detailing

    • Quality Improvement cycles


Sample

Sample

  • 2 Intervention and 2 control sites

  • All Family Medicine

  • All predominantly African American

  • 1 intervention and 1 control site has EMR

  • 100% of patients with CKD in all practices are assessed for outcomes

  • Control practices will do usual care and outcomes will be assessed at the end


Outcome measures

Outcome measures

  • Dx of CKD (GFR < 60)

  • Dx of anemia

  • Dx disorders of bone metabolism

  • Stopping harmful meds

    • Metformin and NSAIDS

  • On meds for proteinuria

  • BP, glucose, and lipid control


Methods

Methods

REGISTRY AND DATABASE CREATED

MEDICAL RECORD

COMPUTER DECISION SUPPORT ALGORITHM

REPORT TO PCP WITH CARE RECOMMENDATION*

PEA

PEA ASSURES DATA FLOW

PCP ACCEPTS, REJECTS OR MODIFIES RECOMMENDATION

PATIENT

*CONTAINS LAB RESULTS; OTHER DATA; AND RESPONSE REQUEST

PCP OFFICE


The qi cycle

The QI Cycle

  • Data is aggregated

  • PEA presents data and change over time to MD and office staff

  • PEA shares insights from other practices working on the same project

  • Discussion of what worked and what didn’t is done and appropriate modifications are made

  • PEAS work with office on system change to sustain the intervention


Preliminary results

PRELIMINARY RESULTS

  • 200 Patients in the study

  • 38% had CKD dx at baseline

  • 39% had anemia dx at baseline

  • < 1% had bone studies done

  • > 30% on unsafe meds

  • Now 100% dx of CKD and anemia

  • Many off non-steroidals

  • Study ends 4/08


Questions

QUESTIONS?


The end

THE END!!

THE END


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