INTRODUCTION TO PRACTICE INTRODUCTION TO PRACTICE BASED RESEARCHBASED RESEARCH

Chet Fox MDChet Fox MD

UB Family MedicineUB Family Medicine

RESEARCH IS A TEAM RESEARCH IS A TEAM SPORTSPORT

• 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 PRACTICE BASED RESEARCHRESEARCH

• 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 MEDICINETHE ECOLOGY OF MEDICINE

• For 1000 pts• 800 have sx• 253 will see

any MD• 113 PCP• 13 ER• 6 Hosp• 1 Academic

Health Center

RATIONALE FOR PBRNSRATIONALE 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 WHAT IS A PRACTICE BASED RESEARCH NETWORK? (PBRN)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 EMERGING METHODOLOGIESMETHODOLOGIES

• BEST PRACTICES RESEARCH

• PRACTICE ENHANCEMENT ASSISTANTS (PEAS)

• TELEPHONIC CASE MANAGEMENT

• CLAIMS DATA FOR CASE FINDING

EXAMPLE: THE CHRONIC EXAMPLE: THE CHRONIC KIDNEY DISEASE STUDYKIDNEY DISEASE STUDY

Making Chronic Making Chronic Kidney Disease Kidney Disease

Guidelines Work in Guidelines Work in Underserved PracticesUnderserved Practices

Chet Fox MDChet Fox MD

Linda Kahn PhDLinda Kahn PhD

Katheryn Glaser BSKatheryn Glaser BS

UNYNETUNYNET

AHRQ R03 H5016031

PCP’S are Unaware of PCP’S are Unaware of GuidelinesGuidelines

• 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

ReferencesReferences• 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 Diseases 48(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 Medicine 3(3): 209-14.

• Yarnall, K. S., K. I. Pollak, et al. (2003). "Primary care: is there enough time for prevention?" American Journal of Public Health 93(4): 635-41.

Testing a model to help PCPTesting 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 measuresOutcome 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

MethodsMethods

MEDICAL RECORD

PEA

REGISTRY AND

DATABASE CREATED

COMPUTER DECISION SUPPORT

ALGORITHM

REPORT TO PCP WITH CARE

RECOMMENDATION*

*CONTAINS LAB RESULTS; OTHER DATA; AND RESPONSE REQUEST

PEA ASSURES DATA FLOW

PCP OFFICE

PCP ACCEPTS, REJECTS OR

MODIFIES RECOMMENDATION

PATIENT

The QI CycleThe 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 RESULTSPRELIMINARY 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