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

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

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) 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? SEEK RESEARCH QUESTIONS FROM CLINICIANS MAKE CLINICIANS PARTNERS IN RESEARCH QUALITY IMPROVEMENT RESEARCH

EMERGING METHODOLOGIES BEST PRACTICES RESEARCH PRACTICE ENHANCEMENT ASSISTANTS (PEAS) TELEPHONIC CASE MANAGEMENT CLAIMS DATA FOR CASE FINDING

EXAMPLE: THE CHRONIC KIDNEY DISEASE STUDY

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 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 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 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 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 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 PATIENT 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 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 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?

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