1. INTRODUCTION TO PRACTICE BASED RESEARCH
Chet Fox MD
UB Family Medicine

2. 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

3. 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”)

4. THE ECOLOGY OF MEDICINE
For pts
800 have sx
253 will see any MD
113 PCP
13 ER
6 Hosp
1 Academic Health Center

5. 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

6. 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.

7. WHAT DO PBRN’S DO? SEEK RESEARCH QUESTIONS FROM CLINICIANS
MAKE CLINICIANS PARTNERS IN RESEARCH
QUALITY IMPROVEMENT RESEARCH

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

9. EXAMPLE: THE CHRONIC KIDNEY DISEASE STUDY

10. Making Chronic Kidney Disease Guidelines Work in Underserved Practices
Chet Fox MD
Linda Kahn PhD
Katheryn Glaser BS
UNYNET
AHRQ R03 H

11. 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

12. 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):
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):
Yarnall, K. S., K. I. Pollak, et al. (2003). "Primary care: is there enough time for prevention?" American Journal of Public Health 93(4):

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. QUESTIONS?

20. THE END!!
THE END