1. Marketing Community-based Interventions to Primary Care Practices: Lessons Learned from Audience Research Teresa J. Brady, PhD Senior Behavioral Scientist Arthritis Program U.S. Centers for Disease Control and Prevention

2. Agenda How we did the audience research Five key findings (and a bonus) Recommendations based on the research Turning the research into action

3. Background Community-based programs complement clinical care Audience research suggests  Dr. referral/recommendation powerful influence on Patients  Patients expect Dr.’s to tell them about self management education programs Few patients are referred to community- based programs by their Primary Care Provider (PCP) Attempts to elicit referrals have had limited success

4. SME recommended 10% (3.7 million) SME attended 10% (3.7 million) SME recommended & attended 5% (1.8 million) The Importance of Provider Recommendation N= 2500 Patients who receive recommendation 18 times more likely to go than those who don ’ t get recommendation. --Murphy 08

5. Increasing Recommendations from Provider Offices Purpose: Develop strategies to entice primary care providers (and their staff) to refer patients to SME and PA programs Process:  Literature Review  Formative Research  In-depth Interviews (32 providers, 8 managers)  Survey (400 providers and staff)

6. Increasing Referrals from Provider Offices Literature Review Results PCPs have limited awareness of exercise guidelines and community resources PCPs lack confidence that their recommendations will result in behavior change Non-physician staff play crucial role in getting word of community programs out

7. Qualitative Methods: In-depth Interviews 31 in-depth interviews with PCPs Recruited from pre-existing database of research volunteers Inclusion criteria: see 20 or more patients per month with arthritis 20-40 minute telephone interview All conducted by same interviewer

8. In-depth Interview Methods Stratified by  Profession (MD, NP, PA)  Specialty (Internal Med.; Fam. Practice)  Practice size (small, med. large)  Location (urban, suburban, rural)  Geography (NE, S, MW, W)  Pt Race/Ethnicity (Cau., Minority) Paid incentives  $90/MD; $75 NP/PA Interviews taped, transcribed, thematically analyzed by question

9. PCP Interview Respondents 68% MDs  16% each NP, PA 42% Small practices  29% each Mid-size, Large practice 45% Urban  42% Suburban, 16% Rural 29% each, Northeast, South  26% West; 16% Midwest 64% serve mostly Caucasian patients

10. Quantitative Methods: On-line Survey On-line survey of MDs, NP, PA, Office managers Recruited from same database Same inclusion criteria Same incentive rates Data analyzed with SPSS  Missing data not included  Open ended responses thematically coded

11. Online Survey Respondents N = 404  51% MDs  25% PA/NP  25% Practice/Office Managers 54% family practice 47% small offices (less than 5 pro.staff) 52% suburban settings 22% at least half minority pt. population Average 130 arthritis patients/month

12. PCP Audience Research Key Learning # Don’t call it a referral.

13. PCP Audience Research Insurance company rules govern referrals “if program low cost rather than covered by insurance…free to recommend it unfettered”

14. PCP Audience Research Key Learning # PCPs welcome information about community programs.

15. In-depth Interview Results Awareness and Use of Local Programs See referral to community resources as part of their job PCP’s likely making referrals to PT, weight loss programs and exercise facilities (YMCA) Unaware of community based-arthritis programs, but idea “very warmly received”.

16. In-depth Interview Results Impression of Community- based Programs After hearing description of programs: “Great!” Near unanimous belief programs would help them care for patients How likely to refer? (1=not, 10= definitely would)  Average rating 8.5;  87% rated 6 or greater

17. On-Line Survey Results: Awareness and Use of Local Programs 80% recommend community programs at least several times per month  60% several times per week 56% reported being aware of programs for arthritis  YMCA, medical facilities, senior centers  PA/NP more aware (71%) than MD (51%) and Office managers (50%) 20% aware of E-B programs described

18. PCP Audience Research Key Learning # Providers top concerns about community-based programs: Cost Convenience Credibility

19. On-Line Survey Results: Factors Influential in Decision to Recommend Low cost (average rating = 4.64)  1= not influential; 5 = very influential) Convenient location (4.63) Convenient times (4.49) Led by trained instructors (4.49) Evidence-base/effective (4.43) Small recommendation influential (4.15) Not for profit/not sell anything (4.14)

20. Low cost – 47% Benefits to patients – 24% Program qualities -- 21% Location/access -- 14% Evidence-base -- 12% Trained instructors – 12% On-Line Survey Results: Which features influence most?

21. On-Line Survey Results : What questions do you have about these programs? 28% Logistics  class time, location, transportation 17% Cost 14% Instructor training/credentials 6% Program effectiveness

22. PCP Audience Research Key Learning # Preferred method to learn about community programs: 1:1 visits from people knowledgeable about program (academic detailing)

23. In-depth Interview Results: Learning about Local Programs Top Sources for general arthritis info  Medical journals, conferences, other professionals, pharma. representatives Learning about local programs  In-person meeting with program representatives  Follow up with print materials  Print materials without personal contact not effective

24. On-line Survey Results: How to Introduce the Program to the Practice Bring materials to the office (average rating 4.17)  80% very/somewhat effective Conferences (3.21)  41% very/somewhat effective Newsletters/e-mail/journals (3.15)  39% very/somewhat effective Send materials by mail (3.7)  36% very/somewhat effective

25. On-Line Survey Results: When bringing materials to office… 61% make appointment in advance 21% drop in without appointment; ask to speak to someone 18% drop off materials to be given to staff Note: 6% mentioned bring food

26. On-Line Survey Results: Who to contact at the Practice 42% Office/Practice Manager 31% Physician 16% PA/NP 8% Front Desk/Referral Desk 5% Medical assistant

27. PCP Audience Research Key Learning # Need to foster facilitators and reduce barriers to recommendation.

28. In-depth Interview Results: Recommendation Facilitators and Barriers Facilitators Convenient times, locations Low cost Knowledge of:  program details, staff Easy to hand-out pt.materials Barriers lack of awareness cumbersome process need to write info

29. On-Line Survey Results: Value of Endorsements Patient word of mouth (average rating 4.22; greatly influence 47%) Arthritis Foundation (4.06; 40%) Local rheumatologists (3.99; 37%) Local PCPs (3.93; 30%) Am. Coll. of Rheumatology (3.90; 34%) AAFP (3.78; 28%) CDC (3.53; 21%) AMA (3.50; 21%)

30. Key Learnings from PCP Audience Research 1. Ask for recommendation, not referral 2. PCPs welcome info 3. Emphasize cost, convenience, and credibility in your pitch 4. Make personal visits to provider offices 5. Use strategy and materials to address facilitators and barriers

31. Recommendations: Strategy Brief in-person visits to targeted PC Practices Make appointment with Office Mgr or Practitioner Brief presentation to address cost, convenience, credibility Leave-behind print materials Easy to use recommendation process Repeat contacts over time

32. Recommendations: Materials Practitioner Oriented Program fact sheet  Cost, Convenience, Credibility  What happens in program  Benefits (evidence) Patient Oriented Brochures/Flyers/Tearoff sheets

33. Translating Research into Action The 1.2.3 Approach to Provider Outreach Marketing Arthritis Interventions to Primary Care Practices  Pilot-test 2010-2011  Currently being revised  Release late 2012/early 2013

34. Bonus Learning: (…from the pilot test) Key Learning # PCPs prefer interventions that address multiple chronic diseases

35. Provider Outreach Guide Marketing Chronic Disease Interventions to PCPs…

36. Teresa J. Brady, PhD Senior Behavioral Scientist Arthritis Program Centers for Disease Control and Prevention 4770 Buford Hwy MS K-51 Atlanta, GA 30341 770-488-5856 tob9@cdc.gov Questions: