Transcript UPSTATE NEW YORK PRACTICE BASED RESEARCH …

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): 20914.
• 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
MEDICAL
RECORD
PEA
REGISTRY
AND
DATABASE
CREATED
COMPUTER
DECISION
SUPPORT
ALGORITHM
REPORT TO PCP WITH
CARE
RECOMMENDATION*
PEA ASSURES
DATA FLOW
PATIENT
*CONTAINS LAB RESULTS; OTHER DATA; AND RESPONSE REQUEST
PCP ACCEPTS,
REJECTS OR
MODIFIES
RECOMMENDATION
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?
THE END!!
THE END