Transcript Slide 1

RURAL HEALTH CARE RESEARCH CENTER
Evidence Based Decision-Making:
Career Challenges for Practice,
Management and Policy
Elizabeth Merwin, PhD, RN, FAAN
Madge M. Jones Professor of Nursing
Associate Dean for Research
Director, Rural Health Care Research Center
Radford University
School of Nursing
April 20, 2007
Acknowledgements
R01 NIMH Shortages of Health
Professionals in Rural Areas
P20 NINR Rural Health Care Research
Center
P50 NIMH, Southeastern Rural Mental
Health Research Center, 1992-2000
Sigma Theta Tau’s Policy Statement: EvidenceBased Nursing
“…..The society defines EBN as an integration of the
best evidence available, nursing expertise, and the
values and preferences of the individuals, families and
communities who are served. This assumes that optimal
nursing care is provided when nurses and health care
decision-makers have access to a synthesis of the latest
research, a consensus of expert opinion, and are thus
able to exercise their judgment as they plan and provide
care that takes into account cultural and personal values
and preferences. This approach to nursing care bridges
the gap between the best evidence available and the
most appropriate nursing care of individuals, groups and
populations with varied needs….”
http://www.nursingsociety.org/research/main.html#ebp
Resources for Evidence Based
Information
National Library of Medicine:
http://www.nlm.nih.gov/hsrinfo/hsrsites.html#Evi
dence%20Based%20Medicine%20and%20Healt
h%20Technology%20Assessment
Cochrane
Library:http://www.mrw.interscience.wiley.com/co
chrane/clsysrev/articles/CD005051/frame.html
AHRQ: http://www.guideline.gov/
Examples:
Evidence:
Cochrane: Interventions to improve hand hygiene
compliance in patient care
(Gould, Chudleigh, Moralejo, Drey)
Only 2 studies met criteria
Data: 2005 National Healthcare Disparities Report
-justification for importance of action
-doesn’t tell what to do
-stimulates research
-over time research findings can be synthesized into evidence
- example, RHCRC study with CHCs
Application to Practice/Policy
Healthy People 2010
http://phpartners.org/hp/
Report, Goals, Topic Area, Specific Goals
Baseline Data
Continued Evidence---data and articles
Mid-term evaluation
CHALLENGES
EDUCATION
– Determining Knowledge, Skills, Critical Thinking for different
levels
DEVELOPING ABILITY TO THINK WITH DATA
INCORPORATING QUALITY IMPROVEMENT DATA
BASED SOLUTIONS INTO PRACTICE
– Benchmarking
Linking practice, management and policy
DEVELOPING RESEARH KNOWLEDGE/SKILLS
–
–
–
–
Research Utilization
Research Dissemination
Participating in Research as Collaborator
Conducting Independent Research
Quality Improvement
Why do many settings/systems act in isolation in
choosing tools, forms, technology, developing
inservice programs etc?
– Why not have model policies, procedures, tools that
can be adapted?
– Need standardized measures, electronic data
collection and contributions to electronic databases
for analysis and comparison of trends among facilities
How can research findings be disseminated in a
more organized, useful way?
Strategies for Integrating Care and
for Quality Improvement
Integrate quality improvement programs of health care agencies with
researchers and research initiatives.
Design with researchers and incorporate into quality improvement programs
ongoing studies/evaluations of referrals, referral follow-up and outcomes
Develop provider network of existing referral/treating agencies
Link existing electronic data systems to facilitate patient follow-up. Do so
following HIPAA guidelines.
Need studies that follow patients over time through their use of health,
mental health and social systems.
These longitudinal studies will allow us to understand effectiveness of
treatment and to identify clinical and system changes to improve care. May
contribute to reduction of disability and mortality and increase probability of
return to optimal health.
Source: http://cdr.virginia.edu/cdr/
DATA BASED PROBLEM: Development of graphs and use of
presentation software for meaningful data presentations
You are responsible for leading an interdisciplinary team tasked with
improving the quality and cost of care provided to a specific patient
population of clients treated in the health system. Tomorrow you have an
initial meeting of this team.
You must begin the work with a data based presentation describing the
characteristics of this population, their utilization of services, the cost of
their care and how it is reimbursed. You must then lead a discussion to
identify priority areas to focus on as the team completes it’s assignment.
Pass out a Fact Sheet for everyone to take with them containing the most
relevant information.
Describe the characteristics of a patient population of your choice. Provide
a description of the utilization and cost of services for this population. From
the data identify a potential issue or problem that requires more in depth
information to fully understand. Compare to benchmarks for the nations
hospitals using data from HCUP-NET.
Cdr login page: https://cdr.virginia.edu
http://hcupnet.ahrq.gov/
http://www.ahd.com/
Hospital Compare: What Percentage of Pts with
Pneumonia received Smoking Cessation
Counseling/Advice?
Top Hospitals 100%
AVERAGE FOR ALL REPORTING HOSPITALS IN THE
UNITED STATES 79%
AVERAGE FOR ALL REPORTING HOSPITALS IN THE
STATE OF VIRGINIA 82%
CARILION NEW RIVER VALLEY MEDICAL CENTER
85%
Top Hospitals represents the top 10% of hospitals
nationwide.
Source:
http://www.hospitalcompare.hhs.gov/Hospital/Home2.asp?version=alternate&browser
=IE%7C6%7CWinXP&language=English&defaultstatus=0&pagelist=Home
Developing Evidence: Original
Research
Rural and Rural Mental Health
Implications for Practice, Management,
Policy
Notice implications of same study or
finding may differ for each area
Notice that concepts are complex and will
take many studies to get to evidence
strong enough for guidelines
Many Commissions/Task Forces
2005 Quality through Collaboration, The Future
of Rural Health , Institute of Medicine
2004 Report to the Secretary from the National
Advisory Committee on Rural Health and Human
Services
2001 Report to Congress: Medicare in Rural
America
Common Themes/Issues and
Problems
Shortage of Providers
Low availability of Resources
Technology has much potential
Integration is needed
Absence of data to inform report is
consistently a problem
Reports consistently present data on
country but often not broken down by rural
Percentages of Racial/Ethnic Populations Uninsured in
2006
Racial/Ethnic
Population
Hispanic
31.4
16.2
Non-Hispnic Black
Non-Hispanic White
10.1
14.5
Overall
0
5
10
15
20
25
30
Percentage Uninsured
Early Release of Selected Estimates Based on Data from the January-March 2006 National Health Interview Survey, CDC
http://www.cdc.gov/nchs/about/major/nhis/released200609.htm, accessed 11-11-06
35
Increasing Median Age in More Rural Areas
Median Age
42
40
38
Median Age
36
34
32
1
2
3
4
5
6
Urban-Rural Continum
7
8
9
Health Status of MSA vs Non-MSA
Percentage
35
30
25
20
NON-MSA
15
MSA
10
5
0
Excellent Very Good
Good
Fair
Perceived Health Status
Poor
Most RURAL to Most URBAN County Level Community
Characteristic Comparisons
Average
Demographics
Census
Per Capita Income
% Minority
Most Urban
Most Rural
724,482
30,814
26%
7,153
18,976
12%
Providers (per 10,000 Census)
MDs (’99)
RNs (’90)
Psychiatrists (’99)
Child psychiatrists (’99)
Psychologists(’90)
Social Workers (’90)
34
87
2
0.3
9
27
5
42
0.1
0.0
2
16
% MH HPSA(’00)
1
76
Merwin, E., Hinton, I, Dembling, B. and Stern, S. (2003) Shortages of Rural Mental Health Professionals.
Archives of Psychiatric Nursing, 17:1, pp.42-51.
Registered Nurses
1. Available in Every Community, in Every Health Setting
2. Shortage of RN’s Limits Potential for improving the availability and quality of
health care in rural areas through increased knowledge and intervention by
nurses.
3. Key to successful quality improvement and other research projects aimed
towards improving care.
•
WHAT IS NECESSARY TO INCREASE NURSING’s CONTRIBUTIONS TO
EVIDENCE BASED CARE?
RN Risk of Malpractice Awards
1994-1998 National Practitioner Databank,
N=1291 Paid Claims
Risk 0.69 per 1000 RNs
Factors explaining Risk (State)
– State Median Per Capita Income
– Physicians/Census
– Attorneys/Census
+
– % Rural Residents
– RNs/Census
--
+
+
--
Fanaeian, N. & Merwin, E. (2001) Malpractice: Provider Risk or Consumer Protection?
American Journal of Medical Quality, Vol. 16, No. 2, p. 43-57.
Southeastern Rural Mental Health Research Center
NIMH Funded 1992-2000
Director 1999-2004; Associate Director 1996-1999;
Director of Mental Health Services Research 1993-1995
R01 Shortage of Health Professionals in Rural Areas
http://www.nursing.virginia.edu/centers/srmhrc/
Goals for Transformed Mental Health System
“Americans Understand that Mental Health is Essential to Overall
Health
MH Care is Consumer and Family Driven
Disparities in MH Services are Eliminated
Early Mental Health Screening, Assessment, and Referral to
Services are Common Practice
Excellent Mental Health Care is Delivered and Research is
Accelerated.
Technology is Used to Access MH Care and Information.”
New Freedom Commission on Mental Health, 2003
Mental Disorders and Help
Seeking in Rural Populations
33% of 646 respondents
positive for 1 disorder
11% with help-seeking
intervention sought help
4.3% without
intervention sought help
Incentives to Seek Care
Differ by Race
White
NON-White
Church
68%
93%
Physician
67%
93%
Family
51%
87%
Police
90%
70%
Spouse
72%
35%
Preferences for Setting of Care
100
80
Home
60
Church
40
Family physician
20
0
Total rural African White
American
Women
Men
Comparison of Percentage of Population with Psychological Distress and Percentage
Receiving MH Care, by Race and Unemployment
25
20
15
10
5
0
White
African
American
American Indian
or Alaskan
Native
Asian
Two+ Races
Hispanic or
PctLatino
Distress
Unemployed
Pct MH Treatment/Counseling
Source: SAMHSA, National Survey on Drug Use and Health, 2005
Routine Screening
“Quality screening and early intervention will
occur in …..low-stigma settings”
Primary care, Schools, justice and child
welfare systems
“Children and adults will be screened for
mental illnesses during their routine
physical exams.”
New Freedom Commission on Mental Health, 2003
CHC Frequency of Administering
Standardized Questionnaire on Patient
Mental State
15
10
Frequency
5
0
Most of
the time
Some of
the time
Rarely
Never
Lack of Resources as Barriers to MH Services
25
20
15
Financial
Transportation
Primary No Time
No MH Provider
Frequency
10
5
0
No Barrier
Minimal
Moderate
Importance
Very
Exceptional
Interpersonal Perceptual or Interpersonal Barriers to
Mental Health Services
20
15
Frequency
10
No Barrier
Minimal
5
Moderate
Very
0
Exceptional
Community Reaction
Family Resistance
Patient Awareness of
Need
Importance
Personal Resistance
Mental Health Services Provided by Virginia
Community Health Centers, 2000
Offers Specific Mental Health
Programs
Offers Counseling n=20
Who does the counseling?1
Physicians
Social Workers
Psychologists
Psychiatrists
46%
56%
Number of
Centers
10
7
3
0
Multiple responses allowed1
Merwin, E., Hinton, I., Harvey, J., Kimble, K., Mackey, S. and Davis, K. (2001) Mental
Health Care in Virginia Community Health Centers. Report prepared for and
distributed by the Virginia Primary Care Association. http://www.vpca.com/
Never to
rarely
60.0
50.0
40.0
30.0
20.0
10.0
0.0
ObGyn
Medical
Pediatrics
Family
Internal
Sometimes
to frequently
Psychiatry
Percentage
Perceptions of Availability of
Quality Outpatient Mental Health
Care, by Physician Specialty
Almost
always to
always
Merwin, Attaporn, Xu, In Progress. From Community Tracking Survey, 2000-2001
Percentage of Graduates of Master's Programs in Nursing
Specializing in Psychiatric Nursing
Percentage of Psychiatric Nursing
Graduates
18
16.35
16
15.74
15.16
14.69
14
13.25
12.48
12
12.00
10
10.30
9.78 9.50
8.92
8.71
8
6.94
6
6.59 6.58
5.56
4.45
4
2
0
80
81
82
83
84
85
86
87
88
89
1980 - 1996
90
91
92
93
94
95
96
Survival Models of Community Tenure and Length of Stay
10 year longitudinal study, Virginia DMHMRSAS
Hospital Stays=61,648; Community Stays=70,051
Constructed 10 year profile for each patient
Survival Analysis: no unobserved heterogeneity
Findings:
– Holding demographic, prior history & diagnoses constant, women
have longer hospital stays than men and also return to the hospital
for another hospital stay more rapidly than men;
– African-American clients leave the community more quickly than
Whites but race did not affect hospital stay duration
– Individuals from rural areas had longer durations of hospital stays but
no difference in community stay duration
Stern, S., Merwin, E., Holt, F. (2002) Survival models of community tenure and length of hospital stay for the seriously mentally ill: a 10-year
perspective. Health Services & Outcomes Research Methodology 2:117-135, 2001.
STRATEGIES
DEVELOP RESEARCH CAPABILITIES
OF ALL NURSES
INCREASE INTERDISCIPLINARY
COLLABORATION
FOSTER COMMUNITY and
INTERORGANIZATIONAL
PARTNERSHIPS
Interdisciplinary/Interagency/Community Partnerships
Merwin, 1995, Interdisciplinary Research
“Bounded Rationality” Simon, 1957
Complexity of research problems beyond one
person Kahn & Prager, 1994
Broader, more relevant
NIMH, 1991
10 YRS--From 1995-2006
– From interdisciplinary research teams
– To interdisciplinary/Interagency/organization changes
– To research networks
Promote Interdisciplinary
Collaborations
Identify existing relationships and expand
relationships between original researchers and
other researchers
Provide leadership in developing
interdisciplinary research teams
Have interdisciplinary workshops and informal
discussions to explore potential collaborations
Lead interdisciplinary groups in developing
proposals to support collaborative research
Promote Interdisciplinary
Collaborations
Identify existing relationships and expand relationships
between organization members and others
Provide leadership in developing interdisciplinary
academic programs, research teams and innovative
practice opportunities;
Integrate education, research and practice
Develop financing mechanisms to support joint
appointments and roles among organizations
Have interdisciplinary workshops and informal
discussions to explore potential collaborations
Lead interdisciplinary groups in developing proposals to
support collaborative research, training and practice
Organizational Goals & Individual
Researcher and Practice Partner Goals and
Realities of Life
Consistently clarify and articulate organizational
goals
Monitor attainment of goal
Develop mechanisms to increase faculty
competencies, productivity and success for all
levels of faculty
To identify faculty’s goals, clarify expectations
and match with organizational goals, support
attaining goals
Develop and promote intrinsic and extrinsic
rewards for meeting goals.
Community-based Participatory Research
“A collaborative research approach that is designed to ensure and
establish structures for participation by communities affected by the
issue being studied, representatives of organizations, and
researchers in all aspects of the research process to improve health
and well-being through taking action, including social change.”
– “Co-learning and reciprocal transfer of expertise, by all research
partners, with particular emphasis on the issues that can be studied with
CBPR methods.”
– “Shared decision-making power.”
– “Mutual ownership of the processes and products of the research
enterprise.”
Source: http://www.ahrq.gov/clinic/epcsums/cbprsum.htm
Community Partnership Strategies
Develop long-term community partnerships among rural clinicians, administrators,
community leaders, academic researchers, policy makers and consumer groups.
In Past, relationships focused around individual projects/studies or discreet
problems or goals.
In Future, need ongoing formal and informal relationships supported by
infrastructure for communication and partnerships.
Formalize the partnerships
–
–
–
–
–
Who can contribute what? Don’t over commit. Better to acknowledge limitations and areas
of possible problems.
For example, if activities are only possible because of availability of one-time funding
make sure everyone knows funding will have to be obtained to continue. Make this a goal
of group to develop plan for sustainability.
Establish ground rules.
Use Memos of Agreements and Contracts
Work out IRB, HIPAA and other regulatory issues
Facilitate Critical Community
Partnerships
Develop an ongoing infrastructure to
support partnership with community
agencies
Develop an Infrastructure to conduct multisite, complex intervention studies
Contribute to those organizations by
studying problems important to them,
providing them data, and doing joint
proposals
Facilitate Critical Community
Partnerships, Con’t
Identify feasibility of ongoing infrastructure
to support partnership with
practice/research agencies
Infrastructure to conduct multi-site,
complex intervention studies, practice and
training
Contribute to those organizations by
studying problems important to them,
providing them data, and doing joint
proposals
Strategies For Organizational
Partnerships
Use of Video-technology to support
communication and implement activities.
Joint Hiring
– Example, Adding an advanced practice nurse to Pact
Team
– Faculty member working 1 day a week as advanced
practice nurse in community agency in non-traditional
role
Joint Appointments/Strategic Appointments to
Boards with Common Interests
From Undergrad to Seasoned
Researcher
Goal: Developing a research program
– Expert on a specific problem/area
– Create new knowledge to contribute to solutions
How to get there
– Educational requirements PhD
BSN to PhD
Get MSN along way
Get Clinical/Leadership experience along way
– Funding
Shortage of Faculty spurs availability of federal funds
– Receive tuition and stipend
– National Student Research Awards
BSN to PhD
Advantages
– Length of time to contribute is extended
– Benefit by increased economic gains of increased
education for longer period
– If choose academic career fit with career
opportunities of most disciplines
Post-Doctoral reimbursement
Higher Academic Ranks at Age equivalent to other
disciplines
Disadvantages
– May not be able to work full-time
Research Development: Helpful
Early Steps
Join a research team
– Research Assistant or Volunteer
Attend research meetings/conferences
Subscribe to research journals
From day 1, PUBLISH
– Your best student paper
– A special experience
– Letters to the editor in response to a publication
Participate in a study or evaluation in the setting
of your employment
– JCAHO requires ongoing quality evaluations
Requirements for Successful
Research Projects
Expertise in Content area
Expertise in Methodologies
Ability to develop close relationships with
interdisciplinary research team
Organization/ Management/Leadership Support
Credible and engaged with relevant
clinical/community partner
Doing important work from society’s
perspective
How to pick a Research Program?
Decision evolves
What do you love? What do you what to
know?
What is a burning interest?
What would you think about or be
concerned about and do if you never
planned to work a day in your life?
What are your special strengths/talents?
STUDY WHAT YOU KNOW
Many Sources of Funds But
Difficult to Obtain
Own organization
Local businesses and Foundations
Professional Organizations
Small Grant 25,000-50,000
R15 150,000
R21 Exploratory/Developmental Research
R01 Investigator Initiated
– New Investigator (~3-4 yrs after PhD)
– Senior Investigator
Potential Funding Examples
Dissertation Awards
– AHRQ Dissertation Funding
– NIMH Dissertation Funding
New Initiative for Minority Students
– NRSAs
Post-Docs in Health Services Research
– Institutional
– Individual
Integrating EVIDENCE and DATA
with Decision-Making
Policy
Practice
Education
Administration
Interdisciplinary
Research Teams
National, State Policy
making Boards and
Task Forces
Review Committees