Transcript Advancing Your Research through PeRC and PROS: Unique Opportunities for Specialists and Generalists Alexander Fiks, MD MSCE Robert Grundmeier, MD James Massey, RN.

Advancing Your Research through
PeRC and PROS: Unique
Opportunities for Specialists and
Generalists
Alexander Fiks, MD MSCE
Robert Grundmeier, MD
James Massey, RN
Aim
• By the conclusion of the session, participants
will be able to:
– Describe the benefits for specialists and
generalists of conducting research in primary care
settings
– Take advantage of electronic health record data to
accelerate research
– Understand how to work with PeRC and PROS to
prepare a research proposal
What is a Practice-Based Research Network
(PBRN)?
“Collaborations of practitioners and
researchers who, over time, conduct
studies to understand and improve
clinical practice, with the ultimate
goal of improving patient health”
Mort Wasserman, 2006
Key Features of PBRNs
• Employ the collaborative model, with high level
of input from practitioners and increasingly
families
• Organizational framework that outlasts a single
study, with an institutional base (e.g., academic
institution, professional organization)
• Regular communications within network before,
during, and after studies
Great Reasons to Do Research in
Practice Settings
• Sutton’s Law: that’s where the majority of
patients and problems are!
• Practices are the best place to study the
prevention of health problems
• Practices are a good place to study problems
over time
• Clinical data which details decision making
and the care delivered resides in practices
Three More Reasons to Do Research in
Practice Settings…
• Patients in practices are more representative of
any clinical problem than those seen in hospitals
• Practices are a good place to study the problems
that cause substantial morbidity, but don’t result
in hospitalization (e.g., mental health) and how
families live with and make decisions regarding
chronic conditions
• Practitioners are more likely to believe and act
upon evidence that is generated in practice
settings
PeRC
• Established in 2002 to permit clinical research
that has potential to improve the delivery of
primary care
• Funded as a PBRN by AHRQ 2002-2005
• Awarded Master Contractor status 2006
• Awarded P30 Center Grant 2012
The Children’s Hospital of
Philadelphia
Primary Care Network
1 Hospital
3 Urban primary care centers
28 Suburban and rural practices
13 Specialty care centers with 6
Pediatric inpatient units at local
community hospitals
PeRC Organizational
Structure
Alex Fiks, MD
Associate Medical
Director, PeRC
PeRC Review Board
Louis Bell, MD
Medical Director, PeRC
Pete White, PhD
Director, CBMi
Jim Massey, RN, BSN, MBA
Network Director
Bob Grundmeier, MD
Scientific Director, CBMi
PeRC Advisory Board
Primary Care Leadership
Valerie McGoldrick, RN
Nurse Coordinator
PeRC Strengths
• Diversity of urban and suburban patient populations
• System-wide EHR to identify eligible participants, facilitate
collection of data, and to allow implementation of decision
support tools
• Integrated health system with single administrative structure
and Institutional Review Board (IRB)
• Over 630,000 total ambulatory visits in 2013 provided to
about 220,000 patients
• 182 physicians, 27 nurse practitioners & 1 physician
assistant
• All practices currently participating in at least 3 active
research studies
Recruitment Methods
• EHR prompt
• Study invitation letters
• Patient rosters
SEAD Study
EHR
# Enrolled
CHOP
Yes
410 in 12 months
Site B
No
86 in 18 months
CHAT Study
• 120 subjects recruited from primary care
SCOUT Study Enrollment to Date
Practice or Dept
Enrolled in
Last 3 Months
CHOP Emergency Department
BROOMALL CARE NTWK
CC CARE NTWK
CENTRAL BUCK CARE NTWK
CHADDS FORD CARE NTWK
CHESTNUT HL CARE NTWK
COATESVILLE CARE NTWK
DREXEL HILL CARE NTWK
FLOURTOWN CARE NTWK
HAVERFORD CARE NTWK
HIGHPOINT CARE NTWK
INDIAN VAL CARE NTWK
KARABOTS CARE NTWK
MARKET ST CARE NTWK
MEDIA CARE NTWK
MKT 3550 CN CHOP CAMP
MKT 3550 GP FAC PRAC
NEWTOWN CARE NTWK
PAOLI CARE NTWK
ROXBOROUGH CARE NTWK
S PHILA CARE NTWK
SMITHVILLE CARE NTWK
SPRINGFIELD CARE NTWK
W CHESTER CARE NTWK
W GROVE CARE NTWK
Number
Enrolled
12
2
6
9
5
2
1
3
1
3
3
2
6
1
4
2
1
5
2
2
6
1
2
2
3
1
3
2
Enrolled in
Last 6 Months
2
1
3
2
1
1
2
1
1
3
2
1
1
5
Total
86
17
1
1
1
1
1
2
1
1
1
1
1
27
KISS Study Prompt
• 526 caregivers referred
• 64 caregivers recruited
Weekly Contact Lists
Clinic Roster
Pediatric Research in Office Settings
(PROS)
• Practice-based research networks of the
American Academy of Pediatrics
• Core activities made possible by funding from
HRSA MCHB
• The mission of PROS is to improve the health
of children and enhance primary care practice
by conducting national collaborative practicebased research
4
PROS Practices
NY I - 23
NY II - 23
NY III - 22
11
3
5
7
CA I -
6
NH - 7
7
1
1
22
15
5
MA - 35
23
31
9
5
4
23
16
22
13
5
17
3
CA II - 20
7
CA IV - 4
VT - 17
9
6
29
10
11
11
2
CA III - 7
2
32
19
6
8
RI - 4
CT -
16
NJ -
16
DE - 4
MD - 30
18
12
DC - 2
42
11/6/2015
13
Canada – 8
E. Military Chapter – 2
W. Military Chapter - 3
Puerto Rico – 2
Randomized Controlled Trial to Prevent
Child Violence (Safety Check)
Pediatrics, 2008
Topics Discussed and Recalled 1 & 6 Months Later –
Intervention and Control Group Comparison
Media
100
90
80
70
60
50
40
30
20
10
0
Post-Visit
1 mo.
Firearms
Discipline
6 mo.
Post-Visit
1 mo.
6 mo.
Light blue bars = Intervention group
Dark blue bars = Control Group
Post-Visit
1 mo.
6 mo.
Clinical Effort Against
Secondhand Smoke Exposure (CEASE)
Pediatrics, 2008
Pediatrics, 2013
C-PRL: Center for Pediatric Research
and Learning
• An affiliation of 3 networks:
– PeRC
– PROS
– Practice Improvement Network (PIN)
• Received an AHRQ grant to:
– Enhance PBRN productivity and efficiency
– Create capacity for rapid response to funding
opportunities available only to center grant recipients
• C-PRL is the only exclusively pediatric “Center”
Combining PeRC and ePROS data
Proportion on 1+ Psychotropic Medication
25
20
15
10
5
0
• Blue=PeRC
• Red=ePROS
CER2: Comparative Effectiveness
Research through Collaborative
Electronic Reporting
• CER2 is a “super-network” including PeRC,
ePROS, and several other EHR based networks
• CER2 will provide EHR data extracts from a
diverse group of over 800,000 children in >100
practices and clinics
• Will provide ability to do point-of-care EHRbased clinical decision support in a subset of
sites
2
CER
Partners
• DARTNet Institute
• ePROS (40 sites)
• eNQUIRENET of the American Academy of
Family Physicians (15 sites)
• MetroHealth/Case Western Reserve (19 sites)
• Boston University Child Health Disparities
Repository (9 sites)
CER2 Studies
• Pharmacoepidemiology / observational
comparative effectiveness research on several
topics
•
•
•
•
Atypical antipsychotic prevalence
Atypical antipsychotic and side effects
Psychotropic polypharmacy
Prevalence and side effects of off-label asthma medications
• Prevalence, recognition, and natural history of
hypertension (HTN)
• Point-of-care clinical decision support trial of HTN
recognition and management
Adventures in Big Data
• PeRC: 350,000 children, 10+ years of data
• ePROS: 80,000 children, 3 years of data
• CER: 750,000 children, 10+ years of data
(planned)
CER Data Model
Data Scope
• Diagnoses (ICD-9)
– Encounter-based and problem-oriented
• Medication
– Psychopharm categories
• Immunizations
• Labs
– Chemistries, LFTs, TFTs, CBC, Coags
Prospective Studies
• Through CER-squared, we will be able to identify
children from across the country with both common
and rare conditions or treatments
– Complex chronic conditions
– Using relatively uncommon medications (atypical
antipsychotics)
– Behavioral problems (sleep disorders)
– Rare disorders
• Electronic health record data can then be
supplemented by prospectively collected data:
– Internet surveys such as REDCap
– Telephone contact
Intervention Studies: Patient Portals
• In February, AHRQ announced interest in “Applications
to Provide Policy Relevant Evaluations to Inform
Development of Health Information Technology (IT)
Meaningful Use Objectives”
• C-PRL is studying the feasibility of using an EHR-linked
patient portal, MyAsthma, to provide education and
enable families to communicate treatment concerns
and goals, and report symptom control, medication
use, and side effects
• Other aims include assessing impact on asthma
management and describing barriers and solutions to
improve adoption, sustainability, and impact on care
Meaningful Use
• Participants:
–
–
–
–
Parents/guardians of children 6-12 years old
Asthma on problem list
English-speaking
At least 1 office visit for asthma in past 12 months
• Setting:
– 10 PeRC practices, 10 ePROS practices
– Practices must meet MU criteria (at least 20% of
children Medicaid/CHIP insured)
– CHOP PolicyLab and AAP Child Health Informatics
Center are key partners in this work
Future…
• We are looking for collaborators here at CHOP
and around the country with interest in using
the resources of C-PRL and the broader CERnetwork to conduct research aimed to
improve child health and health care….
PeRC Process
• Use website to discuss:
http://www.research.chop.edu/programs/per
c/
Family and Clinician Input Can Improve
Study Design
• In PeRC, families (new!) as well as clinicians
and administrators review all proposals
• Studies can then be responsive to both the
needs of the clinical team as well as
participants
How an Idea
Becomes a PROS Study
• Idea suggested to PROS leadership
• Study proposal presented to Steering
Committee
• Proposal presented to Chapter Coordinators
• Study is developed
• Funding is sought
• Study conducted
PROS LOGIC MODEL
Ideas from practitioners
PROS process
Ideas from researchers
PROS studies
New knowledge
Improved child
health outcomes
Better pediatric
health care
Characteristics of a Study
Appropriate for PROS
• Requires a geographically dispersed sample
of patients and/or practitioners
• Requires a very large sample size or
population base
– uncommon condition
– infrequent outcome
Contact Us
Alex Fiks
• 6-2304 or [email protected]
Bob Grundmeier
• 6-6746 or [email protected]
Jim Massey
• 6-5167 or [email protected]
Websites
CRU: http://cbmi.chop.edu/data-reporting-and-management.html
PeRC: http://www.research.chop.edu/programs/perc/
PROS: http://www2.aap.org/pros/
Your Thoughts and Questions….