|
State Networks of Colorado Ambulatory Practices & Partners
~ A collaborative association of practice-based research networks
in Colorado ~
Summary of Studies
Leaders for Effective Activity Planning (LEAP)
Purpose of Study: The Leaders in Effective Activity Planning
(LEAP) project will evaluate whether creating an office environment that supports
wellness will enhance the uptake of effective behavior change interventions
among clinicians, staff, and their patients. Practice members will use the same
behavioral change tools as are offered patients to improve their personal lifestyle.
This project is based on two parallel goals: 1) introduce a set of behavioral
change resources that help people set and attain goals through reasonable modifications
in their current behaviors, and 2) develop a healthy lifestyle culture within
the entire office as a strategy to enhance the uptake of effective behavior
change interventions.
Two distinct but complementary PBRNs will collaborate on this project: the
Colorado Research Network (CaReNet), a network of urban and suburban primary
care practices committed to caring for the unerserved, and the High Plains Research
Network (HPRN), a network of rural health care providers located in medically
underserved regions of Colorado. Project LEAP will evaluate a practice level
intervention to increase uptake of the behavior change program and will demonstrate
the feasibility of patient level data collection. Project LEAP will provide
screening instruments and intervention tools and support for primary care practices
to deliver brief, evidence-based counseling on exercise improvements and dietary
improvements.
The tools include use of pedometers with weekly logs, which provide feedback
to both patients and clinicians, as well as provide patient-level data for the
study. Individualized "coaching" will be available to participants
to support their behavior change efforts. Project LEAP will be evaluated by
quantitative and qualitative methods to understand the barriers and facilitating
factors in implementing the program in primary care.
This project was funded by the Robert Wood Johnson Foundation's grant program
Prescription for Health.
Back to Top
Measuring Readiness to Translate Research into Practice
PI: Debbi Main, PhD
Purpose of Study: Both conducting high quality research and
translating research findings into practice are important measures of success
for practice-based research networks (PBRNs). We are interested in conducting
exploratory research to understand how the organizational features of primary
care practices affect their readiness to translate research into medical practice.
The Colorado Research Network (CaReNet) is an AHRQ-funded PBRN dedicated to
conducting research to improve the health and health care of diverse patient
populations. As an important part of further growth and development, CaReNet
is interested in collecting information to understand and improve how research
is translated in its network practices. CaReNet is collaborating with the Colorado
Health Outcomes Program (COHO) to test and refine methods for measuring readiness
to translate in primary care offices.
The first phase of this study is to conduct interviews of key informants of
issues related to readiness to translate research findings into practice. The
second phase of this study includes developing a quantitative survey for measuring
PBRN practices’ ability to translate research into practice using information
obtained from the qualitative interviews. The quantitative survey will then
be pilot tested with approximately 450 participants within the PBRN practices.
We will also pilot methods for providing useful feedback to practices about
their readiness and potential “interventions.” This study will be
conducted within 8-10 primary care practices in CaReNet. Through the use of
self-report surveys to measure readiness to translate, we will improve our understanding
of factors that affect how well practices adapt to and manage changes involved
in translating research findings into practice.
Back to Top
Mental Health Referrals from Primary Care
PI: Chris Duclos, PhD
Purpose of Study: Through this card study we are interested
in learning more about how primary care clinicians handle mental health issues
among their patients.
Background: Primary care physicians are integral to the provision
of mental health services. However, primary care physicians vary widely in their
ability to diagnose and treat patients with mental health problems. Better linkages
between physicians and mental health providers could facilitate the coordination,
continuity, and quality of mental health services. While the literature and
direct patient care shows us this linkage is important, anecdotal information
tells us there are many barriers to actual referral/recommendations to and collaboration
with mental health providers. Research is lacking regarding collaboration and
referral in primary care. Without an understanding of the dynamics involved
in referral and collaboration, we cannot improve patient quality of care. Objective:
We will describe primary care provider perceptions of facilitators and barriers
to recommendation or referral to a mental health provider where a psychological
problem is a significant component of the ambulatory visit. Methods: Cross-sectional
observational survey study that examines 2400 patient encounters with an estimated
24% (576) of these encounters needing psychological management. Data will be
collected on encounters including patient and physician demographics, if referral
warranted and made, and physician's perceptions of the reasons behind the decision-making.
Discussion: The results will inform the development of a full-scale proposal
to investigate practice-based interventions that target primary care and mental
health collaboration. Results will also inform local and national policy addressing
the service needs of patients with emotional problems. Dissemination of results
will be through peer-reviewed journals, national and local presentations, and
policy alert newsletters.
Back to Top
Patient-Guided Tools to Promote Colon Cancer Screening
PI: Fred Grover, Jr., MD
Purpose of Study: Colorectal cancer (CRC) is the second leading
cause of cancer related death in the U.S. Unfortunately, past and current efforts
have failed to increase CRC screening to the NCI 2000 goal of 50% of people
aged 50-70. Typical interventions to promote CRC screening in primary care are
sporadic and lack a mechanism to achieve the combined involvement of the physician,
patient, and practice. While tracking systems are useful for ensuring patient
compliance with other types of cancer screening (e.g. Paps), they are rarely
used for CRC screening.
This randomized controlled trial will evaluate a multi-level intervention designed
to (1) activate the decision-making process between the provider, patient, and
practice, and (2) ensure follow through with screening decision. 300 patients
between the age of 50-70 who schedule a health maintenance visit in one of 10
practices in the Colorado Research Network will be eligible. Just before their
visit, intervention patients will view an interactive educational module on
a handheld computer. The module will address the known issues that patients
consider when making a decision about CRC screening, such as prevalence of and
vulnerability to CRC and the cost and pain associated with screening. After
viewing the program, patients will take the computer to their clinician, where
she/he will enter the patient's screening decision into a tracking program.
Reminder letters sent by the practice will help patients remember to follow
through with their decision. Both the intervention group and a comparison group
will receive a mailed educational brochure, but the comparison group will receive
no further intervention.
Our primary aim is to test the effectiveness of a multi-level intervention
to improve 12 month rates of (number of people who receive) CRC screening. Secondarily,
we will use mixed methods to describe those practice, provider, and patient
factors that influence whether and how the intervention components are implemented
in primary care. This study will demonstrate that a primary care practice-based
research network can gather and systematically assess data on CRC screening
delivery, utilization, and short-term outcomes. The results will indicate the
feasibility and utility of the intervention and will also shed light on the
factors that influence patient decisions to comply with primary care providers'
recommendations regarding CRC screening. Furthermore, this method of education
and tracking is not specific to CRC and could provide opportunities for increasing
screening rates for other types of cancer.
Back to Top
Domestic Violence in Pregnant Primary Care Patients
PI: Meredith Silverstein, PhD
View
summary of results (access may be limited).
Purpose of Study: The American College of Obstetrics and Gynecology
and the American Medical Association have both recognized interpersonal physical
violence (IPV) during pregnancy as a significant public health problem (Petersen
et al., 1997). Physical violence against pregnant women has been associated
with adverse birth outcomes such as low birthweight and preterm delivery due
to placental dysfunction (Berenson et al., 1991, Parker et al., 1994) as well
as increased risk of neonatal death (Webster, 1996). Primary care is a logical
setting within which to study this problem given the family focused, preventative
medicine orientation of primary care practitioners. Previous research into intimate
partner violence in primary care found that 1 in 5 women had experienced domestic
violence in her lifetime (McCauley et al., 1995). However, the prevalence of
intimate partner violence during pregnancy in a primary care population remains
unknown. Moreover, the factors that may contribute to an increased risk of violence
during pregnancy are also unknown. The proposed research will fill this gap
and is intended to provide primary care practitioners with easily detectable
markers of an increased risk of abuse during pregnancy. The American College
of Obstetrics and Gynecology and the American Medical Association have both
recognized interpersonal physical violence (IPV) during pregnancy as a significant
public health problem (Petersen et al., 1997). Physical violence against pregnant
women has been associated with adverse birth outcomes such as low birthweight
and preterm delivery due to placental dysfunction (Berenson et al., 1991, Parker
et al., 1994) as well as increased risk of neonatal death (Webster, 1996). Primary
care is a logical setting within which to study this problem given the family
focused, preventative medicine orientation of primary care practitioners. Previous
research into intimate partner violence in primary care found that 1 in 5 women
had experienced domestic violence in her lifetime (McCauley et al., 1995). However,
the prevalence of intimate partner violence during pregnancy in a primary care
population remains unknown. Moreover, the factors that may contribute to an
increased risk of violence during pregnancy are also unknown. The proposed research
will fill this gap and is intended to provide primary care practitioners with
easily detectable markers of an increased risk of abuse during pregnancy.
Using an interdisciplinary theoretical model, it is hypothesized that the batterer’s
paternity certainty plays a pivotal role in the expression of physical abuse
during pregnancy. This study will use a cross-sectional survey methodology.
An anonymous, self-administered survey, developed from the investigator’s
pilot project will be distributed to a cross-section of pregnant women who present
for care within a primary care practice based research network. Approximately
1600 women will be surveyed over a six month period. During the Health Services
Dissertation Research Grant, the following aims will be accomplished:
- Determine the prevalence of IPV around the time of pregnancy in a primary
care population.
- Identify changes in the perceived frequency and severity of battery and
the risk factors of these changes around the time of pregnancy in a primary
care population.
Back to Top
National Ambulatory Medical Care Survey (NAMCS)
PI: Wilson D. Pace, MD
Purpose: NAMCS is a nationwide survey of health providers
which provides information about ambulatory medical care services delivered
and demographic, diagnostic and reason for visit information about patients
receiving those services. Randomly selected providers across the United States
collect the survey information on every-other patient for a full week. Surveys
were conducted in 1973, 1975 through 1981, 1985, 1989 through 1991 and continue
annually.
To better understand the patients cared for by CaReNet practices, we revised
the 1994 NAMCS survey. The 1994 NAMCS survey offered six options for answering
the question regarding expected source(s) of payment: HMO/other prepaid, Medicare,
Medicaid, Other Government, Private/Commercial Insurance, Patient Paid, and
Other. Multiple responses could be given to fully describe the expected sources
of payment. In the revised CaReNet version, we added a sub-box under Patient
Paid labeled "Discounted." We gave written instructions to each provider
that define Discounted as "a formal discount program." In the state
of Colorado a formal discount program could include the Colorado Indigent Care
Program or a formal "sliding-scale" program offered by the individual
practice, but not discounts given at the discretion of any clinician.
The 1994 NAMCS survey also required providers to write in any prescription
medications ordered or provided during the visit. In order to reduce the complexity
of the form and shorten the time required to complete this information, we changed
this question to a simple yes/no format for the CaReNet revised form.
Data collection in CaReNet followed the national model for collecting information.
Each site completed surveys on every other patient visiting the practice and
receiving medical services for one full workweek or until 100 forms had been
completed. Patients visiting the practice for administrative reasons, e.g.,
insurance or billing questions, were excluded from the data collection. All
clinicians who saw patients during the assigned week contributed to the data
collection. In order to investigate any seasonality occurring in diagnosis,
reason for visit, or visitation patterns, CaReNet practices repeated the data
collection every 92 days for one year.
A study coordinator at each site checked study forms for completeness, secured
missing data and then mailed the forms to the CaReNet offices. Study forms were
logged in and check for completeness and inconsistencies. Missing or inconsistent
forms were copied and returned to the practice for correction. Data were coded
using the same methods and coding schemes used in NAMCS. Diagnoses were coded
using the International Classification of Diseases, Ninth Revision, Clinical
Modification (ICD-9-CM) and reasons for visit were coded using A Reason for
Visit Classification for Ambulatory Care. A commercial data entry firm entered
and verified the data from the forms. The resulting ASCII data set was then
read into the Statistics for the Social Sciences (SPSS) for data management
and analysis.
Results. Data collection began in April 1998. To date, data
has been collected on 3069 patients by 160 providers. Females account for 67%
of the total, and Hispanics account for 20% of all patients. Just over 23% of
patients were part of a formal discounted program and 22% were on Medicaid.
Back to Top
Practice Based Research Networks (PBRN) - Development Grant
PI: Wilson Pace, MD
Purpose of Study: The funding of this grant provided a unique
opportunity for the Colorado Research Network (CaReNet) to focus efforts and
resources toward creating a sound growth and development plan. A strong group
of consultants and experts met regularly with the CaReNet team. They brought
diverse and experienced perspectives to several key tasks:
- developing bi-directional communication throughout CaReNet,
- ensuring that CaReNet continues to serve disadvantaged and minority populations,
- creating methods to collect data from and return research findings to clinical
practice, and
- ensuring CaReNet has reliable financial backing.
This grant cycle ended in 2001 and resulted in a formal 5-year CaReNet development
plan.
Back to Top
Primary Care Network Survey (PRINS)
PI: Wilson Pace, MD
Purpose: The Primary Care Network Survey (PRINS) is a national
survey that will be conducted in Colorado Research Network (CaReNet) and in
18 other practice-based research networks during the spring and summer of 2002.
PRINS collects information about the practices that participate in practice-based
research networks, the clinicians who work in those practices, and the patients
seen there.
PRINS 1 is a demographic survey about clinicians. Each CaReNet clinician must
complete the Clinician Information survey (PRINS1) and return it to CaReNet.
We expect this form to take less than a minute of each clinician’s time.
PRINS 2 is a survey about patients who receive care at CaReNet practices. A
member of our research staff will be present in your practice to facilitate
this data collection. Over the course of two weeks, selected physicians will
participate in PRINS 2. As patients arrive in the clinic, every other patient
will be invited to participate in the study. The front desk staff will be asked
demographic and insurance questions about each patient invited to participate
in the study. The patient and the clinician will be asked questions about the
patient’s reason for visit and its outcome.
We will collect the data using a paper form or by entering the information
into a small, hand-held computer. The computer is very portable and works with
a touch screen, which we believe makes it easy for most patients and clinicians
to use.
A CaReNet research assistant will come to your practice to administer the surveys.
The research assistant will obtain patient consent, enroll patients, and instruct
them on how to use the computer. We believe that this added help in your practice
will ensure that the study proceeds efficiently.
CaReNet added several questions to the PRINS survey to allow us to learn even
more about the patients who receive care in CaReNet practices. For example,
we ask if patients have had to forego medical treatment because they were concerned
about the cost, and we ask how they usually get to their medical appointments
(by car, bus, walk, etc.). Answers to these and other questions should give
us more comprehensive information about the patients cared for in our practices.
Back to Top
Type 2 Diabetes Card Study 2001
PI: Bennett Parnes, MD
Purpose of Study: The data collected from this pilot study
will be used to better describe patients with type 2 diabetes in CaReNet. This
effort includes understanding variations in patient glycemic control and the
variability of control among practices for developing interventions around improving
care. These data will also help better characterize the network, strengthening
our position when seeking funds for further diabetes investigations. Back to Top
Stressful life events and multisomatoform disorder
in female primary care patients
Aims of Project:
- To determine prevalence of stressful life events and multisomatoform symptomology
severity differentiated by type of practice patient (private, community, residency)
- To determine association of stressful life events with multisomatoform symptomology
severity (low vs. med/high)
Methods
- Cross-sectional anonymous survey design
- Stressful Life Event Scale (events within last year) & PHQ 15
- 75 female patients ³ 18 years per site (n=685)
- 90.3% response rate of eligible patients
- Nine CaReNet practices
Back to Top
Why Don't PCPs Intervene when A1cs are Elevated? (AKA
A1c Decision Making)
PI: Bennett Parnes, MD
A paper describing the results was published in Diabetes
Care. Preliminary results were presented at the Colorado
Convocation 2002 and at the North
American Primary Care Research Group meeting (2002). This study was funded
by AAFP.
Purpose of Study: Improved glycemic control, as measured by glycosylated
hemoglobin (A1c) values, is associated with improved outcomes in Type 2 diabetes.
National diabetes clinical guidelines have established A1c goals of less than
7 or 8. However, in the context of chronic disease management within primary
care settings, there may be many occasions that elevated A1c's are acceptable
to providers. Objective: Determine the frequency and reasons that A1c
values >8 are acceptable to primary care providers. Design: Provider
survey on attitudes about diabetes management. Followed by card study completed
by the primary care provider at the time an A1c result is reviewed. If A1c>8
and no intervention is done, determine the reasons for this. Setting:
Statewide primary-care-based research network with a high percentage of underserved
patients. Patients or other Participants: Providers reviewing A1c results
on their established patients with Type 2 diabetes. Main Outcome Measures:
The frequency and reasons that A1c's >8 are acceptable to providers, as associated
with physician characteristics and attitudes, and patient factors (demographics,
co-morbidities, medications).
Back to Top
|