Majority of daily patient/clinician interactions occur in ambulatory settingsMajority of prescriptions for medications written in ambulatory settings While growth of HMOs and large integrated healthcare systems has been dramatic, >50% of Americans still receive primary care services in smaller (3-10 clinician) practicesSignificant amount of care in these settings flies under radar of most national quality monitoring efforts“Practice-based research networks are designed for research on clinical practice and quality improvement activities. These networks generate both primary and specialty care data, often using data gathered prospectively for the purpose of research (in contrast to most existing data from practice, which document routine clinical care and may have important limitations for research purposes). These data may thus provide detailed clinical information from settings not captured in large integrated systems.” – 2010 IOM Report: Initial National Priorities for Comparative Effectiveness Research, page 151
Data from the AHRQ PBRN Resource Center, June 2011 presented at the Annual AHRQ/PBRN meeting
2/3 of the clinicians are physicians and 1/3 equally divided among NPs and PAs80% family medicine, 12% pediatrics, 8% internal medicine1 out 5 rural Oregonians receives their care in an ORPRN affiliated practice60% of the practices are physician owned
2000 update published in JAMA, 2004 by Mokdad, et al. showed inactivity & diet contributing to death at the 400,000 mark with tobacco at 435,000 deathsIn 2011 obesity has risen to the top of the listDecreasing cardiovascular risk factors may have a larger impact on mortality than the use of beta blockers, anticoagulants, and statins
PBRNs directly engage the medical practice community (solid line) and community members (dashed line). PBRNs may engage the community members through the practice (dotted line). A community may be geographic, demographic, disease specific, or a combination.Participatory research is not a method; it is an orientation to research that embraces sharing of power. Participatory research builds on long term relationships that outlast any specific research project. These relationships from the foundation of a sustained conversation that includes 2-way communication and shared decision making. PBR and PBRNs have solved 2 of the major problems that have vexed clinical researchers. PBRNs have solved the “location” problem by moving research into community practices where people get most of their care and addressing important clinical questions with large and diverse populations. PBR has solved the “orientation” problem by using the principles of community engagement and conducting research with their communities of practices, clinicians, patients, and community members so that the research is highly relevant and action-oriented.
Community research has moved beyond the 1933 Tuskegee Syphilis Study and now represents an economic and health benefit to communities.We use a participatory model as contrasted with helicopter research or mosquito research
CHIRP contrasts with investigator-initiated research testing hypotheses that advance the research agenda and reputation of the researchers compared to the needs and desires of the end-user—clinicians, patients, and communityFirst CREED symposia is Monday, October 24th. We will be oriented the community to the academic research community and go from practice to bedside to the bench
It is all about Partnerships: Community Health Improvement Partnership (CHIP) to the Community Health Improvement & Research Partnership (CHIRP)
Very positive about collaboration!!!
On (wicked witch)….In (Never Cry Wolf)….With (holding hands around the world)
Partnering with practice based research networks (pbrn)
Partnering with Practice-basedResearch Networks (PBRN)Paul B. McGinnis, MPACommunity Health, Quality and Practice Development DirectorOregon Rural Practice-based Research NetworkOregon Health & Science UniversityApril 17, 2013
• Describe the “real-world” laboratories of practice-based research• Show examples of PBRN work• Share experiences in working with CooperativeExtensionLearning Objectives
Green LA, et al. N Engl J Med 2001;344:2021-5.The “Ecology” of Medical Care
The Reach of Research• It is estimated that it takes an average of 17years for 14% of original research to reachpractice and benefit patients.(Balas and Boren. Yearbook of Medical Informatics 2000:65-70)This is part of what a Clinical Translation Science Award(CTSA) is meant to address
Primary Care Practice-Based ResearchNetworks (PBRNs)• A group of ambulatory primary care practices affiliated toinvestigate questions related to community practice• The majority of daily patient/clinician interactions occurin ambulatory settings, especially smaller (3-10 clinician)practices• Uses the community as a laboratory• Provides access to important, neglected phenomena• Designed for research on clinical practice and qualityimprovement activities
“Blue Highways” on the NIH RoadmapWestfall JM, Mold J, Fagnan, LJ. JAMA 2007;297:403-406.
• 152 PBRNs• 16,900 practices• Average 101practices/PBRN• 69,000 clinicians• Average of 4.9studies/PBRN• 69% have an EHRAHRQ Registered PBRNs
www.ohsu.edu/orprnOregon Rural Practice-Based Research NetworkThe mission of ORPRN is to improve the health of rural populations in Oregonthrough conducting and promoting health research in partnerships with thecommunities and practitioners we serve.
• Founded in 2002• A rural PBRN• 49 practices in 37 communities caring for>235,500 patients• 157 member clinicians• Diverse practice ownership and type (Physicianowned, FQHC, RHC, Hospital-based)• Governed by a member clinician SteeringCommittee
Health Extension in New Mexico: An Academic HealthCenter and the Social Determinants of DiseaseThe Agricultural Cooperative Extension Service model offers academic health centersmethodologies for community engagement that can address the social determinants ofdisease. The University of New Mexico Health Sciences Center developed Health ExtensionRural Offices (HEROs) as a vehicle for its model of health extension. Health extension agentsare located in rural communities across the state and are supported by regional coordinatorsand the Office of the Vice President for Community Health at the Health Sciences Center. Therole of agents is to work with different sectors of the community in identifying high-priorityhealth needs and linking those needs with university resources in education, clinical serviceand research. Community needs, interventions, and outcomes are monitored by countyhealth report cards. The Health Sciences Center is a large and varied resource, the breadthand accessibility of which are mostly unknown to communities. Community health needsvary, and agents are able to tap into an array of existing health center resources to addressthose needs. Agents serve a broader purpose beyond immediate, strictly medical needs byaddressing underlying social determinants of disease, such as school retention, foodinsecurity, and local economic development. Developing local capacity to address local needshas become an overriding concern. Community-based health extension agents can effectivelybridge those needs with academic health center resources and extend those resources toaddress the underlying social determinants of disease.Kaufman A, Powell W, Alfero C, et al Ann Fam Med. 2010 January; 8(1): 73–81.
Oregon Experience• Local Cooperative Extension Faculty serve onCommunity Health Improvement Partnerships(CHIPs)• Childhood Obesity Research and NutritionalEducation (MOO, PATCH, Pick of the Month)• Expert Guidance from Main Campus Faculty onCreating Linkages between Clinics andCommunity-based Resources to Manage Obesity(Guidebook)• Community Advisory Councils as part ofCoordinated Care Organizations
Why Research?• Communities want to solve problems. Policymakers and funders want to put resources intoprograms that are “evidence-based.”• Which comes first… the chicken or the egg?
Complexity Science and the Ecology ofHealth Care5Local Community3ClinicalEncounter2Clinician1Patient4Practice6Health SystemCrabtree BF et al. “Understanding practice from the ground up,”The Journal of Family Practice 2001; 50(10):883.
Practice-based Research is CommunityEngagementWestfall, Fagnan, Handley, McGinnis, Zittleman et al. JABFM.2009
Research as a Community AssetORPRN Newsletter, January 2010.http://www.ohsu.edu/research/orprn/news/newsletter/JANUARY%20NEWSLETTER.pdf
• Aim 1. Transform four community-based health coalitions inrural Oregon into receptive partners with the capacity to docommunity-based participatory research (CBPR).• Aim 2. Increase the capacity of academic researchers tounderstand and engage in collaborative community-basedresearch with rural communities, practices and patients.• Aim 3. Collaborate with three CTSAs to develop anddisseminate effective tools for CTSAs and PBRNs to createresearch partnerships between academics and ruralcommunities.Community Research Enhancement andEducation Development (CREED)
Adding Research to the CHIP Model—CHIP to CHIRP(McGinnis PB. Family & Community Health.2010)
PUBLIC POLICYCOMMUNITYORGANIZATIONALINTERPERSONALknowledge, attitudes, skillsINDIVIDUALThe Socio-Ecological Model
Research vs. IntuitionIntuition ScientificGeneral Approach Let’s try this and see how it works Let’s make an assumption, implement aprecise plan to study how it works, try itout, collect data, share with others andrepeatObservation Casual and uncontrolled Very systematic and carefully controlledReporting Ok to be biased and subjective Must be unbiased and objectiveConcepts Ok to be ambiguous (general and evenimprecise)All aspects of activities must be clearlydefinedInstruments The tools used can be informal Tools used could be informal but must beaccurate and preciseMeasurement No real concerns about validity orreliabilityIt is important that measures used areboth valid and reliableHypotheses Do not need to be tested or proven Very important to have a well-articulatedtheory or assumption that you are tryingto prove or disproveAttitude No need to be critical or skeptical ofresults because outcomes are justassumptionsImportant to ask questions about theresultsNational Research Council (2002), Scientific Research in Education. National Academy Press. Wash DC., pg. 104.
Why Research? In Their Own Words• Skill Development– My background is a Science Major. I know about Petri dishresearch but I’m interested in learning about hands onhuman research.– I am interested in learning how community members canenhance their skills [through research training]– I do outreach in the Latino Community and I don’t knowwhat goes on behind the scenes [with research] to developprograms. I’d like to learn more.• Impact/Benefit to Community– I’m trying to understand how to have an impact in mycommunity.– [Research can help us] look at what works and whatdoesn’t work.
Community Engaged Research Spectrum• Low: Conducting surveys on the street, randomphone sampling, posting fliers in the newspaper• Low/Medium: Convening focus groups or forumsat the start or end of a study to assess needs orreport back findings• Medium: Soliciting community to assist inimplementing a study designed by a researcher• High: Participating in bi-directional, collaborativepartnership on problem of mutual interest thatengages community in all stages of researchUCSF. Collaboration with Community-based Organizations and Agencies: A Guide for UCSFResearchers. http://ctsi.ucsf.edu/files/CE_CARE_Guide_for_Investigators.docHow would you like toparticipate in research?
Community Engaged Research vs.“Helicopter Research”...Drive by research, mosquito research...“Outside research teamsswooped down from theskies, swarmed all overtown, asked nosey questionsthat were none of theirbusiness and thendisappeared—never to beheard of again.”Slide adapted with permission from Dr. Ann Macaulay, McGill UniversityMontour LT, Macaulay AC, Adelson N. Diabetes Mellitus and Arteriosclerosis:Returning research results to the Mohawk Community. CMA Journal 1988;34:1591-93.