Research in the Real World:

1
Research in the Real World
Lessons Learned from Prescription for Health

• Rebecca Etz
• Deborah Cohen
• Nicole Isaacson
• Bijal Balasubramanian
• Benjamin Crabtree
• Alfred Tallia

2
Lets Get Real

• Translation
• Realize the shift from efficacy to effectiveness
• Dissemination
• Capture context and strategy as well as outcomes
• Public Health Impact
• Create partnerships in the community

3
Evaluation of P4HThe Analysis Teams Focus

• Conceptualization
• Studying implementation as way to evaluate what
  works in real-life setting (i.e. effectiveness)
• Methods Used
• Practice Surveys
• Site Visits/Interviews
• Online diary

4
Evaluation The Analysis Teams Focus

• Data Analysis Qualitative Data
• 1st Read the diary data
• 2nd Read it again
• 3rd Really read the data

5
Evaluation The Analysis Teams Focus

• Data Analysis Quantitative Data
• 1st Find missing data
• 2nd Fix any inconsistencies
• 3rd Convert numbers into words

6
Lets Get Real

• Translation
• Realize the shift from efficacy to effectiveness
• PBRNs are an ideal environment
• Research oriented, but not unusual
• 85 practices (10 PBRNs)
• 92 Family medicine practices
• Staff turnover of 8-12

7
PBRNs and Getting RealREAIM as our lens
Reach, Effectiveness, Adoption, Implementation,
Maintenance

• REAIM was proactively for the first time in
  practice-based, primary care research
• Across all 10 projects in round 2, P4H

8
PBRNs and Getting RealREAIM as our lens

• REAIM and our qualitative data allowed us to ask
• different kinds of questions
• How do we take something that we know works, or
  that we think will work, and put that thing into
  practice?
• How did you get it to work?
• Why did it work and can we get it to work
  elsewhere?

9
PBRNs and Getting RealREAIM as our lens

• Two themes emerged from the diary data the
  tensions between
• Flexibility Fidelity
• an issue of translation
• Quality Improvement Research
• an issue of dissemination

10
PBRNs and Getting RealFidelity vs Flexibility

• Fidelity and Flexibility
• In the primary care setting, interventions are
  not plug and play
• They are tailored to the contours of the practice
• Dr made the comment that we need to come up
  with something that will work at a 1 nurse office
  like hers

11
PBRNs and Getting RealFidelity vs Flexibility

• Flexibility is a reflection of the inescapable
  realness of the real world
• The other striking thing is the varied ways
  that the practices are implementing the HRA
• Keep it at reception, given to patients at check
  in
• Give it to one staff member, he administers all
• Given to all patients of the in house diabetes
  educator
• Keep it at nurses station, used primarily by
  one care giving team

12
PBRNs and Getting RealFidelity vs Flexibility

• Understanding how research is integrated into
  real life practice is essential
• PBRNs facilitate that translation with all the
  muckiness that it implies

13
Lets Get Real

• Translation
• Realize the shift from efficacy to effectiveness
• Dissemination
• Capture context and strategy as well as outcomes
• Share solutions for navigating the tension
  between QI and research

14
PBRNs and Getting RealQuality Improvement vs
Research

• Research is about
• establishing/following protocols, assessing
  outcomes
• Enrolling the right type and number of patients
• Having a bounded data collection period
• Securing funds to pay for research and sometimes
  the intervention
• Maintaining fidelity implementing the
  intervention according to an established protocol

15
PBRNs and Getting RealQuality Improvement vs
Research

• Quality Improvement is about
• understanding organization and setting
• Tailoring improvement to fit the protocols and
  procedures of the practice
• Adapting to setting/context, allowing for
  flexibility
• Institutionalizing the improvement,
  sustainability

16
PBRNs and Getting RealQuality Improvement vs
Research

• Front line PCPs are overwhelmed this is reality
• Choices for recruitment are often about choosing
  practices positioned for improvement
• PBRNs allow us to see how those that actually
  take the change on are able to make it happen

17
PBRNs and Getting RealQuality Improvement vs
Research

• On the ground, team members manage patient
  expectations
• Staff report this is the first thing the
  patient asks what do I get for participation?
• Projects that were seamless where increased
  service was in the foreground, research in the
  background faired best

18
PBRNs and Getting RealQuality Improvement vs
Research

• QI is institutional where research is finite
  in terms of time resources
• We had practices take a two week break from
  referring patients It has been more difficult
  than I had anticipated to get them back up and
  running ...
• We tried to fine tune our message for the staff
  ... That is, one patient enrollment per staff
  member per day.
• PBRNs showed us institutionalization was
  manageable but involved sacrifices

19
Investigating with REAIMWheres the Tension QI
and Research

• Front line practices dont have a lot of slack
• Research teams bring resources and its hard to
  hold up when they are gone
• This practice does prevention because its
  important, not because its reimbursed. We
  offered to keep the intervention on at this
  practice (but without free services). They pulled
  the plug on the project.

20
Investigating with REAIMWheres the Tension QI
and Research

• PBRN based research allows practices to build a
  line of inquiry that
• shows the value of what they did
• wins funding enabling translation of research
  into practice
• PBRNs are an environment that makes translation
  happen

21
Lets Get Real

• Translation
• Realize the shift from efficacy to effectiveness
• Dissemination
• Capture context and strategy, share solutions
• Public Health Impact
• Create partnerships in the community
• Fill in the missing elements

22
In the Real World linking to community
resources is easier said than done

• Primary Care
• Elements
• Identify patients at risk
• Capacity to refer patients
• Know how to access community resources

• Community Resource
• Elements
• Availability
• Affordability
• Accessibility
• Perceived as valuable

23
Primary Care ElementsIdentifying Patients at Risk

• Many practices did not have processes in
• place to identify patients at risk

24
Primary Care ElementsIdentifying Patients at Risk

• Project teams were able to help them develop
  what was needed
• This practice had, with the help of our
  facilitator, modified their vital signs template
  in the EHR (eClinical Works) to include smoking.
  His staff review smoking and update status at
  every visit. The inclusion of smoking as a vital
  sign plus verbal reminders by the nurses keeps
  the issue in front of the doctor and appears
  to have increased referrals to the Quit Line and
  his use of brief counseling strategies.

25
Primary Care ElementsMaking the Referral

• Limited capacity for referrals was a barrier ...
  
• If we need to print referrals for faxing,
  maybe someone in the research teams office
  could do it (some concern about stressing the
  referral person...)
• Project teams offered different strategies for
  simplifying referrals
• Having the direct real-time link to the
  designated outreach personmakes it very easy
  for the physician to make the referral quick
  and easy.

26
Primary Care ElementsMaking the Time

• Limited time was another barrier ...
• Talked with Doctor 630 am... had read
  material, said it sounded like a good study,
  as long as it didnt take too much time would be
  happy to do it (like 30 seconds).
• And project teams helped practices met these time
  constraints
• The rooming staff person reported that she did
  the P4H pop-up as part of the vital signs
  process. She reports it was not extra work/time.

27
Primary Care ElementsKnowing How to Access/Use
Resources

• Community resources are fluid, many, and
  difficult to track
• Projects addressed this in a number of ways
• Web-tools, HIT, resource cards
• People as portals to community resources
• Tapping into national, state, or health
  systems
• Building relationships with resources

28
Community Resource ElementsAvailability,
Affordability

• Many practices, particularly those in rural and
  low income areas, reported a scarcity of
  community resources
• When resources did exist in communities, they
  were often not affordable
• A barrier for counseling is patients affording
  it - many would be interested in group visits if
  free, reason for interest in the study
• Currently they will refer to some
  nutritionists, but sporadic and dependant on what
  insurance will cover, more often for diabetic
  patients

29
Community Resource ElementsAccessibility

• Grounded and informed by patient need, projects
  teams took many creative approaches
• Offering in-house counseling
• Developing website and IVR systems
• Offering and paying for branded services
• Leveraging their relationships with community
  resources

30
PBRNs are Real

• P4H projects, and the use of REAIM, show
• PBRNs as an ideal setting in which to innovate
• Providing real-world effectiveness
• Balancing internal and external validity
• Fostering proactive intervention designs
• Greater public appeal and rapid adoption
• Enabling view of potential public impact
• Benefit of qualitative and quantitative in
  unison

31
PBRNs are Real

• Translation
• Integrate Full integration of RE-AIM model into
  research and intervention design from project
  conception
• Dissemination
• Context qualitative and quantitative work
  together to suggest potential
• Public Health Impact
• Adapt Interventions must be responsive to site
  specific needs functional, cultural, emotional