[primary care Practice-Based Research Networks:\
putting research into practice and practice into research]{.smallcaps}

[2005 ahrq pbrn research conference]{.smallcaps}

[July 20-22, 2005]{.smallcaps}

Renaissance Hotel, 999 Ninth St. NW, Washington D.C.

# 

# [INSIDE:]{.underline}

# 

# Meeting Agenda 

# Presentation Abstracts

# List of Poster Presentations 

# Poster Abstracts 

# Personal Workplan 

# *Thursday, July 21, 2005* CONFERENCE AGENDA

+-------------------------------------------------+--------------------+
| **[Registration]{.smallcaps}**                  | **7:30 A.M.-11:30  |
|                                                 | A.M.**             |
+-------------------------------------------------+--------------------+
| **[Overview of the Conference]{.smallcaps}**    | **8:00 A.M.-8:15   |
|                                                 | A.M.**             |
| David Lanier, MD                                |                    |
|                                                 | *Grand Ballroom    |
| Associate Director CP3, AHRQ                    | South*             |
+-------------------------------------------------+--------------------+
| **[Welcome]{.smallcaps}**                       | **8:15 A.M.-8:30   |
|                                                 | A.M.**             |
| Carolyn Clancy, MD Helen Burstin, MD, MPH       |                    |
|                                                 | *Grand Ballroom    |
| Director, AHRQ Director CP3, AHRQ               | South*             |
+-------------------------------------------------+--------------------+
| **[Introduction to the PBRN Resource Center: A  | **8:30 A.M.-9:00   |
| National Survey of Primary Care                 | A.M.**             |
| PBRNs]{.smallcaps}**                            |                    |
|                                                 | *Grand Ballroom    |
| William Tierney, MD                             | South*             |
|                                                 |                    |
| Co-director, Resource Center                    |                    |
+-------------------------------------------------+--------------------+
| **[Describing the Primary Care Experience:      | **9:00 A.M.-9:30   |
| Results of the PRINS Survey]{.smallcaps}**      | A.M.**             |
|                                                 |                    |
| Helen Binns, MD, MPH, Children's Memorial       | *Grand Ballroom    |
| Hospital, Chicago (PPRG)                        | South*             |
+-------------------------------------------------+--------------------+
| **[Multi-PBRN Collaborative Research: Lessons   | **9:30 A.M.-10:30  |
| Learned from PRINS, National Children's Study   | A.M.**             |
| pilot, and Prescription for                     |                    |
| Health]{.smallcaps}**                           | *Grand Ballroom    |
|                                                 | South*             |
| -   [Moderator]{.underline} -- David Lanier, MD |                    |
|                                                 |                    |
| -   Helen Binns, MD, MPH                        |                    |
|                                                 |                    |
| -   Caitlin Oppenheimer, MPH, Resource Center   |                    |
|                                                 |                    |
| -   Larry Green, MD, Prescription for Health    |                    |
+-------------------------------------------------+--------------------+
| **[Break \-- view posters, congressional hall   | **10:30 A.M.-11:00 |
| c]{.smallcaps}**                                | A.M.**             |
+-------------------------------------------------+--------------------+
| **[Concurrent Sessions I]{.smallcaps}**         | **11:00 A.M.-12:00 |
|                                                 | P.M.**             |
+-------------------------------------------------+--------------------+
| > **IA *-- Implementing PRINS in Your           | *Meeting Room 2*   |
| > Network***                                    |                    |
+-------------------------------------------------+--------------------+
| -   [Moderator]{.underline} -- Jack Pascoe, MD  |                    |
|                                                 |                    |
| >           Helen Binns, MD, MPH               |                    |
+-------------------------------------------------+--------------------+
| > **IB *-- Working with the PBRN Resource       | *Meeting Room 3*   |
| > Center***                                     |                    |
+-------------------------------------------------+--------------------+
| >           William Tierney, MD                |                    |
| >                                               |                    |
| >           Dan Gaylin, MPA                    |                    |
+-------------------------------------------------+--------------------+
| > **IC *-- Setting the Network Research Agenda  | *Meeting Room 4*   |
| > in Large, Geographically Diverse PBRNs***     |                    |
+-------------------------------------------------+--------------------+
| -   [Moderator]{.underline} -- Tom Stewart      |                    |
|                                                 |                    |
| >           "The PROS Pediatricians'           |                    |
| > Perspective"-Alyna Chien, MD, University of   |                    |
| > Chicago (PROS)                                |                    |
| >                                               |                    |
| >           "International Primary Care        |                    |
| > Research"- John Beasley, MD, University of    |                    |
| > Wisconsin (IFPCRN)                            |                    |
+-------------------------------------------------+--------------------+
| > **ID *-- Working with Your IRB***             | *Meeting Room 5*   |
+-------------------------------------------------+--------------------+
| -   [Moderator]{.underline} -- Kevin Peterson,  |                    |
|     MD                                          |                    |
|                                                 |                    |
| >           Shelley Bizila, Indiana University |                    |
+-------------------------------------------------+--------------------+

+-------------------------------------------------+--------------------+
| **[Lunch:]{.smallcaps}**                        | **12:00 P.M.-1:00  |
|                                                 | P.M.**             |
| **["PBRNs and the Wisdom of                     |                    |
| Crowds"]{.smallcaps}**                          | *Grand Ballroom    |
|                                                 | Central*           |
| Richard Wasserman, MD, MPH                      |                    |
|                                                 |                    |
| University of Vermont (PROS)                    |                    |
+-------------------------------------------------+--------------------+
| **[Practice System Improvements and PBRNs: A    | **1:00 P.M.-2:30   |
| Panel Discussion]{.smallcaps}**                 | P.M.**             |
|                                                 |                    |
|                                                 | *Grand Ballroom    |
|                                                 | South*             |
+-------------------------------------------------+--------------------+
| >           [Moderator:]{.underline} John      |                    |
| > Hickner, MD, MPH                              |                    |
| >                                               |                    |
| >           [Panelists:]{.underline} Charles   |                    |
| > Burger, MD; Allen Dietrich, MD; Mary Ruhe RN, |                    |
| > BS                                            |                    |
+-------------------------------------------------+--------------------+
| **[Concurrent Sessions II]{.smallcaps}**        | **2:30 P.M.-3:45   |
|                                                 | P.M.**             |
+-------------------------------------------------+--------------------+
| > **IIA *-- Measuring and Improving the Quality | *Meeting Room 2*   |
| > of Care***                                    |                    |
+-------------------------------------------------+--------------------+
| -   [Moderator]{.underline} -- Carmela          |                    |
|     Lomonaco, PhD                               |                    |
|                                                 |                    |
| >           "Delivery of Childhood             |                    |
| > Immunizations in Rural Oregon"- Lyle Fagnan,  |                    |
| > MD, University of Oregon (ORPRN)              |                    |
| >                                               |                    |
| >           "Improving Rates of Influenza      |                    |
| > Immunization in Asthma Patients"-Rowena       |                    |
| > Dolor, MD, MPH, Duke PCRC                     |                    |
| >                                               |                    |
| >           "Asthma Medication Adherence in a  |                    |
| > PBRN"-Angela Wisniewski, PharmD, University   |                    |
| > of Buffalo (UNYNet)                           |                    |
| >                                               |                    |
| >           "Supporting Physician Management   |                    |
| > of Dyslipidemia" (Research in                 |                    |
| > Development)-James Notaro, PhD, University of |                    |
| > Buffalo (UNYNet)                              |                    |
+-------------------------------------------------+--------------------+
| > **IIB *-- Using Information Technology to     | *Meeting Room 3*   |
| > Improve the Quality of Care***                |                    |
+-------------------------------------------------+--------------------+
| -   [Moderator]{.underline} -- Michael          |                    |
|     Parchman, MD, MPH                           |                    |
|                                                 |                    |
| >           "PBRNs and PDAs"-Myra Crawford,    |                    |
| > PhD, University of Alabama PBRN               |                    |
| >                                               |                    |
| >           "Effect of EMR on Medication       |                    |
| > Safety"-Grace Kuo, PharmD, Baylor University  |                    |
| > (SPUR-Net)                                    |                    |
| >                                               |                    |
| >           "EHR Applications to Improve Care  |                    |
| > for Acute Respiratory Infections"-Jeffrey     |                    |
| > Linder, MD, MPH, Brigham & Women's PBRN       |                    |
| >                                               |                    |
| >           "Monitoring Compliance after       |                    |
| > Implementation of an Outpatient CPOE system   |                    |
| > with Decision Support" (Research in           |                    |
| > Development)-Michael Matheny, MD Brigham &    |                    |
| > Women's PBRN                                  |                    |
+-------------------------------------------------+--------------------+
| > **IIC *-- Practice Facilitators and PBRNs***  | *Meeting Room 4*   |
+-------------------------------------------------+--------------------+
| -   [Moderator]{.underline} -- David Meyers, MD |                    |
|                                                 |                    |
| >           Zsolt Nagykaldi, PhD, University   |                    |
| > of Oklahoma (OKPRN)                           |                    |
+-------------------------------------------------+--------------------+
| > **IID *-- Connecting Network Practices        | *Meeting Room 5*   |
| > Electronically***                             |                    |
+-------------------------------------------------+--------------------+
| -   [Moderator]{.underline} -- David Lanier, MD |                    |
|                                                 |                    |
| >           "Communication Methods in Primary  |                    |
| > Care Surveillance"- Michael Grasmick, PhD,    |                    |
| > University of Wisconsin (WReN)                |                    |
| >                                               |                    |
| >           "Development of the Electronic     |                    |
| > Primary Care Research Network (ePCRN)"- Kevin |                    |
| > Peterson, MD, MPH, University of Minnesota    |                    |
| > (MAFPRN)                                      |                    |
+-------------------------------------------------+--------------------+
| **[Break]{.smallcaps}**                         | **3:45 P.M.-4:00   |
|                                                 | P.M.**             |
+-------------------------------------------------+--------------------+

+-----------------------------------------------+---+---------------------+
| **[Concurrent Sessions]{.smallcaps} *III***   |   | **4:00 P.M.-5:15    |
|                                               |   | P.M.**              |
+-----------------------------------------------+---+---------------------+
| > **IIIA *-- Best Practices: PBRNs and        |   | *Meeting Room 2*    |
| > Community Practice***                       |   |                     |
+-----------------------------------------------+---+---------------------+
| -   [Moderator]{.underline} -- David Meyers,  |   |                     |
|     MD                                        |   |                     |
|                                               |   |                     |
| -   "Community-based Participatory Research   |   |                     |
|     Principles"-Laura Anderko, PhD,           |   |                     |
|     University of Wisconsin Milwaukee         |   |                     |
|     (MNCCRN)                                  |   |                     |
|                                               |   |                     |
| >           "CHC Clinician Strategies to     |   |                     |
| > Meet Subspecialty Healthcare Needs of       |   |                     |
| > Uninsured Patients"-James Werner, PhD, Case |   |                     |
| > Western Reserve University (RAP)            |   |                     |
|                                               |   |                     |
| -   "Youth Violence Prevention: A Case for    |   |                     |
|     Increasing Provider-Community             |   |                     |
|     Collaborations"-Carmela Lomonaco, PhD,    |   |                     |
|     University of Southern California (LANet) |   |                     |
|                                               |   |                     |
| -   "The Reflective Practitioner              |   |                     |
|     Process"-Lyndee Knox, PhD, University of  |   |                     |
|     Southern California (LANet)               |   |                     |
+-----------------------------------------------+---+---------------------+
| > **IIIB *-- Pediatric/Adolescent Care***     |   | *Meeting Room 3*    |
+-----------------------------------------------+---+---------------------+
| -   [Moderator]{.underline} -- Jack Pascoe,   |   |                     |
|     MD                                        |   |                     |
|                                               |   |                     |
| >           "Systematic Nutritional          |   |                     |
| > Assessment in Pediatric Practice            |   |                     |
| > (SNAPP)"-Adolfo Ariza, MD, Children's       |   |                     |
| > Memorial Hospital, Chicago (PPRG)           |   |                     |
| >                                             |   |                     |
| >           "Office-Based Low Carb Diet      |   |                     |
| > Intervention in Obese Teens"-Robert Siegel, |   |                     |
| > MD, University of Cincinnati (CPRG)         |   |                     |
|                                               |   |                     |
| -   "How Healthy Are Adolescents              |   |                     |
|     Really?"-Cecelia Gaffney, EdD,            |   |                     |
|     Dartmouth(CECH)                           |   |                     |
|                                               |   |                     |
| -   "Better Adolescent Health Visit through   |   |                     |
|     PDA-based Counseling"-Ardis Olson, MD,    |   |                     |
|     Dartmouth (CECH)                          |   |                     |
+-----------------------------------------------+---+---------------------+
| > **IIIC *- Risk Detection/Reduction in       |   | *Meeting Room 4*    |
| > Primary Care***                             |   |                     |
+-----------------------------------------------+---+---------------------+
| -   [Moderator]{.underline} -- Alan Adelman,  |   |                     |
|     MD                                        |   |                     |
|                                               |   |                     |
| >           "Cardiovascular Risk Reduction   |   |                     |
| > Strategy"-Paul Woolf, MD, MBA,              |   |                     |
| > Crozer-Chester Hospital                     |   |                     |
| >                                             |   |                     |
| > (CKHN)                                      |   |                     |
| >                                             |   |                     |
| >           "Diabetes and Cardiovascular     |   |                     |
| > Risk Factors"-Michael Parchman, MD, MPH,    |   |                     |
| > University of Texas (STARNet)               |   |                     |
|                                               |   |                     |
| -   "GALS: Gender and Lifestyle               |   |                     |
|     Study"-Katrina Donahue, MD, MPH,          |   |                     |
|     University of North Carolina (NCFPRN)     |   |                     |
|                                               |   |                     |
| -   "Screening for Behavioral Health Risks in |   |                     |
|     Rural Oregon Children" (Research in       |   |                     |
|     Development)-Lyle Fagnan, MD, University  |   |                     |
|     Oregon (ORPRN)                            |   |                     |
+-----------------------------------------------+---+---------------------+
| > **IIID *- Smoking Cessation***              |   | *Meeting Room 5*    |
+-----------------------------------------------+---+---------------------+
| -   [Moderator]{.underline} -- Tom Stewart    |   |                     |
|                                               |   |                     |
| >           "Smoking Status as a Vital       |   |                     |
| > Sign"-Stephen Rothemich, MD, MS, Medical    |   |                     |
| > College of Virginia (ACORN)                 |   |                     |
| >                                             |   |                     |
| >           "A Practice Sponsored Website to |   |                     |
| > Help Patients Pursue Health                 |   |                     |
| > Behaviors"-Steven Woolf, MD, MPH, Medical   |   |                     |
| > College of Virginia (ACORN)                 |   |                     |
|                                               |   |                     |
| -   "Tobacco Usage among Patients in a        |   |                     |
|     Statewide PBRN"-Shawn Ralston, MD,        |   |                     |
|     University of New Mexico (RIOSNet)        |   |                     |
|                                               |   |                     |
| -   "Assessment of Quitting Behavior in       |   |                     |
|     Smokers within a PBRN"-Daryl Wiley, MD,   |   |                     |
|     Medical College of Georgia (HamesNet)     |   |                     |
+-----------------------------------------------+---+---------------------+
| > ***Reception and Poster Presentations***    | > |                     |
|                                               |   |                     |
|                                               | * |                     |
|                                               | * |                     |
|                                               | 5 |                     |
|                                               | : |                     |
|                                               | 1 |                     |
|                                               | 5 |                     |
|                                               | > |                     |
|                                               |   |                     |
|                                               | P |                     |
|                                               | . |                     |
|                                               | M |                     |
|                                               | . |                     |
|                                               | > |                     |
|                                               |   |                     |
|                                               | - |                     |
|                                               | - |                     |
|                                               | > |                     |
|                                               |   |                     |
|                                               | 6 |                     |
|                                               | : |                     |
|                                               | 1 |                     |
|                                               | 5 |                     |
|                                               | > |                     |
|                                               |   |                     |
|                                               | P |                     |
|                                               | . |                     |
|                                               | M |                     |
|                                               | . |                     |
|                                               | * |                     |
|                                               | * |                     |
|                                               | > |                     |
|                                               | > |                     |
|                                               |   |                     |
|                                               | * |                     |
|                                               | C |                     |
|                                               | o |                     |
|                                               | n |                     |
|                                               | g |                     |
|                                               | r |                     |
|                                               | e |                     |
|                                               | s |                     |
|                                               | s |                     |
|                                               | i |                     |
|                                               | o |                     |
|                                               | n |                     |
|                                               | a |                     |
|                                               | l |                     |
|                                               | > |                     |
|                                               |   |                     |
|                                               | H |                     |
|                                               | a |                     |
|                                               | l |                     |
|                                               | l |                     |
|                                               | > |                     |
|                                               |   |                     |
|                                               | C |                     |
|                                               | * |                     |
+-----------------------------------------------+---+---------------------+

# *Friday, July 22, 2005* CONFERENCE AGENDA

+-------------------------------------------------+---+-------------------+
| **[Overview of Today's Sessions]{.smallcaps}**  |   | **8:00 A.M.-8:15  |
|                                                 |   | A.M.**            |
| David Meyers, MD                                |   |                   |
|                                                 |   | *Grand Ballroom   |
| CP3, AHRQ                                       |   | South*            |
+-------------------------------------------------+---+-------------------+
| **[PBRNs and Health Information Technology: A   |   | **8:15 A.M.-9:45  |
| Panel Discussion]{.smallcaps}**                 |   | A.M.**            |
|                                                 |   |                   |
|                                                 |   | *Grand Ballroom   |
|                                                 |   | South*            |
+-------------------------------------------------+---+-------------------+
| >           ­[Moderator:]{.underline} William   |   |                   |
| > Tierney, MD                                   |   |                   |
| >                                               |   |                   |
| >           [Panelists:]{.underline} Charles   |   |                   |
| > Safran, MD, Harvard Medical School,           |   |                   |
| > President, American Medical Informatics       |   |                   |
| > Association; Marc Overhage, MD, PhD,          |   |                   |
| > Regenstrief Institute (RESNet)                |   |                   |
+-------------------------------------------------+---+-------------------+
| **[Concurrent Sessions IV]{.smallcaps}**        | * |                   |
|                                                 | * |                   |
|                                                 | 9 |                   |
|                                                 | : |                   |
|                                                 | 4 |                   |
|                                                 | 5 |                   |
|                                                 | A |                   |
|                                                 | . |                   |
|                                                 | M |                   |
|                                                 | . |                   |
|                                                 | - |                   |
|                                                 | 1 |                   |
|                                                 | 0 |                   |
|                                                 | : |                   |
|                                                 | 4 |                   |
|                                                 | 5 |                   |
|                                                 | A |                   |
|                                                 | . |                   |
|                                                 | M |                   |
|                                                 | . |                   |
|                                                 | * |                   |
|                                                 | * |                   |
+-------------------------------------------------+---+-------------------+
| > **IVA *-- Ask The Experts: IT Concerns of     | * |                   |
| > Your Network***                               | M |                   |
|                                                 | e |                   |
|                                                 | e |                   |
|                                                 | t |                   |
|                                                 | i |                   |
|                                                 | n |                   |
|                                                 | g |                   |
|                                                 | R |                   |
|                                                 | o |                   |
|                                                 | o |                   |
|                                                 | m |                   |
|                                                 | 2 |                   |
|                                                 | * |                   |
+-------------------------------------------------+---+-------------------+
| -   Charles Safran, MD                          |   |                   |
|                                                 |   |                   |
| -   Marc Overhage, MD, PhD                      |   |                   |
|                                                 |   |                   |
| -   William Tierney, MD                         |   |                   |
+-------------------------------------------------+---+-------------------+
| > **IVB *-- Information Management***           | * |                   |
|                                                 | M |                   |
|                                                 | e |                   |
|                                                 | e |                   |
|                                                 | t |                   |
|                                                 | i |                   |
|                                                 | n |                   |
|                                                 | g |                   |
|                                                 | R |                   |
|                                                 | o |                   |
|                                                 | o |                   |
|                                                 | m |                   |
|                                                 | 3 |                   |
|                                                 | * |                   |
+-------------------------------------------------+---+-------------------+
| -   [Moderator]{.underline} -- John Hickner,    |   |                   |
|     MD, MPH                                     |   |                   |
|                                                 |   |                   |
| -   "Missing Clinical Information during        |   |                   |
|     Private Primary Care Visits"-Peter Smith,   |   |                   |
|     MD, University of Colorado (BIGHORN)        |   |                   |
|                                                 |   |                   |
| -   "Ameliorators of Errors in Primary          |   |                   |
|     Care"-Douglas Fernald, MS, University of    |   |                   |
|     Colorado (CaReNet)                          |   |                   |
|                                                 |   |                   |
| -   "Dashboard Technology" (Research in         |   |                   |
|     Development)-Peggy Wagner, PhD, University  |   |                   |
|     of Georgia (HamesNet)                       |   |                   |
+-------------------------------------------------+---+-------------------+
| > **IVC *-- Best Practices: Translating         | * |                   |
| > Research Into Practice***                     | M |                   |
|                                                 | e |                   |
|                                                 | e |                   |
|                                                 | t |                   |
|                                                 | i |                   |
|                                                 | n |                   |
|                                                 | g |                   |
|                                                 | R |                   |
|                                                 | o |                   |
|                                                 | o |                   |
|                                                 | m |                   |
|                                                 | 4 |                   |
|                                                 | * |                   |
+-------------------------------------------------+---+-------------------+
| -   [Moderator]{.underline} - Michael Parchman, |   |                   |
|     MD, MPH                                     |   |                   |
|                                                 |   |                   |
| -   "Implementing a Complex Diabetes            |   |                   |
|     Intervention in a PBRN"-Wilson Pace, MD,    |   |                   |
|     University of Colorado (CaReNet)            |   |                   |
|                                                 |   |                   |
| -   "TRANSLATE: A best practice example"-Kevin  |   |                   |
|     Peterson, MD, MPH, University of Minnesota  |   |                   |
|     (MAFPRN)                                    |   |                   |
+-------------------------------------------------+---+-------------------+
| > **IVD *-- Best Practices: Developing and      | * |                   |
| > Working with A PBRN Community Advisory        | M |                   |
| > Board***                                      | e |                   |
|                                                 | e |                   |
|                                                 | t |                   |
|                                                 | i |                   |
|                                                 | n |                   |
|                                                 | g |                   |
|                                                 | R |                   |
|                                                 | o |                   |
|                                                 | o |                   |
|                                                 | m |                   |
|                                                 | 5 |                   |
|                                                 | * |                   |
+-------------------------------------------------+---+-------------------+
| -   [Moderator]{.underline} -- David Meyers, MD |   |                   |
|                                                 |   |                   |
| -   John Westfall, MD, University of Colorado,  |   |                   |
|     High Plains Research Network                |   |                   |
+-------------------------------------------------+---+-------------------+
| **[Break]{.smallcaps}**                         | * |                   |
|                                                 | * |                   |
|                                                 | 1 |                   |
|                                                 | 0 |                   |
|                                                 | : |                   |
|                                                 | 4 |                   |
|                                                 | 5 |                   |
|                                                 | A |                   |
|                                                 | . |                   |
|                                                 | M |                   |
|                                                 | . |                   |
|                                                 | - |                   |
|                                                 | 1 |                   |
|                                                 | 1 |                   |
|                                                 | : |                   |
|                                                 | 0 |                   |
|                                                 | 0 |                   |
|                                                 | A |                   |
|                                                 | . |                   |
|                                                 | M |                   |
|                                                 | . |                   |
|                                                 | * |                   |
|                                                 | * |                   |
+-------------------------------------------------+---+-------------------+

+-------------------------------------------------+--------------------+
| **[Concurrent Sessions V]{.smallcaps}**         | **11:00 A.M.-12:15 |
|                                                 | P.M.**             |
+-------------------------------------------------+--------------------+
| > **VA *- Clinical Care***                      | *Meeting Room 2*   |
+-------------------------------------------------+--------------------+
| -   [Moderator]{.underline} -- Alan Adelman, MD |                    |
|                                                 |                    |
| -   "Evaulation of Decision Aids for Screening  |                    |
|     Mammography in Women 40-49"-William Curry,  |                    |
|     MD, MS, Penn State CAN                      |                    |
|                                                 |                    |
| -   "Physicians' Knowledge and Practice         |                    |
|     Patterns in Detecting and Treating Chronic  |                    |
|     Kidney Disease"-Chet Fox, MD, University of |                    |
|     Buffalo (UNYNet)                            |                    |
|                                                 |                    |
| -   "Access and Use of Osteoporosis Technology  |                    |
|     in Rural Oregon"-Lyle Fagnan, MD,           |                    |
|     University of Oregon (ORPRN)                |                    |
|                                                 |                    |
| -   "Screening for Parental Depression during   |                    |
|     Well Child Visits"-Ardis Olson, MD,         |                    |
|     Dartmouth (CECH)                            |                    |
+-------------------------------------------------+--------------------+
| > **VB *-- Chronic Disease Management***        | *Meeting Room 3*   |
+-------------------------------------------------+--------------------+
| -   [Moderator]{.underline} -- David Lanier, MD |                    |
|                                                 |                    |
| -   "Measuring the Reach of a                   |                    |
|     Technology-Oriented Self-Management Support |                    |
|     Tool for Vulnerable Populations"-Dean       |                    |
|     Schillinger, MD, University of California,  |                    |
|     San Francisco (CRN)                         |                    |
|                                                 |                    |
| -   "Engaging Primary Care Physicians to        |                    |
|     Support Family Caregivers of Demented       |                    |
|     Patients"-Jonathan Rosen, MD, ProHealth     |                    |
|     Physician Network Connecticut               |                    |
|                                                 |                    |
| -   "Health Outcomes with Shared Medical        |                    |
|     Appointments" (Research in Development) --  |                    |
|     Renuka Khurana, MD, MPH, Parkland Hospital  |                    |
|                                                 |                    |
| -   "Community Care for Complex Illness"        |                    |
|     (Research in Development) -Lou Lukas, MD,   |                    |
|     Lehigh Valley (EPICnet)                     |                    |
+-------------------------------------------------+--------------------+
| > **VC *-- Best Practices: PBRN Operations***   | *Meeting Room 4*   |
+-------------------------------------------------+--------------------+
| -   [Moderator]{.underline} -- Carmela          |                    |
|     Lomonaco, PhD                               |                    |
|                                                 |                    |
| -   "Solving the HIPAA Dilemma in PBRN          |                    |
|     Practices"-Donald Nease, MD, University of  |                    |
|     Michigan (GRIN)                             |                    |
|                                                 |                    |
| -   "Using an After Hours Nursing Triage        |                    |
|     Service for Patient Recruitment"-Jane       |                    |
|     Garbutt, MBChB, Washington University (WU   |                    |
|     PAARC)                                      |                    |
|                                                 |                    |
| -   "Recruiting Patients From Multiple          |                    |
|     Sites"-Brenda Hudson, MA, Indiana           |                    |
|     University (ResNet)                         |                    |
|                                                 |                    |
| -   "A Cancer Center-based Shared Resource for  |                    |
|     PBRNs"-James Werner, PhD, Case Western      |                    |
|     Reserve University (RAP)                    |                    |
+-------------------------------------------------+--------------------+
| > **VD *-- Research Methods: Study Design       | *Meeting Room 5*   |
| > Considerations for PBRNs***                   |                    |
+-------------------------------------------------+--------------------+
| -   [Moderator]{.underline} -- John Hickner, MD |                    |
|                                                 |                    |
| -   Janella Chapline, PhD, NORC                 |                    |
|                                                 |                    |
| -   Dan Gaylin, MPA, Resource Center            |                    |
+-------------------------------------------------+--------------------+
| **[Lunch:]{.smallcaps}**                        | **12:15 P.M.-1:30  |
|                                                 | P.M.**             |
| **[Development of "Learning                     |                    |
| Collaboratives"]{.smallcaps}**                  | *Grand Ballroom    |
|                                                 | Central*           |
+-------------------------------------------------+--------------------+

+-------------------------------------------------+---+-------------------+
| **[Opportunities for PBRN Funding/Partnering: A | * |                   |
| Panel Discussion]{.smallcaps}**                 | * |                   |
|                                                 | 1 |                   |
|                                                 | : |                   |
|                                                 | 3 |                   |
|                                                 | 0 |                   |
|                                                 | P |                   |
|                                                 | . |                   |
|                                                 | M |                   |
|                                                 | . |                   |
|                                                 | - |                   |
|                                                 | 2 |                   |
|                                                 | : |                   |
|                                                 | 3 |                   |
|                                                 | 0 |                   |
|                                                 | P |                   |
|                                                 | . |                   |
|                                                 | M |                   |
|                                                 | . |                   |
|                                                 | * |                   |
|                                                 | * |                   |
|                                                 |   |                   |
|                                                 | * |                   |
|                                                 | G |                   |
|                                                 | r |                   |
|                                                 | a |                   |
|                                                 | n |                   |
|                                                 | d |                   |
|                                                 | B |                   |
|                                                 | a |                   |
|                                                 | l |                   |
|                                                 | l |                   |
|                                                 | r |                   |
|                                                 | o |                   |
|                                                 | o |                   |
|                                                 | m |                   |
|                                                 | S |                   |
|                                                 | o |                   |
|                                                 | u |                   |
|                                                 | t |                   |
|                                                 | h |                   |
|                                                 | * |                   |
+-------------------------------------------------+---+-------------------+
| -   [Moderator:]{.underline} Dan Gaylin, MPA    |   |                   |
|                                                 |   |                   |
| -   [Panelists:]{.underline} Christine Bechtel, |   |                   |
|     American Health Quality Association         |   |                   |
|                                                 |   |                   |
| > Robert Star, MD, NIH Roadmap Initiative       |   |                   |
| >                                               |   |                   |
| > Martin Brown, PhD, National Cancer Institute  |   |                   |
+-------------------------------------------------+---+-------------------+
| **[Wrap-up/Next Steps]{.smallcaps}**            |   | **2:30 P.M.-2:45  |
|                                                 |   | P.M.**            |
| David Lanier, MD                                |   |                   |
|                                                 |   | *Grand Ballroom   |
| David Meyers, MD                                |   | South*            |
+-------------------------------------------------+---+-------------------+
| **[Adjourn]{.smallcaps}**                       |   | **2:45 P.M.**     |
+-------------------------------------------------+---+-------------------+

**[List of Presentation Abstracts]{.underline}**

**Concurrent Session IC**

"The PROS Pediatricians' Perspective"-Alyna Chien, MD, University of
Chicago (PROS)

"International Primary Care Research"- John Beasley, MD, University of
Wisconsin (IFPCRN)

Author(s): Concurrent Sessions IC

\*John Beasley, MD, University of Wisconsin Meeting Room 4

11:00 A.M. to 12:00 P.M.

PBRN(s):

International Federation of Primary Care Research Networks

Title:

International Collaborations for Primary Care Research \-- The Example
of the IFPCRN.

Context:

Federations of Primary Care Research Networks within countries (the US
and the UK) have proved useful in supporting network research. Recently
an International Federation of Primary Care Research Networks (IFPCRN)
has been developed under WONCA. This network has served sponsored one
qualitative study and is embarking on a second. Further, the linkages
developed between caregivers in different countries has led to
collaborations in other educational and research activities which were
not expected.

Objective/Challenges to Be Overcome:

This \"Best Practices\" session will help attendees understand the
progress that has been made in developing an international consortium of
health care professionals interested in Primary Care Research Networks
(PCRNs); gain an overview of the types of primary care research being
done in various countries around the world, both independently and in
networks; and develop a greater appreciation of the potentials and
problems of international networking.

Approach:

This interactive workshop will present an overview of some international
collaborations, and will draw upon the experience of the participants to
help others plan collaborations and to help the IFPCRN plan for its
future development.

Results & Observations:

International collaborations of primary care researchers, both within
formal networks and outside of them, offer a way to help provide new
information for the discipline and develop a culture of research. For
these collaborations to be successful, issues of communication,
organization, development of a common purpose and funding must be
addressed. Federations of networks may be one way to accomplish this.

Implications for other PBRNs:

Other PBRNs can gain perspectives that may be useful as they plan for
their future development, both independently and within Federations.

Author(s): Concurrent Sessions IC

\*Alyna Chien, MD, University of Chicago Meeting Room 4

Tumaini R. Coker, MD 11:00 A.M. to 12:00 P.M.

Lillian Choi, MD

Julie J. Mohr, PhD

PBRN(s):

PROS

Title:

A Primary Care Research Agenda: The PROS Pediatricians\' Perspective

Context:

Although the vast majority of medical care is provided in community
settings, it is well-established that research agendas are set within
academic centers. While most efforts to bridge the gap between research
and practice have emphasized the importance of translating research into
practice, little work has been done to include the primary care
practitioner in shaping the primary care research agenda at the outset.
This is the first description of such an effort in the pediatric
literature.

Objective:

To describe what PROS practitioners think are important and inadequately
addressed research questions.

Design:

In 2003, all PROS practitioners were surveyed regarding what they
thought were important primary care issues that were inadequately
addressed by previous research as a part of \"The Value of PROS\"
survey. The responses to a single open-ended question within this survey
were analyzed using the constant comparative method of analysis. PROS
Chapter Coordinators independently confirm the analysis.

Setting:

PROS (Pediatric Research in Office Settings) is the American Academy of
Pediatrics\' practice-based research network. It consists of over 1900
primary care pediatric providers 50 States, Puerto Rico and Canada. Its
mission is to improve the health of children and enhance primary care
practice.

Participants:

Only members of PROS were surveyed. Only PROS Chapter Coordinators were
used to confirm the analysis.

Intervention or Essential Feature of Study:

Qualitative analysis of survey responses.

Results (if available):

Response rate to the overall survey after two-waves was 51.3%. PROS
practitioners sought additional research on four main themes: (1) the
efficacy of preventive health services, especially anticipatory
guidance; (2) the role of the primary care physician in caring for
children with mental illnesses, (3) the best methods for managing
obesity and ADHD; and (4) most effective ways to deliver services
through the office practice (e.g. patient scheduling and telephone
triage). The Kappa statistic for the analysis of open-ended questions
was 0.85.

Conclusions:

The primary care research agenda according to PROS practitioners should
focus upon: (1) studying the efficacy of many of the unproven, yet
routine tasks performed in well child care, including anticipatory
guidance, (2) guiding primary care providers in decisions regarding
treating children with mental health concerns, (3) specifying strategies
for managing common long-term conditions, and (4) understanding the role
practice management plays in delivering health services to children.

**Concurrent Session IIA**

"Delivery of Childhood Immunizations in Rural Oregon"- Lyle Fagnan, MD,
University of Oregon (ORPRN)

"Improving Rates of Influenza Immunization in Asthma Patients"-Rowena
Dolor, MD, MPH, Duke PCRC

"Asthma Medication Adherence in a PBRN"-Angela Wisniewski, PharmD,
University of Buffalo (UNYNet)

"Supporting Physician Management of Dyslipidemia" (Research in
Development)-James Notaro, PhD, University of Buffalo (UNYNet)

Author(s): Concurrent Sessions IIA

\*Lyle Fagnan, MD, University of Oregon Meeting Room 2

Scott Shipman, MD, MPH 2:30 P.M. to 3:45 P.M.

James Gaudino, MD, MPH

PBRN(s):

Oregon Rural Practice-based Research Network (ORPRN)

Title:

Delivery of childhood immunizations-an analysis of practice patterns in
rural Oregon

Context:

National health objectives for the year 2010 call for 95% of children to
be listed in a population-based immunization registry and 90% of
providers to conduct reviews of the immunization status of their
patients. The increasing complexity of childhood immunization schedules
and discoordination of immunization delivery across public and private
sectors are potential barriers to achieving these goals. Immunization
practices in rural settings are not well described in the literature.

Objective:

To determine current immunization practices among rural Oregon primary
care clinicians, including the use of public health clinics and the
statewide immunization registry, ALERT.

Design:

A cross-sectional survey

Setting:

A rural practice-based research network

Participants:

All clinicians providing care for children, ages 0 to 3, in rural
Oregon.

Intervention or Essential Feature of Study:

Survey

Results (if available):

A survey of 1136 rural Oregon clinicians yielded a 59% return rate,
including 62% MD/DO clinicians, 27% nurse practitioners, and 11%
physician assistants. Approximately 60% of respondents practice in
communities with less than 20,000 residents, and 50% were in
physician-owned practices. 82% of clinicians provide all or some
childhood immunizations in their own clinic.. However, 90% of clinicians
report that children in their community receive immunizations at the
county health department. Although only 13% of clinicians used
electronic health records, the majority submitted data to ALERT and
almost half of these of clinicians accessed ALERT to check the
immunization status of patients. Over 60% of clinicians lacked a system
to track patients who are behind on immunizations, and a minority of
clinicians had ever systematically reviewed the immunization status of
their patient population.

Conclusions:

Many of the barriers to best practices in child immunizations are
potentially modifiable. Opportunities exist to promote the primary care
practice \"medical home\" as a source of childhood immunizations and to
adopt universal use of the statewide immunization registry to document,
coordinate and track immunizations.

Author(s): Concurrent Sessions IIA

\*Rowena Dolor, MD, MPH, Duke University Meeting Room 2

Virginia B. Patterson RN 2:30 P.M. -- 3:45 P.M.

Anne S. Hellkamp MS

Emmanuel B. Walter MD MPH

PBRN(s):

Duke Primary Care Research Consortium

Title:

Improving Rates of Influenza Immunization in Asthma Patients: A Duke
Primary Care Research Consortium Study

Context:

Many asthmatic patients do not receive an annual flu shot.

Objective:

To compare flu vaccine coverage rates for (1) patients who receive an
educational reminder versus a routine reminder, and (2) practices
participating in a practice improvement process versus control practices

Design:

Randomized controlled trial

Setting:

15 Duke University Health System primary care practices

Participants:

Patients with asthma

Intervention or Essential Feature of Study:

Asthmatics were randomly assigned to receive a flu vaccine postcard
reminder or a reminder with educational information about the safety of
flu vaccine in asthmatic patients (Years 1 & 2). In year 2, eight of the
practices were randomly chosen for a practice improvement intervention
to increase their practice immunization rate.

Outcome Measures (if any):

Immunization coverage rate

Results (if available):

We mailed 9318 postcard reminders (4669 regular, 4649 educational) in
Nov 2002 and 8837 postcard reminders (4422 regular, 4415 educational) in
Nov 2003. From the administrative database, 22.6% and 26% of these
patients received a flu shot in 2002-3 and 2003-2004, respectively.
There was no difference in coverage rates between those who received the
regular versus the educational reminder, nor between the intervention
and control practices. A handheld survey of 394 asthma patients showed
that 192 (49%) reported receiving the flu shot. The top reasons for not
receiving a shot included the perception that the vaccine causes the
flu, a fear that the shot will make them or their child ill, and no
perceived need for the vaccine.

Conclusions:

A mailed reminder with an educational message about the safety of
influenza vaccination for asthmatics did not influence the vaccine
coverage rates over 2 years. A practice improvement intervention
increased vaccination rates, but was not statistically significant
compared to the control practices. Patient misconceptions about the
influenza vaccine are highly prevalent. Future interventions should be
aimed at educating patients about the necessity and safety of the
influenza vaccine.

Author(s): Concurrent Sessions IIA

\*Angela Wisniewski, PharmD, University of Buffalo Meeting Room 2

Laurene Tumiel-Berhalter, PhD 2:30 P.M. -- 3:45 P.M.

Luis Zayas, PhD

Alan Forrest, PharmD

Chester Fox, MD

PBRN(s):

UNYNet

Title:

Cross-sectional Study of Asthma Medication Adherence in a PBRN

Context:

Minority populations disproportionately bear the burden of asthma
morbidity and mortality. The cornerstone of management for persistent
asthma is an anti-inflammatory medication(s). Adherence to appropriately
prescribed anti-inflammatories is low, ranging from 20-60%.

Objective:

To characterize the demographic, socioeconomic, and asthma-related
factors (via patient survey) that are associated with low adherence to
prescribed anti-inflammatories among minority/health-disparity patients.

Design:

Cross-sectional, consecutive sample of eligible primary care patients
using a structured, administered survey to explore patient
characteristics and barriers that may be associated with low adherence.

Setting:

UNYNET is a PBRN encompassing the eight counties of Western New York.
Included are 50 sites with 120 providers serving 228,000 patients
representing urban, suburban, and rural practices.

Participants:

The goal is a total of 300 adult patients with persistent asthma
prescribed an anti-inflammatory asthma medication, representing
primarily minority/health-disparity (Hispanic/Latino and
African-American) and including Caucasian patient populations.

Intervention or Essential Feature of Study:

Identification and survey of adult patients with persistent asthma
prescribed an anti-inflammatory medication(s). Practice enhancement
assistants (PEAs) were integrated into sites and involved in all aspects
of protocol execution, including identification of eligible patients,
informed consent, medical and pharmacy record data extraction, and
administration of the survey.

Outcome Measures (if any):

Adherence to anti-inflammatory medications obtained from objective
analysis of pharmacy records. Patient barriers to adherence, identified
from the survey, will be explored for associations with low adherence.

Results (if available):

Currently, 189 patients have been enrolled; 47.6% Hispanic/Latino, 34.5%
African American, 11.7% Caucasian, and 6.2% other. Low adherence (\<
80%) to one or more prescribed anti-inflammatories was identified in
70.4% of study participants. Only three patients did not have
prescription insurance coverage. Five patients have not consented to
participate in the study.

Conclusions:

Lessons learned during the course of implementing this study include:
minority/health disparity patients are willing and can be successfully
recruited into primary care research studies and cultural matching of
PEAs to practice sites improves study feasibility.

Author(s): Concurrent Sessions IIA

\*James Notaro, PhD, University of Buffalo Meeting Room 2

Chester Fox, MD 2:30 P.M. -- 3:45 P.M.

Vinod Patel, MD

PBRN(s):

UNYNet

Title:

Application of a Patient Registry and Prospective Case Management
Applications to Support Physician Management of Dyslipidemia.

Context:

The gap between clinical evidence and clinical practice has been well
documented with regard to cardiovascular event prevention. The Institute
of Medicine indicates that increased reliability of chronic disease
treatment will be achieved through redesign of the health care delivery
system.

Objective:

To determine the effectiveness of applying a patient registry and
prospective case management application to the treatment of
dyslipidemia.

Basic Study Design:

Specialized patient registry and case management software was applied to
support primary care physicians in monitoring and managing a convenience
sample of dyslipidemic patients. Five physicians from an urban family
medicine practice from UNYNET. UNYNET is a PBRN of 50 practices, 120
clinicians, and 228,000 patients in the eight counties of Western New
York. Patients with dyslipidemia were identified and their charts
reviewed. Relevant data elements were entered into a patient registry
system. Using registry data, pharmacist case managers identified
potential treatment gaps in dyslipidemic care. Physicians were notified
by faxed recommendation of potential treatment deficiencies. Physicians,
if they agreed, could address these deficiencies through the traditional
office based system or delegate their orders to a case management
support unit. Each patient was tagged for follow-up at appropriate
intervals.

Current Challenges:

Currently, payors reimburse clinicians for \"seeing\" patients.
Reimbursement for outcomes of care are not widely available.
Sustainability of the project will require that a return on investment
can be identified and payors are willing to evolve current reimbursement
paradigms.

**Concurrent Session IIB**

"PBRNs and PDAs"-Myra Crawford, PhD, University of Alabama PBRN

"Effect of EMR on Medication Safety"-Grace Kuo, PharmD, Baylor
University (SPUR-Net)

"EHR Applications to Improve Care for Acute Respiratory
Infections"-Jeffrey Linder, MD, MPH, Brigham & Women's PBRN

"Monitoring Compliance after Implementation of an Outpatient CPOE system
with Decision Support" (Research in Development)-Michael Matheny, MD
Brigham & Women's PBRN

Author(s): Concurrent Sessions IIB

\*Myra Crawford, PhD, University of Alabama Meeting Room 3

T. Michael Harrington, MD 2:30 P.M. -- 3:45 P.M.

PBRN(s):

Alabama Practice Based Research Network

Title:

PBRNs and PDAs: Creating an Electronic Network

Context:

The Alabama Practice Based Research Network recently concluded two
studies of clinical intervention protocols using PDA programs (Palm
Operating System) for use by clinicians during delivery of routine care.
Using this methodology, the often quoted lapse of 17-20 years between
the discovery of important research findings and their application in
daily clinical practice was significantly reduced.

Objective:

To implement an electronic system of data collection from multiple,
remote sites and help physicians assess and counsel patients for smoking
and obesity.

Study Design:

Feasibility.

Setting:

The protocols were tested in 21 urban and rural, private and
university-affiliated family practice clinics.

Participants:

24 family physician members of the APBRN participated voluntarily.

Intervention or Essential Feature of Study:

PDA programs were created using Pendragon forms v. 4.0, with content
based on evidence-informed national guidelines, behavior change theories
(e.g., Stages of Change and Motivational Interviewing) and the 5-A
process for diagnosis and treatment. Interventions for smoking and
obesity were delivered to more than 1,000 patients.

Outcome Measures (if any):

Frequency of PDA protocol use was monitored electronically. Data on
feasibility, utility and effectiveness of the system was collected
through surveys and qualitative interviews following each study.

Results (if available):

Creating and maintaining an electronic network requires significant
technical support and resources. PDA program development, server
connectivity and maintenance, physician training, and protocol updates
are all necessary aspects. PDA issues may include equipment failure,
erosion of protocol use over time, and vulnerability to loss or theft.
For PBRNs with member practices in non-academic settings, the ideal
solution is a "provider representative" who is technically adept,
available to travel to study sites, and able to interact well with busy
medical professionals.

Conclusions:

Evidence points to successful use of PDAs for rapid health behavior
assessment, individualized counseling interventions, delivery of patient
education, and research data collection. These studies demonstrate the
potential of PDA technology and PBRNs to translate research into
practice at an unprecedented rate.

Author(s): Concurrent Sessions IIB

\*Grace Kuo, PharmD, Baylor University Meeting Room 3

2:30 P.M. -- 3:45 P.M.

PBRN(s):

Baylor College of Medicine

Title:

The effect of EMR on Medication Safety: A SPUR-Net Study

Context:

While electronic medical records (EMR) have been shown to decrease
medication errors (ME) and adverse drug events (ADE) in the inpatient
setting, its effect in the outpatient setting has not been well studied.

Objective:

To evaluate ME in primary care clinics using an EMR, compared to ME in
clinics using a paper medical record (PMR).

Design:

Cross-sectional. The study proceeded in three phases: 1) patient
recruitment at clinics; 2) medical record review; and 3) telephone
interview occurring within two weeks of the index visit.

Setting:

The Southern Primary-care Urban Research Network (SPUR-Net) is comprised
of six health-care organizations in the Houston metroplex, including 290
primary care providers in 32 practice sites, providing approximately
980,000 patient encounters annually. The study was conducted in four of
the clinics, two using EMR and two using PMR.

Participants:

A convenient sample of patients with the following eligibility criteria
were selected: male and female patients at least 18 years of age,
getting a new prescription during the clinic encounter, taking at least
two medications, English-speaking, and willing to consent and
participate in one telephone follow-up.

Intervention or Essential Feature of Study:

Outcome comparisons between EMR and PMR clinics.

Outcome Measures (if any):

The primary endpoint was ME, including its frequency, type of error,
severity, and preventability.

Results (if available):

Data collection was complete. A total of 432 patients and 3,069
medications (2,357 prescription medications and 712 over-the-counter
products) were included in the study. Our preliminary analyses from 275
patients identified 1,509 MEs classified into four types: prescribing
(24%), dispensing (8%), administering (12%), and monitoring (56%). The
severity of error (from 399 MEs) in causing an ADE was: no potential for
ADE (33.1%), potential for significant ADE (55.9%), and potential for
serious ADE (11.0%). The preventability of these errors by additional
EMR features was estimated to be 55.4%.

Conclusions:

Data analysis will be complete by July 1, 2005.

Author(s): Concurrent Sessions IIB

\*Jeffrey Linder, MD, MPH, Brigham & Women's Hospital Meeting Room 3

David W. Bates, MD, MSc 2:30 P.M. -- 3:45 P.M.

Jeffrey L. Schnipper, MD, MPH

Blackford Middleton, MD, MPH, MSc

PBRN(s):

Brigham & Women's PBRN

Title:

Electronic Health Record Applications to Improve Care for Acute
Respiratory Infections in a Practice-Based Research Network

Context:

Acute Respiratory Infections (ARIs) are the most common reason for
seeking medical care and the number one reason for antibiotic
prescribing in the United States. Quality improvement for ARIs using
electronic health record (EHR)-based clinical decision support is
challenging because of the brevity of visits. Quality improvement and
research into ARIs has been limited because of a lack of standardized
data capture.

Objective:

To improve the care of patients with ARIs, by designing, implementing,
and evaluating an integrated documentation-based clinical decision
support system - the ARI Smart Form - and a physician feedback system -
the ARI Quality Dashboard.

Design:

We are consecutively performing usability testing, pilot testing, and
randomized controlled trials to evaluate the ARI Smart Form and the ARI
Quality Dashboard.

Setting:

The Brigham and Women\'s Primary Care Practice-Based Research Network
consists of 2 community health-centers, 5 hospital-based clinics, and 5
community-based clinics, with approximately 250,000 visits per year.

Participants:

Patients making a visit with a diagnosis of non-specific upper
respiratory tract infection, otitis media, sinusitis, pharyngitis, acute
bronchitis, influenza, or pneumonia.

Intervention or Essential Feature of Study:

The ARI Smart Form integrates display of information, decision support,
ordering and documentation and includes 6 components: entry of clinical
information; patient data display; diagnosis selection; provision of
treatment options with integrated decision support; printing of patient
handouts; and access to supporting medical literature. The ARI Quality
Dashboard provides clinician-level data comparing prescribing practices
to peers and national benchmarks.

Outcome Measures (if any):

The primary outcome for the randomized controlled trials will be the
difference in antibiotic prescribing rates for ARI visits between
control and intervention practices. Secondary outcomes will include the
appropriateness of antibiotic prescribing, revisit rates, antibiotic
costs per visit, and the quality of documentation.

Conclusions:

The ARI Smart Form and ARI Quality Dashboard have the potential to
improve patient care and research, but require further development and
evaluation.

Author(s): Concurrent Sessions IIB

\*Michael Matheny, MD, Brigham & Women's Hospital Meeting Room 3

Eric G. Poon, MD, MPH 2:30 P.M. -- 3:45 P.M.

Lisa P. Newmark

Tejal K. Gandhi, MD

PBRN(s):

Brigham & Women's PBRN

Title:

Medication Laboratory Monitoring Compliance after Implementation of an
Outpatient Computerized Physician Order Entry System with Decision
Support

Context:

Several studies have shown that laboratory monitoring practices for
medication initiation and maintenance are inadequate. Well established
guidelines for these practices are present for a number of medications,
but compliance has been shown to be highly variable.

Objective:

The goal of our study is to evaluate the impact of integrating
computerized physician order entry (CPOE) with advanced clinical
decision support systems in the ambulatory setting to improve medication
monitoring guideline compliance.

Basic Study Design:

The study will be conducted in the 26 on-site and satellite adult
outpatient clinics affiliated with the Brigham & Women\'s Hospital and
Massachusetts General Hospital, the two main teaching hospitals in the
Partners Healthcare System. The Longitudinal Medical Record currently
supports a set of non-actionable evidence-based electronic medication
laboratory monitoring reminders. In this project, these reminders will
be linked to laboratory ordering via one-click CPOE. Physicians will be
divided evenly by clinic into control and intervention arms, and only
physicians in the intervention arm will have access to these
CPOE-enabled reminders. The study will be conducted over nine months
with a three month wash-in period where the new system will be active
but no data will be collected. The primary outcome will be the
difference between the arms in the rate of opportunities associated with
appropriate actions based on the reminder recommendations.

Current Challenges:

In such a large health care network, there are continuing challenges in
addressing individual clinic needs and workflow concerns, based on
integration within the electronic medical record. There are also
significant infrastructure roadblocks to deploying the desired features
because of the need to interact or replace a number of legacy systems
with a variety of inter-dependencies.

**Concurrent Session IIC**

***Practice Facilitators and PBRNs.*** Zsolt Nagykaldi, PhD, University
of Oklahoma (OKPRN)

Author(s): Concurrent Sessions IIC

\*Zsolt Nagykaldi, PhD, University of Oklahoma Meeting Room 4

James, Mold, MD MPH 2:30 P.M. -- 3:45 P.M.

Cheryl, Aspy, PhD

PBRN(s):

OKPRN

Title:

Practice Facilitators: A New Profession

Context:

Practice facilitators (PFs) are health care professionals, who assist
primary care clinicians in research and quality improvement projects.
Although they have been used in Europe and Australia for over twenty
years, the concept is relatively new in the United States. The recent
evolution of primary care practice-based research networks (PBRNs) has
led to greater awareness and expansion of this concept.

Objective:

To review the literature on PFs and describe their origin, training,
funding, roles, methods they use, and their impact on patient care
outcomes.

Design:

We searched four electronic databases from 1966 through the present,
reviewing all articles pertaining to PFs in an effort to understand the
history, training, financing, roles, methods, and impact of PFs.

Setting:

The Oklahoma Physicians Resource/Research Network (OKPRN) has an
extensive experience with Practice Enhancement Assistants (PEAs) who
utilize the PF concept.

Participants:

a\) individuals working with primary care practices in research AND
quality improvement activities;

b\) the work of PF goes beyond data collection and feedback and includes
interaction with the practice(s) over a period of time;

c\) not a commentary or letter to the editor;

Intervention or Essential Feature of Study:

Systematic literature review and adaptation of results.

Results:

Since the early 1980's, PFs have worked with individual practices on
relationship building, education, and quality improvement (QI),
particularly in the area of prevention. Publications provide information
on the roles of PFs in primary care and methods they use to enhance
practices. Many prospective, uncontrolled studies and a few randomized,
controlled trials have documented the effectiveness of PFs but usually
in combination with other interventions. Primary care practice-based
research networks in the US have begun to use PFs as a way to bridge the
gap between research and practice. Limited information is available
about the training, and funding of the PFs.

Conclusions:

The PF concept seems to be a useful practice enhancement approach in
primary care.

**Concurrent Session IID**

"Communication Methods in Primary Care Surveillance"- Michael Grasmick,
PhD, University of Wisconsin (WReN)

"Development of the Electronic Primary Care Research Network
(ePCRN)"- Kevin Peterson, MD, MPH, University of Minnesota (MAFPRN)

Author(s): Concurrent Sessions IID

\*Michael Grasmick, PhD, University of Wisconsin Meeting Room 5

Jonathan Temte, M.D./Ph.D. 2:30 P.M. -- 3:45 P.M.

Van Yasek, Ph.D.

PBRN(s):

Wisconsin Research and Education Network

Title:

Preferred Communication Methods in Primary Care Surveillance

Context:

Little information exists on surveillance systems in primary care. A
recent German study, however, reported that primary care physicians were
hesitant to use electronic means to receive information from
communicable disease surveillance. Given the ubiquitousness of computers
in primary care offices, such conclusions may be invalid for US
clinicians.

Objective:

To assess the experiences of primary care clinicians involved in
collecting surveillance data and receiving clinical information derived
from surveillance.

Design:

Survey of participants in a demonstration surveillance program, followed
by a focus group made up of participating clinicians.

Setting:

Primary care offices in Wisconsin.

Participants:

120 clinicians.

Intervention or Essential Feature of Study:

The URL for a 15-item web-based survey was emailed to all surveillance
participants. Non-respondents received reminder emails. The
questionnaire was designed to assess experiences with conducting
surveillance and receiving compiled information. A focus group was
conducted to further explore attitudes uncovered by the survey.

Outcome Measures (if any):

Time required for surveillance; appropriateness of electronic
communication for reporting; preferred means of receiving feedback
information; structure of feedback; willingness to participate in future
surveillance activities; appropriate incentives.

Results (if available):

71.7% of clinicians completed the survey. The median time spent in
surveillance activities was 5 minutes per week. Only 2% found
participation more difficult than expected; 97% would willingly
participate in future surveillance. Electronic means of reporting
(web-based) and receiving information (email) were overwhelmingly
preferred as means of communication. Clinicians wanted information on
pathogens in circulation (83%) and advice on diagnosis and treatment
(78%). The primary reason for participation in surveillance activities
was contribution to public health endeavors. Quantitative and
qualitative results demonstrated a high level of harmony.

Conclusions:

Public health surveillance can be structured so as to be acceptable,
functional, and clinically useful in primary care settings. This study
illustrates the high level of acceptance of electronic means of
communication to link clinicians together.

Author(s): Concurrent Sessions IID

\*Kevin Peterson, MD, MPH, University of Minnesota Meeting Room 5

2:30 P.M. -- 3:45 P.M.

PBRN(s):

Federation of Practice Based Research Networks

Title:

Development of the electronic Primary Care Research Network (ePCRN)

Context:

In order for the clinical research enterprise to remain successful new
partnerships with primary care providers who deliver the majority of
care to the US population need to be developed. These partnerships
should enhance the ability of investigators to conduct research as well
as facilitate delivery to clinicians of better tools to provide care.

Objective:

The principal aim of this proposal is to enable the development of an
electronic infrastructure that facilitates the recruitment of subjects
and the performance of RCTs in primary care practices anywhere in the
United States, and that promotes the rapid integration of new research
findings into primary care

Design:

The study will 1) develop a web-portal that enables primary care
practices anywhere in the United States to participate in clinical
trials, 2) establish a clinic-based registry in primary care that
promotes the translation of research findings into practice, 3)
implement the solution on open-source Internet-2 components that will
allow additional functionality enhanced communication, additional
decision support, and warehousing of trial data

Setting:

The Federation of Practice Based Research Networks will oversee the
administration of the ePCRN. The ePCRN is owned by NIH, and developed by
the University of Minnesota.

Participants:

PBRNs

Intervention or Essential Feature of Study:

The study will initiate three clinical trials over three years.

The registry implements the Continuity of Care Record (CCR)from the
ASTM.

Outcome Measures (if any):

The ePCRN will provide an infrastructure for performance of both
clinical trials and studies that translate research into practice.

Results (if available):

Extensive infrastructure has been built and the first clinical trials
have begun.

Conclusions:

The development of the ePCRN will provide the ability to perform large
national collaborative studies throughout the US, improve efficiency,
reduce costs for individual trials, provide easier access for data
retrieval and analysis, and involve primary care in recruitment,
performance, and translation of findings into practice. This
functionality could be a foundation for a revolution in clinical
research and in primary care in the United States.

**Concurrent Session IIIA**

"Community-based Participatory Research Principles"-Laura Anderko, PhD,
University of Wisconsin Milwaukee (MNCCRN)

"CHC Clinician Strategies to Meet Subspecialty Healthcare Needs of
Uninsured Patients"-James Werner, PhD, Case Western Reserve University
(RAP)

"Youth Violence Prevention: A Case for Increasing Provider-Community
Collaborations"-Carmela Lomonaco, PhD, University of Southern California
(LANet)

"The Reflective Practitioner Process"-Lyndee Knox, PhD, University of
Southern California (LANet)

Author(s): Concurrent Sessions IIIA

\*Laura Anderko, PhD, University of Wisconsin Milwaukee Meeting Room 2

Sally Lundeen, PhD, MNCCRN 4:00 P.M. to 5:15 P.M.

Claudia Bartz, PhD, MNCCRN

PBRN(s):

MNCCRN

Title:

Improving Research Process and Outcomes Using Community-based
Participatory Research Principles

Context:

As health professionals struggle to address the persistent problem of
health disparities among at-risk populations, the development of \"best
practices\" for conducting credible research in \"real world\" settings
has received increased attention. The application of Community-based
Participatory Research (CBPR) principles to research conducted by
Practice-based Research Networks (PBRNs) can enhance the research
process in practice settings. However, few guidelines outline what
strategies will actually promote successful collaborative research
efforts. This presentation will highlight lessons learned regarding the
application of CBPR principles within a PBRN and outline \"best
practices\" as a result of these endeavors.

Objective/Challenges to Be Overcome:

The populations most at-risk are those disenfranchised from the
mainstream health care system, especially those who are distrustful of
the system and its providers. Research methods that capture the
characteristics of these populations, while simultaneously being
consistent with the community\'s socio-political and economic
environment, are challenging to implement but critical to finding
effective intervention strategies and to new knowledge generation.

Approach:

One strategy for overcoming such challenges and improving the
application of research methods in community settings is CBPR, which is
a collaborative approach to research that combines methods of inquiry
with community capacity building strategies. CBPR, through its
commitment to active involvement of community leaders and a range of
community members, can enhance the contextual appropriateness of the
research process and also can enhance trust among potential subjects.

Results & Observations:

Although centers within the MNCCRN PBRN are community-based, those
emphasizing a community-based participatory approach for outreach and
education were more successful in subject recruitment and retention. A
more rigorous application of CBPR is underway for a research project in
the planning stages.

Implications for other PBRNs:

The evidence suggests that utilization of CBPR principles within PBRNs
can enhance recruitment and retention efforts of at-risk populations,
strengthen research findings, and increase the potential for
evidence-based practice applications.

Author(s): Concurrent Sessions IIIA

\*James Werner, PhD, Case Western Reserve University Meeting Room 2

4:00 P.M. to 5:15 P.M.

PBRN(s):

Research Association of Practices (RAP)

Title:

Strategies used by community health center clinicians to meet uninsured
patients\' needs for outpatient subspecialty healthcare

Context:

Medically uninsured patients obtaining primary care services at
federally qualified health centers (FQHCs) may have limited access to
subspecialty care. It is important to understand how FQHCs bridge the
subspecialty gap for the more than 12 million uninsured patients they
serve.

Objective:

To describe strategies used by community health center (CHC) clinicians
to meet medically uninsured patients\' needs for outpatient subspecialty
healthcare.

Design:

Qualitative research methods were used to examine strategies developed
by CHC primary care clinicians seeking to obtain subspecialty care for
medically uninsured patients. In 3 FQHC clinics, clinicians described
their experiences through 47 in-depth interviews and 3 case studies that
also involved uninsured patients, subspecialists, and health system
administrators.

Setting:

Three clinics within a federally qualified community health center
system in the western U.S.A.

Participants:

10 primary care clinicians within 3 FQHC clinics; 10 subspecialists; 6
FQHC patients; 5 health system administrators.

Intervention or Essential Feature of Study:

This study triangulated findings from interviews, case studies, and
observations, and examined access from multiple perspectives.

Results (if available):

CHC clinicians developed innovative methods to bridge gaps in access to
subspecialty care for medically uninsured patients. Sixteen different
strategies were identified and grouped into 5 categories: practice scope
expansion, quid pro quo tactics, relationship development, personalized
appeal, and other strategies. CHC clinicians with long tenure leveraged
their professional social capital and reported more comfort with
aggressive approaches to access than those with less experience.

Conclusions:

Primary care clinicians in CHCs developed and used adaptive strategies
for patients facing access barriers to subspecialty care. An important
enabling factor was clinicians\' ability to leverage their professional
social capital on behalf of their patients. CHC administrators may wish
to consider the benefits conferred by CHC clinicians\' stature in
medical communities, and policymakers may examine the implications for
patient safety when clinicians expand their normal scope of care to
address patients\' otherwise unmet healthcare needs.

Authors: Concurrent Sessions IIIA

\*Carmela Lomonaco, MA, University of Southern California Meeting Room 2

Lyndee Knox, Ph.D. 4:00 P.M. to 5:15 P.M.

PBRN(s):

LA Net

Title:

Connecting the Dots to Prevent Youth Violence: A Case for Increasing
Provider-Community Collaborations

Context:

LANet, located in inner-city Los Angeles, is devoted to the elimination
of minority health disparities. Violent death and injury is one of the
most significant health disparities in LA, with black males are 6x more
likely to die from violent injury than white males. LANet was selected
to evaluate a training and outreach program developed by the AMA to
increase provider awareness of violent injury risk among their pediatric
patients, and connect providers with resources in their local community
to assist in prevention efforts.

Objective/Challenges to Be Overcome:

1\. To evaluate network providers\' current violent injury prevention
activities

2\. To evaluate provider satisfaction with the AMA training program

3\. To evaluate the impact of the training on provider knowledge,
attitudes and self-reported behavior related to violent injury
prevention

Approach:

We used a quasi-experimental pre-post research design with 3-month
follow-up to evaluate the impact of the guide. The study was conducted
at 12 network clinics.

Results & Observations:

Eighty percent reported the training had \"modified their attitudes
about youth violence\" and 90% reported they would \"modify their
assessment of at-risk behaviors.\" After three months, 89% reported
continued modification of their assessment practices. In addition, two
clinics formed partnerships with local law enforcement, another clinic
had supplemental training with ex-gang members and LANet was asked to
join the community council for the Watts-Compton area of Los Angeles.

Implications for other PBRNs:

Networks can serve as laboratories to evaluate the effectiveness of
national efforts to improve practice. Community participation is of
interest to many PBRNs but is often difficult to accomplish. A
significant outcome was the increase in provider-community interaction.
This approach can be adapted for use in any topic area (obesity, chronic
disease, etc) to stimulate provider-community collaboration and may be
useful to networks seeking to increase community engagement around
specific health-related topics.

Authors: Concurrent Sessions IIIA

\*Lyndee Knox, PhD, University of Southern California Meeting Room 2

Carmela Lomonaco, MA 4:00 P.M. to 5:15 P.M.

PBRN(s):

LA Net

Title:

The Reflective Practitioner Process: Methods to balance funder versus
provider driven research

Context:

Practice based research and Participatory Action Research highlight the
inclusion of primary care providers in the choice and design of research
projects. LANet uses the Reflective Practitioner (RP) process, a
PAR-based provider engagement process developed by Dr. Mary Croughan, to
identify research topics for the network and engage providers in network
projects.

Objective/Challenges to Be Overcome:

1\. Engaging providers in research process and ensuring that the network
is \"provider driven.\"

2\. Using PAR approaches like the reflective practitioner to ensure a
provider driven network structure and agenda

Approach:

We implemented the RP process in LANet during its 2nd year. We use the
process annually to: identify and carry-out provider driven projects,
ensure the work of the network remains relevant and connected to the
provider\'s work and issues of concern in Southern California, to build
connections with new members, and expand the network\'s membership.

Results & Observations:

LANet has completed two rounds of RP. A total of 81 project ideas were
generated by the network providers. Three were ultimately developed into
full-scale research projects; one is nearing completion and will form
the basis for an R01 application to the NIH this fall. Provider buy-in
and interest in network research has grown significantly as a result of
this PAR-based method. Network membership has grown significantly (30%+)
as providers in the community hear about the process and ensuing work by
the network and ask to participate.

Implications for other PBRNs:

PAR-based processes like the RP are a useful tool for increasing
provider involvement and buy-in, growing network members, and ensuring
that network projects remain relevant to provider concerns and community
needs. The RP process can be particularly useful to young networks
seeking to build relationships with the provider community, and to
networks struggling to balance the demands of funder-driven research
with grass-roots provider involvement.

**Concurrent Session IIIB**

"Systematic Nutritional Assessment in Pediatric Practice (SNAPP)"-Adolfo
Ariza, MD, Children's Memorial Hospital, Chicago (PPRG)

"Office-Based Low Carb Diet Intervention in Obese Teens"-Robert Siegel,
MD, University of Cincinnati (CPRG)

"How Healthy Are Adolescents Really?"-Cecelia Gaffney, EdD, Dartmouth
(CECH)

"Better Adolescent Health Visit through PDA-based Counseling"-Ardis
Olson, MD, Dartmouth (CECH)

Author(s): Concurrent Sessions IIIB

\*Adolfo Ariza, MD, Children's Memorial Hospital Meeting Room 3

Roopa Seshadri, PhD 4:00 P.M. to 5:15 P.M.

Christine Sullivan, MBA,MS

Helen J Binns, MD,MPH

PBRN(s):

PPRG

Title:

Systematic Nutritional Assessment in Pediatric Practice (SNAPP): A Pilot
Study

Context:

American Academy of Pediatrics (AAP) guidelines for prevention of
overweight (OW) recommend routine assessment of child s nutritional
status and counseling for families on healthy lifestyles.

Objective:

To develop and pilot a multifaceted, practice-directed intervention
SNAPP to improve compliance with AAP guidelines.

Design:

Cross-sectional evaluations before and after the SNAPP intervention.

Setting:

4 PPRG practices

Participants:

Before and after the SNAPP intervention at 4 pediatric practices,
cross-sectional consecutive samples of 1) parents completed exit surveys
following health maintenance visits (HMV) and had medical record
reviewed and 2) children aged 2-10 years had observations of HMV. A
trained observer collected data on visit content including times for
specific health topics, using handheld computer software.

Intervention or Essential Feature of Study:

The SNAPP intervention included clinician and staff-directed education
including child nutritional status assessment using charts, facilitation
by a practice-change leadership team, suggestions for charting prompts
and distribution of instructions for system changes and handouts.
Handouts were developed for 1) children \<2 years and 2) older children
in 3 age groups across 2 categories of nutritional status (underweight
and normal/OW). Before

Results (if available):

93 and 80 HMV were observed at pre- and post-intervention. Child
characteristics among observed visits did not differ between data
periods: mean 4.5 y; 54% male; 28% African American, 28% Hispanic and
34% white; 45% privately insured. The percentage of OW or at risk for OW
(AROW) children identified increased (35% before vs. 75% after, p\<.01).
Before intervention 27% (10/37) of OW/AROW patients received a handout
with information on growth, diet, or physical activity (PA); after the
intervention 56% (9/16) of OW/AROW patients received a handout (p=0.04).
The intervention did not impact time devoted to counseling/assessment
for growth, diet, and PA (before mean 186. 6 seconds (SD 134.2), vs.
after 157.2 (121.7), p=.14). In charts of non-observed visits (126
before/112 after), documentation of nutritional status increased from
20% to 70%, (p\<.0001).

Conclusions:

The SNAPP intervention significantly improved routine identification of
nutritional status and enhanced counseling. Application of SNAPP in
other primary care settings needs further examination.

Author(s): Concurrent Sessions IIIB

\*Robert Seigel, MD, University of Cincinnati Meeting Room 3

Whitney Rich, RD 4:00 P.M. to 5:15 P.M.

Evie Joseph, MD

Joan Linhardt

Jamie Knight

Jeralyn Bernier

Jane Khoury

Stephen Daniels

PBRN(s):

CPRG

Title:

An Office-Based Low Carbohydrate Diet Intervention in Obese Teens

Context:

Obesity is a major pediatric health problem with over 20% of American
children overweight or obese. This is of great concern as obese children
almost invariably go on to become obese adults and face the risk of
shortened life span. While weight loss will result from caloric
restriction, the traditional low fat/low calorie intervention has met
with limited success in both adults and children. Previous studies have
shown the success of a Low Carbohydrate Diet (LCD) in both adults and
teens. There is no information, however, if the LCD is a practical
intervention in a pediatric office setting.

Objective:

The object of our study was to demonstrate the effectiveness of a low
carbohydrate in obese children in a primary pediatric setting.

Design:

A prospective observational/descriptive study of a dietary intervention

Setting:

The offices of a Midwestern Pediatric Practice-Based Research Network
that is composed of 47 practitioners in 25 offices.

Participants:

Children ages 12 to 18 years with a Body Mass Index greater than 95% for
age.

Intervention or Essential Feature of Study:

Obese teens were put on a LCD of less than 50 grams of carbohydrate per
day. They were seen at regular intervals by their pediatrician and study
dietician. Data collected included height, weight, lipid profile, serum
chemistries, blood count, dietary intake and physical activity.

Outcome Measures (if any):

The primary outcome measured was weight loss.

Results (if available):

During the first half of a projected 18 month study, 41 teens
participated for at least 2 months. The average age was 15.2 years, with
8 boys and 33 girls participating for an average of 4.3 months. Mean
weight was 204.7+39.1 at entry compared to 195.9+38.1 at last visit
(p\<0.0001). In all, 34 of 41 teens lost weight. Eight teens left the
study for non-medical reasons and one left because of muscle cramping.

Conclusions:

The LCD appears to an effective and practical office-based intervention
in obese teens. Ongoing data is being collected.

Author(s): Concurrent Sessions IIIB

\*Cecelia Gaffney, EdD, Dartmouth University Meeting Room 3

Ardis Olson, MD 4:00 P.M. to 5:15 P.M.

Viking Hedberg, MD

Wendy Gladstone, MD

Robert Mathes, MD

Paul Reiss, MD

PBRN(s):

CECH

Title:

How Healthy are Adolescents Really? Screening for Behavioral Risk
Factors in Pediatric Well Care Visits.

Context:

The majority of adolescent have yearly well visits and 63% report not
discussing any health risks with the clinician

Objective:

Test the feasibility of using a PDA based health screener with
adolescents at well visits. Improve the identification of risk factors
to facilitate targeted discussion about risk reduction during well
visits.

Design:

Adolescents completed a comprehensive screener on PDA prior to visit.
Clinicians reviewed responses to identify risks and other health issues
before meeting with the teens.

Setting:

Clinicians to Enhance Child Health (CECH) is network of pediatric and
family practitioners in 28 New England community, private practices.

Participants:

All adolescents presenting for well-care at five (3 pediatric/2 family
practice) practices for nine months.

Intervention or Essential Feature of Study:

The Prescription for Health \"Healthy Teens\" project worked with
physician leaders to implement screening using a CQI process. An office
systems approach was used to incorporate screening into visit with
minimal interruption to office flow. Using brief counseling techniques
clinicians discussed identified health risks with teen patients.

Results (if available):

PDA screener was well accepted and completed by 1053 adolescents (414
aged 11-14 yrs and 639 aged 15-19 yrs). The presence of 8 risk factors
(sedentary lifestyle, diet, alcohol, tobacco, drugs, safety, mood and
sexuality) were determined. Among younger group, 74% had a least one
factor and 21% had 3 or more. In the older group, 85% had at least one
risk and 31% had 3 or more. At least one emotional risk (suicidal,
depression, eating disorders, anger) was reported by 36% of both groups.

Conclusions:

Although most teens are perceived as healthy, the majority had risk
factors that impact their current health and increase their risk for
chronic diseases. Use of the PDA is an effective method to provide
information needed to address adolescents\' health risk behaviors.

Author(s): Concurrent Sessions IIIB

\*Ardis Olson, MD, Dartmouth University Meeting Room 3

Cecelia Gaffney, Med 4:00 P.M. to 5:15 P.M.

Viking Hedberg, MD

Wendy Gladstone, MD

Robert Mathes, MD

Paul Reiss, MD

PBRN(s):

CECH

Title:

A Better Adolescent Health Visit through PDA Based Counseling

Context:

Adolescents face many lifestyle choices with immediate and longterm
health consequences. While teens want to discuss these issues, many of
their concerns are not covered in health visits because clinicians are
not aware of risks or little time is left for behavior change
counseling.

Objective:

Use of the personal digital assistant (PDA) to gather health risk data
from adolescents and review of this data by providers has the potential
to improve counseling.

Design:

For two consecutive weeks teens completed exit surveys prior to and
after implementing PDA screening during well visits. Surveys assessed
satisfaction with visit and discussion of behavioral health risks.

Setting:

Clinicians to Enhance Child Health (CECH) is network of pediatric and
family practitioners in 28 New England community, private practices.

Participants:

All adolescents presenting for well-care during two data collection
period.

Intervention or Essential Feature of Study:

The Prescription for Health \"Healthy Teens\" project introduced PDA
based adolescent health screening for teens presenting for well visits.
Teens completed PDA-based health screener that provides a summary report
for their provider. Clinicians reviewed the results of the screener and
using patient-centered counseling techniques addressed issues identified
by the screener.

Results (if available):

Exit surveys were completed by 163 teens (68 pre/99 post). Frequency and
quality of discussion of 8 health risk related to sedentary lifestyle,
diet, alcohol, tobacco, drugs, safety, sexuality and mood were assessed.
Teens report increased discussion of fruit/vegetable intake (45%/63%
p=.02), tobacco use (43%/60% p=.04), and alcohol use (41%/58%, p=.05).
More teens rated these discussions as very helpful, and 85% said the
using PDA made it easier to discuss their issues. More teens felt they
were listened to carefully (88%/64% p=.002) and were very satisfied with
their visit (88%/64% p=.005).

Conclusions:

Adolescent use of comprehensive screener on PDA is an efficient way to
restructure the health visit and improve behavior change counseling of
important health risks.

**Concurrent Session IIIC**

"Cardiovascular Risk Reduction Strategy"-Paul Woolf, MD, MBA,
Crozer-Chester Hospital (CKHN)

"Diabetes and Cardiovascular Risk Factors"-Michael Parchman, MD, MPH,
University of Texas (STARNet)

"GALS: Gender and Lifestyle Study"-Katrina Donahue, MD, MPH, University
of North Carolina (NCFPRN)

"Screening for Behavioral Health Risks in Rural Oregon Children"
(Research in Development)-Lyle Fagnan, MD, University Oregon (ORPRN)

Author(s): Concurrent Sessions IIIC

\*Paul D. Woolf, MD, MBA, Crozer Chester Medical Center Meeting Room 4

Dale N Schumacher MD, MPH1 4:00 P.M. to 5:15 P.M.

Sharon Scott BS, MSN1

Stephen M Petterson PhD

Mitchell A Kaminski MD, MBA

Edward E Baum MSS, MBA

PBRN(s):

CKHN

Title:

Cardiovascular Risk Reduction Strategy

Context:

Reductions in risk factors have been shown to reduce CV events.

Objective:

To test the effectiveness of multiple integrated interventions for
reducing

cardiovascular risks in our PBRN.

Design:

Nonequivalent Comparison Groups with practices matched for specialty,
and practice demographics

Setting:

Nine Family Medicine and 5 Internal Medicine CKHN PBRN practices

Participants:

From a potential pool of 5245 patients with a Framingham risk for a
ten-year CV event of \>10%, 293 and 237 subjects enrolled from the
intervention and usual care practices respectively, of whom 268 and 216
completed the study. Patient demographics were similar.

Intervention or Essential Feature of Study:

Patient education pamphlets, individualized patient \"passports\"
listing cardiovascular risks; progress note pages modified to list the
data contained in the passport. Data were collected before and 6-18
months after the interventions.

Outcome Measures (if any):

HbA1c and lipid levels, BMI, BP, Framingham Risk Score, smoking and
exercise histories

Results (if available):

Total and LDL cholesterol decreased significantly in both arms (Control:
Total Cholesterol 178.4 vs 166.4; LDLc 104.7 vs 95.2 mg/dL;
Intervention: Total Cholesterol 179.3 vs 170.4; LDLc 104.4 vs 96.3
mg/dL). The reductions in both groups were limited to LDL levels \>130
mg/dL, largely ascribable to initiation/continuation of statin therapy.
Gender, age, race, diabetes, practice specialty and practice
participation in a prior lipid project (PLP) did not affect the
magnitude of the reduction, although diabetics and PLP subjects started
from lower baselines; Blacks had levels 12 mg/dL higher. Mean HbA1c
levels ranged between 6.4 and 6.7%. There were no significant
differences between the two arms for any parameter. Our LDL results
exceeded LDL changes measured at Quest Diagnostics in the greater
Philadelphia area among subjects \>50 years of age (2003: 115.0
\[N=80,398\] vs 2004: 112.4 mg/dL \[N=81,897\]).

Conclusions:

Among high-risk motivated patients, reductions in LDL levels to ATPIII
guidelines are achievable. Targeted interventions did not add to the
PBRN\'s ongoing performance improvement processes.

Author(s): Concurrent Sessions IIIC

\*Michael Parchman, MD, University of Texas Meeting Room 4

John Zeber, PhD 4:00 P.M. to 5:15 P.M.

PBRN(s):

South Texas Ambulatory Research Network

Title:

Diabetes and Cardiovascular Risk Factors

Context:

Among people with type 2 diabetes, some coronary heart disease(CHD) risk
factors are \"fixed:\" age, sex, duration of diabetes, and
race/ethnicity, while others are potentially \"modifiable:\" smoking,
glucose control, blood pressure and lipid levels.

Objective:

1\) estimate 10-year risk of CHD among patients with type 2 diabetes; 2)
calculate the proportion of risk attributable to \"modifiable\" risk
factors; 3) evaluate the variation in risk within and between primary
care practices.

Design:

Cross-sectional.

Setting:

20 primary care practices in the South Texas Ambulatory Research Network

Participants:

424 established patients with type 2 diabetes and no prior history of
CHD.

Intervention or Essential Feature of Study:

None

Outcome Measures:

The UKPDS Risk Engine was used to calculate 10-year risk of developing
CHD. Modifiable risk was calculated by lowering all modifiable risk
factors to recommended levels. The 10-year risk of CHD was recalculated
and the proportion of risk that was modifiable was calculated as the
change in risk score over the baseline risk score.

Results:

The 10-year risk of CHD ranged from 0.006 to 0.80 with a mean of 0.12
(S.D. 0.12). If modifiable risk factors were at recommended levels, the
risk decreased from 12.0% to 8.7%, a 26.9% reduction. Across practices,
the mean risk score ranged from 0.05 to 0.24, a nearly five-fold
difference. The proportion of the practice mean risk score attributable
to modifiable risk factors ranged from 14% to 49%. The intra-cluster
correlation coefficient for the total UKPDS risk factor score was 0.13.

Conclusions:

The potential for reducing 10-year CHD risk varies by a factor of 5
across primary care practices. 13% of the 10-year risk of developing CHD
is explained by the practice where care is delivered. Interventions to
reduce type 2 diabetes CHD risk in primary care may need to be tailored
to the individual practice.

Author(s): Concurrent Sessions IIIC

\*Katrina Donahue, MD, MPH, University of North Carolina at Chapel Hill
Meeting Room 4

Nicholas Didow Jr, PhD, MBA 4:00 P.M. to 5:15 P.M.

Gratia Wright

Leigh Callaha, PhD

Philip Sloane, MD, MPH

PBRN(s):

NCFPRN

Title:

GALS: Gender and Lifestyle Study

Context:

Moderate physical activity can decrease the risk of developing diabetes.
In the North Carolina Family Practice Research Network (NC-FP-RN) over
40% of persons at risk for developing diabetes are both female and
sedentary.

Objective:

To understand motivators and barriers to physical activity in
African-American and Caucasian women at high risk for developing
diabetes, to help inform the development of a practice-based
intervention to increase physical activity.

Design:

Focus groups

Setting:

North Carolina Piedmont area

Participants:

Adult active and inactive African-American and Caucasian women attending
4 NC-FP-RN practices determined to be at high risk for developing
diabetes.

Intervention or Essential Feature of Study:

Semi-structured discussions on motivators and barriers to becoming
active and maintaining activity, current activity, and components of
activities they like and do not like.

Results (if available):

Common emerging concerns include: (1) the need for a motivating reason;
many participants noted that they \'will not do exercise just for
exercise\'s sake\'. This motivator can be physical, like weight loss, a
lab number improving, increasing steps a day or kudos. The motivator can
have a social aspect, such as having a partner or coach. The motivator
can be mental, such as the feeling of stress relief. There was also an
interest in gadgets (i.e. pedometers) but they must be easy to use; (2)
value of physician as a support, sometimes; participants wanted
physicians to be specific in recommendations for activity, otherwise
they felt frustrated. (3) Variety; Many participants had different
activity interests; some asked for a list of possible activities
available in neighborhood. (4) Exercise as luxury; Many women commented
on feeling obligated to put family needs first before considering
activity for themselves.

Conclusions:

Women want activity to have a motivating purpose, to be enjoyable, and
convenient. Physicians are viewed as supportive when their suggestions
are specific. A program should contain multiple options because the
women have varied interests and time constraints, depending on
family/work obligations.

Author(s): Concurrent Sessions IIIC

\*Lyle Fagnan, MD, Oregon Health and Science University Meeting Room 4

Colleen Reuland, MS 4:00 P.M. to 5:15 P.M.

Christina Bethell, PhD., MPH

David Willis, MD

Ann Ford,BA

Anne King, MBA

PBRN(s):

ORPRN

Title:

Screening for Behavioral Health Risks in Rural Oregon Children

Context:

Identification of children at risk for behavioral health problems
accompanied by early intervention has a profound influence on school
success, self-esteem and their development into productive adult members
of society. Studies show that up to 20 percent of all children will have
a behavioral development issue, yet few children are identified as
needing care and even less receive necessary treatment. Information
regarding screening, assessment and referral of children for behavioral
development risks in rural settings is limited.

Objective:

1\. Will the implementation of validated screening tools as a part of
the well-child visit increase the rate of identification and referral of
children and families at risk to appropriate resources? 2. Will the
screening and referral process be accepted, valued, and sustained by
clinicians and patients?

Basic Study Design:

Study population is children ages 0 to 6 years of age and their families
who reside in a frontier, rural Oregon community and receive their
health care from two small independent family practice offices.

The intervention consists of two parts: 1) universal screening at
selected well-child visits with validated tools-Parents Evaluation of
Developmental Status (PEDS), Ages and Stages Questionnaire (ASQ),
Checklist for Autism in Toddlers (CHAT), and the modified New Babies
Questionnaire (NBQ); and 2) follow-up case management for those children
that screen at risk.

Current Challenges:

This state funded project uses a Logic Model evaluation framework.
Developing valid measurement tools to link planned work to intended
results are a challenge. An additional challenge is the uneven interest
and enthusiasm among clinicians for the project.

Goals for Session/Questions for Audience Consideration:

1\. How are interventions that change systems of care studied?

2\. How are these studies classified?

3\. How does the lack of a control group affect the evaluation process?

**Concurrent Session IIID**

"Smoking Status as a Vital Sign"-Stephen Rothemich, MD, MS, Medical
College of Virginia (ACORN)

"A Practice Sponsored Website to Help Patients Pursue Health
Behaviors"-Steven Woolf, MD, MPH, Medical College of Virginia (ACORN)

"Tobacco Usage among Patients in a Statewide PBRN"-Shawn Ralston, MD,
University of New Mexico (RIOSNet)

"Assessment of Quitting Behavior in Smokers within a PBRN"-Daryl Wiley,
MD, Medical College of Georgia (HamesNet)

Author(s): Concurrent Sessions IIID

\*Stephen F. Rothemich, MD, MS, Virginia Commonwealth University Meeting
Room 5

Steven H. Woolf, MD, MPH 4:00 P.M. to 5:15 P.M.

Robert E. Johnson, Ph.D.

Amy E. Burgett, RN

Sharon K. Flores, MS,

David W. Marsland, MD

Jasjit S. Ahluwalia, MD, MPH, MS

PBRN(s):

ACORN

Title:\
Smoking Status as a Vital Sign

Context:

Primary care clinicians should counsel patients about tobacco use but
smoking status is often overlooked. Guidelines encourage practices to
document smoking status along with vital signs, but whether this
promotes counseling is unclear.

Objective:

To test whether the vital sign intervention increases counseling in
primary care settings and the intensity of the counseling it promotes.

Design:

Cluster RCT with allocation and analysis by practice and with outcomes
measured over 6 months.

Setting:

18 primary care practices in greater Richmond (VA).

Participants:

Block randomization identified 9 intervention and 9 control practices.
No practices withdrew. Exit surveys, completed by 6786 adults (3858 and
2928 patients, respectively), provided outcomes data. Eighty-one percent
of eligible patients participated.

Intervention or Essential Feature of Study:

Rooming staff were instructed to assess the tobacco use status of every
adult patient and record the answer in the record where other vital
signs were documented.

Outcome Measures:

Proportion of smokers reporting clinician counseling of any kind, and
the frequency of 2 counseling subcomponents: simple quit advice and more
intensive discussion. Under the \"5As\" model, the main outcome
corresponded to A2-5 (Advise, Assess, Assist, Arrange) and the
subcomponents to A2 and A3-5, respectively.

Results:

Intervention and control practices differed by 8.5% in the proportion of
patients reporting any counseling (A2-5) (61.9% and 53.4%, respectively,
p = 0.038). The effect was largely restricted to simple advice (A2). The
proportion of patients receiving A2 differed by 8.4% (59.9% and 51.5%,
respectively, p = 0.039), but the frequency of more extensive discussion
(A3-5) did not differ (32.5% and 29.3%, respectively, p = 0.178) between
groups.

Conclusions:

The vital sign intervention promotes tobacco counseling in primary care
but its effect is modest and limited to simple advice. This alone
conveys public health benefits, but more extensive redesigns are
necessary for practices to fully assist smokers.

Author(s): Concurrent Sessions IIID

\*Steven Woolf, MD, MPH, Virginia Commonwealth University Meeting Room 5

Alex H. Krist, MD 4:00 P.M. to 5:15 P.M.

Robert E. Johnson, PhD

Diane B. Wilson, EdD, MS, RD

Stephen F. Rothemich, MD, MS

Gregory J. Norman, PhD

Kelly J. Devers, PhD\
\
PBRN(s):

ACORN

Title:\
A Practice Sponsored Website to Help Patients Pursue Health Behaviors

Context:

Unhealthy behaviors (e.g., physical inactivity, smoking) contribute
greatly to disease, but clinicians encounter barriers in addressing the
problem. One challenge is providing patients with essential information
resources for behavior change.

Objective:

To test the effectiveness of a multipurpose website (\"My Healthy
Living\" \[MHL\],
[[www.myhealthyliving.net]{.underline}](../www.myhealthyliving.net)) to
promote healthy behaviors, as part of the Prescription for Health
program.

Design:

Pre-post, with internal controls.

Setting:

Six suburban family practices (4 intervention, 2 control). ACORN is a 6
year-old PBRN comprising 37 practices in Virginia.

Participants:

Sampling frame: adults visiting the practices over 9 months. Subjects
(n=273): patients in sampling frame who visited MHL and completed
consent.

Intervention or Essential Feature of Study:

Practices heavily promoted MHL. The website administered intake
questions to intervention and control patients. For intervention
patients, it offered tailored health advice, a library of national and
local resources, and printouts for providers. For control patients, it
offered static information pages.

Outcome Measures (if any):

Stage of change and health behaviors at baseline and follow-up (1 and 4
months), website usage, and satisfaction.

Results (if available):

Most website visitors were women and under age 50 (71% and 79%,
respectively). Half the visitors (55% and 53%, respectively) wanted
their doctor\'s help with diet and physical inactivity. Stage of change
and health behaviors improved in both intervention and control groups.
At 1 month, net behavioral improvement was greater among intervention
patients, although the differences reached significance only for
physical activity (stage, p=0.02; behavior, p=0.10). The relatively
small number of website visitors who enrolled (n=273) compromised
statistical power. Patients liked MHL-61% said that it was helpful, and
59% revisited 2-5 times. To improve the site, users recommended more
detailed information and interactivity with clinicians.

Conclusions:

The website appealed to patients and may have facilitated behavior
change, but clinician encouragement was by itself insufficient to draw
patients to this resource. A more proactive approach, combined with
personal counseling options, might enhance utility.

Author(s): Concurrent Sessions IIID

\*Shawn Ralston, MD, University of New Mexico Meeting Room 5

Robert Williams, MD 4:00 P.M. to 5:15 P.M.

Nicole Kellet

Cheryl Schmitt

PBRN(s):

RIOSNet

Title:

Tobacco Usage among Patients in a Statewide PBRN

Context:

Lower than average published rates of tobacco product usage among ethnic
groups in the Southwest do not correlate with clinical experience in New
Mexico.

Objective:

To determine the specifics of tobacco usage among low-income primary
care patients in preparation for a network based tobacco cessation
program.

Design:

Tobacco usage was recorded on all patients over 12 years seen in the
primary care practices of RIOS Net members during a two-week sampling
period. To address seasonal variation in patient presentation,
individual clinicians were assigned to two-week data collection periods
scattered within an overall sampling period.

Setting:

Primary care practices in New Mexico participating in RIOS Net,
primarily serving low-income, predominantly Hispanic and Native American
patients.

Participants:

2275 patients were surveyed by 87 different providers representing
predominantly community health centers (29%), Indian Health Service
sites (30%), and University teaching hospital affiliated clinics (32%).
Surveyed patients were 37% Hispanic, 31% Native American, 27%
non-Hispanic white and 64% female. Approximately 50% of patients were
under 45 years of age.

Intervention or Essential Feature of Study:

Rates and intensity of tobacco usage were recorded using standard survey
techniques.

Results (if available):

A total of 22.8% of patients smoked cigarettes, including 73% who smoked
on a daily basis. Non-Hispanic White men smoked at the highest rates
(34.5%); followed by Hispanic men (28.6%), Hispanic women (24.9%),
Non-Hispanic White women (21.3%), Native American men (20.5%) and Native
American women (13%). Among Native Americans, 36% of young adults smoke,
a rate much higher than in their elders.

Conclusions:

A primary care based sample reveals significant differences in tobacco
usage when compared with national telephone survey based prevalence
rates. Hispanic females in this study setting smoked at over twice the
rates reported by the Behavioral Risk Factor Surveillance System. Young
Native Americans report smoking at rates much higher than historically
seen in this group. These issues deserve consideration when planning
tobacco cessation programs.

Author(s): Concurrent Sessions IIID

\*Daryl Wiley, MD, Medical College of Georgia Meeting Room 5

Andria Thomas, PhD 4:00 P.M. to 5:15 P.M.

Peggy Wagner, PhD

Ralph Gillies, PhD

Jennifer Kenrick, BA\
\
PBRN(s):\
HamesNet

Title:

Assessment of Quitting Behavior in Smokers within a Practice-Based
Research Network

Context:

Cigarette smoking is the single most preventable cause of premature
death in the U.S. Annually, more than 400,000 Americans die from
cigarette smoking.

Objective:

The purpose of this study was to determine the rate of smoking in
primary care practices, what methods smokers have used to try to quit,
and which were successful.

Design:

Survey

Setting:

Four HamesNet PBRN practice sites.

Participants:

332 patients, age 18 or older

Intervention or Essential Feature of Study:

Prevelance of smoking cessation strategies

Results (if available):

The mean age for participants was 47.51 (SD = 15.9). The majority of
patients were White (n=206, 63%). Over half of the sample never smoked
(n=178, 53.6%). Of the patients who have smoked, 90 (27.1%) had quit.
29.1 % of successful quitters attempted to quit 2-5 times before their
last attempt. However, over 50% were able to quit on the 1st or 2nd
attempt (n=46). Most of the quitters tried to quit \"cold turkey\"
(n=69, 77.5%), which was a successful method for most (n=63, 72.4%). Of
patients who still smoke (n=63, 19.0%), 76.2% have tried unsuccessfully
to quit, most 2-5 times (n=22, 40.0%). Top three reasons identified as
barriers to success from highest to lowest were lack of willpower (n=34,
53.1%), like to smoke (n=25, 39.1%), and depression (n=20, 31.3%). 75.8%
of these patients have no definite plans to quit in the next 6 months.
Smokers thought quitting cold turkey would be the most effective method
if they tried to quit (mean rating = 3.65). A relationship between
family history of smoking-related illness and quitting behavior was not
observed.

Conclusions:

A large number of smokers utilized quitting \"cold turkey\" as their
method for attempting to quit, and quitters found it to be the most
successful method. These data suggest that patients continue to perceive
and rely on independent, self-control methods as the way to quit
smoking.

**Concurrent Session IVB**

"Missing Clinical Information during Private Primary Care Visits"-Peter
Smith, MD, University of Colorado (BIGHORN)

"Ameliorators of Errors in Primary Care"-Douglas Fernald, MS, University
of Colorado (CaReNet)

"Dashboard Technology" (Research in Development)-Peggy Wagner, PhD,
University of Georgia (HamesNet)

Author(s): Concurrent Sessions IVB

\*Peter Smith MD, University of Colorado Meeting Room 3

Sherry Holcomb 9:45 A.M. to 10:45 A.M.

L. Miriam Dickinson PhD

Elizabeth Staton MSTC

Wilson Pace MD

PBRN(s):\
BIGHORN

Title:

Missing Clinical Information during Private Primary Care Visits

Context:

Providers in 2 PBRNs focusing on rural and underserved care reported
important missing clinical information (MCI) in 13.6% of visits. Whether
this is true in private practice is unknown, as is the validity of
provider report of MCI.

Objective:

1\. Describe the phenomenon of MCI (frequency, typology, predictors, and
consequences) in private primary care practices. 2. Determine validity
of provider report in estimating MCI and its consequences.

Design:

Mixed-methods, combining cross-sectional surveys with simultaneous and
2-month follow-up semi-structured interviews.

Setting:

The Building InvestiGative practices for better Health Outcomes Research
Network (BIGHORN), a new Colorado PBRN of private primary care
practices.

Participants:

All consenting BIGHORN providers.

Intervention or Essential Feature of Study:

1\. Provider questionnaire describing their practice, information
systems, and demographic descriptors. 2. Visit questionnaire completed
by providers at every visit for one day (patient demographics, the
specifics of missing information, and potential confounders). 3.
Semi-structured interviews with providers about MCI visits, conducted
after clinical sessions and again two months later to determine if
information was missing and the accuracy of their predictions.

Outcome Measures:

Main: Proportion of visits with important MCI, and
sensitivity/specificity of provider report of MCI and predictions of
consequences. Secondary: Categories of MCI and their frequencies;
predictors of MCI; time spent by providers and staff trying to find MCI;
and predicted and actual frequencies of adverse effects, delays in care,
and additional services.

Results:

We anticipate the MCI phenomenon will differ between private and
rural/frontier/underserved practices; provider report of MCI will
accurately estimate actual MCI rates; and predictions of adverse
affects, delays, and additional services will be exaggerated.

Conclusions:

We are currently refining the questionnaires and interview data
collection instruments. The next step will be to pilot the surveys and
interviews to maximize data collection while minimizing practice burden,
followed by formal practice recruitment and data collection.

Author(s): Concurrent Sessions IVB

\*Douglas Fernald, MA, University of Colorado Meeting Room 3

Bennett Parnes, MD 9:45 A.M. to 10:45 A.M.

Jav\'n Quintela, BS

Rodrigo Araya-Guerra, BA

John Westfall, MD

Wilson Pace, MD

PBRN(s):

CaReNet

Title:

Ameliorators of Errors in Primary Care

Context:

Little is known about medical errors that are remedied before affecting
patients.

Objective:

Identify and characterize patient safety events that have been
ameliorated. Propose a framework to identify improvement strategies.

Design:

All events from a primary care patient safety reporting system coded as
having an ameliorator were further analyzed qualitatively, using an
editing style of analysis and iterative template coding. Setting:
Applied Strategies for Improving Patient Safety (ASIPS), a demonstration
project that collects and analyzes voluntary medical error reports in
primary care settings.

Setting:

Applied Strategies for Improving Patient Safety (ASIPS), a demonstration
project that collects and analyzes voluntary medical error reports in
primary care settings.

Participants:

Clinicians and staff in two Colorado PBRNs.

Intervention or Essential Feature of Study:

In depth analysis of who were ameliorators; what they did; how
amelioration occurred; resultant system changes.

Results:

Out of 754 coded reports, 60 (8%) involved ameliorators. Ameliorators
were clinicians (17), nurses/MAs (13), pharmacists (10), office staff
(6), laboratory staff (2), patients/family members (9), and unidentified
(3). In the 46 cases ameliorated by someone other than patients, 32
ameliorators (70%) did what would have been expected, whereas in 12
cases (26%) the behavior was exceptional; 2 cases (4%) lacked sufficient
information. Mistakes were most often corrected when ameliorators
double-checked information, noticed something wasn\'t quite right, asked
extra questions, or verified conflicting information. In many cases, the
ameliorator was particularly persistent in investigating or following
through on a problem. While most errors were ameliorated several steps
before they would have reached the patient, 31% occurred just before
reaching or affecting the patient. The ameliorated event resulted in a
system change in 4 cases (7%). Amelioration requires two essential
elements: an opportunity to catch an error (by system, vigilance, or
chance), and action to remedy it.

Conclusions:

Ameliorators of patient safety events represent a spectrum of health
care workers and patients. Understanding when and how errors are
prevented from reaching or affecting patients can help in the design of
effective interventions.

Author(s): Concurrent Sessions IVB

\*Peggy Wagner, PhD, Medical College of Georgia Meeting Room 3

Andria Thomas PhD 9:45 A.M. to 10:45 A.M.

Ralph Gillies PhD

PBRN(s):\
HamesNet

Title:

Dashboard Technology

Context:

Improved health care quality and safety require changes in physicians
and systems of care. Such changes are difficult and slow. Larger
healthcare systems and various businesses and industries have used
real-time data transmission to stimulate improved quality.

Objective:

Our research question is whether a practice dashboard providing ongoing,
glancible data streams might stimulate timely and appropriate practice
change in smaller, ambulatory health care settings. A secondary question
is whether patients and clinicians would accept such systems.

Basic Study Design:

We propose to develop a patient-centered feedback system that would
provide \"glancible\" data to test sites selected from our 40 site
network, HamesNet.

A streaming feedback system, called a \"practice dashboard\" would
gather data from patients using exit questions administered via a touch
screen kiosk and linked, with a small delay to assure patient
confidentiality, to a flat screen monitor display in the clinic.
Additional email reports expressing individual practitioner data would
be sent daily. Preliminary feasibility and acceptability data would be
collected at beta sites. Subsequently a controlled pilot trial over a 6
week period would be conducted in two intervention and two control
sites, each with multiple practitioners. Weekly mean patient responses
per physician will be the unit of analysis using independent sample
t-tests comparing responses across conditions.

Current Challenges:

Current challenges include clinician willingness to participate,
identification of best ways to present data, patient confidentiality,
and potential habituation of clinicians to data presentation.

**Concurrent Session IVC**

"Implementing a Complex Diabetes Intervention in a PBRN"-Wilson Pace,
MD, University of Colorado (CaReNet)

"TRANSLATE: A best practice example"-Kevin Peterson, MD, MPH, University
of Minnesota (MAFPRN)

Author(s): Concurrent Sessions IVC

Bennett Parnes, MD, University of Colorado Meeting Room 4

\*Wilson Pace, MD, University of Colorado 9:45 A.M. to 10:45 A.M.

PBRN(s):

CaReNet

Title:

Implementing a Complex Diabetes Intervention in a PBRN: Challenges,
Success, and Lessons Learned from Year 1 of a 4 year Project

Context:

Much of PBRN research has been cross-sectional or observational studies.
More recently, randomized trials with interventions that may be complex
are being conducted in PBRNs. The challenges associated with these more
complex studies are often not apparent until the study is underway, and
the lessons learned in overcoming the challenges are typically not
reported so that other PBRNs may learn from them.

Objective/Challenges to Be Overcome:

To describe the experience of the first year of the Focus on Reducing
cardiovascular Events in Diabetes through Optimal Management study (The
FREEDOM Study), funded by the Robert Wood Johnson Foundation through its
Generalist Scholars Program.

Approach:

This study encountered multiple obstacles, including unanticipated
budgetary shortfalls, PRA personnel issues, mentorship availability, PI
time constraints, recruitment obstacles, delays in the timetable, the
unanticipated loss of several clinic sites to procedural problems with
the protocol, and multiple IRBs.

Results & Observations:

Many of the obstacles were successfully overcome, but others required
significant adaptations and remain concerns at this time. A novel
approach to consenting patients, which was done entirely by phone
without a face-to-face encounter, will be described, including
overcoming IRB concerns, and the success of this approach.

Implications for other PBRNs:

The experiences and lessons learned from this study, although specific
to this project, are likely of value to other PBRNs embarking on
randomized intervention studies.

Author(s): Concurrent Sessions IVC

\*Kevin Peterson MD, MPH, University of Minnesota Meeting Room 4

Chet Fox, MD 9:45 A.M. to 10:45 A.M.

PBRN(s):\
MAFPRN

Title:

TRANSLATE: A Best Practice Example

Context:

The benefits of medical advances will only be fully realized if they are
effectively translated into clinical practice. A particularly important
focal point for the translation of new findings in diabetes care is the
primary care office where most diabetes care is delivered. However few
operational models for the translation of research into practice in the
primary care office have been developed. A new AHRQ study performed by
the MAFPRN has successfully introduced a new model for translating
research into clinical practice called TRANSLATE. This acronym stands
for Targeting high risk patients, Reminder systems, Administrative
support, Networked information systems, Site coordination, Local
champions, Audit and feedback, Tracking, and Education.

Objective/Challenges to Be Overcome:

The nine components of TRANSLATE have been demonstrated to be important
in several models. The MAFPRN study demonstrated success in altering
clinical practice, suggesting that these elements provide an important
basis for a potentially more generalizable model for translating
research into practice in chronic disease. The strengths and weaknesses
of implementation of this model will be discussed. Both quantitative and
qualitative data will be drawn from the study to demonstrate important
modes of breakdown in primary care systems. The challenges to providing
the financing and infrastructure for this type of project will also be
discussed.

Approach:

Qualitative and quantitative results from the MAFPRN diabetes
translation study (AHRQ), the EMDI pilot study, and baseline results
from the IMPACT randomized controlled trial (NIDDK) will be presented
and discussed.

Results & Observations:

Changes in both clinical outcomes and National Committee on Quality
Assurance performance measures have been demonstrated in the above
studies. Additional perspectives that will be discussed include
implementation methodology, and local buy-in from on-site teams.

Implications for other PBRNs:

TRANSLATE can be used as a model for translating research into practice.
By paying attention to both the components and the methodology, PBRNs
can be more successful at rapidly changing medical practice.

**Concurrent Session VA**

"Evaluation of Decision Aids for Screening Mammography in Women
40-49"-William Curry, MD, MS, Penn State CAN

"Physicians' Knowledge and Practice Patterns in Detecting and Treating
Chronic Kidney Disease"-Chet Fox, MD, University of Buffalo (UNYNet)

"Access and Use of Osteoporosis Technology in Rural Oregon"-Lyle Fagnan,
MD, University of Oregon (ORPRN)

"Screening for Parental Depression during Well Child Visits"-Ardis
Olson, MD, Dartmouth (CECH)

Author(s): Concurrent Sessions VA

\*William Curry, MD, MS, Penn State University Meeting Room 2

Peter Lewis, MD 11:00 A.M. to 12:15 P.M.

Alan Adelman, MD, MS

Marie Graybill, RN

PBRN(s):\
Penn State CAN

Title:

Evaluation of Decision Aids for Screening Mammography in Women 40-49

Context:

The benefit of screening mammography in women in their 40s has not been
clearly demonstrated. With conflicting screening recommendations by
national organizations and professional societies, counseling of women
in their 40s regarding the benefits and harms is important. This
counseling may be difficult in the typically busy office practice. The
only decision aid that specifically addresses screening mammography for
women in their 40s has never been fully evaluated. The written decision
aid communicates risk non-graphically. Many recommend that the
communication of risk be presented graphically.

Objective:

Our ultimate goal is to evaluate how best to implement decision aids
into a busy office practice. The first step in achieving this goal is to
evaluate effective decision aids. The specific aim of this research is
to evaluate and compare an interactive CD-ROM decision aid with the
decision aid developed by the AAFP.

Design:

A convenience sample of sixty women, 40-49 years of age from the Penn
State Ambulatory Research Network (PSARN) will be asked to review either
a written decision aid (American Academy of Family Physicians) or an
interactive CD-ROM decision aid.

Setting:

The Penn State Ambulatory Research Network (PSARN) was established in
2001 and is a cooperative effort by the Division of General Internal
Medicine, Division of General Pediatrics, and the Department of Family
and Community Medicine.

PSARN consists of primary care practice sites of the Milton S. Hershey
Medical Center, the Penn State Good Samaritan Hospital Family Practice
Residency Program and four federally funded community health centers in
south-central Pennsylvania. Over 100 participating clinicians seeing
almost 400,000 outpatient visits annually.

Participants:

1\. Age 40 - 49 years

2\. Ability to read and speak English

3\. No personal history of breast cancer

4\. No history of mastectomy or breast biopsy

5\. No first degree relatives with breast cancer

Intervention or Essential Feature of Study:

Compare interactive CD-ROM decision aid with the American Academy of
Family Physicians\' decision aid.

Outcome Measures (if any):

The primary outcome: change in the patients\' knowledge and perception
of risk. A secondary outcomes: change in the Decisional Conflict Scale
and Satisfaction with Decision.

Results (if available): In Progress

Conclusions: In progress

Author(s): Concurrent Sessions VA

\*Chet Fox MD, University at Buffalo Meeting Room 2

Amanda Brooks BS 11:00 A.M. to 12:15 P.M.

Luis Zayas PhD

Brian Murray MD

PBRN(s):\
UNYNet

Title:

Physicians\' Knowledge and Practice Patterns in Detecting and Treating
Chronic Kidney Disease

Context:

As the prevalence of chronic kidney disease (CKD) continues to rapidly
rise, it has become imperative that earlier treatment and prevention
measures be implemented. Since 62% of CKD patients are seen only in
Primary Care offices, it is important to equip doctors with better tools
for treating this disease.

Objective:

What is the current status of physicians\' knowledge and practice
patterns in treating CKD?

Design:

A qualitative study of a cohort of primary care physicians, chosen at
random. Qualitative analysis was performed using the grounded theory
editing approach by Crabtree and Miller.

Setting:

The study occurred in UNYNET which comprises the eight counties of
Western New York. There are 50 practices, 120 clinicians, and 228,000
patients in the network. The network is a mix of academic and community
sites, and urban, suburban, and rural sites.

Participants:

10 practicing physicians from 10 different practices (20% representative
sample of network practices) from UNYNET

Intervention or Essential Feature of Study:

A medical student served as both research associate and co-investigator.
An hour long open ended interview about CKD treatment followed by a
questionnaire was administered.

Outcome Measures (if any):

Themes generated from the interview

Results (if available):

No physician interviewed was aware of national guidelines for chronic
kidney disease. All were eager for guidance. The knowledge base of
primary care physicians in this cohort is highly variable in regards to
CKD. Physicians were confused as to when to refer to Nephrologists, and
all complained of poor communication and ill-defined roles once the
referral was made.

Conclusions:

Lessons learned from completing this study were: Small research
stimulation grant funds (\$5,000) are available from the AAFP for PBRNs.
PBRNs are good for qualitative studies. Medical students can be used as
both research associates and research trainees simultaneously at a
reasonable cost. Outcomes from these small studies can be used to design
larger intervention projects.

Author(s): Concurrent Sessions VA

\*Lyle J. Fagnan, MD, Oregon Health & Science University Meeting Room 2

Eric Orwoll, MD 11:00 A.M. to 12:15 P.M.

Breanna Percell, BS

Motomi Mori, PhD

PBRN(s):

ORPRN

Title:

Access and Use of Osteoporosis Technology in Rural Oregon

Context:

The U.S. Preventive Services Task Force recommends that all women age 65
and older be routinely screened for osteoporosis.

Objective:

To describe the availability and use of accepted bone mineral density
(BMD) testing in rural Oregon.

Design:

Cross-sectional survey of primary care clinicians and women living in
rural communities to assess awareness of and barriers to screening for
osteoporosis. Separate surveys were used for clinicians and women in the
community.

Setting:

Ten communities with clinicians participating in the Oregon Rural
Practice-based Research Network (ORPRN).

Participants:

Fifty-four primary care clinicians and 6500 women, age 65 and older
living in the participating communities.

Intervention or Essential Feature of Study:

Separate surveys to clinicians and patients linked by community to
describe BMD testing availability and practices.

Results:

A total of 40 clinicians (74%) and 2466 patients (38 %) responded. The
clinicians report that 18% of women age 65 or older inquired about
osteoporosis screening or treatment. Among the clinicians who order BMD
measurements for postmenopausal women (n=30), 23% report that the
primary barrier in obtaining BMD referral is the patient\'s lack of
concern regarding osteoporosis risk. Three-quarters of clinicians feel
that availability or long travel time are not barriers to ordering
osteoporosis screening. Over 90% of women report being aware of BMD
testing and 80% of women reported they would have the test if their
provider recommended it. 90% of women reported that they would consider
taking medication if testing demonstrated osteoporosis. Among women not
receiving screening, 78% indicated their doctor did not order the test.

Conclusions:

Clinicians may underestimate their patients\' concern about osteoporosis
and their willingness to undergo BMD testing and treatment if it is
recommended.

Author(s): Concurrent Sessions VA

\*Ardis Olson, MD, Dartmouth Hitchcock Medical Center Meeting Room 2

Allen Dietrich,MD 11:00 A.M. to 12:15 P.M.

Greg Prazar, MD

Viking Hedberg,MD

James Hurley,MD

Mark Harris,MD

PRBN(s):\
CECH

Title:

Screening for Parental Depression during Well Child Visits

Context:

Parental depression has significant impact on child development and
behavior. Pediatric providers may see more parents than their primary
care provider and thus have greater opportunity to screen for
depression.

Objective:

Determine the yield and feasibility of routine parental depression
screening by pediatric practices.

Design:

Parents were screened and positive screening results addressed by the
pediatric provider during the child\'s well visit. Referred to
telephonic triage and referral or community mental health resources as
appropriate.

Setting:

Clinicians to Enhance Child Health (CECH) is network of pediatric and
family practitioners in 28 New England community, private practices.

Participants:

Parents of children who present with their child for well visits at
participating practices.

Intervention or Essential Feature of Study:

Systematic depression screening conducted for six months with parent
education and support provided by clinicians as needed. The abbreviated
Patient Health Questionnaire (PHQ-2) was used to screen for depressed
mood and anhedonia. Parents who screened positive (score ?3) were
referred to their PCP, local mental health resources or a telephonic
Parent Support Line (PSL).

Results:

PHQ-2s were completed in 50% of 16,716 well child visits. Variations in
screening rates were due to office staffing patterns and provider/nurse
attitudes. Five percent of parents screened positive (same both
genders). For screen positive mothers, 44% felt they might be depressed
and were willing to take action, and 27% thought they were stressed, not
depressed. Clinicians referred 37% of screen positive parents to their
primary care clinician or to mental health provider. Nurse practitioners
were more likely to refer than MDs (46% vs 34%, p=.04). Discussion of
screening results took less than three minutes in 90% of visits and more
than 10 minutes in 1.4%.

Conclusions:

Brief pediatric depression screening during well child visits can
identify parents who are willing to discuss their mental health needs.
It leads to referral with minimal time burden on pediatric practice.

**Concurrent Sessions VB**

"Measuring the Reach of a Technology-Oriented Self-Management Support
Tool for Vulnerable Populations"-Dean Schillinger, MD, University of
California, San Francisco (CRN)

"Engaging Primary Care Physicians to Support Family Caregivers of
Demented Patients"-Jonathan Rosen, MD, ProHealth Physician Network
Connecticut

"Health Outcomes with Shared Medical Appointments" (Research in
Development) -- Renuka Khurana, MD, MPH, Parkland Hospital

"Community Care for Complex Illness" (Research in Development) -Lou
Lukas, MD, Lehigh Valley (EPICnet)

Author(s): Concurrent Sessions VB

\*Dean Schillinger MD, USCF/San Francisco General Hospital Meeting Room
3

Ben Lui MPH, MD 11:00 A.M. to 12:15 P.M.

Frances Wang MS

Jorge Palacios MA

Ivonne Mclean

Audrey Tang FNP

Margaret Handley MPH, PhD

PBRN(s):\
CRN

Title:

Measuring the Reach of a Technology-Oriented Self-Management Support
Tool for Vulnerable Populations

Context:

Patients with limited English proficiency or health literacy often
report sub-optimal quality of care, especially with regard to
self-management support.

Objective:

We explored whether a novel tool - automated telephone disease
management (ATDM) - can help overcome communication-related barriers
among patients with diabetes.

Design:

160 patients have completed a 3-arm randomized trial of diabetes disease
management strategies, one of which was ATDM. We measured the extent to
which patients engaged with the ATDM system and whether engagement
varied by language and literacy. All models accounted for within-patient
clustering using repeated measures analyses.

Setting:

4 safety net clinics in the UCSF Collaborative Research Network

Participants:

Patients with type 2 diabetes and HbA1c \>8.0% randomized to ATDM.

Intervention or Essential Feature of Study:

ATDM patients(N=54)receive weekly automated calls for 9 months to assess
self-management and promote behavior change. Based on their touch-tone
responses, patients receive automated health education and/or receive a
call-back from a bilingual nurse.

Results:

Mean age was 54, mean HbA1c 9.2%, 48% spoke Spanish, and 54% had limited
health literacy (s-TOFHLA score \<23/36). Overall, 56% of weekly ATDM
calls were completed and 60% of patients completed over half of calls.
Among those who completed at least one ATDM call (50/54, 93%), 44% of
ATDM calls generated nurse call-backs. In multivariate models,
Spanish-speakers were more likely than English-speakers to complete ATDM
calls (AOR 2.53, CI 1.08,5.88) and generate nurse call-backs for
out-of-range responses (AOR 2.47, 1.45,4.17). Patients with limited
literacy were less likely than those with adequate literacy to complete
ATDM calls (AOR 0.40, CI 0.17,0.97) but as likely to generate nurse
call-backs (AOR 1.08, CI 0.60,1.91).

Conclusions:

Automated telephone systems can provide self-management support for a
population with poorly controlled diabetes, although rates of engagement
appear to vary with language and literacy. To improve the reach of this
technology, future work should explore contextual factors that explain
differences in engagement.

Author(s): Concurrent Sessions VB

\*Jonathan Rosen, MD, ProHealth Meeting Room 3

Lisa Honigfeld, PhD 11:00 A.M. to 12:15 P.M.

PBRN(s):

ProHealth Physician Network Connecticut

Title:

Engaging Primary Care Physicians to Support Family Caregivers of
Dementia Patients

Context:

Optimal care of patients with dementia requires collaboration between
health care provider, patient, and the patient's family caregiver.
Recognition and support of the needs of family caregivers is critical to
help ensure and enhance the dementia patient's medication adherence,
safety, and capacity to remain in the home setting as long as possible.

Objective:

To engage primary care physicians in a project designed to provide
support for family caregivers of dementia patients.

Design:

Primary care providers were introduced and encouraged to refer family
caregivers of their dementia patients to a project based at the regional
Alzheimer's Association between May 2001 and February 2003. Physicians
were provided with lists of patients with diagnosed memory loss or
dementia and patient recruitment letters. Practices were randomized to
an intervention or control group and blinded to the randomization..

Setting:

ProHealth Physician Network in Connecticut

Participants:

Network family physicians and internists who practiced in northern
Connecticut were eligible to participate (n=66 physicians in 41 practice
sites).

Intervention:

Family caregivers in the intervention group received individualized
counseling for one year from a social worker at the Alzheimer's
Association. Referring physicians received care plans each time the
family caregiver met with the counselor and were encouraged to discuss
care plans with patients and family caregivers at subsequent office
visits. Family caregivers in the control group received educational
materials about dementia care, but no individualized counseling or
feedback to referring physicians.

Outcome measures:

Percent of primary care physicians referring family caregivers to
services; percent of intervention group physicians maintaining care
plans in the patient's medical record; percent of intervention group
family caregivers reporting at the 12-month follow up interview that
physicians discussed care plans with them; and intervention vs. control
physician survey responses regarding knowledge of community resources
for care givers.

Results:

Forty-five participating physicians (68%) from 30 practice sites (73%)
referred a total of 178 family caregivers to the study. Eighty-four
family caregivers enrolled in the study (Intervention group: 54
caregivers from 21 physicians in 13 sites; Control group: 30 caregivers
from 17 physicians in 13 sites). Review of available medical records
from 37 intervention group patients found that 34 records contained one
or more care plan; however only 14 of 40 family caregivers in the
intervention group (35%) reported discussing any care plan information
with physicians. Physician survey results one year post intervention
showed no differences between intervention and control groups on
self-reported measures of confidence in knowledge about community
resources, and referrals of family members to support services.

Conclusions:

Physicians will refer family caregivers of dementia patients to support
services. The feedback to referring physicians works in terms of getting
care plans into charts, but physicians do not usually discuss care plan
information during office visits. This feedback did not appear to result
in greater physician confidence about resources for care givers of
patients with dementia. More proactive efforts are needed to fully
engage physicians in ongoing discussions with family caregivers.

Author(s): Concurrent Sessions VB

\*Renuka Khurana M.D., M.P.H., Parkland Hospital Meeting Room 3

Donald Bradley Walsh, MPH 11:00 A.M. to 12:15 P.M.

Dan Culica M.D., Ph.D.

Jacqualene Jones Stephens, Ph.D., LMFT

Rosemary Hinojosa, M.A

Title:

Health Outcomes with Shared Medical Appointments

Context:

Empirical evidence shows that Shared Medical Appointment (SMA) model is
cost effective and has enhanced patient and provider satisfaction
compared to individual clinical visits if group size and duration
targets are met. Health outcomes in SMA settings have been less
described in the literature. An SMA rotates 11-15 patients between
physician and nurse for routine clinical care, while an educator
facilitates health related discussions. Participation in the SMA is
voluntary, and requires that the patient sign confidentiality
agreements.

Objective:

1\) SMAs\' clinical safety and effectiveness are as good as those
obtained in individual clinical visits.

2\) Increased patient satisfaction with medical care provider, using
health-related quality of life (HRQoL) survey, and a vendor-conducted
telephone survey.

3\) Increased access to clinical care for patients.

4\) SMAs\' cost-effectiveness and financial success for safety net
institutions.

Basic Study Design:

Prospective controlled design, where patients will serve as their own
control. The study will be conducted at our clinics with an ongoing SMA.
Data (clinical and non-clinical) will be collected from medical records,
pharmaceutical database, clinic financial records, health related
quality of life survey (pre and post SMA) and patient satisfaction
survey. Investigators will evaluate health outcomes and HRQoL pre- and
post-SMA and cost effectiveness compared to individual medical visits.

Current Challenges:

1\) Validated surveys evaluating quality of life in adult and pediatric
patients with or without chronic medical diseases

2\) Appropriate, measurable health outcomes

3\) Conducting primary care research in a diverse indigent population
with multiple chronic diseases and capturing adequate valid reproducible
outcomes variables

4\) Patient recruitment and retention over two years

Goals for Session/Questions for Audience Consideration:

1\) Are laboratory and clinical indicators the only useful clinical
outcomes measures?

2\) How do we evaluate long-term impact on changed patient behavior
towards their health and utilization of medical services?

3\) Can SMA become a way for primary care providers to stretch their
financial resources?

Author(s): Concurrent Sessions VB

\*Lou Lukas MD, Lehigh Valley Health Network Meeting Room 3

Julie Dostal MD 11:00 A.M. to 12:15 P.M.

Debra Baker, MS

Melanie Johnson, BA\
\
PBRN(s):\
EPICnet

Title:

Community Care for Complex Illness

Context:

Chronic, non-malignant, illnesses account for six of the top ten causes
of death in the US. Most care for chronic illness is provided by primary
care practices (PCPs). Personal \"medical homes\" have been suggested as
a way to improve quality of life (QOL) and quality of care for people
with advanced chronic illness (ACI). Medical homes differ from typical
PCP\'s in that they provide more prospective, integrated services to
people with complex illness. Facilitating a change from a typical
practice to a medical home may be accomplished using interventions
informed by complex adaptive systems (CAS) theory, which change can be
facilitated by a process of reflective adaptation, fostering
relationships and increasing the range of available tools.

Objective:

Does improving \"medical home-ness\" improve patient satisfaction with
care? Do patients with ACI who receive care from medical homes have
better QOL than those receiving care from typical practices? Does it
effect their healthcare utilization patterns?

Basic Study Design:

Delayed-intervention control trial of the effects of an intervention to
increase \"medical home-ness\" on patient satisfaction, QOL and health
network indicators. Paired practices will enter the study and be
randomized to intervention. Patients identified by hospital
administrative data. Assessment of healthcare utilization, practice and
patient measures, will be obtained at baseline 6, 12 and 24 months.
Qualitative interviews and observations will be conducted with a subset
of sample at the same interval.

Current Challenges:

Severity of illness and inevitability of decline may limit measurement
of improvement in patient measures. Multiple co-morbid conditions
preclude meaningful disease measures. Mortality may challenge follow-up.
Would like to see the effects of practice change on non-target patients,
but questions of sampling. Prospectively selecting appropriate outcomes
for use in dynamic systems interventions that rely on emergent
phenomena.

**Concurrent Session VC**

"Solving the HIPAA Dilemma in PBRN Practices"-Donald Nease, MD,
University of Michigan (GRIN)

"Using an After Hours Nursing Triage Service for Patient
Recruitment"-Jane Garbutt, MBChB, Washington University (WU PAARC)

"Recruiting Patients From Multiple Sites"-Brenda Hudson, MA, Indiana
University (ResNet)

"A Cancer Center-based Shared Resource for PBRNs"-James Werner, PhD,
Case Western Reserve University (RAP)

Author(s): Concurrent Sessions VC

\*Donald Nease, MD, University of Michigan Meeting Room 4

Timothy Morris, MS, GRIN 11:00 A.M. to 12:15 P.M.

PBRN(s):

GRIN

Title:

Solving the HIPAA Dilemma in PBRN Practices

Context:

Translational research in PBRN practices often involves clinical data
for measurement of project outcomes. The Prompting and Reminding at
Encounters for Prevention (PREP) study deployed a computerized registry
and reminder system (CRS) into 13 Great lakes Research In practice
Network (GRIN) PBRN practices with the need to measure and understand
responses to reminders and screening status.

Objective/Challenges to Be Overcome:

HIPAA regulations on the confidentiality of clinical data made it
desirable for each PREP practice to host their own CRS locally.
Additionally because of HIPAA concerns, many practices required that the
CRS not be internet connected. Geographic distances made it impractical
to visit practices to perform periodic data extracts and manipulation,
therefore a remote access solution was needed that could extract
de-identified data, and enable practice printing of patient
lists/letters for potential post-reminder survey participants.

Approach:

We devised a strategy of remote access to each PREP CRS via modem that
generates a locally maintained random generated key for each patient.
When access to a PREP practice\'s CRS is needed, the practice is called
and asked to attach a phone line to the CRS computer. Data extracts that
are de-identified using the random key are executed via the modem
connections. Survey candidates are identified in de-identified data, and
pushed back to the local CRS via another modem call. Another modem
command generates and prints solicitation letters to the survey
candidates for vetting and signing by the primary providers.

Results & Observations:

Our remote access strategy has successfully pulled an average of 4766
data records per practice over the initial 8 months of implementation.
This solves the dilemma created by the competing needs for access and
confidentiality.

Implications for other PBRNs:

The data access strategy uses common database routines and tools and
could be easily translated to other computer platforms, projects and
PBRNs.

Author(s): Concurrent Sessions VC

\*Jane Garbutt, MBChB, Washington University in St. Louis Meeting Room 4

Randall Sterkel, MD 11:00 A.M. to 12:15 P.M.

Christina Banister, BA

Suzanne Wells, RN

Lisa Swerczek, BSN, RN

Jay Epstein, MD

Gordon Bloomberg, MD

PBRN(s):\
WU PAARC

Title:

Using an After Hours Nurse Triage Service for Patient Recruitment

Context:

A randomized controlled trial (RCT) is the most robust study design to
evaluate interventions in primary care, but often require a large sample
size to assess effectiveness. However, identification and recruitment of
eligible patients is difficult in the primary care setting

Objective/Challenges to Be Overcome:

To recruit 360 children (5-12 years old) for a RCT to evaluate the
Telephone Asthma Program, a telephone outreach program to improve
adherence to maintenance medications and self-management behaviors among
children with persistent asthma.

Approach:

We invited all physician subscribers to the St Louis Children\'s
Hospital After Hours nurse triage service to participate in patient
recruitment. We have used 3 strategies to recruit patients of the
115/181 (64%) physicians who agreed to participate. Plan A utilized an
automated reminder to prompt the nurse to invite study participation at
the end of an asthma call. Also, patients who had made an asthma call to
the After Hours service in the past year were called and invited to
participate. Calls were made by After Hours nurses (Plan B) and the
study team (Plan C). 95 (83%) of 115 physicians agreed to Plans B and C.
Study team members completed eligibility screening and enrollment.

Results & Observations:

For Plan A, 159 (46%) of 349 possible invitations have been issued, and
x eligible patients identified. Plan B was abandoned, as the nurses were
unable to reach parents during the daytime. Of the 640 unique
potentially eligible patients identified for Plans B and C, to date 358
have been triaged. Of these, 38% were eligible, 23% were ineligible, 14%
have declined and 25% could not be reached.

Implications for other PBRNs:

Potentially eligible study patients can be identified from and recruited
through an After Hours nurse triage service.

Author(s): Concurrent Sessions VC

\*Brenda Hudson, MA, Indiana University Meeting Room 4

William Tierney, MD 11:00 A.M. to 12:15 P.M.

Deanna Willis, MD, MBA

Jane French, BA

PBRN(s):

ResNet

Title:

Recruiting Patients From Multiple Sites

Context:

How does a PBRN overcome the challenge of identifying and recruiting
patients from multiple primary care sites into collaborative studies?

Objective/Challenges to Be Overcome:

Our objective was to maximize recruitment by minimizing the time
research assistants spend identifying patients eligible for research
projects for recruitment without placing additional burden on the
practices.

Approach:

To discuss how a shared electronic medical record system (EMR) has
allowed our network to more efficiently identify eligible patients with
scheduled appointments so they can be approached for various ongoing
studies.

Results & Observations:

During the past five years, ResNet has used its practices\' shared EMR
to assist in identifying and recruiting patients for more than 40
studies. This system allows the network to deal effectively with a
number of ongoing studies while accommodating practice and health care
system changes. Utilizing this system, the network is able to
efficiently assign research assistants to cover 17 practices recruiting
for more than 4 studies per practice. This process is done by 1)
identifying eligible patients using the study\'s inclusion and exclusion
criteria, 2) providing lists of potential subjects to the patients\'
PCPs to confirm eligibility and approve for recruitment, 3)
electronically tracking eligible patients\' appointments and for which
study(ies) each is eligible, 4) indicating the recruitment status of
each eligible patient, and 5) producing a weekly report for each
study\'s investigators. To accomplish this we have created a local
database and an MS-Access interface that can be accessed via the
Internet by research assistants at each practice. Not only does this
system allow us to provide detailed recruitment information for our
investigators, it allows us to track our efficiency at recruitment,
identify problems to enhance recruitment, and determine average
recruitment rates for various types of studies based on the study
design.

Implications for other PBRNs:

As EMRs become more prevalent in practice settings, they can be a
powerful recruiting tool to assist PBRN in the identification,
recruitment, and tracking of participants in primary care research.

Author(s): Concurrent Sessions VC

\*James Werner, PhD, Case Western Reserve University Meeting Room 4

Kurt Stange, MD, PhD 11:00 A.M. to 12:15 P.M.

PBRN(s):

RAP

Title:

A Cancer Center-based Shared Resource for Practice-based Research

Context:

Many practice-based research networks (PBRNs) are in need of sustained
infrastructure support for core network functions.

Objective/Challenges to Be Overcome:

PBRNs often struggle to maintain an infrastructure that enables
recruitment and retention of participating practices, support for key
network activities, and generation of research proposals. Networks
frequently have little choice but to rely on inconsistent bridge funding
from academic departments and on volunteerism by investigators,
clinician-members, and staff.

Approach:

NIH-funded Centers such as Comprehensive Cancer Centers receive
long-term funding to develop and maintain "Core Facilities" that support
Centers' scientific programs. Core Facilities provide support for
research programs and provide access to specialized expertise. They
serve as stable and reliable resources that are not research grant
dependent.

Results & Observations:

Recently, a Core Facility to provide infrastructure support for PBRNs
was developed within the Case Comprehensive Cancer Center. The Community
Network Core Facility (CNCF) has been instrumental in the development of
PBRNs across the Case research community. It provides infrastructure for
new and existing PBRNs by recruiting practices for membership,
developing network membership databases, assisting investigators in
grant writing and study development, advising on matters of network
governance, developing electronic data systems, developing communication
mechanisms such as newsletters and web sites, fostering community-based
participatory research, and organizing network meetings. Personnel in
the CNCF are supported by Comprehensive Cancer Center Support Grants,
research grants, and charge-back mechanisms.

Implications for other PBRNs:

PBRNs may wish to explore the potential of Core Facilities within NIH
Centers. There are 39 Comprehensive Cancer Centers in the US, and a
variety of other NIH-funded centers support research on AIDS, Diabetes,
Alzheimer's, Autism, and issues such as Minority Health. A PBRN-oriented
Core Facility can provide infrastructure for PBRNs and bring substantial
value to an NIH Center by providing a conduit to high-risk patient
populations, while addressing the increasing need for longitudinal
partnerships with the greater community.

# *Poster Presentations Congressional Hall C*

  ------ -------------------------------------------------------------------
  1\.    "Patient visits to a Midwestern primary care PBRN: a comparison to
         two national data sets," John Pascoe, MD, MPH, Wright State, Dayton
         Primary Care PBRN

  2\.    "PBRNs and their representativeness to family physicians, practices
         and patients: a preliminary assessment," Thomas Stewart, BA, AAFP
         National Research Network

  3\.    "Establishing a rural PBRN within an academic medical center," Anne
         King, MBA, Oregon Rural PBRN

  4\.    "Do nurse-managed health centers qualify as safety net providers?"
         Nancy Rothman, EdD, Temple Univ., National Nursing Centers
         Consortium

  5\.    "How family practice residents learn and apply new medical
         information," William Cairney, PhD, Colorado Springs Osteopathic
         Foundation

  6\.    "Low birth weight prevention through a multifactor risk reduction
         quality improvement initiative," Andrew Coco, MD, Lancaster
         Hospital

  7\.    "Parents perceive pediatric residents as providing high quality
         care," Scott Krugman, MD, Franklin Square Hospital, CORNET

  8\.    "The Telephone Asthma Program," Jane Garbutt, MBChB, Washington
         University, WU PAARC

  9\.    "Early education and child care directors' perspectives of
         children's health and well-being," John Pascoe, MD, MPH, Wright
         State, Dayton Primary Care PBRN

  10\.   "Shaping care delivery by implementing a computerized system,"
         Adolfo Ariza, MD, Children's Memorial Hospital, Chicago, PPRG

  11\.   "Missing clinical information during private primary care visits,"
         Peter Smith, MD, Univ Colorado, BIGHORN

  12\.   "Using IT to improve medication safety for rural elders," James
         Wallace, BA, Univ Oregon, ORPRN

  13\.   "Effectiveness of an Internet-Based, Tool-Enhanced Diabetes
         Management Module for Internists" Jolene Chou, MPH, American
         College of Physicians, ACPNet

  14\.   "Survey of SCOR network physicians on AAP/AAFP acute otitis media
         guideline," Louis Vernacchio, MD, MSc, Boston Univ., SCOR Network

  15\.   "Emerging role of lifestyle in the prevention and management of
         Type 2 DM: 2004 content analysis," Anita Lambert-Lanning, MLS,
         College of Family Physicians of Canada, National Research System
         (NaReS)

  16\.   "A qualitative study of patient experiences with a
         technology-oriented self-management support system," Ivonne McLean,
         BA, UCSF Collaborative Research Network

  17\.   "Patterns of complementary and alternative (CAM) care provider use
         by patients with arthritis followed by family physicians and
         subspecialists," Leigh Callahan, PhD, UNC, North Carolina Family
         Practice Research Network

  18\.   "Chronic opioid therapy and preventive services in rural primary
         care," David Buckley, MD, Oregon Rural Practice-based Research
         Network (ORPRN)

  19\.   "Xylitol for the prevention of acute otitis media: pilot study of
         compliance and tolerability," Louis Vernacchio, MD, MSc, Boston
         Univ, SCOR Network

  20\.   "Characteristics of patients with swallowing difficulty in primary
         care," Thad Wilkins, MD, Univ of Georgia, HamesNet
  ------ -------------------------------------------------------------------

Authors:

John Pascoe, MD, MPH

David Little, MD

Eric Slora, PhD

Kathleen Thoma, MA

Richard Wasserman, MD

PBRN(s):

Dayton Primary Care

Title:

Patient Visits to a Midwestern Primary Care Practice-Based Research
Network: A Comparison to Two National Data Sets

Context:

While there have been descriptive studies of patient visits within
national networks, little is known about patient visit characteristics
within the numerous, recently developed regional networks.

Objective:

To compare patient visit characteristics within the Dayton Primary Care
Practice-Based Research Network (DPCPBRN) to patient visits within the
Pediatric Research in Office Settings (PROS) network and the National
Ambulatory Medical Care Survey (NAMCS).

Design:

DPCPBRN data were collected from 25 of the 35 practitioners in the
network between July 2003 and June 2004 using the Primary Care Network
Survey. Thirty patients were selected randomly throughout the two week
data collection interval for each participating practitioner. Regional
data were compared to data collected by PROS (57 practitioners, 1706
visits) between March and June 2002 and the NAMCS (33 practitioners, 948
visits) between March and June, 2000.

Setting:

Urban and suburban practices that include 35 pediatricians, family
physicians and pediatric nurse practitioners in south central Ohio.

Participants:

25 physicians and pediatric nurse practitioners who volunteered to
collect data for the study.

Results:

Comparison of Patients and Patient Visits Characteristics

DPCPBRN PROS NAMCS

Mean Age (Years) 6.5 6.45 5.45

\% African-American 24.0% 7.5% 17.6%

\% Medicaid 42.0% 22.0% 22.4%

%Visit to Primary MD 75.9% 81.8% 91.6%

%Visit for Non-illness 36.3% 31.3% 31.9%

The top six reasons for patient visits were remarkably similar across
the three data sets: well child examination, cough, fever, sore throat,
earache and skin rash. Practitioners\' diagnoses were also similar
across the three data sets, primarily health supervision visits and
infectious diseases (e.g., pharyngitis/otitis).

Conclusion:

The DPCPBRN has several similarities to PROS and NAMCS (e.g. patient
visit characteristics, number of non-illness visits). Differences
between DPCPBRN and PROS/NAMCS (e.g., more Medicaid recipients and more
African-American families) suggest that DPCPBRN may be a particularly
appropriate network for studying vulnerable populations of children and
their families.

Authors:

Thomas Stewart, BA

Jennifer Kappus, BA

James M. Galliher, PhD

John Hickner, MD, MSc

Darrell Henderson

Mindy Spano

PBRN(s):

AAFP National Research Network

Title:

Practice-Based Research Networks and Their Representativeness to Family
Physicians, Practices, and Patients: A Preliminary Assessment

Context:

Practice-based research networks (PBRNs) have become increasingly
popular and useful laboratories in which to investigate questions of
clinical importance to family physicians and their patients. The
usefulness of PBRNs and the generalizability of research results from
these laboratories are dependent upon the representativeness of these
networks compared to the larger population of family physicians and
patients.

Objective:

To determine if the physicians in the American Academy of Family
Physicians\' National Research Network (AAFP-NRN), their practices, and
their patients are representative of the larger population based on
several demographic and practice characteristics and to document the
extent of this representativeness.

Design:

Applicable comparisons addressing generalizability of PBRN
research/results.

Setting:

The AAFP National Research Network, a national PBRN of 300 clinicians in
45 states and 4 Canadian provinces.

Participants:

199 US physician members of the AAFP-NRN who have completed the National
Network\'s Clinician Demographics Survey and 2,069 patient visits to
these physicians for which the Primary Care Network Survey 2 (PRINS 2)
survey was completed.

Intervention:

Using US Census Bureau, National Ambulatory Medical Care Survey (NAMCS),
and AMA Masterfile data, comparisons will be made in 16 categories to
determine if the AAFP NRN does mirror the overall national population of
family physicians, practices, and patients in the US.

Results:

It is anticipated that the AAFP NRN will reflect the overall national
population of family physicians, practices, and patients in some, but
not all, of the 16 categories.

Conclusion:

Data currently being analyzed. Next steps include targeted recruiting to
address gaps in representativeness.

Authors:

Anne King, MBA

James Wallace, BA ORPRN

Lyle Fagnan, MD ORPRN

PBRN(s):

Oregon Rural Practice-based Research Network

Title:

Establishing a rural practice based research network (PBRN) within an
academic medical center.

Context:

Oregon is largely rural, yet most medical research takes place at the
state\'s urban medical school, Oregon Health & Science University
(OHSU). The Oregon Rural Practice-based Research Network (ORPRN) was
created in 2002 by OHSU and funded by the Oregon Legislature with the
purpose of addressing rural health disparities.

Objective:

To develop a statewide rural PBRN that connects rural primary care
practices to a community of researchers and government partners. ORPRN
faced many challenges establishing itself as a rural network within an
urban university, particularly concerning contracting, HIPAA compliance,
and IRB authorization issues.

Approach:

In 2003, after a period of recruiting rural clinicians, ORPRN hired
staff and began its first study. ORPRN leaders chose to have a steering
committee, with rural clinicians as the only voting members, govern the
network. ORPRN clinicians convene annually to share research interests,
discuss methods, and vote on network policies. ORPRN hired three
rural-based practice facilitators who serve as research assistants.

Results & Observations:

Today ORPRN has approximately 120 rural clinicians in 27 practices, and
ten active research studies. ORPRN staff consists of four investigators
and eight research coordinators. Study designs are reviewed by a
Scientific Review Committee.

Implications for other PBRNs:

Encouraging university staff to re-think existing policies to meet the
unique needs of the PBRN ameliorates some of the challenges. Requesting
designated IRB and grants analysts helps facilitate compliance and
allows the network to orient the university to the PBRN\'s unique needs.
Rural practice facilitators are helpful in translating the needs of
rural areas for university researchers. Having a rural
clinician-governed network with the backing of an influential body, such
as the state legislature, helps secure institutional support in a
challenging environment.

Authors:

Nancy Rothman, EdD, RN, Temple Univ.

Tine Hansen-Turton, MGA

Laura Line, MS

Michelle O\'Connell, MGA Candidate

Jennifer Lauby, PhD

PBRN(s):

National Nursing Centers Consortium

Title:

Do Nurse-managed Health Centers Qualify as Safety Net Providers?

Context:

In 2002, the National Nursing Centers Consortium (a practice-based
research network) received a grant from the Centers for Medicare and
Medicaid Services through a mandate under Public Law 107-116 to conduct
an evaluation of nurse-managed health centers in Pennsylvania. The goal
was to document the ability of this type of health center to serve as
safety net providers, since they are missing from the Institute of
Medicine list of core safety net providers.

Objective:

The two objectives for the project were:

1\. To create an extensive descriptive evaluation of clients served and
services provided at primary care nurse-managed health centers in
Pennsylvania; and

2\. To compare select population-based measures of quality and health
care resource utilization of nurse-managed health centers to those of
like providers including Community Health Centers.

Design:

This is a descriptive study of the clients served and the services
provided at 11 National Nursing Centers Consortium member nurse-managed
centers in Pennsylvania, as well as a comparison of selected
population-based measures of quality and health care resource
utilization in these same nurse-managed centers and like providers.

Setting:

The National Nursing Centers Consortium is the first national
association of nurse-managed health centers in the USA, established
initially in 1996 as a Regional Nursing Centers Consortium.
Nurse-managed health centers address health disparities, provide
accessible comprehensive primary care and community health programs
aimed at health promotion and disease prevention.

Participants:

Inclusion criteria: nurse-managed primary care National Nursing Centers
Consortium member sites in Pennsylvania, collecting the required common
data elements.

Intervention:

Demographics, insurance and employment status and health disparities
diagnoses of the clients served and the health care and enabling
services provided in the selected nurse-managed centers are described.
Patient satisfaction, HEDIS measures, utilization rates and
reimbursement sources were compared in the selected nurse-managed
centers and local like providers.

Outcome Measures:

Outcomes measures included client demographics of race, ethnicity,
gender, age, insurance status, employment status, health disparities
diagnoses, health services, enabling services, patient satisfaction,
HEDIS measures, utilization rates and financial reimbursement.

Results:

Nurse-managed health centers deliver a significant level of health care
to vulnerable populations, provide a medical home for the underserved,
and need cost-based reimbursement to be sustainable.

Conclusion:

Nurse-managed health centers should be recognized as safety net
providers and are viable partners with the federal government to reduce
health disparities.

Authors:

William Cairney, PhD

Joel Dickerman, DO

PBRN(s):

Colorado Springs Osteopathic Foundation

Title:

How Family Practice Residents Learn and Apply New Medical Information

Context:

Despite the wealth of evidence-based medical literature that is now
readily available to clinicians, adoption of this information,
particularly practice guidelines, has been poor. In addition, our
experience shows there is a certain level of intimidation of EBM among
practicing physicians, partially due to lack of familiarity with EBM
principles and research evaluation criteria. The study was designed to
address these issues across our entire practice-based research network.

Objective:

The purpose of this study was to investigate how family practice
residents and faculty acquire and apply new medical information.

Design:

This was a qualitative study involving a series of focus groups
performed at eight family practice programs in the state of Colorado.
Each residency program is a member of our PBRN. Focus Groups were 45-60
minutes in duration. Questions addressed four basic categorical areas,
each with subquestions to help elicit resident responses. Questions were
presented to residents through a PowerPoint presentation, and were
designed to elicit open-ended responses

Setting:

The PBRN consists of family medicine resident physicians and program
faculty located in Colorado. These physicians are located at nine
practice sites state-wide.

Participants:

Focus Group participants consisted of residents and faculty members from
each of the eight Colorado family practice residency programs. At each
focus group and majority of residents from the respective programs were
in attendance.

Intervention:

The essential feature of the study was to determine the sources from
which family medicine residents and faculty acquire new information and
how they apply it in a clinical setting. From there, barriers to the
actual integration of EBM-derived information could be determined and
interventions developed for greater acquisition and integration.

Outcome Measures:

Outcome measures consisted of clearly identifiable, group-specific
factors associated with acquisition and integration (or non-integration)
of new, particularly EBM-derived, medical knowledge.

Results & Observations:

In all, over 70 residents participated in eight focus groups. Focus
group size ranged from 5-15 participants including interns, residents
and program faculty.

Conclusion:

Family practice residents acquire new information primarily from the
internet, colleagues, and lectures. Residents feel point-of-care
learning is the most effective means of retaining information. Residents
apply new medical information when it directly relates to a patient
medical issue. Application of new knowledge occurs nore readily when it
is supported by a colleague or mentor. Residents receive feedback on the
use of new medical information through formal evaluation, reinforcement
through colleague actions, patient results, and patient satisfaction.
Obstacles to implementing new knowledge include lack of point-of-care
resources, lack of time, other administrative duties, skepticsm of new
knowledge, and established habits. More convenient (point-of-care)
distilled resources, more time to research patient questions, and
dedicated staff versed in evidence-based medicine would improve
application of new knowledge.

Authors:

Andrew Coco, MD, MS

Stephen Ratcliffe, MD, MSPH

Wendy Barr, MD

Julie Yeh, MD

Ian Bennett, MD, PhD

PBRN(s):

PA Lowbirth weight

Title:

Low Birth Weight Prevention through a Multi-Factor Risk Reduction
Quality Improvement Initiative

Context:

Low birth weight (LBW) is a serious, complex, health problem. Primary
care interventions that have been shown to improve LBW prevention
include treatment of inflammatory conditions and depression, promoting
smoking cessation, and increasing inter-pregnancy intervals. These
interventions have not been consistently translated into practice;
programs addressing individual risk factors have had little impact.

Objective:

Assess the feasibility of establishing continuous quality improvement
activities around low birth weight prevention in fifteen family practice
residency programs comprising a primary care practice-based research
network (PBRN). Determine whether the incidence of low birth weight
infants can be reduced with this approach.

Design:

Non-randomized before and after study of a quality-improvement
initiative to evaluate the feasibility and efficacy of multi-factor LBW
risk reduction in a PBRN. Data collection will occur over four years. A
web-site will be utilized to facilitate data entry and generation of
quality monitoring reports.

Setting:

PBRN comprised of 15 family practice residency programs in the Northeast
U.S.

Participants:

3, 000 women annually, primarily from underserved, minority populations
at increased risk for LBW.

Intervention:

Establish quality improvement teams at each site that will implement
monitoring of five quality processes for smoking cessation, postpartum
contraceptive planning and screening/treating for depression, bacterial
vaginosis and asymptomatic bacteruria in their maternity population.

Outcome Measures:

The rates of quality process uptake and LBW incidence. Continuous data
analysis by statistical process control charts to allow for the
measurement of temporal trends in the effectiveness of the quality
improvement program.

Results:

Determine whether LBW prevention can be improved through a continuous
quality improvement program that simultaneously addresses five
evidence-based interventions over four years.

Conclusion:

Family medicine physicians, by virtue of providing prenatal and
postpartum care as well as possessing experience in treating depression
and behavioral issues, are uniquely suited to simultaneously address
multiple risk factors that contribute to the complex problem of LBW.

Authors:

Scott Krugman, MD

Janet Serwint, MD

Michael Seid, PhD

PBRN(s):

CORNET

Title:

Parents Perceive Pediatric Residents as Providing High Quality Care: A
Multisite Study from the Continuity Research Network (CORNET)

Context:

A variety of parental quality of care surveys have been utilized to
assess quality in the community setting. To date, there has been no
evaluation of the quality of care provided by residents in their
continuity clinics. This evaluation is relevant from both an educational
standpoint and a healthcare standpoint since resident continuity clinics
serve a large population of minority and underserved children.

Objective:

To measure the quality of primary care provided by pediatric residents
using a version of the Parents\' Perception of Primary Care (P3C) and
compare to previously published community standards.

Design:

Cross sectional survey.

Setting:

19 sites from the Ambulatory Pediatric Association\'s CORNET

Participants:

Parents of 2572 patients of pediatric residents were surveyed over a
two-week time period in May and June 2004. All English and Spanish
speaking parents were eligible to participate. The average participation
rate was 85%.

Intervention:

Survey completion.

Outcome Measures:

Total mean score of survey, mean scores in each primary care domain, and
comparison to previously published community scores.

Results:

2107 surveys were completed for analysis. Families who completed the
survey were 39% Hispanic, 33% African-American, and 16% Caucasian; 81%
of the children had Medicaid, 76% were under 5 years of age and 19% of
the parents had less than a high school education. The overall mean
score for residents was 76.93 compared to the community sample score of
62.07. In comparing the population of resident patients over age 5 to
the community sample who identified a place of care, adjusted mean
scores for residents were significantly higher than the community scores
for the total score and all primary care domains except longitudinal
continuity and access.

Conclusion:

Parents perceive that pediatric residents provide high quality pediatric
care as compared to a previously reported community sample. The P3C tool
is effective in assessing areas for residents to improve the quality of
the primary care they deliver.

Authors:

Jane Garbutt, MBChB

Randall Sterkel, MD

Christina Banister, BA

Suzanne Wells, RN

Lisa Swerczek, BSN, RN

Jay Epstein, MD

Gordon Bloomberg, MD

PBRN(s):

WU PAARC

Title:

The Telephone Asthma Program

Context:

Inhaled corticosteroids and asthma self-management are underused in the
care of children with persistent asthma.

Objective:

To evaluate if the Telephone Asthma Program (TAP) will reduce emergent
asthma care.

Design:

Randomized controlled trial

Setting:

Patients are recruited through WU PAARC, a pediatric PBRN in St Louis,
MO and the After Hours nurse triage service at St Louis Children\'s
Hospital (116 pediatricians participating).

Participants:

360 children (5-12 years old) with persistent asthma and \> 1 emergent
care episode in past year. Eligible patients are identified by an asthma
call to the After Hours Service.

Intervention or Essential Feature of Study:

TAP is based on the transtheoretical model of behavior change. Over a
year, a TAP nurse makes brief phone calls to assist parents with four
asthma care behaviors.

1\. Administering controller asthma medications as prescribed.

2\. Having an up to date asthma action plan (AAP) available to all care
givers.

3\. Administering rescue medications at first symptoms.

4\. Having a collaborative partnership with the primary care provider
that includes asthma-monitoring visits.

Outcome Measures (if any):

Emergent asthma care, asthma care behaviors and the parent and child\'s
asthma-related quality of life.

Results (if available):

Of the first 26 TAP patients (36% Medicaid, 63% white), 56% had \> 1 ED
visit, 4% were hospitalized, and 96% had an unscheduled office visit for
asthma in past year. Nurse assessed adherence with the targeted
behaviors were: controller medications 40%, AAP 27%, rescue medications
42%, and physician partnership 24%. Most (54%) parents initially
selected use of the AAP to work on with the TAP nurse.

Conclusions:

Targeted asthma care behaviors are underutilized. Trained nurses can
identify patient readiness to change these behaviors during a brief
phone call.

Authors:

John Pascoe, MD, MPH

Paula Duncan, M.D

Peter Gorski, M.D

Robert Greenberg, M.D

Ruchi Gupta, M.D

Linda H. Southward, Ph.D

Michael Weitzman, M.D

PBRN(s):

Dayton Primary Care PBRN

Title:

Early Education and Child Care Directors\' Perspectives of Children\'s
Health and Well-Being: A Multi-State Survey

Context:

While many national and regional practice-based research networks have
been created since the 1980s, there are no child health research
networks based in child care centers.

Objective:

To ascertain the perspectives of child care centers\' directors from
five states regarding important child health issues and begin to explore
the feasibility of creating a multi-state child health research network
in child care centers.

Design:

The Social Science Research Center at Mississippi State University in
collaboration with the Child Health, Early Education and Child Care
Consortium, Center for Child Health Research, American Academy of
Pediatrics, conducted a telephone random-digit-dial survey of 2753
licensed child care directors in Florida, Mississippi, New Mexico, Ohio
and Vermont.

Setting:

Licensed early education/child care centers (LCCC) in five states.

Participants:

LCCC directors

Results & Observations:

51% of LCCC directors (n=1404) reported that they would be interested in
collaborating with pediatricians to conduct child health research at
their centers. 46% of all LCCC directors reported that \>5% of the
children at their centers (CAC) were impacted by parental smoking, 39%
reported \>5% of CAC were impacted by discipline problems and 20%
reported that \>5% of CAC were impacted by dental health problems. Head
Start Centers (HSC)(N=267) were more likely to screen for health
problems than non-HSC (N=2486) (93% vs 63%, p \< 0.01). Children from
HSC had a higher prevalence of dental problems than children from
non-HSC (44% vs 19%, pâ‰¤0.01).

Conclusion:

One half of LCCC directors expressed interest in collaborating with
pediatricians to study important child health problems in child care
settings. A number of health concerns affect the children at their
centers including parental smoking, discipline and dental problems.
Children from HSC were more likely to experience dental problems than
children from non-HSC. A \"second wave\" survey is being created to
delineate further the perspectives/expertise of LCCC directors
interested in child health research.

Authors:

Ariza, Adolfo, MD

Sherry Lyons, MA

J. Scott Thompson

Jeremy Samkowiak

Helen J Binns, MD,MPH

PBRN(s):

PPRG

Title:

Shaping Care Delivery by Implementing a Computerized System: A Pilot
Study

Context:

The PPRG is conducting a pilot study to test the use of a computerized
system using wireless technology and newly-developed software with the
ability to track growth and provide personalized handouts about child
nutrition according to child age and nutritional status categories. The
study includes office-based education and pre/post measures.

Objective:

To describe challenges faced when implementing a new computerized
system.

Design:

Practice-based intervention pilot study

Setting:

The study is being conducted at 2 PPRG practices

Participants:

One practice with a majority of white, privately-insured patients and
the other a community health center serving low-income, minority
patients.

Intervention:

Current Challenges include: 1) technical problems; 2) security concerns;
3) transitions of care delivery (moving between systems); and 4)
adapting the software to accommodate practice needs and advances in
technology/emerging computer standards. Training of practice members for
a systems change that modifies charting methods, personnel
responsibilities, and care delivery must focus on multiple
issues/topics, i.e., how to deal with health issues identified using the
new system; technical transition of practice; blending past and new
systems which may involve additional change; and paper
flow/documentation methods.

Outcome Measures:

Final outcomes will include visit observations and medical record
reviews to evaluate practice system and care delivery changes.
Acceptance of the system will be measured through practice member
surveys and key informant interviews.

Results & Observations:

Final outcomes will include visit observations and medical record
reviews to evaluate practice system and care delivery changes.
Acceptance of the system will be measured through practice member
surveys and key informant interviews.

Conclusion:

Implementing a practice system change aimed at improving care in a
specific area involves addressing multiple technical and educational
challenges at the practice and examining overall systems of care
delivery at the practice.

Authors:

Peter Smith MD

Sherry Holcomb

L. Miriam Dickinson PhD

Elizabeth Staton MSTC

Wilson Pace MD

PBRN(s):

BIGHORN, CaReNet

Title:

Missing clinical information during private primary care visits: a
report from BIGHORN

Context:

Providers in 2 PBRNs focusing on rural and underserved care reported
important missing clinical information (MCI) in 13.6% of visits. Whether
this is true in private practice is unknown, as is the validity of
provider report of MCI.

Objective:

1\. Describe the phenomenon of MCI (frequency, typology, predictors, and
consequences) in private primary care practices. 2. Determine validity
of provider report in estimating MCI and its consequences.

Design:

Mixed-methods, combining cross-sectional surveys with simultaneous and
2-month follow-up semi-structured interviews.

Setting:

The Building InvestiGative practices for better Health Outcomes Research
Network (BIGHORN), a new Colorado PBRN of private primary care
practices.

Participants:

All consenting BIGHORN providers.

Intervention or Essential Feature of Study:

1\. Provider questionnaire describing their practice, information
systems, and demographic descriptors. 2. Visit questionnaire completed
by providers at every visit for one day (patient demographics, the
specifics of missing information, and potential confounders). 3.
Semi-structured interviews with providers about MCI visits, conducted
after clinical sessions and again two months later to determine if
information was missing and the accuracy of their predictions.

Outcome Measures (if any):

Main: Proportion of visits with important MCI, and
sensitivity/specificity of provider report of MCI and predictions of
consequences. Secondary: Categories of MCI and their frequencies;
predictors of MCI; time spent by providers and staff trying to find MCI;
and predicted and actual frequencies of adverse effects, delays in care,
and additional services.

Results (if available):

We anticipate the MCI phenomenon will differ between private and
rural/frontier/underserved practices; provider report of MCI will
accurately estimate actual MCI rates; and predictions of adverse
affects, delays, and additional services will be exaggerated.

Conclusions:

We are currently refining the questionnaires and interview data
collection instruments. The next step will be to pilot the surveys and
interviews to maximize data collection while minimizing practice burden,
followed by formal practice recruitment and data collection.

Authors:

James, Wallace, BA

Gorman, Paul MD

Karl, Ordelheide, MD

Monica, Goubaud, MA

Heather, Young, PhD, GNP, FAAN

Lyle, Fagnan, MD

King, Valerie MD, MPH

PBRN(s):

ORPRN

Title:

Using IT to Improve Medication Safety for Rural Elders

Context:

Medication safety is a significant public health problem that affects
both quality of life and health care costs. Chronically ill elders
usually have parallel, not necessarily concordant, medical records.
These multiple record sets or \"medication lists\" are a logistical
challenge that may result in medication errors.

Objective:

The project aims to address this problem by implementing, testing, and
disseminating a single, accurate master medication list for rural
Lincoln City, Oregon.

Design:

Goals of the project include implementation of a master medication list
for Lincoln City\'s chronically ill residents of assisted living and
skilled nursing facilities; to demonstrate the accuracy, availability,
and acceptability of the master medication list; to demonstrate the
expandability of the technology and the policies used to create it to
the Lincoln City community.

Setting:

The project partners involve most of the sites where patient medication
lists are generated and used with rural elders: Samaritan North Lincoln
Hospital, the county\'s acute care hospital; three long-term care
facilities (2 ALFs, 1 SNF); all five local community pharmacies and two
long-term care contract pharmacies; and local medical practices who care
for these residents. A partnering Community Advisory Board will help
inform and ground the project.

Partnering academic institutions: Oregon Rural Practice-based Research
Network (ORPRN)at Oregon Health & Science University (OHSU); Oregon
Graduate Institute of Technology (OGI); Portland State University; the
OHSU School of Nursing, and Oregon State University.

Participants:

Residents of long term care facilities, staff, family and clinicians of
participating partners.

Intervention or Essential Feature of Study:

see above

Outcome Measures (if any):

Outcome Measures: Concordance of medication lists across inpatient,
outpatient, facility and pharmacy sites; identification of potential
medication errors or events; changes/improvements in communication among
members of the care team, satisfaction with the master medication list,
including the ease of use and efficiency of the medication
reconciliation process.

Results (if available):

n/a

Conclusions:

Organizational and infrastructure development. Baseline data collection
for evaluation.

Authors:

Jolene Chou, MPH

Amir Qaseem, MD, PhD, MHA

Peter Martelli

Christel Mottur-Pilson, PhD

PBRN(s):

ACPNet

Title:

Effectiveness of an Internet-Based, Tool-Enhanced Diabetes Management
Module for Internists

Context:

The increasing prominence of practice-based research and continued
under-representation of internal medicine specialty in this endeavor,
especially at the national level, prompted the American College of
Physicians to establish its own research network for internists.

Objective:

To examine the impact of implementation and effectiveness of a
tool-enhanced electronic education module, which focuses on reinforcing
educational methods and readily adaptable practice tools, using
established diabetes performance measures.

Design:

The study employed a group randomized parallel design. Participants were
assigned into two groups based on the use of EMR or computer-based
diabetes registry, with each group randomized into "intervention" and
"control" groups.

Setting:

Office-based practices.

Participants:

The sample of this study includes 40 ACPNet members who completed the
baseline data collection. The average size of practice is 15 physicians
(median: 6, range: 1-100); on average participants see 81 patients per
week (range: 28-150).

Intervention:

The intervention in this study was the computer-based diabetes
management education module for physicians. The module contains concise
clinical information and a supporting reference bibliography,
self-assessment questions, management tools, and patient education
materials. The intervention group participants accessed the module in
the months between baseline and 6-month data collections.

Outcome Measures:

Diabetes process and outcome measures included frequencies and values of
HbA1c, blood pressure readings, lipids, urinalysis, eye and foot exams,
biometrics, and vaccination status.

Results & Observations:

Baseline data showed that 72% of patients in the study had at least 2
HbA1c readings in the last year, and 51% were well-controlled (below
7%). Annual eye exam was only performed on 43% of patients.
Seventy-eight percent of patients had their blood pressure taken at
least 3 times in the last year, and 49% were controlled (135/80 or
below).

Conclusion:

We are currently entering data from 6-month follow-up, and expect to
complete the final data collection and the entire project in the fall of
2005.

Authors:

Louis Vernacchio, MD, MSc

Richard M. Vezina, MPH

Allen A. Mitchell, MD

PBRN(s):

SCOR Network

Title:

Survey of SCOR Network physicians on AAP/AAFP acute otitis media
guideline

Context:

In May 2004, the American Academy of Pediatrics (AAP) and the American
Academy of Family Practice (AAFP) issued a clinical practice guideline
entitled \"Diagnosis and Management of Acute Otitis Media (AOM)\" which
emphasized appropriate diagnosis and pain control, endorsed observation
for selected cases of AOM, and recommended specific antibiotics for a
variety of common AOM scenarios.

Objective:

To assess physicians\' knowledge of and adherence to the AAP/AAFP AOM
guideline.

Design:

Mail survey.

Setting;

The Slone Center Office-based Research (SCOR) Network.

Participants:

470 U.S. pediatricians and family practitioners.

Intervention:

Survey of familiarity with and adherence to AOM guideline
recommendations.

Results & Observations:

The response rate to the survey was 280/470 (60%). 90.5% of respondents
had read the guideline or summaries of it. In diagnosing AOM, pneumatic
otoscopy was used always by 16.0%, \>Â½ the time by 23.3%, \<Â½ the time
by 34.7%, and never by 25.6%. The most common pain medications
recommended were acetaminophen (median: 70% of cases; 25th, 75th
percentiles: 80%, 90%) and ibuprofen (median: 50% of cases; 25th, 75th
percentiles: 30%, 80%). 88.4% of respondents believe that observation is
a reasonable option for some cases of AOM. Over the previous three
months, observation was used in a median of 10% of diagnosed AOM cases
(25th, 75th percentiles: 5%, 25%). 76.0% of respondents are not
concerned at all or only slightly concerned about an increase in AOM
complications if observation is used; 24.1% are moderately or very
concerned. Antibiotic choices for AOM vary substantially from the
guideline\'s recommendations.

Conclusion:

Most physicians in this survey are familiar with the AAP/AAFP AOM
guideline, but only a minority follow the diagnosis and antibiotic
choice recommendations. Observation for AOM is acceptable in principle
to most of these physicians and is currently used in a small number of
AOM cases.

Authors:

Anita Lambert-Lanning MLS

Stewart Harris MD, CCFP

Robert Petrella MD, CCFP

Anita Lambert-Lanning MLS

Patricia Marturano

Luciano Ieraci MSc

PBRN(s):

National Research System (NaReS)

Title:

Emerging Role of Lifestyle in the Prevention & Management of T2D 2004
-Content Analysis

Context:

Recent studies have demonstrated that physical activity and dietary
interventions improve glycemic control in patients diagnosed with T2D.
Overwhelming response to \'open text\' questions on the Canada wide 2002
type 2 diabetes survey was unexpected and required separate analysis.

Objective:

To provide additional insight into practices & perceptions of FPs
regarding lifestyle interventions for the prevention & management of
type 2 diabetes by exploring the detailed written responses provided to
\'open text\' questions in the 2002-03 survey.

Design:

Themes were derived using traditional content analysis technique via
definitions, iterative coding, and re-coding process. It included
assignment of multiple coding types to each respondent\'s commentary.

Setting:

NaReS supports CFPC member based research by inviting member sentinels
to participate in individual projects such as the T2D nationwide survey.

Participants:

While NaReS registered sentinels have various levels of research
experience most of the participants in studies come from the national
CFPC membership at large (approximately 14,000 active members) with 23%
of individual members having participated in at least one NaReS
supported research study since the year 2000.

Intervention:

The qualitative data analysis was based on the broad number of open
responses from the 749/1499 participants to the original survey.

Conclusion:

The qualitative findings underscore family physicians\' desire to play a
vital role in lifestyle intervention. However, they feel certain
supports are needed, such as better access to community resources like
health specialists (e.g. fitness & diet), as well as community-based
programs. They recognize that patients also play a vital role in
implementing lifestyle change and see patient education and
environment/system resources as a vehicle to that end.

Results & Observations:

Major coding themes: environment/system, system-funding, patient
education, doctor education, lifestyle, and time. Frequently occurring
themes in the area of physician needs for the prevention of T2D focused
on environmental issues such as computer systems, better access to
specialists in fitness and nutrition or community based programs
\[(27.5%) 241/876 comments\]. Funding issues, such as lack of physician
compensation for providing preventive health care services for the
prevention of T2D and time issues \[(10.8%) 95/876 comments\]were not as
large a concern as originally suspected \[(10.6%) 93/876 and
\[(10.8%)95/876 comments, respectively\] from the quantitative analysis.

Authors:

McLean, Ivonne, BA

Handley, Margaret, PhD, MPH

Gonzalez-Maddux, Catherine, BA

Tang, Audrey, NP; Hammer, Hali, MD

Palacios, Jorge, MA; Schillinger, Dean, MD.

PBRN(s):

UCSF Collaborative Research Network

Title:

A Qualitative Study of Patient Experiences With a Technology-Oriented
Self-Management Support System.

Context:

While a growing number of self-management support interventions have
emerged, little is known about how populations with limited health
literacy and/or limited English proficiency experience such
interventions.

Objective:

To describe the framework by which patients view their experiences with
a weekly automated telephone diabetes management system (ATDM). ATDM
provides interactive health education and triggers a nurse care manager
to call those patients who need additional support.

Design:

Thematic analysis of audiotaped, semi-structured, patient interviews
after 9 months of ATDM exposure.

Setting:

4 safety net clinics in the UCSF Collaborative Research Network.

Participants:

23 patients with type 2 diabetes and HbA1c \> 8% who completed at least
one ATDM call.

Outcome Measures:

Themes generated through coding of interviews creating a framework of
patientsâ€™ perceived function of ATDM.

Results & Observations:

We have analyzed 23 of 90 audiotapes (13 English, 10 Spanish). 12 out of
23 patients (52%) had limited health literacy (STOFHLA \< 23). Patients'
experiences were captured in 3 major domains: 1) structural factors, 2)
interpersonal relations, and 3) self-management support. Structural
factor themes included the degree to which patients viewed the ATDM
system as: an acceptable adjunct to their care, expanded access to care,
and was integrated into the activities of both family and health
providers. Interpersonal relation themes included social support and
communication resulting from interactions with the nurse care manager.
Self-management support themes included awareness about diabetes
self-care, empowerment, and changes in self-efficacy.

Conclusions:

Diabetes patients in a safety net setting view their experience with the
ATDM system not only from the perspective of how it affects their self
management, but also how it affects the care delivery model, their
access to care, and the interpersonal support it provides. Future work
will explore how these contextual factors influence the effectiveness of
ATDM on clinical outcomes.

Authors:

Leigh Callahan, PhD

Yevgeniy Sheyn, MD, MPH

Thelma Mielenz, PhD

Philip Sloane, MD, MPH

PBRN(s):

North Carolina Family Practice Research Network

Title:

Patterns of Complementary and Alternative Care (CAM) Providers Use by
Patients with Arthritis followed by Family Physicians and Subspecialists

Context:

CAM continues to gain popularity in the US and the number of visits to
CAM providers is comparable with the number of visits to medical
offices. Arthritis is associated with particularly frequent use of CAM.

Objective:

To examine the use of CAM providers between patients with arthritis
followed in primary care and subspecialty clinics, and to assess whether
sociodemographic and clinical variables modify the relationship between
clinic setting and the prevalence of use of CAM providers.

Design:

A cross-sectional survey of CAM use was mailed to individuals with
arthritis. Logistic regression was used to estimate adjusted odds
ratios.

Setting:

North Carolina Health Project (a cohort database from 16 participating
practices of the NC Family Practice Research Network - NC-FP-RN) and the
UNC Musculoskeletal Database.

Participant:

777 participants with arthritis symptoms from family practice offices
and 1366 from rheumatologist or orthopedist offices.

Intervention:

Assessment of CAM use in individuals with arthritis.

Conclusion:

A significant minority (16%) of patients with arthritis see CAM
providers in addition to their primary care physician or subspecialist.
CAM use rates are similar in primary care and subspecialty settings.
Race and gender were meaningful effect modifiers of the association
between type of medical provider and the use of CAM providers for
arthritis.

Results & Observations:

More than 16 % of the study sample reported currently using CAM
providers for the management of arthritis symptoms in addition to their
family physician or subspecialist, 14% among those seeing family
practice physicians and 17 % among those seeing subspecialists. Type of
medical care did not meaningfully affect the use of CAM providers in
most patients with arthritis (OR 0.89 comparing family practice to
subspecialists, 95% CI 0.67, 1.19). Family practice care was inversely
associated with the use of CAM providers by black women OR 0.46 (95% CI
0.23, 0.92) and positively associated among white men OR 1.71 (95% CI
0.92, 3.16).

Authors:

David I. Buckley, MD

James Calvert, MD

PBRN(s):

Oregon Rural Practice-based Research Network (ORPRN)

Title:

Chronic Opioid Therapy and Preventive Services in Rural Primary Care

Context:

Chronic opioid therapy for non-malignant pain has become increasingly
accepted in primary care practice. Studies suggest, however, that
clinical encounters involving chronic pain and opioids often result in
\"time-consuming activities\" and \"failures in patient-physician
relationship\". Such stresses on the clinical encounter might
detrimentally affect the provision of other primary care services,
including preventive services. A possible association between chronic
opioid therapy and quality of preventive services has not been well
studied. Detection of such an association could lead to improved
preventive care for those with chronic pain.

Objective:

To evaluate a possible association between chronic opioid therapy and
quality of preventive services, as measured by rates of screening for
cervical cancer, hyperlipidemia, and colorectal cancer; and rates of
smoking cessation counseling.

Design:

Retrospective cohort study, comparing patients receiving chronic opioid
therapy to those who are not, using data abstracted from medical
records. Hypothesis testing is two-sided. Analysis includes relative
risk of performance of preventive/screening services between groups, and
GEE regression modeling of independent variables predictive of each
outcome. Analysis controls for demographics, utilization, and comorbid
diagnoses.

Setting:

Eight rural primary care practices that are members of the Oregon Rural
Practice-based Research Network (ORPRN).

Participants:

Six hundred subjects classified by opioid therapy status and frequency
matched (2:1) by gender and smoking status. Males and females; any
ethnicity; 35 to 85 years old; seen in participating clinics over a
three-year period.

Outcome Measures:

Screening rates of: Pap testing, lipid testing, fecal occult blood
testing, flexible sigmoidoscopy, and colonoscopy; and counseling for
smoking cessation.

Results & Observations:

Will include relative risk of each preventive service between groups,
and regression model coefficients.

Conclusion:

(Anticipated): If results support the study hypothesis, patients on
chronic opioid therapy for non-malignant pain receive preventive and
screening services at lower rates than those not on chronic opioid
therapy.

Authors:

Louis Vernacchio, MD, MSc

Richard M. Vezina, MPH

Allen A. Mitchell, MD

PBRN(s):

SCOR Network

Title:

Xylitol for the prevention of acute otitis media: pilot study of
compliance and tolerability

Context:

Xylitol at a dose of 2g five times-a-day has been shown to reduce acute
otitis media (AOM) by 30-40%, but a less frequent dosing schedule is
needed for this treatment to be used widely.

Objective:

To assess compliance and tolerability of oral xylitol solution given
once daily (QD) and three times-a-day (TID).

Design:

Pilot randomized controlled trial in two phases. Phase one compared the
tolerability of xylitol at 2.5g, 5g, and 7.5g QD and at 2.5g, 5g, and
7.5g TID with placebo for seven days. Based on phase one results, phase
two evaluated compliance and tolerability of a three-month course of
xylitol at 7.5g QD and at 5g TID compared to placebo.

Setting:

The Slone Center Office-based Research (SCOR) Network.

Participants:

80 children 6-24 months old (phase one) and 120 children 6-36 months old
(phase two) with â‰¥2 AOM episodes in the previous year.

Intervention:

Oral xylitol solution versus placebo.

Outcome Measures:

Compliance and adverse effects.

Results & Observations:

Phase One: All QD doses were well-tolerated, with no increase in the
occurrence of gastrointestinal side effects compared to placebo. All TID
doses were also well-tolerated; however compliance in the 7.5g TID group
was worse than in the other groups. Phase Two: Completion rates for the
three-month study were: QD xylitol: 70.0%; QD placebo 76.7%; TID
xylitol: 70.0%; TID placebo: 70.0%. Withdrawals due to gastrointestinal
side effects occurred in the following number of subjects: QD xylitol:
2(6.7%); QD placebo: 1(3.3%); TID xylitol: 3(10.0%); TID placebo:
1(3.3%). Physician visits for gastrointestinal symptoms were no more
common among the subjects taking xylitol compared to placebo.

Conclusion:

Oral xylitol solution at doses of 7.5g QD and 5g TID is well-tolerated
in young children. A large efficacy trial of these dosing regimens is
therefore feasible.

Authors:

Thad Wilkins, M.D.

Peggy Wagner, Ph.D.

Andria Thomas, Ph.D.

Ralph A. Gilles, Ph.D.

Jennifer Kenrick, B.A.

PBRN(s):

HamesNet

Title:

The Characteristics of Patients with Swallowing Difficulty in Primary
Care

Context:

Dysphagia is the perception of an obstruction during swallowing. A
number of benign and malignant disorders cause dysphagia which can occur
primarily with solids, liquids, or both.

Objective:

The purpose of this study was to define the characteristics of patients
with dysphagia in primary care.

Design:

A cross-sectional descriptive study using a convenience sample of adult
outpatients being seen within a practice-based research network.

Setting:

Twelve family medicine clinics in HamesNet, a research network in
Georgia participated.

Participants:

Men and women aged 18 years and over presenting for any reason to a
family physicians\' office were the subjects of an anonymous survey.

Results & Observations:

Of the 955 study participates, 313 (32.8%) reported dysphagia. The mean
age was 46.1 (SD = 16.4) with 73.2% female. Overall, more women (35.1%)
reported dysphagia than men (26.4%) (p=.006). While statistically more
women than men were concerned about dysphagia (p=.014), there was no
gender difference in discussing dysphagia with a health care provider (p
= .407). Of all patients with dysphagia, 51.8% reported dysphagia with
solids only, 7.5% with liquids, and 40.7% with both solids and liquids.
Seventy-nine (25.7%) reported having the problem less than one year.
Fifty-five percent of patients with dysphagia reported that they were
concerned about their symptoms. Over half of the patients with dysphagia
(57.0%) had not spoken with their doctor about their dysphagia.
Approximately 38% of those who did not talk to their doctor regarding
their trouble swallowing were concerned with their symptoms.

Conclusion:

Dysphagia is a common problem among adults seen in primary care and its
presence is often not discussed with a health care provider. Additional
research is needed to examine the reasons patients concerned with their
dysphagia symptoms are reluctant to discuss their concerns with their
physician.

# *Personal Workplan: Thursday* 

**Opening Remarks:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Introduction to the Resource Center:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**The PRINS Survey and Panel on Multi-PBRN Collaborative Research:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Concurrent Session I:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Lunch -- PBRNs and the Wisdom of the Crowds:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Practice Systems Improvements and PBRNs Panel:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Concurrent Session II:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Concurrent Session III:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Additional Notes:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

# *Personal Workplan: Friday* 

**PBRNs and HIT Panel:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Concurrent Session IV:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Concurrent Session V:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Lunch -- Learning Collaboratives:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Funding and Partnering Opportunities:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Wrap-Up:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**

**Additional Notes:**

**\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_**