# Presentation: 075700

**Rural Research as Jazz: Improvisations in Interventional Research**
**Jay H. Shore M.D., M.P.H.**
**Assistant Professor**
**University of Colorado Denver, School of Medicine**
**Department of Veterans Affairs**
**TATRC**
**South Central MIRECC Retreat**
**The Peabody Hotel / Little Rock, AR**
**April 16-18, 2008**

**Notes:**
Hello my name is Jay Shore. And I am here to talk about the Center for Native American TeleHealth and TeleEducation, otherwise known as CNATT.   CNATT at University of Colorado Health Sciences Center in Denver 

## Conclusions

- There is value in examining, reporting and sharing regardless of level of evidence
- Important to be partnered with clinical enterprises and community partners
- Research can be done with a range of resources and commitments

## Outline

- Who am I
- Organizations I work with (collaboration potential)
- Examples of research

## Who am I

- Psychiatrist
- Clinic work in telehealth, PTSD, addictions with American Indian, Veterans and Physicians
- Research in areas of clinical interest

## American Indian and Alaska Native Programs

- Spero Manson, Head
- 7-8 National Centers focused on improving health and well-being of American Indian and Alaska Native populations
- Over 100 community partners from around the country

## VA Partnerships

- Denver VAMC
- Denver MIRECC (Suicide)
- VISN 19 and VISN 23

## Telemedicine and Advanced Technology Research Center (TATRC)

- Advances military medicine
- Congressional and internal funding mechanisms
- Triple Helix model
- Interested in collaboration between DOD-VA

## Current Clinical Services

- Telepsychiatry for American Indian Veterans in the Northern Plains struggling with PTSD
- Psychiatric Resident Training Clinics in Southern Colorado
- Residential Alcohol Treatment, Anchorage, Alaska (non-VA)

## Level of Evidence for Research Studies

- U.S. Preventive Services Task Force
- Level I: randomized controlled trial.
- Level II-1: controlled trials without randomization.
- Level II-2: cohort or case-control analytic studies, preferably from more than one center or research group.
- Level II-3: multiple time series with or without the intervention. Dramatic results in uncontrolled trials.
- Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees

## Level of Evidence for Research Studies

## Level of Evidence

- Parachute use to prevent death and major trauma related to gravitational challenge: systematic review of randomised controlled trials.
- RESULTS: We were unable to identify any randomised controlled trials of parachute intervention.
- CONCLUSIONS: As with many interventions intended to prevent ill health, the effectiveness of parachutes has not been subjected to rigorous evaluation by using randomised controlled trials.

- Smith, Pell. BMJ. 2003 Dec 20;327(7429):1459-61. Review.** **

## Blood, Sweat and Tears Study Design

- Blood/Tears: Externally funded, need to create research infrastructure, more “rigorous” product (?)
- Sweat: Internally funded, drawing on clinical experiences, faster and feasible, more “clinically applicable” product (?)

## Example 1: RCT

- RCT of telemental health assessments of American Indian Veterans
- Effort: Blood/tears
- Design: needed to set-up rural research infrastructure
- Funding: External
- Time: Externally determined (Jurassic)
- Product: Level I evidence (reliability, cost, process)

## Challenges

- Rural infrastructure, distance management
- Multiple collaborators
- Multiple IRBs
- Travel and transportation issues

## Example 2: Descriptive Reports

- Case Report: American Indian Veteran with PTSD
- Program report: Residency Training in Telepsychiatry
- Guidelines: Emergency Management for Telepsychiatry

## Example 2: Descriptive Reports

- Effort: Sweat
- Design: Mine existing work
- Funding: None
- Time: Internally determined
- Product: Level II-3 and III evidence

## Challenges

- Motivating participants
- Negotiating approvals with communities

## Barriers to Rural Research

- Community skepticism
- Distance
- Infrastructure

## Benefits to Rural Research

- Need
- Appreciation from communities
- Array of opportunities

## Key Points

- Partnerships (community and clinical services)
- Synergy between different levels of research
- Strategic execution of projects

## Contact Information

- Jay H. Shore, MD, MPH
- Assistant Professor
- American Indian and Alaska Native Programs
- University of Colorado Denver
- Mail Stop F800
- PO Box 6508
- Aurora, CO 80045-0508
- Phone: 303-724-1465, Fax: 303-724-1474
- E-mail: _jay.shore@uchsc.edu_
**NEW EMAIL 2008: **_**jay.shore@ucdenver.edu**_