# Presentation: 045169

## PBRNs:  Making Prevention Possible through HIT

- David Meyers, MD
- Medical Officer
- Center for Primary Care, Prevention, and Clinical Partnerships
- October 25, 2005

## Goals

- Provide an overview of AHRQ
- Provide an overview of primary care Practice-Based Research Networks (PBRNs)
- Share examples of how PBRNs are promoting prevention through the use of HIT

## What’s in a name

- Agency for Healthcare Research and Quality

## What’s in a name

- Agency for Healthcare Research and Quality
- A part of the federal Department of Health and Human Services
- Along with NIH, CDC, and HRSA

## What’s in a name

- Agency for Healthcare Research and Quality
- A part of the federal Department of Health and Human Services
- A scientific research agency
- Only federal agency with a focus on health services research
- With an expanding focus on implementation and system change

## What’s in a name

- Agency for Healthcare Research and Quality
- A part of the federal Department of Health and Human Services
- A scientific research agency
- The leading federal agency on health care quality and safety

## What’s not in our name

- Agency for Healthcare Research and Quality
- A part of the federal Department of Health and Human Services
- A scientific research agency
- The leading federal agency on health care quality and safety
- Not a policy-making or regulatory agency

## AHRQ

- Improves health care quality for all Americans
- Transforms research into practice
- Improves health care outcomes through research
- Uses evidence to improve health care

## AHRQ’s Mission Statement

*   **To improve the quality, safety, efficiency, and effectiveness of health care for all Americans*

## Research at HHS:Where Does AHRQ Fit In?

- NIH -- basic biomedical bench research and “efficacy” clinical trials
- CDC -- the public health system and community-based interventions
- AHRQ -- “effectiveness” of health care services and the health care delivery system

**Notes:**
To further help differentiate AHRQ’s research from CDC’s and  NIH’s research, I’ll use an example related to diabetes--a condition that occurs with great frequency within the African American population.. NIH research identifies what can work to improve patient health.  NIH’s primary orientation is laboratory bench science, which seeks to broaden our understanding of basic biology and the biological mechanisms of disease, and clinical trials, designed to establish the potential usefulness of new interventions under ideal conditions (“efficacy”).  For example, how does type A and B diabetes differ and what treatments might be instituted to cure the disease. CDC evaluates health behaviors and tests community interventions that might be used to reverse unhealthy behaviors or reinforce healthy ones.  For example, programs to increase exercise or improve diet.
By contrast, AHRQ develops evidence to help clinicians and patients select the best interventions for that individual.  For example, do multiple medications control the patient’s diabetes or does it work better to combine medication therapy with support from team made up of doctors, nurses, and exercise coaches?  AHRQ research then helps providers develop measures to evaluate what works best.  This research relates to quality improvement efforts.
In its clinical research, AHRQ assesses the effectiveness in daily practice of promising new interventions, compares their benefits, costs, and side-effects with existing approaches, and when effective interventions are not being used, identifies options for overcoming barriers to their widespread use.   AHRQ’s clinical research is unique in two other ways: its focus on the interaction between patients and their care-givers and patient-centered research (rather than treating each disease in isolation), recognizing that the number of individuals with multiple chronic conditions is growing and the care for their different conditions must be coordinated.
AHRQ’s research on the health care delivery system reflects the belief that health care services are not delivered in a vacuum.  The outcomes, effectiveness, and quality of health care interventions are influenced by who delivers the service, the extent to which the systems in which clinicians work support or frustrate their efforts, and the financial incentives or barriers to provide the right service at the right time in the right way.  For example, research related to the development of effective disease management strategies and improved coordination of care draws upon both clinical and health systems research.  

## Cross Cutting Portfolios

- Prevention
- Health Information Technology*** ***
- Quality and safety of patient care
- Care management
- Data development

- Long-term care
- Pharmaceutical outcomes
- Cost, organization, and socio-economics
- Training
- System capacity and emergency preparedness

**Notes:**
Prevention and HIT, along with our Practice-based research network initiatives sit in the Center for Primary Care Prevention and Clinical Partnerships

## Practice-Based Research Networks (PBRNs)

## A PBRN Defined

-    A group of ambulatory practices or clinicians devoted principally to the primary care of patients...

## A PBRN Defined

-    A group of ambulatory practices or clinicians devoted principally to the primary care of patients, affiliated with each other in order to investigate questions related to community-based practice and to improve the quality of primary care.

## AHRQ definition of a PBRN

- A PBRN is a group of ambulatory practices affiliated with each other in order to investigate questions related to community-based practice and to improve the quality of primary care.
- This definition includes a sense of ongoing commitment to network activities. and an organizational structure that transcends a single project.

## Four Basic Features of PBRNs

- Networks capture health care events that reflect and characterize primary care in community-based patient populations.
- Nutting, Beasley, Wenrer, JAMA 281(8), 1999.

## Four Basic Features of PBRNs

- 2.   PBRNs provide access to the practice experience and care provided by full-time primary care clinicians.
- Nutting, Beasley, Wenrer, JAMA 281(8), 1999.

## Four Basic Features of PBRNs

- 3.   PBRNs focus their activities on practice-relevant research questions and apply appropriate multi-method research designs.
- Nutting, Beasley, Wenrer, JAMA 281(8), 1999.

## Four Basic Features of PBRNs

- 4.   PBRNs strive for the systematic involvement of network clinicians in defining the research questions, participating in the study design, and interpreting study results.
- Nutting, Beasley, Wenrer, JAMA 281(8), 1999.

## Brief History of PBRNs

- Beginnings in efforts in early 1970s in UK and Europe
- By 1980s PBRNs developing in the US, Canada, Israel, New Zealand, Australia

## Brief History of PBRNs

- Beginnings in efforts in early 1970s in UK and Europe
- By 1980s PBRNs developing in the US, Canada, Israel, New Zealand, Australia
- In 1999, Congressional reauthorization of AHRQ includes mandate to support primary care PBRNs

## AHRQ and PBRNs

- In 2000, AHRQ releases first federal solicitation specifically targeted to PBRNs
- Utilized P20 mechanism (planning grants)
- 90 applications received
- 19 networks funded
- Funded PBRNs representing over 4000 clinicians and 6 million patients

## AHRQ and PBRNs

- In 2000, AHRQ releases first federal solicitation specifically targeted to PBRNs
- In 2002, new funding for 36 networks
- Funds for infrastructure support and pilot studies
- 36 networks funded
- 10,000 clinicians serving 10 million patients

## Practice-Based Research Networks (PBRNs)

**Practice-Based Research Networks (PBRNs)**

- 36 PBRN grants awarded in 2002

- 19 PBRN grants awarded in 2000

## AHRQ and PBRNs

- In 2000, AHRQ releases first federal solicitation specifically targeted to PBRNs
- In 2002, new funding for 36 networks
- Since 2002
- Established a National PBRN Resource Center
- Small Research Grants (R03)
- Translational Research Grants
- New and emerging network research grants
- National PBRN Research Meetings

## U.S. PBRNs in 2004

- 111 Active PBRNs in 44 States and Puerto Rico
- Headquartered in urban, suburban and rural areas
- A survey including 87 PBRNs, found they included
- 		2,724 practices and 13,000 clinicians
- 		caring for 14 million patients.

- No PBRN activity
- PBRN activity present

## Research Experience

- 75% of PBRNs have conducted at least one study
- Almost 50% have completed 4 or more studies
- The mean number of patients included per study is 1,775 (median 888, range 16-20,000)

## Common Research Foci

**Prevention**

**Diabetes**

**Cardiovascular**
**Risk**

**Mental**
**Health**

**Cancer**

## PBRNs, Prevention, and HIT

## PBRNs, Prevention, and HIT

- Examples from three PBRNs:
- Ambulatory Care Outcomes Research Network (ACORN)
- Oklahoma Physician Resource and Research Network (OKPRN)
- Clinicians Research Network (CRN)

## PBRNs, Prevention, and HIT

- Three stages of research:
- From efficacy (CRN)
- to effectiveness (ACORN)
- to translation (OKPRN)

## PBRNs, Prevention, and HIT

- Three examples locations:
- Rural (OKPRN)
- Suburban (ACORN)
- Urban (CRN)

## PBRNs, Prevention, and HIT

- Three examples of how HIT can assist with prevention activities:
- Before the office visit (ACORN)
- During the office visit (OKPRN)
- After the office visit (CRN)

## Ambulatory Care Outcomes Research Network

**Ambulatory Care Outcomes Research Network**

## Ambulatory Care Outcomes Research Network

- Established in 1999
- Administered through the Department of Family Medicine at Virginia Commonwealth University
- Includes over 35 practice sites in Northern and Central Virginia
- Over 30 published articles in the past five years

## ACORN, Prevention, and HIT

**Patient-centered, internet-based tools**
*MyHealthyLiving*:  stage-based resources to help patients pursue healthy behaviors

## Prescription for Health

- Program of the Robert Wood Johnson Foundation, co-sponsored by AHRQ
- Utilizing PBRNs to address prevention through health behavior change
- Focus on improving, increasing physical activity, smoking cessation and decreasing risky drinking
- For more information see: www.prescriptionforhealth.org

## ACORN, Prevention, and HIT

**Patient-centered, internet-based tools**
*MyHealthyLiving*:  stage-based resources to help patients pursue healthy behaviors (Prescription for Health-Round 1, RWJF-AHRQ)
***MyPreventiveCare***: system to help patients learn more about recommended clinical preventive services (VCU Massey Cancer Center)

## Slide 40

## ACORN, Prevention, and IT

**Practice-level systems** (Prescription for Health, Round 2, RWJF-AHRQ)
- EHR-based prompts to help clinicians identify and offer brief advice to patients with unhealthy behaviors
- Practices use EHR templates to refer patients to services outside the practice for more intensive assistance

## OKPRN

- Oklahoma Physicians Resource/Research Network
- 235 clinicians (MD, DO, PA, NP)
-  90 practices throughout Oklahoma
-  500,000 patients
-  Academic health centers, family residencies, private providers, community health centers, Native American clinics

## OKPRN

- [add screen shot of website]

## Public-Private Partnerships

- Oklahoma State Department of Health (OSDH)
- Oklahoma Health Care Authority (Medicaid)
- Oklahoma Foundation for Medical Quality (OFMQ)
- Oklahoma State Medical Association (OSMA)
- Oklahoma Academy of Family Physicians (OAFP)

## Public Health Prevention:Influenza-Like Illness (ILI) Surveillance Project

- State-wide sentinel surveillance system
- 30 primary care providers report on a daily basis via the web
- Real-time ILI data is relayed to health department (OSDH)
- Health alerts to providers on a weekly basis based on ILI data (OKAlert® system)

## Sentinel Site Reporting System

## Preventive Services Reminder System Project

- Preventive services management and forecasting system
- Immunization and prev. service registry
- Patient-specific, point-of-care prompts and reminders
- HL7 interface to OSIIS (state database)

## CRN

**Collaborative Research Network**
- UCSF Department of Family and Community Medicine
- University of California, San Francisco

## Description of the CRN

**Established in 1984**
**400 clinicians in 50 cities throughout Northern and Central California**
**Diverse Practice Settings **
- Includes academic clinics, public health clinics, and a wide variety of private group and solo practices
**Diverse Patient Population**
- >50% non-white

## Sample CRN Projects

**Action Plan Project **– Self-Management Action Plans for Patients with CHD Risk Factors** **(*Bodenheimer)*
**Medication Adherence Project – **Using Pharmacy Claims Data to Identify and Intervene with Poorly Adherent Type 2 Diabetics *(Potter)*
**Medical Assistants Project – **Investigating the Role of Medical Assistants in Primary Care**  ***(Tache)*

## Improving Diabetes Efforts Across Language & Literacy (IDEALL PROJECT)

** ****Principal Investigator:**  Dean Schillinger
-  **Research Team:**
- 	Hali Hammer,Jorge Palacios,Yvonne McLean, Audrey Tang, Michelle Schneiderman, Sharon Youmans, Andy Bindman, Margaret Handley
**Setting:**
- 	Family Health Center and
- 	General Internal Medicine Clinic,
- 	San Francisco General Hospital
-       San Francisco Department of Public Health

**Notes:**
Key Research Question:  CAN DISEASE MANAGEMENT INTERVENTIONS ENGAGE HARD-TO-REACH PATIENTS IN PRIMARY CARE? Plans to expand to Silver Avenue Health Center (Latino) and Chinatown Health Center

## Background

- Health systems place high literacy and language demands on patients
- Few tailored interventions exist to support self-management

## Aims

- Develop, implement and evaluate diabetes disease management strategies tailored to the literacy and language needs of patients within a public delivery system
- Focus on self-care and patient-generated action plans using one of two models:
**Assistive Technology Model**: Automated Telephone Disease Management (ATDM)
**Interpersonal Model**: Group Medical Visits (GMV)
- Describe patient engagement with the process and activities generated by each approach

##  IDEALL PROJECT OVERVIEW

- Randomize Patients w/HbA1c>8.0 & Administer Baseline Questionnaires (n= 399)

- 6-10 Patients
- Health Educator
- Primary Care
-  Physician

- Usual Care
- (n= 133)

- Monthly Group Medical Visits Clinic (n= 133)

- Weekly Interactive Technology           (n= 133)

- Nurse Care Manager

- Primary Care Physician

- Weekly
- ATDM

- Patient

- Cantonese-Speaking Group

- English-Speaking Group

- Spanish-Speaking Group

- Administer Follow-Up Questionnaires (Satisfaction, Self-Care, Self-Efficacy, Functional Status, Glycemic Control, Utilization)

** ****IDEALL PROJECT OVERVIEW**

## Automated Telephone Disease Management (ATDM)

- Interactive touch tone response technology
- Weekly surveillance & health education/self-management
- In patients’ preferred language (English, Spanish or Cantonese)
- Generates weekly reports of out of range responses
- Live phone follow-up through a bilingual nurse

**Notes:**
Health Education Messages generated w/help of California Literacy, Inc. and with extensive pilot testing and input from patients and other volunteers.  Messages chosen tended to be  “narratives”, rather than prescriptive messages.  Health Education Messages rotated based on patient responses.  The role of the nurse was to help the patient generate and follow through with an action plan to improve self-management.

## Activities Generated 

**100**

**0**

**Notes:**
Similar rates of making and following through with action plans among the two groups.
GMV – more med changes (?b/c of pharmacist involvement)
ATDM – more counseling on glucose monitoring and signs of hyper/hypoglycemia
	(?b/c of programmed messaged in ATDM vs. more patient-directed counseling for ATDM)

## Preliminary Conclusions

- Both self-management interventions:
- Can generate significant levels of patient engagement and clinical activity
- May be be useful adjuncts to improve the care of high risk patients in a public health setting
- Levels of engagement and kinds of activities generated may vary by type and design of intervention, especially with regard to:
- Pharmacological management
- Psychosocial concerns

## Additional Analysis

- To what extent do patients engage with ATDM?
- Proportion of enrolled subjects who
- completed ≥1 ATDM call
- triggered ≥1 nurse call-back
- generated action plan
- achieved action plan
- Explore whether language and/or literacy associated with engagement
- Patient is unit of analysis
- Overall and stratified by language and literacy
- Multivariate models adjust for age, sex, HbA1c, and account for within-patient clustering, using GEE

## Subject Characteristics ATDM Arm  (N=91)

|  | # /mean | % /STD |
| --- | --- | --- |
| Age | 55 yrs | (13) |
| HbA1c | 9.0 | (2) |
| Sex:   male | 40 | 44% |
|            female | 51 | 56% |
| Literacy:  low | 41 | 45% |
|                high | 37 | 41% |
| Language: 
       English | 
40 | 
44% |
|        Spanish | 38 | 42% |
|      Cantonese | 13 | 14% |

## Measures of Engagement

-  89% generated Action Plan

- 81% achieved Action Plan

- 93% returned ≥1 call

- 95% had ≥1 nurse call-back

**n=91**

- n=85

- n=72

- n=58

## Preliminary Conclusions II

- Automated telephone diabetes system
- generates significant levels of engagement overall
- can offer self-management support and has potential as adjunct to care for high risk diabetes patients in a public health setting
- Levels of engagement may vary by language/literacy
- LEP appear more likely to engage in ongoing fashion and trigger clinical responses
- Initial engagement similar across literacy levels, but low literacy Spanish speakers less likely than high literacy Spanish speakers to engage in ongoing fashion
- Low literacy appear more likely to trigger clinical responses

## For More Information

- AHRQ and PBRNs
- David Meyers   _[DMeyers@AHRQ.gov](mailto:DMeyers@AHRQ.gov)_
- ACORN and MyHealthyLiving
- Steve Wolff    _[SWoolf@vcu.edu](mailto:SWoolf@vcu.edu)_
- OKPRN and Preventive Services Reminder System
- Zsolt Nagykaldi    _[Zsolt-Nagykaldi@ouhsc.edu](mailto:Zsolt-Nagykaldi@ouhsc.edu)_
- CRN and IDEALL study
- Dean Schillinger   _[dschillinger@medsfgh.ucsf.edu](mailto:dschillinger@medsfgh.ucsf.edu)_