Practice-Based Research Netw

th VHA S ti C ll b the VHA: 

Supporting 

C

oll

a

bo

to Accelerate Im

proveme

Michael L. Parchman, MD, MPH

Investigator, VERDICT

South Texas Veterans Health Care 

System

July 30, 2009
We’ll cover:

 What is a PBRN.  Why do we do it? Examples of research done in PBRNs The Sout e as a y Ca e esea 

South Texas VA Primary Care Resear

Network

 Dental Practice-based Research in the VA
W s c ce hat is a Practice-b sed ese c ased Research 

Network?

 An organization of clinicians and rese

united by a shared commitment expand the science base of primpractice through systematic inquiry tund t d th h lth d h lth 

derstand the health and health ca

that unfold daily in their practice set
Why do Practice-Based Res

 Practice-based research informs the 

most people receive most of the time
Com

Kerr White and the Ecology of Medical Care

Ha

y

or cSaw phy

Admireferr

Adm

White KL, Williams TF, Greenberg BG. The ecology of tertimedical care. N Engl J Med 1961;265:885-92
Ecology of Medical Care 

Revisited

Green LA et al. NEJM 2001;344:2021-2025
Wh D P i Why Do Practice-b d R 

based Re

 Examine health and health care phenom

typ p yp p y 

ical patients in typical primary care s

 Answer questions of great relevance to 

practicing clinicians

 Capture the wisdom, insight, and exper

practicing clinicians

 Reunite practice and research It’s fun and energizing*

*Nityamo Sinclair-Lian, Robert L. Rhyne, Shirley H. Alexander, and Robert L. WiPractice-based Research Network Membership is Associated with RetClinicians in Underserved Communities: A Research Involving Outpatient Network (RIOS Net) Study. J Am Board Fam Med, July-August 2008; 21: 353 - 
Why do Practice-Based Res

 “If we want more 

evidence-based practice we need more practice-based evid ” ence.

”

L G MD awrence 

Green, MD

Green LW. Public health asks of systems science: to advance our evidenpractice, can you help us get more practice-based evidence? Am J Publi96: 406–9 
Why do Practice-Based Res

Life isn't only seeing sick kids, old people with mamedical problems in nursing homes, and patients smedical problems in nursing homes, and patients s

path of self destruction. It is being able to ask a quabout a medical problem, and arriving at a conclu

doing a st d ith o r peers It's a oiding "b rn doing

a st

u

dy with

o

u

r peers. It's

a

voiding "b

urn

while expanding our horizons and helping patients

Catherine KrollGwinn, Michigan
Why do Practice-Based Res

There is a sense that what we are doing is not only but is particularly important in these times of turmmedicine As we try to solve our health care problemedicine. As we try to solve our health care proble

becoming increasingly apparent that the answers lprimary care and cost effective medicine, the 

understanding of which depends on practice based research.

Tillman Farley

Brighton, Colorado
Translational Scienc

Translational Scienc

“T1”

“T2

”

The Academic Health Science Center:

Bench Bedside Com

“T1” T2

Bookshelf
"Blue Highways" on the N

Roadmap

Westfall J M et al JAMA 2007;297:403 406

Copyright restrictions may apply.

Westfall, 

J. 

M. et al. JAMA 2007;297:403

-406.
Methods: How do we do it?

 NOT just research in practice settin Research with practices with the practices, with the

physicians, nurses, office staff, and 

 P i i l f ti i t h P

r

inc

i

p

les o

f parti

c

ipa

tor

y researc

h

 trust building,  long term relationships,  recognition and incorporation of local  shared decision making, and  identification of relevant clinical ques
Not what we have in mind!

We have a collaborative arrangement

h l t th d th I t hi he cleans my 

teeth an

d then I ea

t him
Identify g gp knowledge gap

Systematic Systematic 

adequate 

Implement in 

practice

Generate 

Al d

study q

Analyze and

interpret results

Collect data Collect Design Study Design Study data
Identify g gp knowledge gap

SystematSystemat

adequa

Implement in 

practice

Serious input 

from

Gene

Al d

community 

clinicians and 

clinic staff Gene

clarif

que

Analyze and

interpret results

clinic staff

Collect data Collect Design Study Design Study data
History of PBRNs

 Dutch Sentinel Stations – 1970 Dartmouth COOP Project – 1978 Ambulatory Sentinel Practice Netwo Pediatric Practice Research Group –  Pediatric Research in Office Settings  Other regional networks in MI., MN., 

mid 1980’ id 1980’

s

 Dental, Mental Health, Pharmacy PB

started in last 10 started in last 10

-15 years 15 years
Current status of 

practice-b

research networks

 Over 100 regional and national prima

networks in the U.S. in 2007

 National Networks National Networks

 PROS: pediatric research in office settin AAFP NRN ACPNet

 Not just primary care

 Dental Nurse Practitioners Pediatrics

Examples of Research in 

PBRNs

 Relevant Clinical Questions

 Carpal Tunnel Syndrome Carpal Tunnel Syndrome MRSA Skin and Soft Tissue Infecti

 Accelerating Improvement Accelerating Improvement

 Depression Case Management I i Ri k F t f Di b t Improvin

g Ri

s

k

Factors 

for Di

a

b

e

te

Complications (NIH/NIDDK)
Carpal Tunnel Syndrome (CTS)

Ambulatory Sentinel Practice Network (ASPN)

 N=552 patients f fl rom 74 

family practices

 Describe how CTS present to primary ca

and h i iti ll l t d d 

d

how initi

ally evalua

te

d an

d mana

g

e

 In most patients, this condition was 

successfully managed by family doctors successfully managed by family doctors

 Treatment was generally conservative

Miller RS, Iverson DC, Fried RA, Green LA, Nutting PA. Carpal tunnel primary care: A report from ASPN. J Fam Pract 1994; 38:337–44.
ASPN card for CTS Study
ASPN Carpal Tunnel Syndrom

At 4 month follow up: over 50

reported improvement in symreported improvement in sym

 17% had worsened symptoms 4% not able to ca o t o tine a

4% not able to carry 

o

u

t ro

utine a

 39% modified job requirements 10% bl t ti i j b 10% unable 

to continue in 

j

o

b
Potential for Selection Bia

Potential for Selection Bia

Carpal Tunnel Study

All Patients

N=380

S

Ne

Management:

Referral for sur

gical eval 7.9% 

Surgery 2.9% 

Outcomes at 4 months:

Continued usual activities

57.2% 

Unable to continue job 5.8% 
MRSA Skin and Soft Tissue Inf

 South Texas Ambulatory Resear

Network (STARNet) Network (STARNet)

 Since 1992 Non

-VA small offices VA, small offices

 Annual membership meeting

 “Seems like I am seein

g a lot of M

my office”

Parchman ML, Munoz A. Risk Factors for Methicillin-Resistant Staphyloco

aureus Skin and Soft Tissue Infections Presenting in Primary Care: A So

Ambulatory Research Network (STARNet) Study. J Am Board Fam Med 2
Physician “Card” Study

 168 cases collected in 6 months 

5 clinics

 Two-thirds of all cultures were M No historical risk factors assoc w

No historical risk factors assoc w

likelihood of MRSA except “healtworker.”

 No physical exam features assoc

MRSA except abscess
MRSA Next Steps

 UT College of Pharmacy faculty Used card study for 2 year pilot Used card study for

2 year pilot

research funding from our CTSA



“Community Acquired MRSA Skin Community Acquired MRSA Skin

Infections: Genetics, Resistance, a

Treatment in a South Texas PractTreatment in

a South Texas Pract

Research Network”
Implementation Research

 The challenge is no longer to sho

something works we now have tsomething works, we now have t

figure out how it works in everyd

practice.

 17 years to translate research fin

into community into community. (Science Sept 2008) (Science Sept 2008)
ASPN Depression RCT (199

 24 physicians in 12 practices: 24 physicians in 12 practices:

Randomization by practice

 Usual care vs care management and Usual care vs care management and

tracking

 Care management embedded in practic

Care management embedded in practic

operations--not ‘carved out’

 12 000 patients screened 480 with maj

12,000 patients screened, 480 with maj

depression enrolled in trial

 Patients followed for 2 years Patients followed for

2 years

 21 articles published from study
ASPN Depression Tri

Intervention

 Use of the PHQ-9 for monitoring severity 

adjusting treatment

 C d d b ffi Care mana

gement con

ducte

d

by an office 

with training from the research staff

 Used a manual (pencil and paper) trackin

Used

a manual (pencil and paper) trackin

system

 Contacted patients frequently during acut

Contacted patients frequently during acut

chronic phases

 Helped patients identify and work through 

barriers to care
ASPN Depression Tri

Major Findings

 Significant improvement in depression se

6 months and increased benefit at 2 yea

 Significant improvements in general heal Si

gnificantly more satisfied with their ove

 Patients in rural areas and those with no 

insurance derived even 

greater benefit. 
Improving Risk Factors for Diab

Improving Risk Factors for Dia

Complications in Primary Care

 STARNet Study; Parchman PI NIH/NIDDK 5 year cluster-randomize

(2007-2012)

 40 small family physician and genera

internist offices internist offices

 Practice Facilitator/Office Coach: Imp

Chronic Care Model Chronic Care Model

 Practice Teams and Learning Session

Parchman ML, Pugh JA, Culler SD, Noel PH, Arar NH, Romero RL, Palmer RF. A grtrial of a complexity-based organizational intervention to improve risk factors for complications in primary care settings: study protocol. Implementation Science 2
PBRNs: A Learning Organ

 PBRNs can and will 

continue to evolve to be more effective, real time, learning organi ti za ons.

 Key: participatory 

based research based research
South Texas VA Primary Care 

 VA HSR&D funded Short Term H

Project ( Project

(SHP 08

-157

)

 March 2008-Sept 2008 Objectives:

 Recruit members: 8 VA OPCs Establ h h is

h researc

h priorities

 Develop pilot study
Results

 Initial Meeting Sept 2008 at VA 

Care Service Line Meeting Care Service Line Meeting

 Pre-meeting survey of research 

interests

 Prioritization of topics, developm

initial research questions initial research questions
Initial Study

 Is the level of competing demands c

clinical reminders during a visit inverassociated with the patient’s percepttheir needs were met? 

 Post-visit Card completed by clinician 

of visit)

 P i b il d b k P

Patient survey to be mailed back to P

office (satisfaction with visit)
Pro

gress to Date

 Instruments piloted March-April 2009 CITI training required for all physicia

participate

 Difficult due to high level of other mand

training requirements

 University IRB an

d VA R&D committe

approval pending CITI training

 Medical Directors and AOs kept infor

Medical Directors and AOs kept infor

progress at monthly V-Tel primary caservice line meeting
Characteristics Of Successful Ne

 Clear clinician involvement all aspect

network 

g p overnance and o

peration

 Clear rewards for clinicians participat

the 

( ) often diverse

) network activities

 A “network of researchers” who have 

how to work within a network how to work within

a network
Characteristics Of Successful Ne

 Visionary leadership

A hu

g y p

e dose of commitment b

y all 

p

 Consistent infrastructure support  A varied stream of project revenue A varied stream of project revenue A benevolent academic program(s) t

not t y to o t e et o t

ry to “

own” 

t

h

e network
Future Challenges to PBRN

the VA

 Infrastructure Support

 PBRNs are a “laboratory q ” and re

qu

minimum maintenance to keep 

go

 Admin Staff and Director

 Re

gulatory/Trainin

g for Full Tim

Clinicians

 Human subjects protection VA specific research training
The Future of PBRNs in the VA

Th I ’ ti l There, I can see you....you’re eating an appl

you’re not exactly eating it.....
Recommended Readin

g

s

 J Am Board Fam Med June 2009 Specia

PBRNs

 W tf ll J M ld J P ti Westfall

J, 

Mold

J. 

Practice-B dR 

ase

d

Resea

“Blue Highways” on the NIH Roadmap. 2007;297:403-406.

 Mold JW, Peterson KA. Primary Care Pr

Based Research Networks: Working at Interface Between Research and QualitInterface Between Research and Qualit

Improvement. Ann Fam Med 2005 3: S

 Green LA. Infrastructure requirements f

practice-based research networks. Ann 2005;3(S).
VA DENTISTS ENGAGED 

RESEARCH

Donald J. DeNucci D.D.S., M.S.

Research Consultant/VA Office of Dentistry

Program Officer/NIH/Practice-based Research Netw
VA Mission Stateme

 Our Mission... The mission of the Veterans Healthcare S

to serve the needs of America's veterans by providing pcare, specialized care, and related medical and social suservices.

 To accomplish this mission VHA needs to be a compreh

To accomplish this mission, VHA needs to be a compreh

integrated healthcare system that provides excellence in 

care value, excellence in service as defined by its custo

and excellence in education and research,.........
VA Office of Dentistry (OO

I t t d ht h I

ntegrated approach

to research

education, and quality measures

 VA OOD Quality Group VA OOD Quality Group

 VA Dental Practice-based Researc

Network (PBRN)

 VA OOD Education Initiative
VA OOD Qy 

uality Grou

 Mission is to improve the oral health of Mission is to improve the oral health of

veterans by promoting clinical practice bon the best evidence available

 D l Q lit I di t d S 

Develops Quality Indicators and Scoreca

 Develops Information Papers Develops Clinical Guidelines Develops Clinical Guidelines
VA Dental Practice-bas

Research Network

 Mission is to conduct research and provide answe

the questions facing VA Dentists in their daily prathe questions facing VA Dentists in their daily pra

 Strengthen the knowledge base for making clinic

decisions.

 Provide data to the VA Quality Group to assist the

addressing issues of greatest importance to the ohealth of veterans

 Provide information to the Educational Group to 

the development of education and training for thDental Team
VA OOD Education Gro

 Mission is to improve the oral health of 

veterans by enhancing the translation animplementation of evidence into clinical practice

 Provides monthly VA wide webinars on t

of interest to the VA Dental Team

 Maintains a VA website with educational 

materials, archived webinars, and links tother educational resources
Integrated Approach to Rese

Ed ti d Q lit C

Oral Health Providers

Education, an

d

Quality 

Ca

Oral Health Providers

VA Leadership

Improved 

Veteran Oral 

H lh

VADER PBRN Education 

Hea

l

t

h

Quality Group
VA Dental Practice-Base

Research Network (VADE

 Deployed in September 2007 A virtual network open to all 600+ VA Dental Professionals Governed by an executive committee of Governed by an executive committee of “volunteers” composed of VA practitioners, researchers, IT experts, educators, residents, 

fellows
VADER Participants VADER Participants

 204 dental clinics VA wide

 127 f iliti (h it l ) 127

facilities (hospit

als

)

 77 outpatient clinics

 Oral Health Research Officers (OHRO) Oral Health Research Officers (OHRO)

 44 Officers: Certified VA Researchers V

 37 Dentists 37 Dentists 7 Dental Hygienists
VA Dental Practice-Base

Research Network (VADE

 Primary objectives:

 Conduct clinical studies to improve the 

health of Veterans health of Veterans

 Emphasize effectiveness of oral health 

treatment and disease prevention

 Facilitate clear and clinically meaningf

Facilitate clear and clinically meaningf

outcomes

 Secondary objectives:

 Surveillance: Provide data on disease 

treatment trends 

 Obtain estimates of the prevalence of Obtain estimates of the prevalence of

less common conditions
Dental Practice-Based 

Research Network in the 

 Research Ideas: Research Ideas:

 Stimulated by the clinical challenges f

by VA practitioners

 Generated by practicing dentists and d

hygienists (i.e. practitioner - investiga

 Accepted from sources outside the VA 

Accepted from sources outside the VA 

(academia, individuals, etc...)
Uniq p ue As ects of th

VADER PBRN

 A virtual network with no defined budge

and staffed by volunteer VA dental and staffed by volunteer VA dental

professionals!

 The first VA practice-based research 

network!
Establishing A Researc

Network in the VA

STRENGTHS

 El t i H lth R d Electronic Health Records Uniform Practice Environment Relatively Stable Research Population Relatively Stable Research Population Access to the superb VA Research Culture Potential Access to the VA Central IRB Potential Access to the VA Central IRB
VA Dental Record Manager Module: CPR
Establishing A Researc

Network in the VA

CHALLENGES

 Integration of research into a patient car

Integration of research into a patient car

environment

 Providing pp incentives to participate in res Managing fluctuations in fiscal and other 

support resources
VADER PBRN Research Por

Studies in Progress

 VADER Study One: Assessment of Caries 

Diagnosis and Caries Treatment

 VA/UAB Study of ONJ in Veterans VA/DOD R i t f V t ith C i 

VA/DOD

Regis

try o

f

V

e

terans with

Crania

Implants
VADER Study One: Assessme

Caries Diagnosis and Treatm

A Quality Survey

Caries Diagnosis and Treatm
VADER Study One: Assessme

Caries Diagnosis and Treatm

A Quality Survey

Caries Diagnosis and Treatm
Osteonecrosis of the Jaw

VADER/UAB/ IOWA City VAVADER/UAB/ IOWA City VA

VA Pharmacy

 Cohort study of ONJ in Veterans (AHRQ 

funded)

 Case-Control study of ONJ in Veterans (V

funded

)
VA Cranial Implant Regis

A Joint VA / DOD projec
VADER PBRN Research Por

Studies in Developmen

 Endodontic Outcomes Study
VADER PBRN Research Por

Studies under Considerat

 Web/computer based smoking cessatio

Web/computer based smoking cessatio

study

 Implant outcomes study Oral cancer detection study  Effective treatments for dry mouth
ADA Professional Produ

Review (PPR) – VADE
ADA Professional Produ

Review (PPR) – VADE

 Evaluation of dental products and equipm

by VA Dental Professionals by VA Dental Professionals

 Provided by the American Dental Associa

hence no direct contact with industry

 Evaluated in the real-world environment 

clinical practice

 Potenti l i f iii d ii ial to inform VA acquisition decisio

and the oral health community in genera
Integrated Approach to Rese

Ed ti d Q lit C

Oral Health Providers

Education, an

d

Quality 

Ca

Oral Health Providers

VA Leadership

Improved 

Veteran Oral 

H lh

VADER PBRN Education 

Hea

l

t

h

Quality Group
VA Office of Dentistry (OO

I t t d ht h I

ntegrated approach

to research

education, and quality measures

Donald J. DeNucci, D.D.S., M.S.Research Consultant/VA Office of Dentistry Research Consultant/VA Office of DentistryProgram Officer/NIH/Practice-based ResearcTelephone: 301-451-5096P f dE re

ferre

d

E-mail: d id@ id ih denuccid@

nidcr.nih.gov

VA Outlook: denucci.donald@va.gov