Partnering with Practice-based Research Networks (PBRN)

Paul B. McGinnis, MPACommunity Health, Quality and Practice Development Director

Oregon Rural Practice-based Research Network

Oregon Health & Science University

April 17, 2013

• Describe the “real-world” laboratories of practice-based research

• Show examples of PBRN work• Share experiences in working with Cooperative

Extension

Learning Objectives

What Topics Interest You?

Green LA, et al. N Engl J Med 2001;344:2021-5.

The “Ecology” of Medical Care

The Reach of Research

• It is estimated that it takes an average of 17 years for 14% of original research to reach practice and benefit patients.

(Balas and Boren. Yearbook of Medical Informatics 2000:65-70)

This is part of what a Clinical Translation Science Award (CTSA) is meant to address

Primary Care Practice-Based Research Networks (PBRNs)

• A group of ambulatory primary care practices affiliated to investigate questions related to community practice

• The majority of daily patient/clinician interactions occur in ambulatory settings, especially smaller (3-10 clinician) practices

• Uses the community as a laboratory• Provides access to important, neglected phenomena• Designed for research on clinical practice and quality

improvement activities

“Blue Highways” on the NIH Roadmap

Westfall JM, Mold J, Fagnan, LJ. JAMA 2007;297:403-406.

• 152 PBRNs• 16,900 practices• Average 101

practices/PBRN• 69,000 clinicians• Average of 4.9

studies/PBRN• 69% have an EHR

AHRQ Registered PBRNs

www.ohsu.edu/orprn

Oregon Rural Practice-Based Research NetworkThe mission of ORPRN is to improve the health of rural populations in Oregon through conducting and promoting health research in partnerships with the communities and practitioners we serve.

• Founded in 2002• A rural PBRN• 49 practices in 37 communities caring for >235,500

patients• 157 member clinicians• Diverse practice ownership and type (Physician

owned, FQHC, RHC, Hospital-based)• Governed by a member clinician Steering Committee

Health Extension in New Mexico: An Academic Health Center and the Social Determinants of Disease

The Agricultural Cooperative Extension Service model offers academic health centers methodologies for community engagement that can address the social determinants of disease. The University of New Mexico Health Sciences Center developed Health Extension Rural Offices (HEROs) as a vehicle for its model of health extension. Health extension agents are located in rural communities across the state and are supported by regional coordinators and the Office of the Vice President for Community Health at the Health Sciences Center. The role of agents is to work with different sectors of the community in identifying high-priority health needs and linking those needs with university resources in education, clinical service and research. Community needs, interventions, and outcomes are monitored by county health report cards. The Health Sciences Center is a large and varied resource, the breadth and accessibility of which are mostly unknown to communities. Community health needs vary, and agents are able to tap into an array of existing health center resources to address those needs. Agents serve a broader purpose beyond immediate, strictly medical needs by addressing underlying social determinants of disease, such as school retention, food insecurity, and local economic development. Developing local capacity to address local needs has become an overriding concern. Community-based health extension agents can effectively bridge those needs with academic health center resources and extend those resources to address the underlying social determinants of disease.

Kaufman A, Powell W, Alfero C, et al Ann Fam Med. 2010 January; 8(1): 73–81.

Oregon Experience

• Local Cooperative Extension Faculty serve on Community Health Improvement Partnerships (CHIPs)

• Childhood Obesity Research and Nutritional Education (MOO, PATCH, Pick of the Month)

• Expert Guidance from Main Campus Faculty on Creating Linkages between Clinics and Community-based Resources to Manage Obesity (Guidebook)

• Community Advisory Councils as part of Coordinated Care Organizations

Why Research?

• Communities want to solve problems. Policy makers and funders want to put resources into programs that are “evidence-based.”

• Which comes first… the chicken or the egg?

Complexity Science and the Ecology of Health Care

5Local Community

3Clinical

Encounter

2Clinician

1Patient

4Practice

6Health System

Crabtree BF et al. “Understanding practice from the ground up,”The Journal of Family Practice 2001; 50(10):883.

Modifiable Factors Associated with Deaths, US, 1990

0 100,000 200,000 300,000 400,000 500,000

Illicit Drugs

Motor Vehicles

Sexual Behavior

Firearms

Toxic Agents

Infections

Alcohol

Inactivity & Diet

Tobacco

Source: McGinnis JM, Foege WH. JAMA 1993;270:2207-12.

Practice-based Research is Community Engagement

Westfall, Fagnan, Handley, McGinnis, Zittleman et al. JABFM.2009

Research as a Community Asset

ORPRN Newsletter, January 2010. http://www.ohsu.edu/research/orprn/news/newsletter/JANUARY%20NEWSLETTER.pdf

• Aim 1. Transform four community-based health coalitions in rural Oregon into receptive partners with the capacity to do community-based participatory research (CBPR).

• Aim 2. Increase the capacity of academic researchers to understand and engage in collaborative community-based research with rural communities, practices and patients.

• Aim 3. Collaborate with three CTSAs to develop and disseminate effective tools for CTSAs and PBRNs to create research partnerships between academics and rural communities.

Community Research Enhancement and Education Development (CREED)

Adding Research to the CHIP Model—CHIP to CHIRP(McGinnis PB. Family & Community Health.2010)

PUBLIC POLICY

COMMUNITY

ORGANIZATIONAL

INTERPERSONAL

knowledge, attitudes, skillsINDIVIDUAL

The Socio-Ecological Model

Research vs. IntuitionIntuition Scientific

General Approach Let’s try this and see how it works Let’s make an assumption, implement a precise plan to study how it works, try it out, collect data, share with others and repeat

Observation Casual and uncontrolled Very systematic and carefully controlled

Reporting Ok to be biased and subjective Must be unbiased and objective

Concepts Ok to be ambiguous (general and even imprecise)

All aspects of activities must be clearly defined

Instruments The tools used can be informal Tools used could be informal but must be accurate and precise

Measurement No real concerns about validity or reliability

It is important that measures used are both valid and reliable

Hypotheses Do not need to be tested or proven Very important to have a well-articulated theory or assumption that you are trying to prove or disprove

Attitude No need to be critical or skeptical of results because outcomes are just assumptions

Important to ask questions about the results

National Research Council (2002), Scientific Research in Education. National Academy Press. Wash DC., pg. 104.

Why Research? In Their Own Words• Skill Development

– My background is a Science Major. I know about Petri dish research but I’m interested in learning about hands on human research.

– I am interested in learning how community members can enhance their skills [through research training]

– I do outreach in the Latino Community and I don’t know what goes on behind the scenes [with research] to develop programs. I’d like to learn more.

• Impact/Benefit to Community– I’m trying to understand how to have an impact in my community. – [Research can help us] look at what works and what doesn’t work.

Community Engaged Research Spectrum

• Low: Conducting surveys on the street, random phone sampling, posting fliers in the newspaper

• Low/Medium: Convening focus groups or forums at the start or end of a study to assess needs or report back findings

• Medium: Soliciting community to assist in implementing a study designed by a researcher

• High: Participating in bi-directional, collaborative partnership on problem of mutual interest that engages community in all stages of research

UCSF. Collaboration with Community-based Organizations and Agencies: A Guide for UCSF Researchers. http://ctsi.ucsf.edu/files/CE_CARE_Guide_for_Investigators.doc

How would you like to participate in research?

Community Engaged Research vs. “Helicopter Research” ...Drive by research, mosquito research...

“Outside research teams swooped down from the skies, swarmed all over town, asked nosey questions that were none of their business and then disappeared—never to be heard of again.”

Slide adapted with permission from Dr. Ann Macaulay, McGill University

Montour LT, Macaulay AC, Adelson N. Diabetes Mellitus and Arteriosclerosis: Returning research results to the Mohawk Community. CMA Journal 1988; 34:1591-93.

New Model of “Drive by Research”