Colorado Public Health PracticeBased Research Network

1
Colorado Public HealthPractice-Based Research
Network
Engaging Public Health Practice in the Research
Enterprise AND Engaging Academics in Public
Health Practice Julie A. Marshall
May 11, 2009
2
Overview

• Background on CO PH PBRN initiative
• The case for practice-based evidence
• PBRNs in primary care (30 year history)
• PBRNs in public health (experiment 2009-gt)
• Activities of the CO PH PBRN

3
PH PBRN Problem Statement

• limited evidence on how best to organize, finance
  and deliver public health services
• previous unsuccessful attempts to reform public
  health or gain policy maker support
• limited infrastructure to support on-going
  research and its translation into practice
• research lowest ranked essential service in 2002
  Colorado local PH systems assessment

4
PH PBRN Proposal

• To engage practitioners in Colorados 54 public
  health agencies and the state health department
  along with researchers from the CSPH to establish
  a network that supports informed and strategic
  research in a setting that allows effective
  strategies to be rapidly put into practice.

5
Partner Institutions

• Public Health Alliance of Colorado
• Colorado Association of Local Public Health
  Officials (CALPHO)
• 9 additional member organizations
• Colorado Department of Public Health and
  Environment (CDPHE)
• Office of Local Liaison/Office of Planning and
  Partnerships
• Colorado School of Public Health
• Rocky Mountain Prevention Research Center
• Center for Public Health Practice

6
RWJF Funded PBRNs
Selected for Round I Other interested PBRNs
SPH School of Public Health PRC Prevention
Research Center
7
.
Prevention Research Centers
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
.
33 CDC funded centers in the PRC network
Rocky Mountain Prevention
Research Center
8
Rocky Mountain Prevention Research
CenterTranslating Research into Practice since
1998
From the RMPRC 2009-2014 renewal application
Our work is based on the premise that increased
integration of research and practice will lead to
research that is more informed of and responsive
to the issues that the public health community
faces in reducing health disparities and
improving community and population health.
9
Practice-Based EvidenceMaking Research relevant

• Gap (chasm) between science practice
• How and why does current evidence
• account for the gap?
• Why, with growing volume and apparent
• quality of evidence, would practitioners
• be resistant to using it more assiduously?

(LW Green Fam Pract 2008)
10
Practice-Based EvidenceMaking Research relevant
PIPELINE implicit assumption underlying much of
the literature on knowledge translation is that
evidence is produced and delivered
to practitioners.

(LW Green Fam Pract 2008)
11
FUNNEL implicit assumption that much more
research will be done than will be useable in
practice.
The drip at the end indicates that the
evidence-based guideline often has a poor fit
with practice circumstances such as funding, time
constraints and patient demands.

17 years to turn 14 of original research to
benefit of patient care
Empty vessel?
(LW Green Fam Pract 2008)
12
Practice-Based EvidenceMaking Research relevant

• REMEDY 1 (of several)
• Participatory research, PBRNS, continuous quality
  improvement
• Speaks to a future in which we would not have to
  get more acceptance of evidence-based practice,
  but one in which we would ask how to sustain the
  engagement of practitioners and communities in a
  participatory process of generating
  practice-based research and program evaluation.
• a future in which the cumulative, building
  block tradition of evidence-based medicine from
  highly controlled trials would be complemented by
  a parallel development and support of a tradition
  of participatory research and evaluation
  conducted in practice settings. creating
  practice-based evidence and a resulting culture
  of evidence based practice

(LW Green Fam Pract 2008)
13
Practice-Based EvidenceMaking Research relevant

• Practice-based research networks one strategy
  in
• bridging the
• translation chasm

14
What is a Primary Care PBRN?

• A group of ambulatory care practices devoted
  principally to the primary care of patients, and
  affiliated in their mission to investigate
  questions related to community-based practice and
  to improve the quality of primary care.
• On-going commitment to network activities
• Organizational structure that transcends a single
  research project
• Collaboration of academic and community
  physicians, researchers, office staff and patients

Source www.ahrq.org
15
First US primary care PBRN

• Family Medicine Information System (FMIS)
• Ambulatory Practice Sentinel Network (ASPN)
• (both started here in Colorado)
• New knowledge, not otherwise accessible, could be
  discovered
• Data as a by-product of basic clinical operations
• Longitudinal studies of patients with particular
  disorder
• Sentinel, early detection, of emerging health
  threats
• Recommended reading A short history of primary
  care practice-based research networks From
  concept of essential research laboratories by LA
  Green, J Hickner. JABFM 2006.

16
State Networks of Colorado Ambulatory Practices
Partners (SNOCAP)

• Network of PBRN networks in Colorado
• private practices (BIGHORN)
• community health center clinics and other groups
  focusing on disadvantaged populations (CaReNet)
• rural providers including some public health
  (HPRN)
• palliative care (PoPCRN)
• pharmacies
• and now, public health (COPHPBRN)

17
Expanding the PBRN Concept to Public Health

• Public health system (vs health care system)
• Public health agencies (vs community based
  primary care clinics)
• Shift in balance of efforts toward prevention
• Practice performance outcomes (public health
  agencies vs clinical practices)
• Population health outcomes (vs clinical patient
  outcomes)

18
What is the public health system?

• The public health system is distinct from the
• public health department, in that it includes all
• the community organizations and agencies that
• contribute to the conditions in which people
• can be healthy. It includes all of the public
  and
• private resources that contribute to the delivery
• of public health services.

(Scutchfield 2009 webinar)
19
Getting Inside the Black Box
Breadth of organizations
Scope of activity
Scale ofoperations
Public Health Agency
Division of responsibility
Scope of services
Statutory authority
Public HealthSystem
Governing structure
Funding levels mix
Compatibility of missions
Staffing levels mix
Resources expertise
Leadership
Distribution of effort
Intergovernmentalrelationships
Participation incentives
Nature intensity of relationships
Decision Support

• Accreditation
• Performance measures
• Practice guidelines

Needs
Preferences
StrategicDecisions
Perceptions
Population Environment
Risks
Threats
Outputs and Outcomes
Social determinants
Adherence to EBPs
Reach
Resources
Efficiency
Effectiveness
Equity
Timeliness
(Adapted from Mays 2009)
20
Public health Core Functions Essential Services
www.naccho.org
21
IOM Perspective (2003)

• The committee had hoped to provide specific
  guidance elaborating on the types and levels of
  workforce, infrastructure, related resources, and
  financial investments necessary to ensure the
  availability of essential public health services
  to all of the nations communities. However, such
  evidence is limited, and there is no agenda or
  support for this type of research, despite the
  critical need for such data to promote and
  protect the nations health.

22
Definition of PHSSR

• Public Health Systems Research is a field of
  study that examines the organization, financing
  and delivery of public health services within
  communities, and the impact of these services on
  public health.

(Mays, Halverson and Scutchfield, JPHMP 2003)
23
Public Health Systems Research AgendaThe Top Five

• Determine how public health agency structure
  affects performance.
• Define and quantify dimensions of public health
  systems, including interorganizational
  relationships (including the role of the agency
  within the public health system).
• Explore the relationship between performance and
  health outcomes (and the chain of impacts that
  leads from improved performance to improved
  health outcomes).
• Define the characteristics of high-performing
  local, state, and federal public health agencies.
  
• Explore the relationship between social
  determinants of health and system performance.
• SOURCE Lenaway et al, AJPH 2006

24
Public Health Systems Research AgendaThe Second
Five

• Evaluate the costs of achieving and maintaining
  acceptable/optimal levels of performance
• Explore the relationship between public health
  infrastructure/performance and the design,
  implementation, and impact/outcomes of
  categorical programs
• Conceptualize a framework for high-performing
  public health systems that includes key elements
• Identify, develop, and refine measures of health
  outcomes that are sensitive to public health
  systems change in capacity and performance
• Explore models and outcomes of accreditation of
  public health agencies and/or public health
  systems as performance improvement methods
• SOURCE Lenaway et al, AJPH 2006

25
PHSSRs place in the continuum
Intervention Research
Services/Systems Research

• How to organize, implement and sustain in the
  real-world
• Reach
• Quality/Effectiveness
• Cost/Efficiency
• Equity/Disparities
• Impact on population health

• What works proof of efficacy
• Controlled trials
• Guide to Community Preventive Services

(Mays 2009)
26
Developmental Path for PHSSR
Descriptive Inferential Translational
? Measuring practice performance ? Detecting
variation in practice ? Examining determinants
of variation Organization Law
policy Financing Information
Workforce Preference ? Determining
consequences of variation Health outcomes
Disparities Economic outcomes ? Testing
strategies to reduce harmful, unnecessary,
inequitable variation in practice and
outcomes
(Mays 2009)
27
Logic Model
Macro context Social, Political, Economic forces
operating in the overall society (e.g. National
economy) Extent of Demand and need for public
health services within the population Social
values and preferences for products of public
health systems (e.g. clean water) External forces
such as Medical delivery systems, Technological
advances, Nature of federal-state-local
relationships
Local Public Health System
PHS Mission and Purpose Goals and how they are to
be implemented Performance of the core functions
of assessment, policy development, and assurance
Capacity System Inputs Workforce Facilities Techn
ology Organizational relationships Funding
Processes Essential Public Health Services
Outputs Programs and Services consistent with
mandates and community priorities
Process Outcomes Improved organizational
performance Improved program performance
Community Health Outcomes Improved Health
Practices, Environment, Life Styles Improved
Morbidity and Mortality Rates Improved Health
Status
(Scutchfield 2009 webinar)
28
Public-sector organization practice
Beitsch 2007
29
Variation in system performance
Mays et al. AJPH 2006
30
Identifying structural typologies in public
health systems
Differentiation High High High
Mod Mod Low Low
Concentration Mod Low
High High Low High
LowIntegration High High
Low Mod Mod Low
Mod
Comprehensive
Conventional
Limited
Mays et al 2008
31
Examples of types of PBRN studies

• Comparative case studies document processes,
  identify scope and scale of problems, examine
  innovations
• Large-scale observational studies document
  practice variation across public health settings
  identify causes consequences of variation
• Intervention studies test intervention and
  program effectiveness
• Adoption/diffusion studies identify the pace and
  patterns through which evidence-based practices
  are adopted, and factors that facilitate and
  inhibit adoption
• Quality improvement studies evaluate strategies
  for improving program operations outcomes
• Policy evaluations and natural experiments
  monitor effects of key policy and administrative
  changes

(Adapted from Mays 2009)
32
Main Activities (RWJF funding)

• develop network infrastructure
• develop data system infrastructure
• conduct study of SB08-194
• Identify high priority research questions
• Identify strategies/resources to institutionalize
  research as integrated component of PH system

33
Network Infrastructure

• Geographic scope
• Membership size and type
• Organizational structure
• Governance
• Staffing
• Research liaisons

• Financial resources
• Informational technology and data resources
• Communication and decision making processes
• Research focus areas
• Technical assistance

34
Progress To Date

• Partnership in place
• Public Health Alliance of Colorado
• Colorado School of Public Health
• Colorado Department of Public Health
  Environment
• Interest gathered from practitioners faculty
• First e-newsletter May 1, 2009
• Founding Steering Committee named
• Local Public Health Agency Members
• State Health Agency Members
• Faculty Members

35
Initial Network Survey

• Brief practitioner and faculty surveys
• To gauge interest
• To create contact databases.
• 89 faculty replied
• 10 with immediate projects
• 21 interested in developing projects within a
  year
• 58 practitioners replied
• 7 with immediate projects
• 28 interested in becoming a network member

36
Founding Steering Committee

• Alyson Shupe, CDPHE (State PH)
• Heath Harmon, Boulder (Local PH)
• Kyle Legleiter, Prowers (Local PH)
• Lorann Stallones, CSU (CSPH)
• Lucinda Bryant, CU-Denver (CSPH)
• Sheana Bull, CU-Denver (CSPH)
• Snip Young, Consultant (State/National/Academ
  ia)
• Tista Ghosh, Tri-county (Local PH)
• Terry Bryant, CDPHE (State PH)

37
Pilot Project to get started

• To focus infrastructure development, we will
  track changes that occur after passage of
  SB08-194 in
• Staffing
• Qualifications
• Resources
• Services
• Partnerships
• Budgets
• Structure

38
SB08-194 Public Health Reauthorization Act

• Objective to restructure and update Colorados
  public health laws
• Key Principles
• Assuring provision of basic services to every
  person in Colorado with consistent standard of
  quality
• State and local collaboration
• Financial feasibility
• Functional regionalization

39
SB08-194 Public Health Reauthorization Act

• Statewide Public Health Improvement Plan
• Set public health priorities
• Guide PH system in targeting core services/fct
• Increase efficiency and effectiveness
• Identify areas needing greater resources
• Incorporate local goals and priorities
• Consider available funding, and be subject to
  modification based on actual subsequent funding

40
SB08-194 Public Health Reauthorization Act

• Defines power and duties of
• State Board or Health
• Colorado Department of Public Health and
  Environment
• County Commissioners
• Local Public Health Agencies
• Local Public Health Directors
• Local Boards of Health

41
PBRN Pilot Project Description

• Purpose
• Evaluate impact of the Public Health
  Reauthorization Act (SB008-194)
• Inform future research agenda
• Provide data for future funding opportunities
• Measurement
• 2005, 2008, 2010 NACCHO Profiles data for
  baseline and change
• Selected items to be added to local health
  department annual report
• Build data collection into ongoing reporting
  mechanism
• New developments
• Validation study of selected survey items (NACCHO
  funding)
• In depth study of partnerships and
  regionalization (unfunded CCTSI proposal RWJF
  Public Health Law proposal)

42
Pilot Project Committee

• Kathleen Matthews, CDPHE
• Terry Bryant, CDPHE
• Julie Marshall, CSPH/RMPRC
• Judy Baxter, CSPH
• Lisa VanRaemdonck, CALPHO
• Lee Thielen, Alliance/CALPHO

43
Benefits of RWJF funding

• Part of a larger mission and vision
• Networking/sharing with other PH PBRNs
• Technical assistance expert consultants
• Resources
• Literature
• Data

44
Anticipating

• Learning from other states and consultants
• New and stronger academic partnerships
• Stronger commitment to Essential Service on
  Research by Alliance
• Faster development of coordinated and integrated
  population health monitoring
• Increased capacity to respond to research funding
  opportunities
• Improved public health services over time

45
The promise of Public Health PBRNs

• Rigorous public health practice questions linked
  with rigorous research methods
• to produce externally valid evidence
• that is more easily assimilated into practice
• Support of quality improvement activities
• Adoption of an evidence-based culture
• Places of learning
• Practitioners engaged in reflective practice
  inquiries
• Collaboration in search of answers to improve
  delivery of public health services

46
COPHPBRN Contacts

• Lee Thielen, Director
• leethielen_at_aol.com
• Julie Marshall, Principle Investigator
• julie.marshall_at_ucdenver.edu
• Lisa VanRaemdonck, Project Coordinator
• lisa_at_calpho.org