Kentucky HSR Development: Building Partnerships

1
Kentucky HSR Development Building Partnerships

• Margaret M. Love, Ph.D.
• University of Kentucky
• Family Community Medicine (Medicine)
• Health Behavior (Public Health)

2
Infrastructure Development Aims

• Improve ability of faculty to develop proposals
  and publish papers in health services research
  (HSR)
• Promote collaboration of physicians with other
  health services researchers
• Cultivate research ideas from the Kentucky
  Ambulatory Network (KAN) into research designs
  and fundable proposals

3
University of Kentucky BRIC

• Overarching structure collaboration
• College of Public Health (subsumed Center for
  Health Services Management Research)
• 2001-2003 PI Beaulieu/Fleming (BRIC I)
• 2003-2006 PI Fleming (BRIC II)
• Department of Family and Community Medicine
  (DFCM)
• 2001-2006 Co-PI Love

4
University of Kentucky BRIC

• Premises of todays talk
• Practice-based research networks (PBRNs) can
  respond to community needs and partnerships are
  at the core of PBRN activities
• Learning collaboratives can improve health care
  quality
• Through its support of partnerships, BRIC built
  HSR capacity in Kentucky

5
University of Kentucky BRIC

• Two examples of building leveraging
  partnerships processes of engagement
• BRIC involvement with the Kentucky Ambulatory
  Network (KAN)
• BRIC I Prevention Research Project
• BRIC II Small Research Projects
• BRIC involvement with the University of
  Kentuckys participation in the Academic Chronic
  Care Collaborative (ACCC)

6
Practice-Based Research Networks (PBRNs)

• PBRNs are groups of primary care clinicians and
  practices working together to answer
  community-based health care questions and
  translate research findings into practice.
• PBRNs engage clinicians in quality improvement
  activities and an evidence-based culture in
  primary care practice to improve the health of
  all Americans.
• http//pbrn.ahrq.gov/portal/server.pt

7
Practice-Based Research Networks (PBRNs)

• Model for university-community partnership for
  health services research
• Potential to improve quality of care
• Implement and study process of adoption and
  outcomes in primary care practice
• Respond to community
• Inside-out vs. outside-in models
• I.e., Top down vs. bottom up
• Bedside to bench not just Bench to bedside

8
Kentucky Ambulatory Network (KAN)

• Kentucky Ambulatory Network (KAN)
• Statewide primary care practice-based research
  network founded in 2000
• More than 200 community-based clinicians
• 80 are family physicians
• 75 practice in rural, medically underserved
  areas
• KAN has practices in 31 of KYs 51 Appalachian
  counties

9
BRIC I Prevention Research Project

• Planned with/for KAN
• Solicited feedback from community-based PCPs
  about topics of prevention intervention
  features
• Break-out sessions at annual meeting
• E.g., Wanted an intervention with evidence for
  high likelihood of success, i.e., not obesity
• Involved community-based FP as consultant
• Final planning input to focus on FOBT colorectal
  cancer screening (surprised own rates so low!)
• Assumed leadership role when joined faculty

10
BRIC I Prevention Research Project

• Conducted pilot project in 6 KAN practices
• Multiple strategies to increase FOBT rates
• E.g., chart stickers, information about billing

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BRIC I Prevention Research Project

• Outcomes included lessons learned by FP leader
• Difficulties in abstracting screening rates from
  billing data
• Usefulness of RA assistance in scheduling and
  preparing for orientation visits
• Necessity of ongoing contact with practice to
  assure fidelity to intervention, complete
  documentation, and access to outcomes data

12
BRIC I Prevention Research Project

• Lessons learned by BRIC team
• Discussion with KAN members led to principles
  guiding QI focus
• It takes a team
• Outcomes
• Directly MPH Capstone for FP leader
• Possibly contributed to track record or
  experience Future KAN involvement in federally
  funded CRC screening research

13
BRIC II Small Research ProjectsPhysician
Collaborator Model

• The real world for tenure track academic family
  physicians (FPs)
• Most can devote only 10 25 time to research
• Many will not become independent researchers
• Many can become physician collaborators
• Make substantial contributions to HSR led by
  faculty in other departments

14
BRIC II Small Research Projects

• Junior FPs partnered with experienced health
  services researchers (HSRers)
• HSRers nominated 7 projects in own areas of
  expertise and interest
• 3 FPs nominated selves
• FPs to transition from co-I to PI
• FPs 20 protected research time (1/2 in-kind)
• HSRers paid protected time (10-20)

15
Additional Support for BRIC II Small Research
Partnerships

• More training for FPs
• Capacity-building seminars
• Professional writing workshops
• HSR methods seminars
• Development of Grant Applications
• National HSR meetings (AcademyHealth)

16
Additional Support for BRIC II Small Research
Partnerships

• BRIC PI (Fleming) Co-I (Love)
• Co-investigators on projects
• Facilitated partnerships
• E.g., sounding board for HSR mentors
• E.g., nudge for FPs
• Served as program mentors/coaches for FPs
• Overall grant administration

17
BRIC II Small Research Projects

• 3 projects/teams
• Killip/Ireson (3 years) Patient safety in
  after-hours telephone medicine
• Joyce/Wackerbarth (2 years) Colorectal cancer
  screening decision-making
• Dassow/Costich (1 year) Generic drug
  utilization (became study of Medicare Part D)

18
BRIC II Small Research Projects

• Relationship to KAN
• Patient safety in after-hours telephone medicine
• Designed for/conducted in residency practice
• Next step was funded pilot in community practices
• Colorectal cancer screening decision-making
• Designed as KAN study
• Generic drug utilization (Medicare Part D)
• Involved KAN input feasibility testing

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BRIC II Small Research Projects Pt Safety /
Telephone Med

• Initiative from UKy or Community?
• Initiative stayed inside academia
• Outcomes
• FP came to own this topic as research program
• FP acquired qualitative quantitative research
  skills
• Multiple national/international research
  presentations
• 1 pub (so far) with FP as 1st author
• FP as PI earned NPSF grant
• Also Because of process analysis, changed steps
  in residencys after-hours telephone medicine
  (e.g., messages in charts) good example of QI

20
BRIC II Small Research Projects CRC Screening
Decision-Making

• Initiative from UKy or Community?
• Idea originated inside academia
• However, by design, study solicited input from
  community on what is needed to design
  decision-supports
• Qualitative research with FPs patients leading
  to identification of barriers and
  facilitators for CRC screening
• Next steps would be design of decision supports
  engaging FPs to test them

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BRIC II Small Research Projects CRC Screening
Decision-Making

• Outcomes
• 2 pubs with HSRer as 1st author
• FP acquired qualitative research skills
• Co-Investigator on federally funded research
  project(s) led by other UK qualitative
  researchers
• PI on own federally funded education grants
• Could apply skills to evaluation of
  patient-centered care curriculum
• FP tenured as Associate Professor

22
BRIC II Small Research Projects Generic Drugs ?
Medicare Part D

• Initiative from UKy or Community?
• Thats a long storyevolution in terms of whats
  meaningful and whats feasible
• Initial plan In KAN, evaluate barriers to
  prescribing generic drugs
• Reaction of KAN advisory committee members
  suggested more comprehensive approach necessary
  to capture prescribing issues that matter
• Continued

23
BRIC II Small Research Projects Generic Drugs ?
Medicare Part D

• Coincided with Medicare Part D implementation
• Alternative Approach
• Chart review in KAN practices to determine if
  prescribing practices changed following Medicare
  Part D coverage
• Initial chart reviews showed charts dont contain
  needed info
• Continued

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BRIC II Small Research Projects Generic Drugs ?
Medicare Part D

• Final Approach
• Survey assessing physician experiences and
  opinions regarding Medicare Part D
• Conducted during Continuing Education programs
  for family physicians held in Lexington, KY
  (attendees from many states)
• In sum, iterative process informed by KAN
  community-based members feasibility pretesting
  in KAN

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BRIC II Small Research Projects Generic Drugs ?
Medicare Part D

• Outcomes
• Completed survey with 98 responses
• Analyses completed manuscript in progress
• FP tenured as Associate Professor

26
BRIC II Small Research Projects Overall Outcomes

• FP transition into leadership role
• One effectively transitioned into leadership role
  (with coaching)
• One maintained a co-investigator role
• One already had more research experience
• Did HSRers develop, too?
• Better at working with FPs? with KAN?
• E.g., structuring FP input managing logistics?
• E.g., involving KAN input evaluating
  feasibility?

27
BRIC meets ACCC

• Academic Chronic Care Collaborative (ACCC)
• American Association of Medical Colleges (AAMC)
• Consortium designed to develop quality
  improvement programs of clinical care,
  evaluation, research
• University of Kentucky Department of Family and
  Community Medicine selected as one of 23 academic
  health centers

28
BRIC meets ACCC

• Features of University of Kentucky initiative
• Diabetes as clinical target in the Family Medical
  Center
• Chronic Care Model with quality improvement
  cycles
• Implemented group visits

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BRIC meets ACCC

• To supplement College of Medicine funding, BRIC
  provided resources to support systematic
  evaluation and research
• Half year RA assistance in creating, entering and
  managing the Family Medical Centers Diabetes
  Registry
• Trial period of registry software
• Junior FP travel to national QI meeting

30
BRIC meets ACCC

• Outcomes
• Multi-year database of over 600 DM patients
• Doctor of Nurse Practitioner (DNP) thesis
• 2 Masters of Public Health (MPH) capstone
  projects
• Draft manuscript under development
• 3rd MPH capstone underway (for junior FP)
• Medical student summer research project

31
BRIC meets ACCC

• Outcomes
• Greater sophistication across the department in
  evaluating quality improvement processes
• Collaboration with non-BRIC faculty members in
  Public Health and Pharmacy
• Department struggles with how to maintain
  database
• Ongoing systematic evaluation of QI elusive

32
BRIC II What (Seemed to) Work

• Leadership from experienced HSRers invaluable in
  the small research project partnerships
• Specialized set of topic-relevant skills and
  knowledge
• Project management
• How to get started what to do next
• Breaking the project down into steps
• Establishing and pressing project timeline
• Relationships important to FP growth

33
BRIC II Facilitators

• Flexibility built into the multi-year BRIC II
  award enabled research partners to adapt (e.g.,
  Medicare Part D)
• In future, solicit KAN input prior to submitting
  grant application or as a development phase
  within a funded application but would depend on
  time, resources, FOA

34
BRIC II What (Seemed to) Work

• Support for Partnerships
• PI Co-PI helped Small Research Project partners
  work together
• HSRers had to chase FP Fellows PI Co-PI
  helped catch them (but also needed to know when
  to get out of the way)
• Co-PI facilitated partnerships with KAN
• PI facilitated partnerships with HSRers

35
BRIC II Lessons Learning

• Might more HSRer PI/CoPI direction increase
  scholarly productivity UKy ACCC?
• Note Actual research using data has been
  conducted by professional degree candidates with
  significant mentorship outside our department
• Do we need to facilitate FP partnering with HSR
  mentors?
• How can we bridge QI processes and typical
  scholarly productivity?

36
BRIC II What (Seemed to) Work

• 25 protected time needed for junior FP to
  channel time attention toward research and
  developing own capacity
• E.g., Dedicated day away from the office
  connection to a national grant-writing program
  helped SK protect time

37
BRIC II Lessons Learning

• Its OK to let success overtake you
• Genesis of College of Public Health
• Center for Health Services Mgt Research then
  School of Public Health then College
• NIH Clinical Translational Science Awards
  (CTSA)
• University-wide restructuring to support
  formation of Center for Clinical and
  Translational Science
• DFCM KAN leadership in outreach core function

38
BRIC II Lessons Learned

• Would have been helpful to have continued BRIC
  Brass from BRIC I
• Advisory group of Chair Academic Vice Chair of
  Fam Comm Med, and Director of Center for Health
  Services Management and Research (later Director
  of School of Public Health)
• To promote knowledge of faculty activities,
  buy-in and support of program, and view to
  bigger picture of university, community, U.S.

39
Implications for Health Reform

• Overall, in both KAN (PBRN) and ACCC (or other
  health care collaboratives), the physicians and
  their practices are part of the solution, that
  is, for improving health care and health outcomes.

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Implications for Health Reform

• As primary care plays a central role
• PBRNs can link AHCs communities to implement
  evaluate programmatic change and quality
  improvement processes
• PBRNs can help inform policy makers of barriers
  facilitators to better design systems that work
• PBRNs reach diverse communities and can represent
  diverse types of practice

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Implications for Health Reform

• Based on our experience in Kentucky, layers of
  specific types of support can build or leverage
  academic-community partnerships
• Expert HSRers from multiple disciplines
• Primary care physicians trained as research
  collaborators
• Collaborative teams
• Facilitators (people who help with teamwork)

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Implications for Health Reform

• However
• Quality improvement processes require ongoing,
  rapid evaluation
• E.g., Plan-Do-Study-Act (PDSA)
• This is not like traditional interventional
  research models in geological time
• Similarities to traditional research
• Systematic evaluation of impact
• Evidence based change strategies

43
Implications for Health Reform

• Both practice-based research and QI cycles take
  many university researchers outside their
  comfort zone
• Less controlled circumstances
• Participants can benefit from the research (not
  just for the greater good in the future)

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Implications for Health Reform

• Special expertise in PBR QI needed
• HSRers may want retraining to capture rapid
  healthcare change
• Physician faculty may need HSR training/experience
  
• Facilitated partnerships enable on-the-job
  training
• Funding for partnership development could enable
  new players in federally funded research
• New institutions
• New disciplines

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UKy BRIC Faculty

• Family Comm Medicine
• Mel Bennett MD MPH
• Paul Dassow MD MSPH
• Robert Hosey MD
• Jennifer Joyce MD
• Shersten Killip MD MPH
• Michael King MD
• Margaret Love PhD (Co-PI)
• Samuel Matheny MD MPH
• Kevin Pearce MD MPH
• Steve Wrightson MD

• College of Public Health
• Joyce Beaulieu PhD (1st PI)
• Julia Costich PhD JD
• Carol Ireson PhD
• Steve Fleming PhD (2nd PI)
• F. Douglas Scutchfield MD
• Sarah Wackerbarth PhD
• And thanks to AHRQ
• Kay Anderson, PhD
• P20 HS-011845
• R24 HS-011845