Erik Lindbloom

Practice-based research networks: the laboratories of primary care research.

Medical research has traditionally been based in academic centers, and the findings are frequently not applicable in community primary care settings. The result is a large gap between the possible and the practical in delivering high-quality primary medical care in the United States. Practice-based research networks (PBRNs), laboratories for primary care clinical research, are the appropriate vehicles for uniting the worlds of community primary care practice and clinical research. Although they have received little attention in the mainstream of clinical and health services research, PBRNs have already reported a variety of findings useful for primary care providers, and these networks have helped to identify key issues in healthcare delivery that affect important outcomes. In this report, we outline the rationale for and history of PBRNs. We describe the organization and work of several productive PBRNs, giving examples of their studies that have changed the standards of modern primary care practice. Finally, we describe a developing electronic process for identifying research questions obtained directly from primary care providers that can be used to focus the national primary care research agenda on questions of clinical relevance and importance. As electronic technologies are fully developed and tested, they will facilitate communication between clinicians and researchers, thereby improving the effectiveness and efficiency of practice-based research.

Barriers to Timely Care of Acute Infections in Nursing Homes: A Preliminary Qualitative Study

BACKGROUND AND OBJECTIVES During a large prospective study of lower respiratory infections in nursing home residents, project staff observed that in some facilities there was consistent difficulty in obtaining timely identification of potential subjects. Starting with this motivation, we conducted a preliminary qualitative study to investigate the process of illness identification and initiating management in episodes of acute infection. We sought factors promoting timely or delayed identification and treatment of acute infections among nursing home residents. DESIGN Qualitative study using focus groups and in-depth semi-structured interviews of residents, nurses, and physicians involved in episodes of acute-illness care in nursing home residents. SETTING Four nursing homes participating in a longitudinal study of the course and outcomes of lower respiratory infection. PARTICIPANTS Focus groups included nurses and physicians with experience in nursing home care. Interviews were conducted with those involved in six episodes of acute illness. Interviewees included four nursing home residents (two others were not cognitively intact), seven nurses, and six physicians or their staff. DATA ANALYSIS Identifying themes from focus group contributions and content analyses of interviews. RESULTS We identified a four-stage model describing illness identification and management. Content analysis of interview transcripts revealed 22 factors that influenced timeliness of effective care with communication problems commanding the central focus. Barriers included: (1) failure of the communication medium; (2) evening or weekend illness onset with concomitant difficulty in contacting an on-call physician; (3) clinical decision-makers who interact through intermediaries; (4) the communication of inappropriate or inaccurate information; (5) inadequate information transfer at shift changes; and (6) prior relationship between staff nurse and physician. CONCLUSION Effective identification and management of acute infections requires successful communication at multiple levels; however, breakdowns are common. Our model provides a framework for improving acute illness care in nursing homes, which offers important insights potentially useful in quality improvement activities in nursing homes and may facilitate further research.

Intentions of Older Homebound Women to Reduce the Risk of Falling Again

PURPOSE Researchers have tested interventions to prevent recurrent falls for older people without exploring their intentions to prevent another fall. Lack of knowledge about such intentions is an impediment to intervention effectiveness. The purpose was to describe intentions to prevent another fall as discerned during a study with older homebound women. METHODS Data were obtained during a series of four in-home interviews over 18 months with monthly telephone contacts between interviews; fall history was updated at each contact. A descriptive phenomenological method was used to analyze data. FINDINGS Of the 40 women, 36 (aged 85 to 98 years) had fallen at home at least once before enrolling in the study, or had a subsequent or initial fall during the study. The overall intention was reducing my risk of falling again at home, with its components figuring out the reason that I fell and changing my ways to reduce my risk of falling again at home. Most women explained reasons for a fall and voiced intentions to prevent a similar fall. Women who viewed falls as unexpected events were uncertain that they could prevent a fall or felt unable to do so and voiced few preventive intentions. A few women voiced generalized preventive intentions to change health-related behaviors or habits. CONCLUSIONS Most intentions were tied directly to the situation in which a fall had occurred. Such specificity could limit effectiveness of personal efforts to prevent falls in other situations. CLINICAL RELEVANCE Practitioners should converse with older women who have fallen about their intentions to prevent another fall and weigh the need to help them generalize both the risk of falling again and their risk reduction intentions.

Assessing the impact of innovative training of family physicians for the patient-centered medical home.

BACKGROUND New approaches to enhance access in primary care necessitate change in the model for residency education. PURPOSE To describe instrument design, development and testing, and data collection strategies for residency programs, continuity clinics, residents, and program graduates participating in the Preparing the Personal Physician for Practice (P(4)) project. METHODS We developed and pilot-tested surveys to assess demographic characteristics of residents, clinical and operational features of the continuity clinics and educational programs, and attitudes about and implementation status of Patient Centered Medical Home (PCMH) characteristics. Surveys were administered annually to P(4) residency programs since the project started in 2007. Descriptive statistics were used to profile data from the P(4) baseline year. RESULTS Most P(4) residents were non-Hispanic white women (60.7%), married or partnered, attended medical school in the United States and were the first physicians in their families to attend medical school. Nearly 85% of residency continuity clinics were family health centers, and about 8% were federally qualified health centers. The most likely PCMH features in continuity clinics were having an electronic health record and having fully secure remote access available; both of which were found in more than 50% of continuity clinics. Approximately one-half of continuity clinics used the electronic health record for safety projects, and nearly 60% used it for quality-improvement projects. CONCLUSIONS We created a collaborative evaluation model in all 14 P(4) residencies. Successful implementation of new surveys revealed important baseline features of residencies and residents that are pertinent to studying the effects of new training models for the PCMH.

Peer Support Interventions for Adults With Diabetes: A Meta-Analysis of Hemoglobin A1c Outcomes

PURPOSE Peer support intervention trials have shown varying effects on glycemic control. We aimed to estimate the effect of peer support interventions delivered by people affected by diabetes (those with the disease or a caregiver) on hemoglobin A1c (HbA1c) levels in adults. METHODS We searched multiple databases from 1960 to November 2015, including Ovid MEDLINE, the Cochrane Central Register of Controlled Trials, CINAHL, and Scopus. We included randomized controlled trials (RCTs) of adults with diabetes receiving peer support interventions compared with otherwise similar care. Seventeen of 205 retrieved studies were eligible for inclusion. Quality was assessed with the Cochrane risk of bias tool. We calculated the standardized mean difference (SMD) of change in HbA1c level from baseline between groups using a random effects model. Subgroup analyses were predefined. RESULTS Seventeen studies (3 cluster RCTs, 14 RCTs) with 4,715 participants showed an improvement in pooled HbA1c level with an SMD of 0.121 (95% CI, 0.026–0.217; P = .01; I2 = 60.66%) in the peer support intervention group compared with the control group; this difference translated to an improvement in HbA1c level of 0.24% (95% CI, 0.05%–0.43%). Peer support interventions showed an HbA1c improvement of 0.48% (95% CI, 0.25%–0.70%; P <.001; I2 = 17.12%) in the subset of studies with predominantly Hispanic participants and 0.53% (95% CI, 0.32%–0.73%; P <.001; I2 = 9.24%) in the subset of studies with predominantly minority participants; both were clinically relevant. In sensitivity analysis excluding cluster RCTs, the overall effect size changed little. CONCLUSIONS Peer support interventions for diabetes overall achieved a statistically significant but minor improvement in HbA1c levels. These interventions may, however, be particularly effective in improving glycemic control for people from minority groups, especially those of Hispanic ethnicity.

An Update on Family Medicine Participation in Clinical and Translational Science Awards (CTSAs)

Family medicine researchers play leading roles in many of the 38 institutions that have received Clinical Translational Science Awards (CTSAs). We have described the purposes, successes, and strategies for engaging in institutional CTSA applications in past Annals columns in 2007 and 2008.1,2 We refer interested readers to those columns and the cited references for rich sources of background material. NIH plans to award 50 to 60 CTSAs and applications for the next round due in October 2009. Our purpose here is to provide an update on family medicine participation in CTSAs. We conducted a Web-based survey of the 145 Chairs of departments (which includes allopathic, osteopathic, and large regional medical center members of ADFM) in October 2008 and received responses from 69 departments (48%). Of these 69, 22 (32%) departments were in institutions that had been awarded a CTSA. The medical school in which the department was located was the lead institution in all but 1 case, in which the department was located in a collaborating institution. Of those who have not yet been awarded a CTSA, 44 (64%) had applied for a planning grant, and 17 received a planning grant. We conclude that a majority of the medical schools in this sample would like to obtain CTSA funding. Among our respondents, family medicine faculty have leadership positions in 12—about one-third—of all funded CTSAs. These roles include leading units devoted to engaging the community in research, leading the development and implementation of practice based research networks, and directing training units in clinical translational research. Family medicine faculty also have important roles in bioinformatics, clinical trials, epidemiology, biostatistics, and knowledge translation components. In each of these instances, family medicine faculty contributed directly to the success of their institution’s CTSA application. In several cases, participation by family medicine was instrumental in achieving funding on the first submission, and in several additional cases family medicine participation was instrumental in getting funded on a revised application. Despite these key roles, the majority of family medicine departments do not have substantive involvement in a CTSA. Either their medical school does not have a CTSA, or the department does not have faculty with the requisite experience to contribute meaningfully. In contrast to the first 2 rounds of CTSA applications, in which we learned of several departments with valuable research track records who, by their estimation, were not sufficiently included in their institutional CTSA proposal, none of the respondents to this survey indicated that they had not been appropriately engaged. Examination of the 38 funded CTSAs reveals that areas such as community engagement and practice based research, the primary components to which family medicine has made essential contributions, are important elements for successful funding in most, though not all, instances. Many respondents indicated that their institution, department, or both lacked the infrastructure to be competitive for these awards. The original budgets for the CTSA were reduced, which affected 71% of our responding institutions. Somewhat to our surprise, only 40% of our respondents said that the budget cuts specifically impacted components that involve family medicine faculty. The often expressed perception that community engagement and practice-based research were cut more than other CTSA components was not supported by the responses we received. Of course, we do not know what the original allocation was relative to other components, and our anecdotal impression is that only some CTSAs have managed to support community engagement and practice-based research at levels adequate to build a robust infrastructure for research in these settings. For departments that plan to participate in future CTSA applications, our respondents made recommendations along the following themes: Identify strengths that the department can contribute to a successful application. Focus on “T2” translation, especially community engagement, community based participatory research and practice based research. Educate the principal investigator through personal meetings and in writing about what you have to offer. We would add that reviewing the applications of funded CTSAs, engaging funded CSA researchers as consultants, and approaching the CTSA process as team players are all potentially productive strategies. The CTSA Web site of the National Center for Research Resources of the NIH contains a plethora of information as well as links to all currently funded CTSA Web sites.3 A final strategy that we will mention is that 8 of our respondents indicated that they would be applying as a collaborative institution rather than as a lead institution. As mentioned above, 1 family medicine department is currently participating through a collaborative arrangement. This may be a productive strategy for departments that have a distinctive contribution to make, but are located in institutions that would not otherwise be competitive for a CTSA. Collaboration across institutions and between CTSAs is strongly encouraged as part of the vision of accelerating research findings into improved outcomes for patients.

BUILDING RESEARCH & SCHOLARSHIP CAPACITY IN DEPARTMENTS OF FAMILY MEDICINE: A NEW JOINT ADFM-NAPCRG INITIATIVE.

Transformative growth in the capacity of family medicine and primary care research and scholarship in the United States and Canada is crucial.[1][1] Far greater capacity is needed to: generate the necessary knowledge; design, evaluate, and disseminate the innovations; and inform the implementation

From the Association of Departments of Family Medicine: From the North American Primary Care Research Group: BUILDING RESEARCH & SCHOLARSHIP CAPACITY IN DEPARTMENTS OF FAMILY MEDICINE: A NEW JOINT ADFM-NAPCRG INITIATIVE

Transformative growth in the capacity of family medicine and primary care research and scholarship in the United States and Canada is crucial.[1][1] Far greater capacity is needed to: generate the necessary knowledge; design, evaluate, and disseminate the innovations; and inform the implementation

Building research & scholarship capacity in departments of family medicine

Transformative growth in the capacity of family medicine and primary care research and scholarship in the United States and Canada is crucial.[1][1] Far greater capacity is needed to: generate the necessary knowledge; design, evaluate, and disseminate the innovations; and inform the implementation