James J. Werner

Linking practice-based research networks and Clinical and Translational Science Awards: new opportunities for community engagement by academic health centers.

Purpose Practice-based research networks (PBRNs) are a part of many National Institutes of Health (NIH)-funded Clinical and Translational Science Award (CTSA) sites. PBRNs, groups of primary care practices committed to collaborating on practice-relevant research, are unfamiliar to many CTSA leaders. Conversely, the CTSAs, as new research structures designed to transform clinical research, are unfamiliar to many PBRN directors. This study examined the extent to which these programs have congruent goals and expectations, and whether their engagement is likely to be mutually beneficial. Method The authors sent a Web-based survey to 38 CTSA community engagement directors and a similar survey to 114 PBRN directors during the fall of 2008. Results A total of 66% (25/38) CTSA community engagement directors and 61% (69/114) PBRN directors responded. Two thirds of responding CTSAs reported working with PBRNs, and over half of responding PBRNs reported a CTSA affiliation. Both groups indicated this relationship was important. CTSAs looked to PBRNs for access to patients and expertise in engaging communities and clinical practices. PBRNs reported seeking stable infrastructure support and greater collaboration and visibility in the academic research community. PBRN infrastructure support from CTSAs was highly variable. Both groups perceived considerable promise for building sustainable relationships and a bidirectional flow of information and research opportunities. Conclusions With fewer than three years of experience, the PBRN/CTSA relationship remains in the discovery phase; the participants are still negotiating expectations. If these collaborations prove mutually beneficial, they may advance the community engagement goals of many academic health centers.

Data Collection Outcomes Comparing Paper Forms With PDA Forms in an Office-Based Patient Survey

PURPOSE We compared the completeness of data collection using paper forms and using electronic forms loaded on handheld computers in an office-based patient interview survey conducted within the American Academy of Family Physicians National Research Network. METHODS We asked 19 medical assistants and nurses in family practices to administer a survey about pneumococcal immunizations to 60 older adults each, 30 using paper forms and 30 using electronic forms on handheld computers. By random assignment, the interviewers used either the paper or electronic form first. Using multilevel analyses adjusted for patient characteristics and clustering of forms by practice, we analyzed the completeness of the data. RESULTS A total of 1,003 of the expected 1,140 forms were returned to the data center. The overall return rate was better for paper forms (537 of 570, 94%) than for electronic forms (466 of 570, 82%) because of technical difficulties experienced with electronic data collection and stolen or lost handheld computers. Errors of omission on the returned forms, however, were more common using paper forms. Of the returned forms, only 3% of those gathered electronically had errors of omission, compared with 35% of those gathered on paper. Similarly, only 0.04% of total survey items were missing on the electronic forms, compared with 3.5% of the survey items using paper forms. CONCLUSIONS Although handheld computers produced more complete data than the paper method for the returned forms, they were not superior because of the large amount of missing data due to technical difficulties with the hand-held computers or loss or theft. Other hardware solutions, such as tablet computers or cell phones linked via a wireless network directly to a Web site, may be better electronic solutions for the future.

Static, dynamic, integrated, and contextualized: A framework for understanding mental health service utilization among young adults

Research has illuminated the problem of untreated mental illness among young adults, including evidence that young people who exit public care systems often discontinue mental health services in adulthood. The present study explored mental health service use experiences during the transition to adulthood among sixty young adults, ages 18-25, from a Midwestern U.S. state. In-depth semi-structured interviews were conducted. All participants had mood difficulties, and shared three childhood experiences: (a) mood disorder diagnosis; (b) use of public mental health services; and (c) experience with social service systems. Immersion and grounded theory coding techniques were applied to the interview data. Two major themes about mental health service use emerged from the findings, namely the changing nature of service use over time and characterizations of experiences associated with service use at a given point in time. Categories of explanatory constructs that emerged in the latter theme included perceived need, emotions, perceived efficacy of services, and social considerations, among others. Findings suggested a four-facet mid-level theory of service utilization, highlighting both the cross-sectional and time-variant character of service use and decision-making within context. Links between broader theoretical frameworks of service utilization and social psychological models of decision making were noted, and guidelines were presented for ten classes of variables that researchers interested in understanding service use by young adults should consider.

Appreciative Inquiry for quality improvement in primary care practices.

Purpose: To test the effect of an Appreciative Inquiry (AI) quality improvement strategy on clinical quality management and practice development outcomes. Appreciative inquiry enables the discovery of shared motivations, envisioning a transformed future, and learning around the implementation of a change process. Methods: Thirty diverse primary care practices were randomly assigned to receive an AI-based intervention focused on a practice-chosen topic and on improving preventive service delivery (PSD) rates. Medical-record review assessed change in PSD rates. Ethnographic field notes and observational checklist analysis used editing and immersion/crystallization methods to identify factors affecting intervention implementation and practice development outcomes. Results: The PSD rates did not change. Field note analysis suggested that the intervention elicited core motivations, facilitated development of a shared vision, defined change objectives, and fostered respectful interactions. Practices most likely to implement the intervention or develop new practice capacities exhibited 1 or more of the following: support from key leader(s), a sense of urgency for change, a mission focused on serving patients, health care system and practice flexibility, and a history of constructive practice change. Conclusions: An AI approach and enabling practice conditions can lead to intervention implementation and practice development by connecting individual and practice strengths and motivations to the change objective.

Impact of family history assessment on communication with family members and health care providers: A report from the Family Healthware™ Impact Trial (FHITr)

OBJECTIVE This study examines the impact of Family Healthware™ on communication behaviors; specifically, communication with family members and health care providers about family health history. METHODS A total of 3786 participants were enrolled in the Family Healthware™ Impact Trial (FHITr) in the United States from 2005-7. The trial employed a two-arm cluster-randomized design, with primary care practices serving as the unit of randomization. Using generalized estimating equations (GEE), analyses focused on communication behaviors at 6month follow-up, adjusting for age, site and practice clustering. RESULTS A significant interaction was observed between study arm and baseline communication status for the family communication outcomes (ps<.01), indicating that intervention had effects of different magnitude between those already communicating at baseline and those who were not. Among participants who were not communicating at baseline, intervention participants had higher odds of communicating with family members about family history risk (OR=1.24, p=0.042) and actively collecting family history information at follow-up (OR=2.67, p=0.026). Family Healthware™ did not have a significant effect on family communication among those already communicating at baseline, or on provider communication, regardless of baseline communication status. Greater communication was observed among those at increased familial risk for a greater number of diseases. CONCLUSION Family Healthware™ prompted more communication about family history with family members, among those who were not previously communicating. Efforts are needed to identify approaches to encourage greater sharing of family history information, particularly with health care providers.

Measuring the Impact of Practice-based Research Networks (PBRNs)

Practice-based research networks (PBRNs) continue their upward trajectory in scope and numbers, now engaging community practices that reach approximately 15% of the US population. In this issue, Peterson et al,[1][1] characterizes US PBRNs based on data from the 2011 Agency for Healthcare Research

Barriers to supplemental calcium use among women in suburban family practice: A report from the Cleveland Clinic Ambulatory Research Network (CleAR-eN)

Background: The majority of adult women in the United States fail to meet daily calcium intake recommendations. This study was undertaken to (1) identify predictors of calcium supplement use versus non-use, (2) understand barriers to calcium supplementation, and (3) determine the potential impact of physician recommendation on calcium supplement use. Methods: Surveys were self-administered by 185 women, ages 20 to 64, presenting consecutively for care at 6 suburban community-based family medicine practices within the Cleveland Clinic Ambulatory Research Network (CleAR-eN). We compared demographic characteristics, health beliefs, and health behaviors of those women who reported never using calcium supplements with those who presently took calcium supplements. Women who never took calcium were also queried about reasons for non-use and whether physician recommendation would influence their adoption of calcium supplementation. Results: Multivitamin use, self-perceived risk of osteoporosis, and age were independent predictors of calcium supplement use. Leading barriers for never-users were lack of knowledge about the need/importance of increasing calcium intake, lack of motivation to start supplements, and the belief that their dietary calcium intake alone was sufficient. Ninety-six percent of never-users reported that they would consider taking a calcium supplement if recommended by their physician. Conclusions: Many patient-identified barriers to calcium supplementation seem amenable to focused and brief office-based interventions that could increase the number of women meeting calcium intake guidelines.

Praxis-based research networks: An emerging paradigm for research that is rigorous, relevant, and inclusive

Practice-based research networks (PBRNs) have developed a grounded approach to conducting practice-relevant and translational research in community practice settings. Seismic shifts in the health care landscape are shaping PBRNs that work across organizational and institutional margins to address complex problems. Praxis-based research networks combine PBRN knowledge generation with multistakeholder learning, experimentation, and application of practical knowledge. The catalytic processes in praxis-based research networks are cycles of action and reflection based on experience, observation, conceptualization, and experimentation by network members and partners. To facilitate co-learning and solution-building, these networks have a flexible architecture that allows pragmatic inclusion of stakeholders based on the demands of the problem and the needs of the network. Praxis-based research networks represent an evolving trend that combines the core values of PBRNs with new opportunities for relevance, rigor, and broad participation.

Characteristics of nurse practitioners interested in participating in a practice‐based research network

Purpose: Practice‐based Research Networks (PBRNs) have emerged as key laboratories for generating new knowledge that reflects community‐based practice; however, the representativeness of nurse practitioners (NPs) interested in PBRN participation is not known. This study describes characteristics of NP members interested in participating in a regional PBRN in comparison with state and national data. Data sources: All 1016 NPs in northeast (NE) Ohio were surveyed by mail and Internet. The survey captured NP demographics, practice characteristics, and gauged interest in participating in future PBRN studies. Survey respondents data were compared with Ohio and national data obtained from the 2004 AANP National Nurse Practitioner Sample Survey. Conclusions: NE Ohio NPs were similar to an Ohio and national sample of NPs. Northeast Ohio NPs practicing in ambulatory settings who were interested in participating in subsequent PBRN studies were not significantly different from non‐interested NPs. Implications for practice: NPs interested in participation in a PBRN appear to be representative of the NE Ohio population of ambulatory practice NPs and are similar demographically to a national sample of NPs. Findings from studies conducted in the NE Ohio PBRN may generalize to other NPs practicing in the region and across the country.

Practice-based Research Networks (PBRNs) Bridging the Gaps between Communities, Funders, and Policymakers

In this commentary, we propose that practice-based research networks (PBRNs) engage with funders and policymakers by applying the same engagement strategies they have successfully used to build relationships with community stakeholders. A community engagement approach to achieve new funding streams for PBRNs should include a strategy to engage key stakeholders from the communities of funders, thought leaders, and policymakers using collaborative principles and methods. PBRNs that implement this strategy would build a robust network of engaged partners at the community level, across networks, and would reach state and federal policymakers, academic family medicine departments, funding bodies, and national thought leaders in the redesign of health care delivery.