James W. Mold

Primary Care Practice-Based Research Networks: Working at the Interface Between Research and Quality Improvement

PURPOSE We wanted to describe the emerging role of primary care practice-based in research, quality improvement (QI), and translation of research into practice (TRIP). METHODS We gathered information from the published literature, discussions with PBRN leaders, case examples, and our own personal experience to describe a role for PBRNs that comfortably bridges the gap between research and QI, discovery and application, academicians and practitioners—a role that may lead to the establishment of true learning communities. We provide specific recommendations for network directors, network clinicians, and other potential stakeholders. RESULTS PBRNs function at the interface between research and QI, an interface called TRIP by some members of the research community. In doing so, PBRNs are helping to clarify the difficulty of applying study findings to everyday care as an inappropriate disconnect between discovery and implementation, research and practice. Participatory models are emerging in which stakeholders agree on their goals; apply their collective knowledge, skills, and resources to accomplish these goals; and use research and QI methods when appropriate. CONCLUSIONS PBRNs appear to be evolving from clinical laboratories into learning communities, proving grounds for generalizable solutions to clinical problems, and engines for improvement of primary care delivery systems.

Utility of the RBANS in detecting cognitive impairment associated with Alzheimer's disease : Sensitivity, specificity, and positive and negative predictive powers

Although initially developed as a brief dementia battery, the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) has not yet demonstrated its sensitivity, specificity, and positive and negative predictive powers in detecting cognitive impairment in patients with Alzheimers disease (AD). Therefore, the current study examined the clinical utility of the RBANS by comparing two age-, education-, and gender-matched groups: patients with AD (n=69) and comparators (n=69). Significant differences (p<0.001) were observed on the RBANS Total score, all 5 Indexes, and all 12 subtests, with patients performing worse than the comparison participants. An optimal balance between sensitivity and specificity on RBANS scores was obtained when cutoffs of one and one and a half standard deviations below the mean of the comparison sample were implemented. Areas under the Receiver Operating Characteristic curves for all RBANS Indexes were impressive though Immediate and Delayed Memory Indexes were excellent (0.96 and 0.98, respectively). Results suggest that RBANS scores yield excellent estimates of diagnostic accuracy and that the RBANS is a useful screening tool in detection of cognitive deficits associated with AD.

Age- and Education-Corrected Independent Normative Data for the RBANS in a Community Dwelling Elderly Sample

The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS, Randolph, 1998) is likely to become a popular screening instrument for measuring cognitive functioning, particularly in elderly patients. As such, the present study attempted to extend the original normative data by reporting on RBANS performances in a group of 718 community dwelling older adults. Participants were recruited from an outpatient primary care setting, and were assessed for demographic, medical status, functional status, and quality of life information. Utilizing four empirically supported overlapping midpoint age ranges, individual subtest raw scores were converted to age-corrected scaled scores based on their position within a cumulative frequency distribution. These age-corrected scaled scores were also converted into education-corrected scaled scores using the same methodology across four education levels. Independent Index and Total scores were also calculated based on the data from this large elderly sample. These data may considerably advance the clinical utility of the RBANS by allowing clinicians to interpret individual subtests and make direct comparisons between subtests. Practitioners and researchers who elect to use the current normative data are encouraged to consider the similarities and differences between the present sample and their individual patients or research participants.

A Health Care Cooperative Extension Service: Transforming Primary Care and Community Health

RIMARY CARE IS THE ESSENTIAL FOUNDATION FOR AN effective, efficient, and equitable health care system.Callstorebuildthecrumblingprimarycareinfrastructure in the United States are reaching receptive ears, with public and private advisory groups includingtheMedicarePaymentAdvisoryCommissionand the National Business Group on Health recommending increased payments for primary care. 1 The American RecoveryandReinvestmentAct(ARRA) 2 of2009appropriated

Test-Retest Stability and Practice Effects of the RBANS in a Community Dwelling Elderly Sample

19 billion for the purchase of health information technology (HIT), with primary care physicians’ offices slated to be among the beneficiaries. Policy makers expect that new investments will transform primary care by creating more effective and efficient patient-centered medical homes. The primary care physician community acknowledges the need for new practice models that provide accessible, comprehensive, integrated care based on healing relationships over time. 3 New investment in primary care is necessary but not sufficienttorevitalizeprimarycareunlesscombinedwithastrategy for disseminating and implementing innovations and best practices. Acquiring an electronic health record (EHR) will not create a highly functioning medical home unless it can be used to create functional patient registries. Receivingenhancedpaymentsforcarecoordinationwithoutaworkable plan for hiring and training health coaches for patient self-management leaves a gap between expectations and reality. Large, organized delivery systems such as Geisenger, Kaiser Permanente, and the Veterans Administration have theinstitutionalwherewithalandeconomiesofscaletoimplement practice redesign in a systematic and successful manner. However, two-thirds of office-based physicians work in practices of 4 or fewer physicians. 4 These clinicians oftenhavelittleornotechnicalassistancetodeployandmaintain new practice improvements like EHRs. To successfully redesign practices requires knowledge transfer, performance feedback, facilitation, and HIT support provided by individuals with whom practices have established relationships over time. The farming community learned these principles a century ago. Primary care practices are like small farms of that era, which were geographically dispersed, poorly resourced for change, and inefficient in adopting new techniques or technology but vital tothenation’swell-being.Practicingphysiciansneedsomething akin to the agricultural extension agent who was so transformativeforfarming. 5,6 AnationwidePrimaryCareCooperative Extension Service, modeled after the US Department of Agriculture’s Cooperative State Research, Education,andExtensionService(CooperativeExtension),which so successfully accelerated farm transformation, should be created.County-basedhealthextensionorganizationswould supportprimarycarecliniciansinthesamemannerthatthe agricultural model assists family farmers, providing infrastructureforlocallearningcommunitiesandpracticetransformation. ARRA establishes a Health Information Technology Extension Program 2 to “assist health care providers toadopt,implement,andeffectivelyusecertifiedEHRtechnology,” which could serve as the nidus for a broader program to revitalize primary care and community health.

Electronic health record functionality needed to better support primary care

Repeated neuropsychological assessments are common with older adults, and the determination of true neurocognitive change is important for diagnostic assessment. Several statistical formulas are available to assist in this determination, but they rely on access to test-retest stability coefficients and practice effect values. The current study presents data on these psychometric properties of the RBANS in a large community dwelling elderly sample. Across a one-year retest interval, stability coefficients ranged from .58 to .83 for the Index scores, and from .51 to .83 for the subtest scores. Practice effects were largely absent, with most performances slightly decreasing at retest. These psychometric properties are contrasted with those reported in the RBANS manual, and possible reasons for these differences are discussed. A case example is provided that demonstrates the use of the current findings in conjunction with existing change formulas.

Management of venous thromboembolism: a clinical practice guideline from the American College of Physicians and the American Academy of Family Physicians.

Electronic health records (EHRs) must support primary care clinicians and patients, yet many clinicians remain dissatisfied with their system. This article presents a consensus statement about gaps in current EHR functionality and needed enhancements to support primary care. The Institute of Medicine primary care attributes were used to define needs and meaningful use (MU) objectives to define EHR functionality. Current objectives remain focused on disease rather than the whole person, ignoring factors such as personal risks, behaviors, family structure, and occupational and environmental influences. Primary care needs EHRs to move beyond documentation to interpreting and tracking information over time, as well as patient-partnering activities, support for team-based care, population-management tools that deliver care, and reduced documentation burden. While stage 3 MUs focus on outcomes is laudable, enhanced functionality is still needed, including EHR modifications, expanded use of patient portals, seamless integration with external applications, and advancement of national infrastructure and policies.

Implementation of Evidence-Based Preventive Services Delivery Processes in Primary Care: An Oklahoma Physicians Resource/Research Network (OKPRN) Study

Venous thromboembolism is a common condition affecting 7.1 persons per 10,000 person-years among community residents. Incidence rates for venous thromboembolism are higher in men, African-Americans, and increase substantially with age. It is critical to treat deep venous thrombosis at an early stage to avoid development of further complications, such as pulmonary embolism or recurrent deep venous thrombosis. The target audience for this guideline is all clinicians caring for patients who have been given a diagnosis of deep venous thrombosis or pulmonary embolism. The target patient population is patients receiving a diagnosis of pulmonary embolism or lower-extremity deep venous thrombosis.

Performance of Cognitively Normal African Americans on the RBANS in Community Dwelling Older Adults

Background: Previous research has found that wellness visits, recall and reminder systems, and standing orders are associated with higher rates of delivery of preventive services in primary care practices. However, there is little information about how to help practices implement these processes. Methods: A 6-month randomized, controlled trial comparing a multicomponent quality improvement intervention to feedback and benchmarking. One clinician/nurse team from each of 24 practices was randomly assigned to one of 2 study arms. Intervention practices received performance feedback, peer-to-peer education (academic detailing), a practice facilitator, and computer (information technology) support. Implementation of the 3 targeted processes was determined by a blinded 3-clinician panel that reviewed transcribed clinician interviews before and after intervention using performance definitions. Rates of delivery of selected preventive services were determined by chart audit. Results: Intervention practices implemented more of the processes than control practices overall (P = .003), for adults (P = .05), and for children (P = .04). They were also more likely to implement at least one of the processes for children (P = .04) and to implement standing orders for either children or adults (P = .02). Mammography rates increased significantly. Neither clinician and practice characteristics nor clinician readiness to change predicted implementation. Conclusions: A multicomponent implementation strategy consisting of feedback, benchmarking, academic detailing, facilitation, and IT support increased implementation of evidence-based processes for delivering preventive services to a greater extent than performance feedback and benchmarking alone.

RBANS Performance: Influences of Sex and Education

Recent research suggests that cognitively normal African Americans are more likely to be misdiagnosed as impaired compared to Caucasians due to lower neuropsychological test scores (e.g., Manly et al., 1998). Given this, the present study sought to determine whether such racial discrepancies exist on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). Performances of 50 cognitively normal older African Americans on the RBANS were compared to those of 50 Caucasians matched on age, education, and gender. The African Americans scored significantly lower on 10 of 12 subtests, 3 of 5 Index scores, and the Total Scale score. Results underscored the utility of demographically appropriate norms when serving minority clients. Given that there remains a paucity of normative data for minority groups, RBANS normative data for older African Americans are provided. Although preliminary, it is hoped that data presented will offer the practitioner assistance with clinical diagnosis and decision-making in a manner that will help minimize diagnostic errors.