Lyle J. Fagnan

Community characteristics affecting emergency department use by Medicaid enrollees.

Objectives:In seeking to identify modifiable, system-level factors affecting emergency department (ED) use, we used a statewide Medicaid database to study community variation in ED use and ascertain community characteristics associated with higher use. Methods:This historical cohort study used administrative data from July 1, 2003 to December 31, 2004. Residence ZIP codes were used to assign all 555,219 Medicaid enrollees to 130 primary care service areas (PCSAs). PCSA characteristics studied included rural/urban status, presence of hospital(s), driving time to hospital, and several measures of primary care capacity. Statistical analyses used a 2-stage model. In the first stage (enrollee level), ED utilization rates adjusted for enrollee demographics and medical conditions were calculated for each PCSA. In the second stage (community level), a mixed effects linear model was used to determine the association between PCSA characteristics and ED use. Results:ED utilization rates varied more than 20-fold among the PCSAs. Compared with PCSAs with primary care capacity less than need, PCSAs with capacity 1 to 2 times the need had 0.12 (95% CI: −0.044, −0.20) fewer ED visits/person/yr. Compared with PCSAs with the nearest hospital accessible within 10 minutes, PCSAs with the nearest hospital >30 minutes’ drive had 0.26 (95% CI: −0.38, −0.13) fewer ED visits/person/yr. Conclusions:Within this Medicaid population, ED utilization was determined not only by patient characteristics but by community characteristics. Better understanding of system-level factors affecting ED use can enable communities to improve their health care delivery systems–augmenting access to care and reducing reliance on EDs.

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.

Practice-based Research is Community Engagement

Community engagement has become a major contributor to medical research during the past 10 years and is an essential component of the current National Institutes of Health (NIH) Roadmap and the Clinical and Translational Science Awards program.[1][1][,2][2] But, what is a community? And what

Field test results of a new ambulatory care Medication Error and Adverse Drug Event Reporting System--MEADERS.

PURPOSE In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)—an easy-to-use, Web-based reporting system designed for busy office practices. METHODS We conducted a 10-week field test of MEADERS in which 220 physicians and office staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with office managers and lead physicians, and (2) distributions of characteristics of the medication event reports. RESULTS A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication errors and adverse drug events were communication problems (41%) and knowledge deficits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in office medication management; however, 36% agreed or strongly agreed that the event reporting “has increased the fear of repercussion in the practice.” Time pressure was the main barrier to reporting. CONCLUSIONS It is feasible for primary care clinicians and office staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted.

Perceptions of Shared Decision Making and Decision Aids Among Rural Primary Care Clinicians

Background Shared decision making (SDM) and decision aids (DAs) increase patients’ involvement in health care decisions and enhance satisfaction with their choices. Studies of SDM and DAs have primarily occurred in academic centers and large health systems, but most primary care is delivered in smaller practices, and over 20% of Americans live in rural areas, where poverty, disease prevalence, and limited access to care may increase the need for SDM and DAs. Objective To explore perceptions and practices of rural primary care clinicians regarding SDM and DAs. Design Cross-sectional survey. Setting and Participants Primary care clinicians affiliated with the Oregon Rural Practice-based Research Network. Results Surveys were returned by 181 of 231 eligible participants (78%); 174 could be analyzed. Two-thirds of participants were physicians, 84% practiced family medicine, and 55% were male. Sixty-five percent of respondents were unfamiliar with the term shared decision making, but following definition, 97% reported that they found the approach useful for conditions with multiple treatment options. Over 90% of clinicians perceived helping patients make decisions regarding chronic pain and health behavior change as moderate/hard in difficulty. Although 69% of respondents preferred that patients play an equal role in making decisions, they estimate that this happens only 35% of the time. Time was reported as the largest barrier to engaging in SDM (63%). Respondents were receptive to using DAs to facilitate SDM in print- (95%) or web-based formats (72%), and topic preference varied by clinician specialty and decision difficulty. Conclusions Rural clinicians recognized the value of SDM and were receptive to using DAs in multiple formats. Integration of DAs to facilitate SDM in routine patient care may require addressing practice operation and reimbursement.

Influence of health insurance coverage on breast, cervical, and colorectal cancer screening in rural primary care settings.

The current study was performed to determine, in rural settings, the relation between the type and status of insurance coverage and being up‐to‐date for breast, cervical, and colorectal cancer screening.

Voices from left of the dial: reflections of practice-based researchers.

Purpose: Practice-based research networks (PBRNs) provide an important approach to implementing primary care research at the community level, thus increasing the relevance and utility of research findings for routine primary care practices. PBRNs expend considerable time and energy in the recruitment, engagement, and retention of network clinicians and practices to establish this community-based primary care research laboratory. This study assessed factors motivating PBRN clinicians to participate and stay involved in practice-based research in their primary care office setting. Methods: We invited practicing clinicians across the United States who are affiliated with a PBRN to share their stories regarding motivations to participate in practice-based research. Using qualitative methods, we categorized the stories into the main motivation for participation and the perceived impact of participation. Results: We collected 37 stories from clinicians affiliated with 12 PBRNS located in 14 states. Motivations for participation in practice-based research included themes associated with personal satisfaction, improving local clinic-based care, and contributing to community- and system-level improvements. Sources of personal satisfaction corresponded to the 3 psychological needs postulated by Decis and Ryans Self-Determination Theory: competence, autonomy, and relatedness. Conclusions: These stories from PBRN clinicians describe the values, motivations, and unique paths that clinicians took as they chose to participate and stay active in a PBRN. Their voices have the potential to influence others to participate in practice-based research.

The Rural Older Adult Memory (ROAM) Study: A Practice-based Intervention to Improve Dementia Screening and Diagnosis

Introduction: The aim of the Rural Older Adult Memory (ROAM) pilot study was to evaluate the feasibility of screening and diagnosing dementia in patients aged 75 years or older in 6 rural primary care practices in a practice-based research network. Methods: Clinicians and medical assistants were trained in dementia screening using the ROAM protocol via distance learning methods. Medical assistants screened patients aged 75 years of age and older. For patients who screened positive, the clinician was alerted to the need for a dementia work-up. Outcomes included change in the proportion of patients who were screened and diagnosed with dementia or mild cognitive impairment, clinician confidence in diagnosing and managing dementia, and response to the intervention. Results: Results included a substantial increase in screening for dementia, a modest increase in the proportion of patients who were diagnosed with dementia or mild cognitive impairment, and improved clinician confidence in diagnosing dementia. Although clinicians and medical assistants found the ROAM protocol easy to implement, there was substantial variability in adherence to the protocol among the 6 practices. Conclusion: This study demonstrated the complex issues that must be addressed in implementing a dementia screening process in rural primary care. Further study is needed to develop effective strategies for overcoming the factors that impeded the full uptake of the protocol, including the logistic challenges in implementing practice change and clinicians’ attitudes toward dementia screening and diagnosis.

Unmet Dental Needs in Rural Primary Care: A Clinic-, Community-, and Practice-based Research Network Collaborative

Background: Oral health is an essential component of general health and well-being, yet barriers to the access of dental care and unmet needs are pronounced, particularly in rural areas. Despite associations with systemic health, few studies have assessed unmet dental needs across the lifespan as they present in primary care. This study describes the prevalence of oral health conditions and unmet dental needs among patients presenting for routine care in a rural Oregon family medicine practice. Methods: Eight primary care clinicians were trained to conduct basic oral health screenings for 7 dental conditions associated with International Statistical Classification of Diseases and Related Health Problems 9—Clinical Modification codes. During the 6-week study period, patients older than 12 months of age who presented to the practice for a regularly scheduled appointment received the screening and completed a brief dental access survey. Results: Of 1655 eligible patients, 40.7% (n = 674) received the screening and 66.9% (n = 1108) completed the survey. Half of the patients who were screened (46.0%, n = 310) had oral health conditions detected, including partial edentulism (24.5%), dental caries (12.9%), complete edentulism (9.9%), and cracked teeth (8.9%). Twenty-eight percent of the patients reported experiencing unmet dental needs. Patients with dental insurance were significantly more likely to report better oral and general health outcomes as compared with those who had no insurance or health insurance only. Conclusions: Oral health diseases and unmet dental needs presented substantially in patients with ages ranging across the lifespan from one rural primary care practice. Primary care settings may present opportune environments for reaching patients who are unable to obtain regular dental care.

Characterizing a Practice-based Research Network: Oregon Rural Practice-based Research Network (ORPRN) Survey Tools

Objective: To present the survey methods and instruments used to characterize a geographically and professionally diverse rural practice-based research network (PBRN). Methods: A cross-sectional study of Oregon PBRN (ORPRN) member practices and clinicians using a 3-part survey including a survey of the practices, of clinician members, and an anonymous survey of clinician satisfaction. Results: A total of 31 of 32 (97%) participating ORPRN practices completed the practice survey, 96 of 129 (74%) clinicians within these practices completed the clinician member survey, and 81 of 129 (63%) clinicians completed an anonymous survey of clinician satisfaction. The survey provided a detailed description of the structure of member practices, patient and clinician demographics, services provided by the practices, and access to specialty and ancillary services. Conclusions: Survey tools that describe the network practices and individual clinician characteristics contribute to an understanding of the research capacity of an individual PBRN.