Abstracts In Press

The abstracts below are from articles currently ‘in press’ at the JABFM. Content and publication dates are subject to change during the copy editing process; please check back here for weekly updates.

POLICY BRIEF

New Allopathic Medical Schools Train Fewer Family Physicians Than Older Ones

Brian Beachler, MD; Yalda Jabbarpour, MD; Douglas B. Kamerow, MD, MPH; Elizabeth Wilkinson, BA; Zachary Levin, BA; Andrew Bazemore, MD, MPH

Corresponding Author: Yalda Jabbarpour, MD; Robert Graham Center. Email: yjabbarpour@aafp.org

Publication: September/October 2019 (Full article available online for free on September 10, 2019)

DOI: 10.3122/jabfm.2019.05.190105 

The first significant expansion of allopathic medical schools since the 1970s was anticipated to produce more physicians capable of addressing the nation’s current and projected primary care shortages. However, our analysis of the early outputs of new allopathic medical schools suggests that these students were nearly 40% less likely to specialize in family medicine than existing schools.

ORIGINAL RESEARCH

Process for Setting Research Priorities:  A Case Study from the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP) Consortium

Mary Fisher, MPH; Sarah E. Brewer, MPA; Douglas H. Fernald, MA; Jodi Summers Holtrop, PhD; Andrea Nederveld, MD, MPH; Sean T. O’Leary, MD, MPH; Matthew Simpson, MD, MPH; John M. Westfall, MD, MPH; Linda Zittleman, MSPH; Donald E. Nease, Jr., MD

Corresponding Author: Mary Fisher, MPH; University of Colorado Denver. Email: mary.fisher@ucdenver.edu

Publication: September/October 2019 (Full article available online for free on September 10, 2019)

DOI: 10.3122/jabfm.2019.05.190037 

Purpose: It is important to share processes that practice-based research networks (PBRNs) can implement with PBRN members and partners to determine research topics of priority. Engaging partners at a pre-project phase, and continuing engagement throughout a project, can help address topics of great need and increase meaningfulness at a local level. Methods: The State Networks of Colorado Ambulatory Practices and Partners (SNOCAP) practice-based research network has a 20-year history of research topic prioritization. Annually, PBRN members and partners come together to set new priorities for SNOCAP to put focus on in the coming years. Methods from these Colorado PBRNs are shared as a framework for other PBRN networks, community and patient partners, and stakeholders to use. Results: Engaging PBRN members and researchers in a bi-directional manner in pre-project prioritization helps address current needs and gaps in care, and identifies topics that are meaningful and important statewide. SNOCAP shares various approaches and lessons learned, provides guidance to PBRNs wanting to establish priorities, and helps guide groups that want to engage, or engage more deeply with, network members. Priority setting methods, a sample agenda, and resulting SNOCAP projects from the past five years of prioritization are shared. Conclusions: Inquiry on a regular basis is an important step in practice- or community-based research. Getting to the local level to determine and fully address priority needs is not only “the right thing to do,” rather, it is essential in true bi-directional work. 

ORIGINAL RESEARCH

Strategies for Developing and Sustaining Patient and Community Advisory Groups: Lessons from the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP) Consortium of Practice-based Research Networks

Mary Fisher, MPH; Sarah E. Brewer, MPA; John M. Westfall, MD, MPH; Matthew Simpson, MD, MPH; Linda Zittleman, MSPH; Sean T. O’Leary, MD, MPH; Douglas H. Fernald, MA; Andrea Nederveld MD, MPH; Donald E. Nease, Jr, MD

Corresponding Author: Mary Fisher, MPH; University of Colorado Denver. Email: mary.fisher@ucdenver.edu

Publication: September/October 2019 (Full article available online for free on September 10, 2019)

DOI: 10.3122/jabfm.2019.05.190038

Background: Patient and community engagement is essential to maintain the relevance of practicebased research. Empowered engagement requires going beyond the check box, with advisory groups involved in every aspect of a project. Here, four Colorado practice-based research networks (PBRNs) share their advisory group origins, as well as methods for continued engagement and the work that has resulted. Methods: PBRNs, like communities and practices, vary in form and function. In a four-part case series, we describe commonalities and differences among advisory groups within the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP), a consortium of PBRNs in Colorado. Three SNOCAP advisory groups are well established, while a fourth is under development. Results: Each case shares ways in which advisory groups have been structured within SNOCAP, including meeting frequency, compensation, and member activities to ensure the design, conduct, analysis, and dissemination of research are grounded in the needs of patients and communities. We share six lessons learned regarding membership, relationships, relevance, care and feeding, listening, and showing up. Conclusions: SNOCAP believes advisory groups are the backbone and guidepost of PBRN work. Patient advisors are an essential and invaluable complement to traditional research when engaged beyond “basic” participation. When determining best structures for your advisory group, work with your stakeholders to ensure best fit and proper structures that work for their specific needs.

ORIGINAL RESEARCH

Patient-Centered Research Priorities: A Mixed-Methods Approach from the Colorado Children's Outcomes Network (COCONet) 

Sarah E. Brewer, MPA; Natalie M. Crump, MS; Sean T. O’Leary, MD, MPH

Corresponding Author: Sarah E. Brewer, MPA; University of Colorado Denver. Email: sarah.brewer@ucdenver.edu

Publication: September/October 2019 (Full article available online for free on September 10, 2019)

DOI: 10.3122/jabfm.2019.05.190028

Background: Practice‐Based Research Networks (PBRNs) perform clinically-relevant research designed for immediate translation to patient care. Research questions developed with patients and parents are more likely to be relevant to stakeholders. This study developed priority areas for patient-centered outcomes research in pediatric health within the context of the Colorado Children’s Outcomes Network (COCONet), a statewide pediatric PBRN, and in collaboration with stakeholders. Methods: We undertook a mixed-methods, community-engaged process to understand and develop a research agenda for our pediatric PBRN.  With a stakeholder-engaged research team, we conducted 52 stakeholder interviews and 1 focus group (n=9) addressing topics including child health issues, personal healthcare experiences, community health, and the healthcare system. Transcripts were coded and analyzed by researchers and parent advisors.  We conducted a web-based survey of PBRN stakeholders (n=75) to rate priority issues identified in qualitative findings.  Finally, we facilitated a community-engaged mixed-methods interpretation and issue selection process with our Network Advisory Board (NAB) to identify issues of highest importance for COCONet. Results: Six topic areas of importance to pediatric health stakeholders emerged from qualitative work. Participating stakeholders used rating surveys to rank these six topics. Pediatric mental health coordination and communication/integration with primary care was ranked as the most important and highest research priority. The NAB additionally identified immunization uptake and transition from pediatric to adult healthcare as research priority areas. Conclusions: This pediatric PBRN identified numerous research priorities in pediatric health and selected three for immediate research action. PBRNs can utilize community-engaged, mixed-methods research approaches to set research priorities and develop patient-centered pediatric research agendas.

ORIGINAL RESEARCH

Parent Perceptions of and Preferences for Participation in Child Health Research: Results from a Pediatric Practice-based Research Network 

Stacey A. Engster, MD, MS; Carrie Fascetti, LSW; Kristine Daw, RN, BS; Evelyn Cohen Reis, MD

Corresponding Author: Stacey A. Engster, MD, MS; University of Pittsburgh. Email: engstersa2@upmc.edu

Publication: September/October 2019 (Full article available online for free on September 10, 2019)

DOI: 10.3122/jabfm.2019.05.190030 

Background: Recruitment efforts for child health research are often based on assumptions, therefore improving knowledge about parents’ perceptions and preferences could enhance engagement. Aim/Objective: 1) To describe parents’ perceptions about and preferences for participation in child health research within a pediatric practice-based research network (PBRN), and 2) to investigate any associations with the presence of on-site PBRN research staff, office location, and child age. Methods: We conducted a two-phase study with a convenience sample of parents from diverse office settings. Phase 1 was a qualitative assessment using semi-structured, in-person interviews. Phase 2 consisted of a quantitative self-administered survey assessing: 1) perceptions of importance, benefits/motivations, and risks/barriers of child health research, and 2) preferences for recruitment method and enrollment location. Results: Parents (n=627) uniformly perceived child health research to be important in prevention (89%), diagnosis (89%), and treatment (92%). They were motivated to participate most commonly by altruism and rarely by compensation. Parents perceived side effects (60%), discomfort (52%), and time (45%) as the main risks of participation. Most parents preferred to learn about research opportunities at their pediatric office (70%), and if interested, to enroll their child in their pediatric office (57%) or in their home (52%). Parents were significantly more altruistic and interested in participation in offices with onsite PBRN research staff and greater proximity to the University. Conclusions: Child health researchers could enhance participation by utilizing recruitment resources and enrollment strategies that match parent preferences, including engagement by on-site PBRN staff.

ORIGINAL RESEARCH

A Practical Approach to Establishing a Practice-based Research Network Stakeholder Engagement Infrastructure 

Anne H. Gaglioti, MD, MS; Denita Walston, MS; Cirila Estela Vasquez Guzman, PhD; Nikita Toppin Dera, MPH; Clarissa Ortiz; LaShun Wright; Tisa Roberts, MD; Sharon Parker, RN; Vicki Young, PhD

Corresponding Author: Anne H. Gaglioti, MD, MS; Morehouse School of Medicine. Email: agaglioti@msm.edu

Publication: September/October 2019 (Full article available online for free on September 10, 2019)

DOI: 10.3122/jabfm.2019.05.190046

Introduction: While there have been several papers detailing the importance of stakeholder engagement in research broadly and in practice-based research networks (PBRNs) specifically, few of these papers offer a replicable engagement approach that is detailed enough to translate to another setting. The goal of this paper is to offer a detailed example of building stakeholder engagement infrastructure that could be replicated or translated to other settings. Approach: We offer a detailed review of one regional PBRN’s approach to building a stakeholder engagement infrastructure over a two-year period by describing engagement activities deployed across a large, regional PBRN including a needs assessment around research and training conducted in each state of the network and a centralized conference where themes from that needs assessment were leveraged to produce a stakeholder-defined research agenda and elect a steering committee. Results: Products from this process presented in this paper include the stakeholder-defined research agenda as well as a multi-level organizational framework for assessing facilitators and barriers in a large PBRN and an example of a framework of individualized stakeholder group preferences for engagement modalities. Conclusions: This paper presents a detailed timeline and replicable approach to building a stakeholder engagement infrastructure in a regional PBRN. This paper details a practical process that is embedded in the lived values of practice-based research. 

ORIGINAL RESEARCH

A Qualitative Analysis of Implementing EvidenceNow to Improve Cardiovascular Care  

Debora Goldberg, PhD, MHA, MBA; Sahar Haghighat, MA; Sneha Kavalloor, MD, MS; Len M. Nichols, PhD

Corresponding Author: Debora Goldberg, PhD, MHA, MBA; George Mason University. Email: dgoldbe4@gmu.edu

Publication: September/October 2019 (Full article available online for free on September 10, 2019)

DOI: 10.3122/jabfm.2019.05.190084

Purpose: The Heart of Virginia Healthcare (HVH) was a regional cooperative under the EvidenceNOW initiative to assist primary care practices implement evidence-based cardiovascular care and build capacity for quality improvement. The HVH implementation team included individuals from multiple universities, quality improvement organizations, and consulting firms. The goal of this study was to understand HVH team member viewpoints on the challenges, strengths, and lessons learned in each phase of the project. Methods: Qualitative methods were used to facilitate reflection on the implementation and dissemination of the EvidenceNOW initiative in Virginia. In-depth interviews were conducted at the end of the project with 22 HVH team members. A non-participant, multidisciplinary research team completed thematic analysis of interview transcripts. Results: Positive attributes of the HVH initiative included diverse team member skills and areas of expertise, a well-received kick-off event, and a comprehensive set of practice improvement resources. Major challenges included recruiting primary care practices, varying types and capabilities of EHRs, and working with practices at different transformation stages, with different objectives for participating, and involvement in other government initiatives. Conclusions: Study findings provide insights for future dissemination research and implementation of evidence-based practices in primary care. Challenges experienced in project development can result in a domino effect that could change the project timeline, type of practices recruited for study participation, resource allocation, and planned activities for quality improvement. Effectiveness of external quality improvement support may depend upon practice engagement, preexisting organizational structures and processes, availability of resources, and length and continuity of practice facilitation. 

ORIGINAL RESEARCH

Staff and Clinician Work Life Perceptions after Implementing Systems-Based Improvements to Opioid Management  

Brooke Ike, MPH; Laura-Mae Baldwin, MD, MPH; Sarah Sutton; Nicole Van Borkulo, MEd; Christine Packer, MEd; Michael L. Parchman, MD, MPH

Corresponding Author: Brooke Ike, MPH; University of Washington. Email: bike2@uw.edu

Publication: September/October 2019 (Full article available online for free on September 10, 2019)

DOI: 10.3122/jabfm.2019.05.190027

Background: The Six Building Blocks Program is an evidence-based approach to primary care redesign for opioid management among patients with chronic pain. This analysis assesses the impact of implementing the Six Building Blocks on the work life of primary care providers and staff. Methods: Six rural and rural-serving primary care organizations with 20 clinic locations implemented the Six Building Blocks with support from a practice facilitator, clinical experts, and an informatics specialist. After 15 months of support, interviews and focus groups were conducted with staff and clinicians in each organization to stimulate reflection on the process and outcomes of implementing the Six Building Blocks Program. Transcripts of interviews and focus groups were coded and analyzed using template analysis. Once a set of themes was agreed upon, the primary qualitative analyst revisited the source data to confirm that they accurately reflected the data. Results: Overall, implementing the Six Building Blocks improved provider and staff work life experience. Reported improvements to work life included increased confidence and comfort in care provided to patients with long term opioid therapy (LtOT), increased collaboration among clinicians and staff, improved ability to respond to external administrative requests, improved relationships with patients using LtOT, and an overall decrease in stress. Conclusions: Clinicians and staff reported improvement in their work life after implementing the Six Building Blocks Program to improve opioid medication management. Further research is needed on patient experiences specific to practice redesign programs. 

ORIGINAL RESEARCH

Predictors of Medication-Assisted Treatment Initiation for Opioid Use Disorder in an Interdisciplinary Primary Care Model  

Rebecca E. Cantone, MD; Brian Garvey, MD, MPH; Allison O’Neill, MPH; Joan Fleishman, PsyD; Deborah Cohen, PhD; John Muench, MD, MPH; Steffani R. Bailey, PhD

Corresponding Author: Rebecca E. Cantone, MD; Oregon Health & Science University. Email: cantone@ohsu.edu

Publication: September/October 2019 (Full article available online for free on September 10, 2019)

DOI: 10.3122/jabfm.2019.05.190012

Introduction: Medication-Assisted Treatment (MAT) for opioid use disorder (OUD) is underutilized in primary care. Little is known about patient demographics associated with MAT initiation, particularly among models with an interdisciplinary approach including behavioral health integration. We hypothesize few disparities in MAT initiation by patient characteristics after implementing this model for OUD. Methods: Electronic health record (EHR) data were used to identify adults with ≥1 primary care visit in one of two study clinics in a Pacific Northwest academic health system between 9/1/2015 and 8/31/2017 (n=23,372). Rates of documented OUD diagnosis were calculated. Multivariate logistic regression estimated odds ratios of MAT initiation, defined as ≥1 EHR order for buprenorphine or naltrexone, by patient covariates. Results: Seven percent of the study sample had an OUD diagnosis. Of those patients, 32% had ≥1 MAT order. Patients with documented psychiatric diagnoses or tobacco use had higher odds of initiating MAT (OR 1.62, p=0.0003; OR 2.46, p<0.0001 respectively). Uninsured, Medicaid and Medicare patients had lower odds than those commercially insured (OR 0.53, 0.38, 0.31, respectively, p<0.0001). Patients who were older, of a race/ethnicity other than Non-Hispanic White, had documented diabetes, and had documented asthma or chronic obstructive pulmonary disease showed lower odds of initiation. Discussion: MAT initiation varied by patient characteristics, including disparities by insurance coverage and race/ethnicity. The addition of behavioral health did noteliminate disparities in care, but higher odds of initiation among those with a documented psychiatric diagnosis may Abstract suggest this model reaches some vulnerable populations. Additional research is needed to further examine these findings.

ORIGINAL RESEARCH

Sources of Error in Office Blood Pressure Measurement 

Roy N. Morcos, MD, FAAFP; Kimbroe J. Carter, MD; Frank Castro, MS; Sumira Koirala, MD; Deepti Sharma, MD; Haroon Syed, MD

Corresponding Author: Roy N. Morcos, MD; St. Elizabeth Boardman Family Health Center. Email: roy_morcos@mercy.com

Publication: September/October 2019 (Full article available online for free on September 10, 2019)

DOI: 10.3122/jabfm.2019.05.190085

Purposes: To evaluate two commonly overlooked sources of error in measuring blood pressure (BP) in the office, improper patient positioning and frequency of terminal digit bias (TDB) using manual and automated (BP) devices. Methods: BPs recorded by three nurses using manual and automated devices were analyzed for TDB. In the next part of the study, 294 patients were recruited and tested with each patient’s BP measured twice in the table position and compared with BP measured in the chair position.  To eliminate concern for position sequence, a randomized controlled trial was initially conducted. Results: Significant TDB for the digit zero was identified in BPs measured by all nurses using a manual device . No such bias was identified for any nurse when measuring BP with an automated device. For the positional study, the randomized controlled study showed No significant sequencing effect therefore the sequence of table then chair BP measurements was adopted. Significant BP lowering was observed in 128 patients (42.7%) in the chair compared to the table position. Misclassification of pre-hypertension and hypertension would have occurred in 15.3% and 16% of patients, respectively, when BP was recorded in the table instead of the chair position. Conclusions: Significant TDB was identified for all nurses when using a manual but not an automated device. Patient positioning on the examination table resulted in elevations of systolic and diastolic BPs.

FAMILY MEDICINE AND THE HEALTH CARE SYSTEM

Visit Entropy Associated with Diabetic Control Outcomes

Benjamin T. Dilger, MD; Margaret C. Gill, MD, MS; Jill G. Lenhart, MD; Gregory M. Garrison, MD, MS, FAAFP

Corresponding Author: Gregory M. Garrison, MD, MS, FAAFP; Mayo Clinic. Email: garrison.gregory@mayo.edu

Publication: September/October 2019 (Full article available online for free on September 10, 2019)

DOI: 10.3122/jabfm.2019.05.190026

Background: Chronic diseases such as type II diabetes place a large burden on the healthcare system and are associated with increased morbidity and mortality. A team-based multidisciplinary approach which organizes care to improve chronic disease management may actually decrease traditional continuity of care metrics. Visit Entropy (VE) provides a novel measure of care organization produced by team-based approaches. Higher VE, reflecting more disorganized care, has been associated with more hospital readmissions. We hypothesized that higher VE was also associated with reduced adherence to the D5 quality criteria. Methods: A retrospective study of 6,590 adult diabetic patients in five established medical home practices was conducted. Multivariate logistic regression was used to determine if VE was associated with the dependent variable of D5 control. Separate models for usual provider continuity, continuity of care index, and sequence continuity were also constructed. Results: Less organized care with a higher VE was associated with decreased odds of D5 control (OR=0.88, 95%CI 0.80-0.97). The other continuity measures were not significant. Age, education level, and initial HgA1c were significant covariates, but gender, race, endocrine consults, and Charlson comorbidity were not significant. The Number Needed to be Exposed to more organized care to produce one more controlled diabetic was 32.5. Conclusions: More organized care reflected by a lower VE is associated with improved odds of D5 diabetic control. VE represents a better measure of care organization in team based medical home environments than traditional continuity of care metrics.

RESEARCH LETTER

Blood Donation Rates in the United States 1999-2016: From the National Health and Nutrition Examination Survey (NHANES)

John P. Twarog, BS, MPH; Ashley T. Russo, BS, MS; Tara C. McElroy, BS, MPH; Elizabet Peraj, BA; Martin P. McGrath, BS; Austin C. Davidow, BS

Corresponding Author: John P. Twarog, BS, MPH; New York College of Podiatric Medicine. Email: jtwarog2021@nycpm.edu

Publication: September/October 2019 (Full article available online for free on September 10, 2019)

DOI: 10.3122/jabfm.2019.05.180378

Clinicians have historically relied on members of the local community to voluntarily donate blood to be used in necessarily medical situations for those in need of a blood transfusion. While there have been analyses on the qualities associated with individuals who chose to repeatedly donate blood, there is little know about national blood donation rates in the United States. This paper uses data from the National Health and Nutrition Examination Surveys conducted from 1999-2016 to assess changes in the national rates of blood donation among adults aged 20 years and older.

RESEARCH LETTER

The Effects of Telephone Visits and Rurality on Veterans Perceptions of Access to Primary Care

Michelle Lampman, PhD; Susan Stockdale, PhD; Peter J. Kaboli, MD, MS; Erin Jaske, MPH; G. Blake Wood, MS; Walter L. Clinton, PhD; Greg Stewart, PhD

Corresponding Author: Michelle Lampman, PhD; Mayo Clinic Email: lampman.michelle@mayo.edu

Publication: September/October 2019 (Full article available online for free on September 10, 2019)

DOI: 10.3122/jabfm.2019.05.190047

Introduction: The objectives of this study were to examine if self-reported access to primary care is associated with actual patient wait times and use of telephone visits, and to assess whether this relationship differs by rural residence. Methods: This study used 2016 administrative data from 994 primary care clinics within the Veterans Health Administration. Multiple-linear regression was used to examine relationships between patient perceptions of access and average actual patient wait-time, use of telephone visits, and rural residence. Average panel size, clinic type, and panel severity were included as model covariates with cross-product terms for actual wait time, telephone use, and rurality to test for interactions. Results: This study found patient perceptions of access aggregated at the clinic level to be conditional on the relationship between use of telephone visits, actual patient wait times, and rural residence. As actual wait time for routine appointments increases, Veterans served by clinics with a higher percent of rural Veterans perceive telephone visits more positively. Discussion: These findings contribute to our understanding of factors associated with patient perceptions of access by highlighting complex interrelationships between strategies intended to improve access to care and how they can have differing impacts on perceptions among those living in rural or urban locations.