Discriminative Accuracy of the CAPTURE Tool for Identifying Chronic Obstructive Pulmonary Disease in US Primary Care Settings.

Importance: Chronic obstructive pulmonary disease (COPD) is underdiagnosed in primary care. Objective: To evaluate the operating characteristics of the CAPTURE (COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk) screening tool for identifying US primary care patients with undiagnosed, clinically significant COPD. Design, Setting, and Participants: In this cross-sectional study, 4679 primary care patients aged 45 years to 80 years without a prior COPD diagnosis were enrolled by 7 primary care practice-based research networks across the US between October 12, 2018, and April 1, 2022. The CAPTURE questionnaire responses, peak expiratory flow rate, COPD Assessment Test scores, history of acute respiratory illnesses, demographics, and spirometry results were collected. Exposure: Undiagnosed COPD. Main Outcomes and Measures: The primary outcome was the CAPTURE tool's sensitivity and specificity for identifying patients with undiagnosed, clinically significant COPD. The secondary outcomes included the analyses of varying thresholds for defining a positive screening result for clinically significant COPD. A positive screening result was defined as (1) a CAPTURE questionnaire score of 5 or 6 or (2) a questionnaire score of 2, 3, or 4 together with a peak expiratory flow rate of less than 250 L/min for females or less than 350 L/min for males. Clinically significant COPD was defined as spirometry-defined COPD (postbronchodilator ratio of forced expiratory volume in the first second of expiration [FEV1] to forced vital capacity [FEV1:FVC] <0.70 or prebronchodilator FEV1:FVC <0.65 if postbronchodilator spirometry was not completed) combined with either an FEV1 less than 60% of the predicted value or a self-reported history of an acute respiratory illness within the past 12 months. Results: Of the 4325 patients who had adequate data for analysis (63.0% were women; the mean age was 61.6 years [SD, 9.1 years]), 44.6% had ever smoked cigarettes, 18.3% reported a prior asthma diagnosis or use of inhaled respiratory medications, 13.2% currently smoked cigarettes, and 10.0% reported at least 1 cardiovascular comorbidity. Among the 110 patients (2.5% of 4325) with undiagnosed, clinically significant COPD, 53 had a positive screening result with a sensitivity of 48.2% (95% CI, 38.6%-57.9%) and a specificity of 88.6% (95% CI, 87.6%-89.6%). The area under the receiver operating curve for varying positive screening thresholds was 0.81 (95% CI, 0.77-0.85). Conclusions and Relevance: Within this US primary care population, the CAPTURE screening tool had a low sensitivity but a high specificity for identifying clinically significant COPD defined by presence of airflow obstruction that is of moderate severity or accompanied by a history of acute respiratory illness. Further research is needed to optimize performance of the screening tool and to understand whether its use affects clinical outcomes.

Clinicians' Core Needs in a Pandemic: Qualitative Findings From the Chat Box in a Statewide COVID-19 ECHO Program.

PURPOSE: Research on primary care's role in a pandemic response has not adequately considered the day-to-day needs of clinicians in the midst of a crisis. We created an Oregon COVID-19 ECHO (Extension for Community Healthcare Outcomes) program, a telementoring education model for clinicians. The program was adapted for a large audience and encouraged interactivity among the hundreds of participants via the chat box. We assessed how chat box communications within the statewide program identified and ameliorated some of clinicians' needs during the pandemic. METHODS: We conducted a qualitative analysis of chat box transcripts from 11 sessions.We coded transcripts using the editing method, whereby analysts generate categories predominantly from the data, but also from prior knowledge. We then explored the context of clinicians' needs in a pandemic, as conceptualized in Maslow's hierarchy of needs adapted for physicians: physiologic, safety, love and belonging, esteem, and self-actualization. RESULTS: The mean number of chat box participants was 492 per session (range, 385 to 763). Participants asked 1,462 questions and made 819 comments throughout the program. We identified 3 key themes: seeking answers and trustworthy information, seeking practical resources, and seeking and providing affirmation and peer support. These themes mapped onto the Maslow's needs framework. We found that participants were able to create a virtual community in the chat box that supported many of their needs. CONCLUSIONS: Using a novel data source, we found sharing the experience of practicing in a rapidly changing environment via comments and questions in an ECHO program both defined and supported participants' needs.

Integration of Improvement and Implementation Science in Practice-Based Research Networks: a Longitudinal, Comparative Case Study.

BACKGROUND: Implementation science (IS) and quality improvement (QI) inhabit distinct areas of scholarly literature, but are often blended in practice. Because practice-based research networks (PBRNs) draw from both traditions, their experience could inform opportunities for strategic IS-QI alignment. OBJECTIVE: To systematically examine IS, QI, and IS/QI projects conducted within a PBRN over time to identify similarities, differences, and synergies. DESIGN: Longitudinal, comparative case study of projects conducted in the Oregon Rural Practice-based Research Network (ORPRN) from January 2007 to January 2019. APPROACH: We reviewed documents and conducted staff interviews. We classified projects as IS, QI, IS/QI, or other using established criteria. We abstracted project details (e.g., objective, setting, theoretical framework) and used qualitative synthesis to compare projects by classification and to identify the contributions of IS and QI within the same project. KEY RESULTS: Almost 30% (26/99) of ORPRN's projects included IS or QI elements; 54% (14/26) were classified as IS/QI. All 26 projects used an evidence-based intervention and shared many similarities in relation to objective and setting. Over half of the IS and IS/QI projects used randomized designs and theoretical frameworks, while no QI projects did. Projects displayed an upward trend in complexity over time. Project used a similar number of practice change strategies; however, projects classified as IS predominantly employed education/training while all IS/QI and most QI projects used practice facilitation. Projects including IS/QI elements demonstrated the following contributions: QI provides the mechanism by which the principles of IS are operationalized in order to support local practice change and IS in turn provides theories to inform implementation and evaluation to produce generalizable knowledge. CONCLUSIONS: Our review of projects conducted over a 12-year period in one PBRN demonstrates key synergies for IS and QI. Strategic alignment of IS/QI within projects may help improve care quality and bridge the research-practice gap.

Hypertensive ED patients: Missed opportunities for addressing hypertension and facilitating outpatient follow-up.

OBJECTIVES: Hypertension is a leading cause of morbidity and mortality. The emergency department (ED) frequently serves populations with unmet health needs and could have a greater and more systematic role in secondary prevention for hypertension. This study sought to determine, among hypertensive patients discharged from the ED, the frequency that patients 1) received hypertension-specific education, and 2) followed-up with a primary care provider. We secondarily assessed participant beliefs about hypertension. METHODS: This non-experimental, observational study enrolled a convenience sample of consenting patients with asymptomatic, markedly elevated blood pressure (systolic ≥160 mmHg or diastolic ≥100 mmHg) with medium to low triage acuity discharged from an urban, academic ED. Discharge instructions were assessed through chart review. Patients followed up per their normal routine without intervention. Participants were interviewed by phone two to four weeks after ED discharge to ascertain outpatient follow-up and describe beliefs about hypertension. RESULTS: From April through June 2014, 200 patients were approached, of whom 90 were enrolled. Of these, 77% of patients reported a previous diagnosis of hypertension, and 60% reported current treatment with antihypertensive medications. Five patients (5.5%) received written instructions at discharge addressing hypertension, although 59 (65.6%) reported that they were informed about their elevated blood pressure during the ED visit. Follow-up with a primary care provider within 2-4 weeks of discharge was completed in 57% of cases. None of the patients who received hypertension-specific discharge instructions completed follow-up. CONCLUSIONS: Over half of markedly hypertensive patients discharged from the ED followed up with primary care within four weeks. Nonetheless, missed opportunities for improved secondary prevention among ED patients with hypertension are common. There is an urgent need for evidence-based interventions to assist emergency departments in addressing this health threat.

Patterns of relating between physicians and medical assistants in small family medicine offices.

PURPOSE: The clinician-colleague relationship is a cornerstone of relationship-centered care (RCC); in small family medicine offices, the clinician-medical assistant (MA) relationship is especially important. We sought to better understand the relationship between MA roles and the clinician-MA relationship within the RCC framework. METHODS: We conducted an ethnographic study of 5 small family medicine offices (having <5 clinicians) in the Cincinnati Area Research and Improvement Group (CARInG) Network using interviews, surveys, and observations. We interviewed 19 MAs and supervisors and 11 clinicians (9 family physicians and 2 nurse practitioners) and observed 15 MAs in practice. Qualitative analysis used the editing style. RESULTS: MAs' roles in small family medicine offices were determined by MA career motivations and clinician-MA relationships. MA career motivations comprised interest in health care, easy training/workload, and customer service orientation. Clinician-MA relationships were influenced by how MAs and clinicians respond to their perceptions of MA clinical competence (illustrated predominantly by comparing MAs with nurses) and organizational structure. We propose a model, trust and verify, to describe the structure of the clinician-MA relationship. This model is informed by clinicians' roles in hiring and managing MAs and the social familiarity of MAs and clinicians. Within the RCC framework, these findings can be seen as previously undefined constraints and freedoms in what is known as the Complex Responsive Process of Relating between clinicians and MAs. CONCLUSIONS: Improved understanding of clinician-MA relationships will allow a better appreciation of how clinicians and MAs function in family medicine teams. Our findings may assist small offices undergoing practice transformation and guide future research to improve the education, training, and use of MAs in the family medicine setting.

Impact of the COVID-19 vaccination mandate on the primary care workforce and differences between rural and urban settings to inform future policy decision-making.

INTRODUCTION: Little is known about the impact of mandated vaccination policies on the primary care clinic workforce in the United States or differences between rural and urban settings, especially for COVID-19. With the continued pandemic and an anticipated increase in novel disease outbreaks and emerging vaccines, healthcare systems need additional information on how vaccine mandates impact the healthcare workforce to aid in future decision-making. METHODS: We conducted a cross-sectional survey of Oregon primary care clinic staff between October 28, 2021- November 18, 2021, following implementation of a COVID-19 vaccination mandate for healthcare personnel. The survey consisted of 19 questions that assessed the clinic-level impacts of the vaccination mandate. Outcomes included job loss among staff, receipt of an approved vaccination waiver, new vaccination among staff, and the perceived significance of the policy on clinic staffing. We used univariable descriptive statistics to compare outcomes between rural and urban clinics. The survey also included three open-ended questions that were analyzed using a template analysis approach. RESULTS: Staff from 80 clinics across 28 counties completed surveys, representing 38 rural and 42 urban clinics. Clinics reported job loss (46%), use of vaccination waivers (51%), and newly vaccinated staff (60%). Significantly more rural clinics (compared to urban) utilized medical and/or religious vaccination waivers (71% vs 33%, p = 0.04) and reported significant impact on clinic staffing (45% vs 21%, p = 0.048). There was also a non-significant trend toward more job loss for rural compared to urban clinics (53% vs. 41%, p = 0.547). Qualitative analysis highlighted a decline in clinic morale, small but meaningful detriments to patient care, and mixed opinions of the vaccination mandate. CONCLUSIONS: Oregon's COVID-19 vaccination mandate increased healthcare personnel vaccination rates, yet amplified staffing challenges with disproportionate impacts in rural areas. Staffing impacts in primary care clinics were greater than reported previously in hospital settings and with other vaccination mandates. Mitigating primary care staffing impacts, particularly in rural areas, will be critical in response to the continued pandemic and novel viruses in the future.

Behavioral profiling of multiple pairs of rats selectively bred for high and low alcohol intake using the MCSF test.

Genetic aspects of alcoholism have been modeled using rats selectively bred for extremes of alcohol preference and voluntary alcohol intake. These lines show similar alcohol drinking phenotypes but have different genetic and environmental backgrounds and may therefore display diverse behavioral traits as seen in human alcoholics. The multivariate concentric square field™ (MCSF) test is designed to provoke exploration and behaviors associated with risk assessment, risk taking and shelter seeking in a novel environment. The aim was to use the MCSF to characterize behavioral profiles in rat lines from selective breeding programs in the United States (P/NP, HAD1/LAD1, HAD2/LAD2), Italy (sP/sNP) and Finland (AA/ANA). The open field and elevated plus maze tests were used as reference tests. There were substantial differences within some of the pairs of selectively bred rat lines as well as between all alcohol-preferring rats. The most pronounced differences within the pairs of lines were between AA and ANA rats and between sP and sNP rats followed by intermediate differences between P and NP rats and minor differences comparing HAD and LAD rats. Among all preferring lines, P, HAD1 and HAD2 rats shared similar behavioral profiles, while AA and sP rats were quite different from each other and the others. No single trait appeared to form a common 'pathway' associated with a high alcohol drinking phenotype among all of the alcohol-preferring lines of rats. The marked behavioral differences found in the different alcohol-preferring lines may mimic the heterogeneity observed among human alcoholic subtypes.

"But what does it mean for me?" Primary care patients' communication preferences for test results notification.

BACKGROUND: The best ways to communicate test results in primary care to achieve patient satisfaction and assist patients to incorporate results into their personal health decision making are unknown. A study was conducted to determine the factors that patients believe are important in achieving those goals. METHODS: Semistructured interviews were conducted with a convenience sample of 12 adults, at least half with a chronic disease requiring regular testing, who shared experiences about receiving test results from physicians' offices and how they used them in their health decision making. In addition, "think aloud" interviewing techniques were used to assess participants' satisfaction and stated understanding with six different formats for receiving a hypothetical test result (a mildly elevated lipid profile). The interviews were analyzed using the editing technique to determine important factors in test results notification. FINDINGS: Three themes were found to be important in satisfaction with and stated understanding and use of test results: (1) the information shared (test result, clinician interpretation and guidance), (2) significance of the results (testing purpose, abnormal or normal result) and (3) personal preferences for communication (timeliness, interpersonal connection, and hard copy). Participants' stated understanding was highest, among several potential formats, for actual values with desired/normal values, a low-literacy description of the test's purpose, and a simple graph. CONCLUSIONS: A results notification algorithm includes (1) communication elements (the purpose of the test, the actual results with desired values, clinician guidance, and a graphical representation) and (2) appropriate choice of notification technique (phone/visit for diagnostic tests and all significantly abnormal results and mail/e-mail/Web for all others).

Telehealth-guided provider-to-provider communication to improve rural health: A systematic review.

INTRODUCTION: Telehealth may address healthcare disparities for rural populations. This systematic review assesses the use, effectiveness, and implementation of telehealth-supported provider-to-provider collaboration to improve rural healthcare. METHODS: We searched Ovid MEDLINE®, CINAHL®, EMBASE, and Cochrane CENTRAL from 1 January 2010 to 12 October 2021 for trials and observational studies of rural provider-to-provider telehealth. Abstracts and full text were dual-reviewed. We assessed the risk of bias for individual studies and strength of evidence for studies with similar outcomes. RESULTS: Seven studies of rural uptake of provider-to-provider telehealth documented increases over time but variability across geographic regions. In 97 effectiveness studies, outcomes were similar with rural provider-to-provider telehealth versus without for inpatient consultations, neonatal care, outpatient depression and diabetes, and emergency care. Better or similar results were reported for changes in rural clinician behavior, knowledge, confidence, and self-efficacy. Evidence was insufficient for other clinical uses and outcomes. Sixty-seven (67) evaluation and qualitative studies identified barriers and facilitators to implementing rural provider-to-provider telehealth. Success was linked to well-functioning technology, sufficient resources, and adequate payment. Barriers included lack of understanding of rural context and resources. Methodologic weaknesses of studies included less rigorous study designs and small samples. DISCUSSION: Rural provider-to-provider telehealth produces similar or better results versus care without telehealth. Barriers to rural provider-to-provider telehealth implementation are common to practice change but include some specific to rural adaptation and adoption. Evidence gaps are partially due to studies that do not address differences in the groups compared or do not include sufficient sample sizes.

Improving screening, treatment, and intervention for unhealthy alcohol use in primary care through clinic, practice-based research network, and health plan partnerships: Protocol of the ANTECEDENT study.

BACKGROUND: Unhealthy alcohol use (UAU) is a leading cause of morbidity and mortality in the United States, contributing to 95,000 deaths annually. When offered in primary care, screening, brief intervention, referral to treatment (SBIRT), and medication-assisted treatment for alcohol use disorder (MAUD) can effectively address UAU. However, these interventions are not yet routine in primary care clinics. Therefore, our study evaluates tailored implementation support to increase SBIRT and MAUD in primary care. METHODS: ANTECEDENT is a pragmatic implementation study designed to support 150 primary care clinics in Oregon adopting and optimizing SBIRT and MAUD workflows to address UAU. The study is a partnership between the Oregon Health Authority Transformation Center-state leaders in Medicaid health system transformation-SBIRT Oregon and the Oregon Rural Practice-based Research Network. We recruited clinics providing primary care in Oregon and prioritized reaching clinics that were small to medium in size (<10 providers). All participating clinics receive foundational support (i.e., a baseline assessment, exit assessment, and access to the online SBIRT Oregon materials) and may opt to receive tailored implementation support delivered by a practice facilitator over 12 months. Tailored implementation support is designed to address identified needs and may include health information technology support, peer-to-peer learning, workflow mapping, or expert consultation via academic detailing. The study aims are to 1) engage, recruit, and conduct needs assessments with 150 primary care clinics and their regional Medicaid health plans called Coordinated Care Organizations within the state of Oregon, 2) implement and evaluate the impact of foundational and supplemental implementation support on clinic change in SBIRT and MAUD, and 3) describe how practice facilitators tailor implementation support based on context and personal expertise. Our convergent parallel mixed-methods analysis uses RE-AIM (reach, effectiveness, adoption, implementation, maintenance). It is informed by a hybrid of the i-PARIHS (integrated Promoting Action on Research Implementation in Health Services) and the Dynamic Sustainability Framework. DISCUSSION: This study will explore how primary care clinics implement SBIRT and MAUD in routine practice and how practice facilitators vary implementation support across diverse clinic settings. Findings will inform how to effectively align implementation support to context, advance our understanding of practice facilitator skill development over time, and ultimately improve detection and treatment of UAU across diverse primary care clinics.

Mailed fecal testing and patient navigation versus usual care to improve rates of colorectal cancer screening and follow-up colonoscopy in rural Medicaid enrollees: a cluster-randomized controlled trial.

BACKGROUND: Screening reduces incidence and mortality from colorectal cancer (CRC), yet US screening rates are low, particularly among Medicaid enrollees in rural communities. We describe a two-phase project, SMARTER CRC, designed to achieve the National Cancer Institute Cancer MoonshotSM objectives by reducing the burden of CRC on the US population. Specifically, SMARTER CRC aims to test the implementation, effectiveness, and maintenance of a mailed fecal test and patient navigation program to improve rates of CRC screening, follow-up colonoscopy, and referral to care in clinics serving rural Medicaid enrollees. METHODS: Phase I activities in SMARTER CRC include a two-arm cluster-randomized controlled trial of a mailed fecal test and patient navigation program involving three Medicaid health plans and 30 rural primary care practices in Oregon and Idaho; the implementation of the program is supported by training and practice facilitation. Participating clinic units were randomized 1:1 into the intervention or usual care. The intervention combines (1) mailed fecal testing outreach supported by clinics, health plans, and vendors and (2) patient navigation for colonoscopy following an abnormal fecal test result. We will evaluate the effectiveness, implementation, and maintenance of the intervention and track adaptations to the intervention and to implementation strategies, using quantitative and qualitative methods. Our primary effectiveness outcome is receipt of any CRC screening within 6 months of enrollee identification. Our primary implementation outcome is health plan- and clinic-level rates of program delivery, by component (mailed FIT and patient navigation). Trial results will inform phase II activities to scale up the program through partnerships with health plans, primary care clinics, and regional and national organizations that serve rural primary care clinics; scale-up will include webinars, train-the-trainer workshops, and collaborative learning activities. DISCUSSION: This study will test the implementation, effectiveness, and scale-up of a multi-component mailed fecal testing and patient navigation program to improve CRC screening rates in rural Medicaid enrollees. Our findings may inform approaches for adapting and scaling evidence-based approaches to promote CRC screening participation in underserved populations and settings. TRIAL REGISTRATION: Registered at clinicaltrial.gov ( NCT04890054 ) and at the NCI's Clinical Trials Reporting Program (CTRP #: NCI-2021-01032) on May 11, 2021.

Clinical work intensity among physician specialties: how might we assess it? What do we find?

BACKGROUND: The level of work intensity associated with patient encounters has implications for quality of care, patient safety, practice management, and reimbursement. The utility of available instruments for clinical work intensity assessment is unknown. OBJECTIVE: We assessed, in the clinical setting, the performance of existing measures of work intensity that are valid for nonclinical contexts. RESEARCH DESIGN: A cross-sectional, multimeasure design involving work intensity assessments for the last patient encounter and for an entire half-day clinic session. SUBJECTS: A convenience sample of 14 providers from the following 4 specialties: family medicine, general internal medicine, neurology, and surgery. MEASURES: Perceived clinical work intensity was measured by the following 3 instruments: National Aeronautic and Space Administration-Task Load Index, Subjective Workload Assessment Technique, and Multiple Resources Questionnaire; stress was measured by the Dundee Stress State Questionnaire. Convergent validity was assessed by correlation among the instruments. RESULTS: For the last patient encounter, there was a moderate to high correlation between the work intensity instruments' scores (Pearson's r ranged from 0.41 to 0.73) and low to moderate correlation with the distress subscale of the Dundee Stress State Questionnaire (Pearson's r ranged from -0.11 to 0.46), reflecting their stress dimension. Provider personality was associated with reported levels of work intensity and stress. Similar results were obtained when the entire clinic session was the unit of reference. CONCLUSION: Existing measures of work intensity and stress appear to be valid for use in the clinical setting to generate evidence on perceived intensity and stress experienced by providers in the performance of medical services.

Temporal and subjective work demands in office-based patient care: an exploration of the dimensions of physician work intensity.

BACKGROUND: Physician work intensity (WI) during office-based patient care affects quality of care and patient safety as well as physician job-satisfaction and reimbursement. Existing, brief work intensity measures have been used in physician studies, but their validity in clinical settings has not been established. OBJECTIVES: Document and describe subjective and temporal WI dimensions for physicians in office-based clinical settings. Examine these in relation to the measurement procedures and dimensions of the SWAT and NASA-TLX intensity measures. DESIGN: A focused ethnographic study using interviews and direct observations. PARTICIPANTS: Five family physicians, 5 general internists, 5 neurologists, and 4 surgeons. METHODS: Through interviews, each physician was asked to describe low and high intensity work responsibilities, patients, and events. To document time and task allotments, physicians were observed during a routine workday. Notes and transcripts were analyzed using the editing method in which categories are obtained from the data. RESULTS: WI factors identified by physicians matched dimensions assessed by standard, generic instruments of work intensity. Physicians also reported WI factors outside of the direct patient encounter. Across specialties, physician time spent in direct contact with patients averaged 61% for office-based services. CONCLUSIONS: Brief work intensity measures such as the SWAT and NASA-TLX can be used to assess WI in the office-based clinical setting. However, because these measures define the physician work "task" in terms of effort in the presence of the patient (ie, intraservice time), substantial physician effort dedicated to pre- and postservice activities is not captured.

Crossing the finish line: follow-up of abnormal test results in a multisite community health center.

BACKGROUND: Inadequate follow-up of abnormal test results is a common safety problem in outpatient practice. However, it is unclear exactly where and how often failures occur in the results management process. Our goal was to determine where breakdowns occur by examining 4 high-risk abnormal test results in a group of 11 clinics of an urban community health center organization. METHODS: Using a chart audit, we counted failures in the management of abnormal results of 4 tests: Pap smears, mammograms, international normalized ratio (INR), and prostate-specific antigen (PSA). We assessed documentation that the result was filed in the chart; the provider signed and responded to the result; the patient was notified of the result; the appropriate follow-up occurred, and it occurred in a timely manner or there was explicit patient refusal of the recommended follow-up. RESULTS: There were 344 abnormal test results (105 Pap smears, 82 mammograms, 61 INRs, and 96 PSAs). The highest rate of failures in the management process was at follow-up care; 34% of the abnormal results did not have documentation that appropriate follow-up had occurred (11% for mammography, 26% for INR, 45% for Pap smears, and 46% for PSA). All of the earlier steps were performed with far fewer failures. For patients receiving follow-up care, 49% of the time, follow-up care did not occur in a timely manner. CONCLUSIONS: Most breakdowns in the testing process for these 4 abnormal tests were in the final step, documenting that appropriate follow-up care occurred. Office systems for managing abnormal results reporting and patient follow-up are needed to improve the safety and quality of care.

Project ECHO Integrated Within the Oregon Rural Practice-based Research Network (ORPRN).

Two key advancements in improving the quality of primary care have been practice-based research networks (PBRNs) and Project Extension for Community Health care Outcomes (ECHO). PBRNs advance quality through research and transformation projects, often using practice facilitation. Project ECHO uses case-based telementoring to support community clinicians to deliver best-practice care. Although some PBRNs sponsor ECHO programs, the Oregon Rural Practice-based Research Network (ORPRN) has created a statewide network for ECHO programs (Oregon ECHO Network [OEN]). We facilitated a unique funding stream for the OEN by partnering with payers and health systems. The purpose of this article is to share our experience of how OEN programs and ORPRN research and transformation projects enhance practice recruitment and retention and improve financial stability. We describe the synergy between ORPRN projects and ECHO programs using 3 examples: tobacco cessation, chronic pain and opioid prescribing, and diabetes management. We highlight challenges and opportunities in these examples, beginning with their development, their implementation, and their ultimate alignment, despite varied funding streams and timelines. We believe that incorporating the OEN within ORPRN has been a success for both PBRN research and Project ECHO programs, allowing us to better support primary care practices across the state.

Increasing collaboration on substance use disorder research with primary care practices through the National Drug Abuse Treatment Clinical Trials Network.

BACKGROUND: The National Drug Abuse Treatment Clinical Trials Network (CTN) called for its national nodes to promote the translation of evidence-based interventions from substance use disorder (SUD) research into clinical practices. This collaborative demonstration project engaged CTN-affiliated practice-based research networks (PBRNs) in research that describes aspects of opioid prescribing in primary care. METHODS: Six PBRNs queried electronic health records from a convenience sample of 134 practices (84 participants) to identify the percent of adult patients with an office visit who were prescribed an opioid medication from October 1, 2015, to September 30, 2016, and, of those, the percent also prescribed a sedative in that year. Seven PBRNs sent an e-mail survey to a convenience sample of 108 practices (58 participants) about their opioid management policies and procedures during the project year. RESULTS: Of 561,017 adult patients with a visit to one of the 84 clinics in the project year, 22.9% (PBRN range 3.1%-25.4%) were prescribed opioid medications, and 52.1% (PBRN range 8.5%-60.6%) of those were prescribed a sedative in the same year. Of the 58 practices returning a survey (45.3% response rate), 98.1% had formal written treatment agreements for chronic opioid therapy, 68.5% had written opioid prescribing policies, and 43.4% provided reports to providers with feedback on opioid management. Only 24.1% were providing buprenorphine for OUD. CONCLUSION: CTN-affiliated PBRNs demonstrated their ability to collaborate on a project related to opioid management; results highlight the important role for PBRNs in OUD treatment, research, and the need for interventions and additional policies addressing opioid prescribing in primary care practice.

A Community-based Assessment of Skin Care, Allergies, and Eczema (CASCADE): an atopic dermatitis primary prevention study using emollients-protocol for a randomized controlled trial.

BACKGROUND: Atopic dermatitis (AD) is a common, chronic skin disorder often beginning in infancy. Skin barrier dysfunction early in life serves as a central event in the pathogenesis of AD. In infants at high risk of developing AD, preventative application of lipid-rich emollients may reduce the risk of developing AD. This study aims to measure the effectiveness of this intervention in a population not selected for risk via a pragmatic, randomized, physician-blinded trial in the primary care setting. METHODS: Infant-parent dyads are recruited from a primary care practice participating through one of four practice-based research networks in Oregon, Colorado, Wisconsin, and North Carolina. Eligible dyads are randomized to the intervention (daily use of lipid-rich emollient) or the control (no emollient) group (n = 625 infants in each) and are followed for 24 months. The primary outcome is the cumulative incidence of physician-diagnosed AD and secondary outcomes include caregiver-reported measures of AD and development of other atopic diseases. Data collection occurs via chart review and surveys, with no study visits required. Data will be analyzed utilizing intention-to-treat principles. DISCUSSION: AD is a common skin condition in infants that affects quality of life and is associated with the development of other atopic diseases. If a safe intervention, such as application of lipid-rich emollients, in the general population effectively decreases AD prevalence, this could alter the guidance given by providers regarding routine skin care of infants. Because of the pragmatic design, we anticipate that this trial will yield generalizable results. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03409367. Registered on 11 February 2018.

Management of test results in family medicine offices.

PURPOSE: We wanted to explore test results management systems in family medicine offices and to delineate the components of quality in results management. METHODS: Using a multimethod protocol, we intensively studied 4 purposefully chosen family medicine offices using observations, interviews, and surveys. Data analysis consisted of iterative qualitative analysis, descriptive frequencies, and individual case studies, followed by a comparative case analysis. We assessed the quality of results management at each practice by both the presence of and adherence to systemwide practices for each results management step, as well as outcomes from chart reviews, patient surveys, and interview and observation notes. RESULTS: We found variability between offices in how they performed the tasks for each of the specific steps of results management. No office consistently had or adhered to office-wide results management practices, and only 2 offices had written protocols or procedures for any results management steps. Whereas most patients surveyed acknowledged receiving their test results (87% to 100%), a far smaller proportion of patient charts documented patient notification (58% to 85%), clinician response to the result (47% to 84%), and follow-up for abnormal results (28% to 55%). We found 2 themes that emerged as factors of importance in assessing test results management quality: safety awareness-a leadership focus and communication that occurs around quality and safety, teamwork in the office, and the presence of appropriate policies and procedures; and technological adoption-the presence of an electronic health record, digital connections between the office and testing facilities, use of technology to facilitate patient communication, and the presence of forcing functions (built-in safeguards and requirements). CONCLUSION: Understanding the components of safety awareness and technological adoption can assist family medicine offices in evaluating their own results management processes and help them design systems that can lead to higher quality care.

Practice-Based Research Today: A Changing Primary Care Landscape Requires Changes in Practice-Based Research Network (PBRN) Research.

Primary care has changed in the past 40 years, and research performed within and by practice-based research networks (PBRN) needs to change to keep up with the current practice landscape. A key task for PBRNs is to connect with today's stakeholders, not only the traditional physicians, providers, office staff, and patients, but health systems, insurance companies, and government agencies. In addition to one-time externally funded engagement efforts, PBRNs must develop and report on sustainable, long-term strategies. PBRNs are also demonstrating how they use classic practice-based research techniques of practice facilitation and electronic health record (EHR) data extraction and reporting in new and important research areas, such as studying the opioid epidemic. PBRNs are adapting and transforming along with primary care.