A Cluster Randomized Trial of Primary Care Practice Redesign to Integrate Behavioral Health for Those Who Need It Most: Patients With Multiple Chronic Conditions.

PURPOSE: Patient outcomes can improve when primary care and behavioral health providers use a collaborative system of care, but integrating these services is difficult. We tested the effectiveness of a practice intervention for improving patient outcomes by enhancing integrated behavioral health (IBH) activities. METHODS: We conducted a pragmatic, cluster randomized controlled trial. The intervention combined practice redesign, quality improvement coaching, provider and staff education, and collaborative learning. At baseline and 2 years, staff at 42 primary care practices completed the Practice Integration Profile (PIP) as a measure of IBH. Adult patients with multiple chronic medical and behavioral conditions completed the Patient-Reported Outcomes Measurement Information System (PROMIS-29) survey. Primary outcomes were the change in 8 PROMIS-29 domain scores. Secondary outcomes included change in level of integration. RESULTS: Intervention assignment had no effect on change in outcomes reported by 2,426 patients who completed both baseline and 2-year surveys. Practices assigned to the intervention improved PIP workflow scores but not PIP total scores. Baseline PIP total score was significantly associated with patient-reported function, independent of intervention. Active practices that completed intervention workbooks (n = 13) improved patient-reported outcomes and practice integration (P ≤ .05) compared with other active practices (n = 7). CONCLUSION: Intervention assignment had no effect on change in patient outcomes; however, we did observe improved patient outcomes among practices that entered the study with greater IBH. We also observed more improvement of integration and patient outcomes among active practices that completed the intervention compared to active practices that did not. Additional research is needed to understand how implementation efforts to enhance IBH can best reach patients.

Identifying Priorities and Strategies for Improving Colorectal Cancer Screening in Tribal Clinics.

BACKGROUND: Colorectal cancer (CRC) is the 3rd most frequently diagnosed cancer and the 2nd leading cause of cancer death in the United States (US), and incidence and mortality rates in Oklahoma are higher for many American Indian (AI) populations than other populations. The AI CRC Screening Consortium addresses major regional CRC screening disparities among AIs with shared objectives to increase CRC screening delivery and uptake in AIs aged 50 to 75 years at average risk for CRC and to assess the effectiveness of implementations of the interventions. This manuscript reports environmental scan findings related to current practices and multi-stakeholder experiences with CRC screening in two Oklahoma Indian health care systems. METHOD: We conducted a mixed methods environmental scan across five clinical sites and with multiple stakeholders to determine the scope and scale of colorectal cancer screening in two separate AI health care delivery systems in Oklahoma. Data collection consisted of a mixture of individual interviews and group discussions at an urban site, and four clinical care sites within a tribal health system. RESULTS: Sixty-two individuals completed interviews. Data from these interviews will inform the development of evidence-based intervention strategies to increase provider delivery, community access to, and community priority for CRC screening in diverse AI health care delivery systems. Conversations with patients, providers, and clinical leadership point to individual and system-level opportunities for improvement at each site, shaped in part by differences in the delivery of services, structure of the health care system, and capacity to implement new intervention strategies. The thematic areas most central to the process of evidenced-based intervention development included: current practices, needs and recommendations, and CRC site priorities. CONCLUSION: Environmental scan data indicated clear opportunities for individual and system-level interventions to enhance CRC screening and was critical for understanding readiness for EBI implementation at each site.

Integrating behavioral health & primary care for multiple chronic diseases: Clinical trial of a practice redesign toolkit.

Context: Most patients in need of behavioral health (BH) care are seen in primary care, which often has difficulty responding. Some practices integrate behavioral health care (IBH), with medical and BH providers at the same location, working as a team. However, it is difficult to achieve high levels of integration. Objective: Test the effectiveness of a practice intervention designed to increase BH integration. Study Design: Pragmatic, cluster-randomized controlled trial. Setting: 43 primary care practices with on-site BH services in 13 states. Population: 2,460 adults with multiple chronic medical and behavioral conditions. Intervention: 24-month practice change process including an online curriculum, a practice redesign and implementation workbook, remote quality improvement coaching services, and an online learning community. Outcomes: Primary outcomes were changes in the 8 Patient-Reported Outcomes Measurement Information System (PROMIS-29) domain scores. Secondary outcomes were changes in medication adherence, self-reported healthcare utilization, time lost due to disability, cardiovascular capacity, patient centeredness, provider empathy, and several condition-specific measures. A sample of practice staff completed the Practice Integration Profile at each time point to estimate the degree of BH integration in that site. Practice-level case studies estimated the typical costs of implementing the intervention. Results: The intervention had no significant effect on any of the primary or secondary outcomes. Subgroup analyses showed no convincing patterns of effect in any populations. COVID-19 was apparently not a moderating influence of the effect of the intervention on outcomes. The intervention had a modest effect on the degree of practice integration, reaching statistical significance in the Workflow domain. The median cost of the intervention was $18,204 per practice. In post-hoc analysis, level of BH integration was associated with improved patient outcomes independent of the intervention, both at baseline and longitudinally. Conclusions: The specific intervention tested in this study was inexpensive, but had only a small impact on the degree of BH integration, and none on patient outcomes. However, practices that had more integration at baseline had better patient outcomes, independent of the intervention. Although this particular intervention was ineffective, IBH remains an attractive strategy for improving patient outcomes.

Moving From Problem-Oriented to Goal-Directed Health Records.

Electronic health records (EHRs) have been in place for decades; however, most existing systems were designed in the prevailing disease- and payment-focused care paradigm that often loses sight of the goals, needs, and values of patients and clinicians. The goal-directed health care model was proposed more than 20 years ago, but no design principles have been developed for corresponding electronic record systems. Newly designed EHRs are needed to facilitate health care that is anchored by patient life and health goals. We explore the limitations of current EHRs and propose a blueprint for a new EHR design that may facilitate goal-directed health care. To reflect patient goals as a thread through the care continuum, we propose 5 major system functions for goal-directed health records based on the 8 characteristics of primary health care defined by the Institute of Medicine. We also discuss how new EHR functions could support goal-directed health care and how payment and quality measurement systems will need to be transformed. It may be possible for patient life and health goals to drive health care that is reinforced by a corresponding health record design; however, synchronized shifts must occur in the models of providing, documenting, and paying for health care.

Disseminating, implementing, and evaluating patient-centered outcomes to improve cardiovascular care using a stepped-wedge design: healthy hearts for Oklahoma.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in the US and incurs high health care costs. While many initiatives promote the implementation of ABCS (aspirin therapy, blood pressure control, cholesterol management, and smoking cessation) measures, most primary care practices (PCPs) lack quality improvement (QI) support and resources to achieve meaningful targets. The Healthy Hearts for Oklahoma (H2O) Study proposes to build a QI infrastructure by (1) constructing a sustainable Oklahoma Primary Healthcare Improvement Collaborative (OPHIC) to support dissemination and implementation (D&I) of QI methods; (2) providing QI support in PCPs to better manage patients at risk for CVD events. Parallel to infrastructure building, H2O aims to conduct a comprehensive evaluation of the QI support D&I in primary care and assess the relationship between QI support uptake and changes in ABCS measures. METHODS: H2O has partnered with public health agencies and communities to build OPHIC and facilitate QI. H2O has 263 small primary care practices across Oklahoma that receive the bundled QI intervention to improve ABCS performance. A stepped-wedge designed is used to evaluate D&I of QI support. Changes in ABCS measures will be estimated as a function of various components of the QI support and capacity and readiness of PCPs to change. Notes from academic detailing and practice facilitation sessions will be analyzed to help interpret findings on ABCS performance. DISCUSSION: H2O program is designed to improve cardiovascular health and outcomes for more than 1.25 million Oklahomans. The infrastructure established as a result of this funding will help reach medically underserved Oklahomans, particularly among rural and tribal populations. Lessons learned from this project will guide future strategies for D&I of evidence-based practices in PCPs. Trained practice facilitators will continue to serve as critical resource to assists small, rural PCPs in adapting to the ever-changing health environment and continue to deliver quality care to their communities.

Pet Dogs and Children's Health: Opportunities for Chronic Disease Prevention?

INTRODUCTION: Positive associations between having a pet dog and adult health outcomes have been documented; however, little evidence exists regarding the benefits of pet dogs for young children. This study investigates the hypothesis that pet dogs are positively associated with healthy weight and mental health among children. METHODS: This cross-sectional study accrued a consecutive sample of children over 18 months in a pediatric primary care setting. The study enrolled 643 children (mean age, 6.7 years); 96% were white, 45% were female, 56% were privately insured, and 58% had pet dogs in the home. Before an annual visit, parents of children aged 4 to 10 years completed the DartScreen, a comprehensive Web-based health risk screener administered using an electronic tablet. The screener domains were child body mass index (BMI), physical activity, screen time, mental health, and pet-related questions. RESULTS: Children with and children without pet dogs did not differ in BMI (P = .80), screen time of 2 hours or less (P = 0.99), or physical activity (P = .07). A lower percentage of children with dogs (12%) met the clinical cut-off value of Screen for Child Anxiety and Related Disorders (SCARED-5) of 3 or more, compared with children without dogs (21%, P = .002). The mean SCARED-5 score was lower among children with dogs (1.13) compared with children without dogs (1.40; P = .01). This relationship was retained in multivariate analysis after controlling for several covariates. CONCLUSIONS: Having a pet dog in the home was associated with a decreased probability of childhood anxiety. Future studies need to establish whether this relationship is causal and, if so, how pet dogs alleviate childhood anxiety.

Integrating a tailored e-health self-management application for chronic obstructive pulmonary disease patients into primary care: a pilot study.

BACKGROUND: Changes in reimbursement have been compelling for Dutch primary care practices to apply a disease management approach for patients with chronic obstructive pulmonary disease (COPD). This approach includes individual patient consultations with a practice nurse, who coaches patients in COPD management. The aim of this study was to gauge the feasibility of adding a web-based patient self-management support application, by assessing patients' self-management, patients' health status, the impact on the organization of care, and the level of application use and appreciation. METHODS: The study employed a mixed methods design. Six practice nurses recruited COPD patients during a consultation. The e-Health application included a questionnaire that captured information on demographics, self-management related behaviors (smoking cessation, physical activity and medication adherence) and their determinants, and nurse recommendations. The application provided tailored feedback messages to patients and provided the nurse with reports. Data were collected through questionnaires and medical record abstractions at baseline and one year later. Semi-structured interviews with patients and nurses were conducted. Descriptive statistics were calculated for quantitative data and content analysis was used to analyze the qualitative data. RESULTS: Eleven patients, recruited by three nurses, used the application 1 to 7 times (median 4). Most patients thought that the application supported self-management, but their interest diminished after multiple uses. Impact on patients' health could not be determined due to the small sample size. Nurses reported benefits for the organization of care and made suggestions to optimize the use of the reports. CONCLUSION: Results suggest that it is possible to integrate a web-based COPD self-management application into the current primary care disease management process. The pilot study also revealed opportunities to improve the application and reports, in order to increase technology use and appreciation.

A randomised controlled trial testing a web-based, computer-tailored self-management intervention for people with or at risk for chronic obstructive pulmonary disease: a study protocol.

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is a major cause of morbidity and mortality. Effective self-management support interventions are needed to improve the health and functional status of people with COPD or at risk for COPD. Computer-tailored technology could be an effective way to provide this support. METHODS/DESIGN: This paper presents the protocol of a randomised controlled trial testing the effectiveness of a web-based, computer-tailored self-management intervention to change health behaviours of people with or at risk for COPD. An intervention group will be compared to a usual care control group, in which the intervention group will receive a web-based, computer-tailored self-management intervention. Participants will be recruited from an online panel and through general practices. Outcomes will be measured at baseline and at 6 months. The primary outcomes will be smoking behaviour, measuring the 7-day point prevalence abstinence and physical activity, measured in minutes. Secondary outcomes will include dyspnoea score, quality of life, stages of change, intention to change behaviour and alternative smoking behaviour measures, including current smoking behaviour, 24-hour point prevalence abstinence, prolonged abstinence, continued abstinence and number of quit attempts. DISCUSSION: To the best of our knowledge, this will be the first randomised controlled trial to test the effectiveness of a web-based, computer-tailored self-management intervention for people with or at risk for COPD. The results will be important to explore the possible benefits of computer-tailored interventions for the self-management of people with or at risk for COPD and potentially other chronic health conditions. DUTCH TRIAL REGISTER: NTR3421.

[Patient satisfaction with care in gastrooesophageal reflux disease]. / A gastrooesophagealis refluxban szenvedo betegek elégedettségének felmérése.

INTRODUCTION: Besides medical treatment, adequate communication and personal relationships between physicians and patients are the most important determinants of patient satisfaction. AIM: To explore doctor-patient relationships, and factors that may determine patient satisfaction with care. METHOD: Patients with gastroesophageal reflux (n = 80) were divided into subgroups treated by family doctors or by gastroenterologists. Patients were asked to fill in a questionnaire about communication and patient satisfaction. RESULTS: Significantly more patients visited family doctors than gastroenterologists with health problems (80%; 20%, p < 0.001). Patients were significantly more satisfied with the information they received about the process of care provided by family doctors (95%) compared to that they obtained from gastroenterologists (65%; p = 0.002). Significantly more patients in family practices indicated that their doctors spent enough time with them compared to subspecialists (96.7%; 80% p = 0.032). CONCLUSIONS: Patients develop a closer personal relationship and more appropriate communication with family doctors compared to specialists, which can be an important component of successful treatment.

Mobile Health Interventions to Improve Health Behaviors and Healthcare Services among Vietnamese Individuals: A Systematic Review.

The purpose of this review is to summarize the feasibility, acceptability, and efficacy of interventions that utilize mobile health (mHealth) technology to promote health behavior changes or improve healthcare services among the Vietnamese population. Ovid MEDLINE, CINAHL, EMBASE, Scopus, and Web of Science were used to identify studies published from 2011-2022. Studies utilizing mHealth to promote behavior change and/or improve healthcare services among Vietnamese were included. Studies that included Vietnamese people among other Asians but did not analyze the Vietnamese group separately were excluded. Three independent researchers extracted data using Covidence following PRISMA guidelines. Measures of feasibility, acceptability, and efficacy were synthesized. The ROBINS-I and RoB2 tools were used to evaluate methodological quality. Fourteen articles met inclusion criteria and included 5660 participants. Participants rated high satisfaction, usefulness, and efficacy of mHealth interventions. Short message service was most frequently used to provide health education, support smoking cessation, monitor chronic diseases, provide follow-up, and manage vaccination. Measures of feasibility, acceptability, and efficacy varied across studies; overall findings indicated that mHealth is promising for promoting lifestyle behavior change and improving healthcare services. Cost effectiveness and long-term outcomes of mHealth interventions among the Vietnamese population are unknown and merit further research. Recommendations to integrate mHealth interventions are provided to promote the health of Vietnamese people.

mHealth Intervention for Vietnamese Living With Diabetes: Protocol for a Stepped Wedge Pilot Study.

BACKGROUND: Evidence indicates participation in a diabetes self-management education and support program improves self-care behaviors and hemoglobin A1c. Language and cultural differences may be barriers to program participation resulting in ineffective self-management, but these factors can be addressed with appropriate interventions. Given the high health care costs associated with diabetes complications, we developed a multicomponent, culturally tailored Self-Management Mobile Health Intervention for US Vietnamese With Diabetes (SMart-D). OBJECTIVE: This study aims to evaluate the SMart-D intervention's feasibility, acceptability, and effectiveness with intentions to scale up the intervention in the future. This mixed methods study incorporates the Reach, Effectiveness, Adoption, Implementation, Maintenance framework to evaluate the intervention. METHODS: This stepped wedge randomized controlled pilot study will be conducted over 2 years in collaboration with primary care clinics. Eligible participants are patients with type 2 diabetes who are receiving health care from participating clinics. Clinics will be randomly assigned to an implementation date and will begin with patients enrolling in the control period while receiving standard care, then cross over to the intervention period where patients receive standard care plus the SMart-D intervention for over 12 weeks. Focus groups or interviews will be conducted with clinicians and patients after study completion. Qualitative data will be analyzed using NVivo. Outcomes on self-care behavior changes will be measured with the Summary of Diabetes Self-Care Activities scale and clinical changes will be measured using laboratory tests. A generalized linear mixed-effect model will be used to compute time effect, clustering effect, and the interaction of the control and intervention periods using SAS (version 9.4; SAS Institute). RESULTS: We hypothesize that (1) at least 50% (n=5) of eligible clinics and 50% (n=40) of eligible patients who are invited will participate, and at least 70% (n=56) of patients will complete the program, and (2) patients who receive the intervention will have improved self-care behaviors and clinical test results with at least 75% (n=60) of the patients maintaining improved outcomes at follow-up visits compared with baseline, and participants will verbalize that the intervention is feasible and acceptable. As of August 2023, we enrolled 10 clinics and 60 patients. Baseline data results will be available by the end of 2023 and outcome data will be published in 2025. CONCLUSIONS: This is the first Vietnamese diabetes self-management education and support intervention that leverages mobile health technology to address the barriers of language and culture differences through collaboration with primary care clinics. This study will provide a better understanding of the implementation process, demonstrate the potential effectiveness of the intervention, accelerate the pace of moving evidence-based interventions to practice among the US Vietnamese population, and potentially provide a replicable implementation model that can be culturally adapted to other non-English speaking ethnic minorities. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/48585.

Primary Care Provider Familiarity and Compliance With Preferred Practice Patterns for Comprehensive Eye Examinations.

PURPOSE: To assess primary care practitioners' (PCPs) familiarity with American Academy of Ophthalmology Preferred Practice Pattern (PPP) guidelines on the frequency of comprehensive eye examinations (CEEs), and to explore their opinions and practices on counseling and referring patients for CEEs. DESIGN: Cross-sectional study. METHODS: Between February 1, 2019, and June 25, 2019, an anonymous survey was emailed to clinicians holding an MD, DO, PA, or NP degree, and residents at Brigham and Women's Hospital and the University of Oklahoma. Descriptive statistics of participants' responses were reported. RESULTS: Regarding patient counseling on CEEs, 15.4% of PCPs reported "always," 48.1% "usually," and 36.5% "seldom" or "never" doing so. Few PCPs (11.1%) reported being able to describe the guidelines, and 63.9% were unaware of their existence. A strong majority of PCPs (90.7%) correctly referred a type 2 diabetic patient at their time of diagnosis, but a similar majority (77.8%) prematurely referred a newly diagnosed type 1 diabetic patient. One in 7 PCPs (13.4%) would refer a patient with family history of glaucoma only upon developing visual/ocular symptoms. Compared to other providers, PAs/NPs were more likely to recommend unnecessary CEEs for low-risk individuals (P = .009), whereas residents counseled patients less frequently (P = .003), were less likely to be familiar with PPP guidelines (P = .026), and were less likely to recommend appropriate follow-ups for patients with family history of glaucoma (P = .004). CONCLUSIONS: PCPs' awareness of and familiarity with AAO CEE guidelines is variable and improves with provider age and experience. Efforts to improve PCP guideline awareness may be especially well suited to residents and mid-level practitioners.

Econometric evaluation of implementing a behavioral health integration intervention in primary care settings.

Integrated behavioral health (IBH) is an approach to patient care that brings medical and behavioral health providers (BHPs) together to address both behavioral and medical needs within primary care settings. A large, pragmatic, national study aimed to test the effectiveness and measure the implementation costs of an intervention to improve IBH integration within primary care practices (IBH-PC). Assess the time and cost to practices of implementing a comprehensive practice-level intervention designed from the perspective of clinic owners to move behavioral service integration from co-location toward full integration as part of the IBH-PC study. IBH-PC program implementation costs were estimated in a representative sample of 8 practices using standard micro-econometric evaluation of activities outlined in the implementation workbook, including program implementation tasks, remote quality improvement coaching services, educational curricula, and learning community activities, over a 24-month period. The total median cost of implementing the IBH-PC program across all stages was $20,726 (range: $12,381 - $60,427). The median cost of the Planning Stage was $10,258 (range: $4,625 - $14,840), while the median cost of the Implementation Stage was $9,208 (range: $6,017 - 49,993). There were no statistically significant differences in practice or patient characteristics between the 8 selected practices and the larger IBH-PC practice sample (N=34). This study aimed to quantify the relative costs associated with integrating behavioral health into primary care. Although the cost assessment approach did not include all costs (fixed, variable, operational, and opportunity costs), the study aimed to develop a replicable and pragmatic measurement process with flexibility to adapt to emerging developments in each practice environment, providing a reasonable ballpark estimate of costs associated with implementation to help guide future executive decisions.

This study estimated the cost of implementing a program that helped 8 primary care practices transition from a co-located behavioral health services model to greater integration. Our study was part of a larger study across the United States. The authors found that the per-practice program implementation cost ranged between $12,381 and $60,427 and the median cost was $20,726. Leaders of healthcare organizations that participated in this study thought that these costs represented the work of program implementation and that they were reasonable and acceptable.

Oncology and Primary Care Provider Views on Cancer Survivorship Care: Mind the Gap.

CONTEXT: Coordination between oncology and primary care practices in cancer survivorship is lacking. OBJECTIVE: To identify cancer care coordination perceptions, knowledge, and practices in a sample of Oklahoma oncology care providers (ONCs) and primary care providers (PCPs) regarding post-treatment care of adult cancer survivors. DESIGN: Cross-sectional, statewide survey by mail/web link in 2014/5. SETTING: PCPs identified through a primary care research network, primary care organization membership lists; ONCs identified through www.Healthgrades.com. PARTICIPANTS: Contacts who were clinically active and seeing cancer patients were eligible. The final sample size included 101 ONCs and 58 PCPs who reported actively seeing cancer patients. MEASURES: Responses to predominately Likert scale or ranked-order questions derived from the Survey of Physician Attitudes Regarding the Care of Cancer Survivors. ANALYSES: Chi square and t tests were performed to test bivariate associations between provider type and survey measures. RESULTS: Statistically significant differences (P < .05) between ONC and PCP perceptions were observed for several questions on communication between the 2 provider types, ONC perceptions of PCP ability to address survivorship care, and responsibilities for post-treatment care. CONCLUSIONS: Highly discrepant perspectives between ONCs and PCPs regarding communications and responsibilities for survivorship care may lead to adverse health outcomes. Interventions aimed at improving care coordination for cancer survivors should define each provider group's responsibilities in survivorship care, and create structures and processes that foster clear channels of communication between ONC and PCP practices.

Provider Communication: The Key to Care Coordination Between Tribal Primary Care and Community Oncology Providers.

PURPOSE: To explore tribal primary care providers' and community oncology providers' experiences of caring for individuals with cancer to inform intervention development and improve cancer care coordination in this high-need population. PARTICIPANTS & SETTING: 33 tribal primary care providers and 22 nontribal, community-based oncology providers. METHODOLOGIC APPROACH: A qualitative, descriptive design was used, and 55 semistructured individual interviews were completed. Data were analyzed using conventional inductive content analysis to identify major themes. FINDINGS: Effective care coordination for individuals with cancer was characterized by timely communication. Providers in both settings identified unhindered communication between providers as a key element of care coordination. Identification of points of contact in each setting enhanced information exchange. As patient needs related to cancer care intensified, care coordination increased in complexity. IMPLICATIONS FOR NURSING: Evaluating strategies to enhance communication between tribal primary care providers and community oncology providers is an important next step in enhancing the coordination of care for tribal individuals with cancer.

A Review of 50 Years of International Literature on the External Environment of Building Practice-Based Research Networks (PBRNs).

BACKGROUND: This article is the second part of a novel scoping review of the international literature that presents those key elements that underpin the foundational activities of Practice-Based Research Networks (PBRNs). In this article, we examine the external environment and the intersection between the internal and external environment domains. METHODS: We searched electronic databases, including MEDLINE (PubMed), OVID, CINAHL (EBSCOhost), Scopus, and SAGE for publications in English between 1/1/1965 and 9/15/2021. We also searched reference lists of selected publications, gray literature and other online sources. Inductive thematic analysis was applied to construct the main themes, subthemes, and key elements from a scoping review covering up to 10 years of reported experiences of each of the 98 PBRNs that met the inclusion criteria. RESULTS: In this study we present 2 main themes: "Stakeholders at the Intersection Between the Internal and External Environment" and the "External Environment." The first is linked to the subthemes "Patient and Community Stakeholders" and "Other Healthcare Stakeholders" and 11 key elements. The second relates to the subthemes "National Health System," "Institutional/Governmental Support, National/State Policy and Regulatory Environment" "Professional Organizations," "Leveraging Previous Research and PBRN Experience and Interacting with Other Networks" and "Health Information Technology (HIT) and HIT Vendors" and 21 key elements. CONCLUSIONS: Despite variations in geography, time, and healthcare context, PBRNs shared many similar developmental experiences over the past 5 decades. Their external environment contributed significantly to their developmental trajectories during the first 10 years of their operation.

A Review of 50-Years of International Literature on the Internal Environment of Building Practice-Based Research Networks (PBRNs).

PURPOSE: Practice-based research networks (PBRNs) have developed dynamically across the world, paralleling the emergence of the primary care discipline. While this review focuses on the internal environment of PBRNs, the complete framework will be presented incrementally in future publications. METHODS: We conducted a scoping review of the published and gray literature. Electronic databases, including MEDLINE (PubMed), OVID, CINAHL (EBSCOhost), Scopus, and SAGE Premier, were searched for publications between January 1, 1965 and December 31, 2020 for English-language articles. Rigorous inclusion/exclusion criteria were implemented to identify relevant publications, and inductive thematic analysis was applied to elucidate key elements, subthemes, and themes. Social network theory was used to synthesize findings. RESULTS: A total of 229 publications described the establishment of 93 PBRNs in 15 countries that met the inclusion criteria. The overall framework yielded 3 main themes, 12 subthemes, and 57 key elements. Key PBRN activities included relationship building between academia and practitioners and development of a learning environment through multidirectional communication. CONCLUSIONS: PBRNs across many countries contributed significantly to shaping the landscape of primary health care and became an integral part of it. Many common features within the sphere of PBRNs can be identified that seem to promote their establishment across the world.