Card studies for observational research in practice.

PURPOSE: Observational studies that collect patient-level survey data at the point-of-care are often called card studies. Card studies have been used to describe clinical problems, management, and outcomes in primary care for more than 30 years. In this article we describe 2 types of card studies and the methods for conducting them. METHODS: We undertook a descriptive review of card studies conducted in 3 Colorado practice-based research networks and several other networks throughout the United States. We summarized experiences of the State Networks of Colorado Ambulatory Practices and Partners (SNOCAP). RESULTS: Card studies can be designed to study specific conditions or care (clinicians complete a card when they encounter patients who meet inclusion criteria) and to determine trends and prevalence of conditions (clinicians complete a card on all patients seen during a period). Data can be collected from clinicians and patients and can be linked. CONCLUSIONS: Card studies provide cross-sectional descriptive data about clinical care, knowledge and behavior, perception of care, and prevalence of conditions. Card studies remain a robust method for describing primary care.

UPSTREAM! Together evaluation results from community efforts to prevent mental, emotional, and behavioral health problems.

Mental, emotional, and behavioral (MEB) health problems are prevalent globally. Despite effective programs that can prevent MEB problems and promote mental health, there has not been widespread adoption. UPSTREAM! Together was a planning project in three Colorado communities. Communities partnered with academic and policy entities to 1) translate evidence about MEB problem prevention into locally-relevant messages and materials and 2) develop long-term plans for broad implementation of interventions to prevent high-priority MEB problems. Community members recognized the need to talk about MEB problems to prevent them. The UPSTREAM! communities localized messages designed to start conversations and sustain attention on preventing MEB problems. The communities understood that prevention takes sustained community attention and advocacy, knowing that important outcomes may be years away. Long-term implementation plans aimed to strengthen families and enhance social connections among youth. Despite community readiness and capacity to implement evidence-based programs, there were few funding opportunities, delaying program implementation and revealing gaps between funding policies and community readiness. This community-engaged experience suggests an achievable approach, acceptable to communities, and worthy of further development and testing. Policies that cultivate and support local expertise may help to increase wider community adoption of evidence-based programs that promote mental health among youth.

Prescription for health: changing primary care practice to foster healthy behaviors.

PURPOSE: The leading causes of premature death in the United States are linked to 4 behaviors: smoking, unhealthy diet, physical inactivity, and risky alcohol use. We report lessons from 17 exploratory projects funded under Prescription for Health that tested the feasibility of innovative behavior change strategies for at least 2 of these behaviors in primary care practices. METHODS: Seventeen practice-based research networks (PBRNs) implemented and evaluated tools, cues, and techniques in 120 family medicine, internal medicine, pediatric, and nursing practices across an ethnically diverse sample of adults, children, and adolescents in rural and urban settings. We reviewed progress reports and notes from site visits and 3 meetings to generate overarching lessons. RESULTS: PBRNs successfully implemented their projects in diverse practices despite reported logistical challenges and practice constraints. The networks showed that distributing the effort across the care team and throughout the practice and community is possible. Although each behavior required specific attention, each did not require its own separate staff and system. Three models emerged as helpful guides for the comprehensive redesign of health behavior counseling, but they require adaptation for use in real-world primary care settings. Traditional methods of collaboration yielded mixed results, making obvious a need for dedicated collaboration funds and a better framework to identify and align high-yield opportunities. CONCLUSIONS: These projects confirm the feasibility of health behavior counseling in primary care practice. They also highlight the need for substantive practice redesign, and the value of models and frameworks to guide redesign and collaborative efforts.

Clinical decisions regarding HbA1c results in primary care: a report from CaReNet and HPRN.

OBJECTIVE: To describe decisions made by primary care providers on elevated HbA(1c) results and their reasons for not intensifying therapy. RESEARCH DESIGN AND METHODS: In this cross-sectional study, a provider survey was administered in two practice-based research networks when HbA(1c) results were reviewed on all nonpregnant patients >18 years old with type 2 diabetes. Univariate and Mantel-Hantel analyses assessed associations between patient characteristics and clinical decisions. RESULTS: A total of 483 surveys were completed by at least 88 providers at 19 clinics. Most patients were female (62.5%), mean age was 60 years, and 28.6% were Hispanic. The overall action rate on HbA(1c) results >/=7% (n = 294) was 70.7%. Patients who were black or had Medicare without medication insurance had lower rates of action on HbA(1c) >/=7 and >/=8%, respectively (P < 0.05). The most common reasons providers reported for inaction were "patient improving/doing well," "competing demands," and "hypoglycemic risk." CONCLUSIONS: Primary care providers generally adhere to national glycemic control guidelines, although there may be disparities in black patients and patients without medication insurance coverage. A variety of reasons were given when control was not intensified.

Engaging communities in education and research: PBRNs, AHEC, and CTSA.

BACKGROUND: Community engagement has become a prominent element in medical research and is an important component of the Clinical and Translational Science Awards program. Area Health Education Centers engage communities in education and workforce development. METHODS: Engaging Communities in Education and Research (ECER) is a successful collaboration among the Colorado Area Health Education Center (AHEC), the Colorado Clinical Translational Science Institute, and Shared Network of Collaborative Ambulatory Practices and Partners--Colorado's practice-based research collaborative. The ECER Conference is an annual conference of community members, health care providers, clinical preceptors, AHEC board members, university faculty, primary care investigators, program administrators, and community organization leaders. RESULTS: Over 1,000 people have participated in the ECER Conference representing all regions of Colorado. Several projects from the "new ideas" breakout session have been developed and completed. Six-month follow-up provided evidence of numerous new collaborations, campus-community partnerships, and developing research projects. Several new collaborations highlight the long-term nature of building on relationships started at the ECER Conference. DISCUSSION AND CONCLUSION: ECER has been a successful collaboration to develop and support campus-community collaborations in Colorado. Although seemingly just a simple 3-day conference, we have found that this event has lead to many important partnerships.

Common measures, better outcomes (COMBO): a field test of brief health behavior measures in primary care.

BACKGROUND: Primary care offices have been characterized as underutilized settings for routinely addressing health behaviors that contribute to premature death and unnecessary suffering. Practical tools are needed to routinely assess multiple health risk behaviors among diverse primary care patients. The performance of a brief set of behavioral measures used in primary care practice is reported here. METHODS: Between August 2005 and January 2007, 75 primary care practices assessed four health behaviors, using a 21-item patient self-report questionnaire for adults or a 16-item questionnaire for adolescents. Data were collected via telephone, paper, or electronic means, either with or without assistance. The performance of these measures was evaluated by describing risk-behavior prevalences, combinations of risk behaviors, and missing data. RESULTS: Of 227 adolescents and 5358 adults, most patients completed all of the survey questions. Two or more unhealthy behaviors were reported by 47.1% of adolescents and 69.2% of adults. Percentages of adults who completed all the survey items varied by health behavior: tobacco use, 98.5%; diet, 98.2%; physical activity, 96.2%; alcohol use, 85.1%. Missing data rates were higher for unassisted patient self-reporting. CONCLUSIONS: A relatively brief set of health behavior measures was usable in a variety of primary care settings with adults and adolescents. The performance of these measures was uneven across behaviors and administration modes, but yielded estimates of unhealthy behaviors consistent overall with what would be expected based on published population estimates. Further work is needed on measures for alcohol use and physical activity to bring practical assessment tools for key health behaviors to routine primary care practice.

Provider deferred decisions on hemoglobin A1c results: a report from the Colorado Research Network (CaReNet) and the High Plains Research Network (HPRN).

BACKGROUND: Hemoglobin A1c (HbA1c) results are generally reviewed several days after office visits. The clinical decisions on elevated HbA1cs may be complex and are rarely urgent. Providers may elect to defer the decision or its implementation to a future clinical encounter. OBJECTIVE: To determine the occurrence rate, predictors, and eventual decision outcomes for HbA1c deferred decisions. DESIGN: Provider questionnaire completed when HbA1c results from type 2 diabetes patients were reviewed, followed by a chart review on deferred cases 6 months later. PARTICIPANTS: Providers at 19 Colorado primary care clinics. MEASUREMENTS: For HbA1c > or =7%, whether the decision or its implementation was deferred. In deferred cases, whether a clinical decision was eventually made. RESULTS: Of the 311 HbA1cs > or =7%, 31 (10.0%) had deferred decisions. In multivariate analysis, deferred decisions were more likely in African Americans (odds ratio [OR] 4.91, 95% CI 1.81, 13.3) and less likely when the patient's usual provider reviewed the HbA1c (OR 0.40, 95% CI 0.18, 0.90). In the chart review, for deferred cases (n = 18), a clinical decision was made in 14 cases, usually at the next clinical encounter. In 4 cases, the HbA1c was never addressed. CONCLUSION: Deferred decisions on HbA1c results are infrequent, and usually the HbA1c is eventually addressed.

Practice facilitators and practice-based research networks.

Practice facilitators (PFs) are health care professionals, who assist primary care practices in research and quality improvement activities. Their work goes beyond data collection and feedback and includes practice enhancement methods to facilitate system-level changes. PFs provide a framework for translating research into practice by building relationships, improving communication, facilitating change, and sharing resources in practice-based research networks (PBRNs). The work of PFs is funded from a variety of sources, including academic grants and renewable contracts with national, state, and local health care agencies. Limited information is available on cost-effectiveness of PF interventions. This article provides examples of how the PF model was implemented in 4 PBRNs in the United States.