why research networks?

THE POWER OF
RESEARCH NETWORKS
Primary Care PBRNs
• Define Practice-Based Research Networks
(PBRNs)
• Examine types of research that can be
embedded into care
• Present examples of prior and current CDN
and N2-PBRN studies and future NYCCDRN/PCORnet studies
• Discuss challenges and opportunities for scaleup and building a Learning Healthcare System
The Power of Networks:
Building a Learning Healthcare System
with Practice-based Research Networks (PBRNs)
Jonathan N. Tobin, PhD
President/CEO
Clinical Directors Network (CDN)
Co-Director, Community Engaged Research Core
The Rockefeller University Center for Clinical & Translational Science
Professor, Department of Epidemiology & Population Health
Albert Einstein College of Medicine of Yeshiva University
•
Group of ambulatory care practices
•
Organizational structure transcends a single research project
•
Link practicing clinicians with experienced investigators
•
Enhance research skills of network clinician members
•
Ongoing commitment to network activities
•
Mission:
•
Service - primary care of patients
•
Goal - improve quality of primary care
•
Investigation - questions related to community-based practice
Source: AHRQ PBRN www.ahrq.gov/research/pbrn/pbrnfact.htm
[email protected]
www.CDNetwork.org
AHRQ PBRN REGISTRY (2013)
Practice-Based Research Networks (PBRNs)
The Importance of Setting
Models of Practice-Based Research
• Top-Down
– Researcher-focused
– Funder-focused
• Ambulatory care represents the ambient conditions under which most people
present for care and under which most care (Usual Care) is provided
CER/PCOR
CEnR
PCTs
• Bottom-up
– Clinician-focused (PBRN)
– Patient-focused (CBPR)
•
PBRNs in ambulatory care settings (such as Primary Care PBRNs)
represent organized practices in which care is provided and care
can be studied systematically
•
Conduct Studies that follow Clinical Workflow in order to minimize
disruption to the practices, clinicians, staff and patients
• PBRNs also represent an established mechanism for the
dissemination and implementation of medical innovations
• Mixed Model (Bi-directional)
N=155
Clinician
Source: http://pbrn.ahrq.gov/pbrn-registry/pbrn-map
Practice-Based Research
Networks (PBRNs)
MIXED MODEL PBRNS:
• Can potentiate the bi-directional exchange of what is best
in each model of research (lab vs. field)
• Provide the venue for translating practice into research,
thereby changing the pattern of information flow
• Serve as both the venue for conducting research and
the mechanism for disseminating research results
Researcher
4
5
Types of Research
Conducted in PBRNs
• Descriptive
• Observational
• Experimental – Randomized Controlled Trials (RCTs)
– Comparative Effectiveness Research (CER)
– Patient Centered Outcomes Research (PCOR)
– Cluster RCTs
• Dissemination & Implementation (D&I)
• Quality Improvement
• ?Mechanistic Studies
Full Spectrum of Translational Research
NIH “Blue Highways”
T0
Basic
Science
T4
Public
Health
Impact
Source: Westfall, et al., “Practice-Based Research—‘Blue Highways’ on the NIH Roadmap”
JAMA 2007; 297: 403-406
Types of T2 T3 T4 Research
• PBRN
• CER
• PCOR
Practice-based Research Networks
Comparative Effectiveness Research
Patient Centered Outcomes Research
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
• CEnR
Community-Engaged Research
• CBPR
Community-based Participatory Research
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------
• PCT
Pragmatic Clinical Trials
Comparative Effectiveness Research
(CER)
• “A rigorous evaluation of the impact of different
options that are available for treating a given
medical condition for a particular set of
patients” (OMB)
• Includes Randomized Controlled Trials (RCTs),
pragmatic, and observational trials and cost
analysis comparing drugs, treatments, or
diagnostic tools
• CER is closely related to Patient-Centered
Outcomes Research (PCOR)
Lauer MS. Comparative Effectiveness Research: The View From the NHLBI.
Journal of the American College of Cardiology. 2010;53(12):1084-1086.
MacPherson’s Key Steps in
Conducting a Pragmatic Clinical Trial
Pragmatic-Explanatory Continuum
Indicator Summary (PRECIS) Tool
1. Appropriate research question
2. Defining the patient group
3. Identify a comparison group
4. Defining the treatment protocol
5. Ensuring adequate sample size
6. Referral, recruitment and randomisation
7. Outcomes
8. Analysis
9. Reporting and dissemination
Source: MacPherson H. Pragmatic clinical trials. Complementary Therapies in Medicine. 2004. 12:136-140.
WHY RESEARCH NETWORKS?
Advantages:
Accelerate study start-up & conduct
Follow clinical workflow and embed
at point of care
Build shared infrastructure
Facilitate data-sharing
Conduct full spectrum of translational
research
Opportunities for dissemination & scale-up
www.CDNetwork.org
Four-Stage Model of
Community-Engaged Research (CEnR)
*CBPR
One
Two
Researchers retain
total control of the
project. There is
community
involvement, but it is
passive.
Persons
consulted by the
researchers are
at the periphery
of the
community.
Three
Community
leaders are asked
not only for
endorsement of
the project, but
for guidance in
hiring community
residents to serve
as interviewers,
outreach workers,
etc.
Four
Community
members are
first among
equals in
defining the
research
agenda.
GOALS OF COMMUNITY-ENGAGED RESEARCH
•
•
•
Build Trust & Capacity
Enlist new resources and allies
Create better communication
• = Improve overall health outcomes Public Health Impact
Source: Hatch J, Moss N, Saran A et al. Community research: Partnership in Black communities.
Am J Prev Med 1993 Nov-Dec;9(6 Suppl):27-31; discussion 32-34.
Challenges for PBRNs
A common aim behind Comparative Effectiveness Research (CER) and
Practice-based Research Network (PBRN)-conducted research is to
produce new evidence-based medical knowledge that fills gaps between
primary care practice realities and findings produced by
academic/tertiary-care research and clinical trials
Less control over
Patient characteristics
Variability in practice clinical and research capacity
Multiple IRBs
Significant resource problems that impede research
Other challenges include:
selecting studies that meet network’s & practices’ priorities
working within an adequate and sufficient budget
developing study teams and agreements among team members
training practice staff for participation
Source: Thorpe KE et al. A pragmatic-explanatory continuum indicator summary tool (PRECIS): a tool to
help trial designers. CMAJ 2009; 180(10):E47-57.
THE POWER OF
RESEARCH NETWORKS
• Structure of CDN and N2-PBRN
• Examples of prior and current PBRN studies
conducted by CDN and N2-PBRN
www.CDNetwork.org
Clinical Directors Network
A Practice-based Research Network (PBRN)
that works with
Primary Health Care Safety-net Practices
---Research Infrastructure to build a Learning
Healthcare System
CDN Recognition
AHRQ Designated
“Center of
Excellence” (P30)
For Practice-based
Research and
Learning (2012)
CDN: Beginnings
CDN’S OVERALL GOAL
• CDN is dedicated to providing and improving
comprehensive and accessible community oriented
Primary and Preventative Health Care services for
poor, minority, and underserved populations
NIH Roadmap
Initiative
Designated “Best
Practice” Clinical
Research Network
(2006)
• CDN’S overall goal is to engage communities, clinicians
and patients to translate clinical research into clinical
practice for the elimination of health disparities
US Department of Health
& Human Services
Award for “Outstanding
Contribution Toward
the
Elimination of Racial and
Ethnic
Disparities in Health”
(2001)
Improving Healthcare Systems (2012)
Eliminating Health Disparities (2013)
Clinical Data Research Networks x2 (NYC & Chicago, 2013)
CDN’S Primary Activities
www.CDNetwork.org
Factors Contributing to Physician
Retention in FQHCs
• “… while salary and benefit levels are a major variable in retention, other factors
related to personal and professional satisfaction are also significant. These
include workload, relationship to other staff, sense of mission, health center
morale, reputation of the center and participation in decision-making within the
organization.”
• John Snow study of national retention rates of
physicians at Community/Migrant Health Centers
examined conditions which contribute to
professional satisfaction or dissatisfaction.
• Retention was found to be positively related to job
satisfaction
• Perception that the management of the health
center had created a professionally satisfying
environment (& connected to mission)
• The most satisfying aspects of their jobs:
“team-building",
"diversity and versatility of their role“
"working with the community and community groups“
"taking a larger view of health care in the community“
“Clinical leadership and administrative skills”
"personal commitment to the job and the mission”
Sardell A. (1996) “Clinical Networks and Clinician Retention: The Case of CDN.”
J Community Health. 21(6):437-51.
The HRSA Primary Health Care Safety-Net (2013)
Mission External Validity
Generalizability Social Justice
-
People: Eligibility - inclusion/exclusion criteria
Place:
Setting - types of services available
Time:
Seasonality - novel/established
Ideal vs. Real World:
• Practice Settings
• Populations
• Heterogeneity
Sardell A. (1996) “Clinical Networks and Clinician Retention: The Case of CDN.”
J Community Health. 21(6):437-51.
Grantees, Delivery Sites and FTE Clinicians (2013)
USA
New York
Grantees
Delivery Sites
1,202
9,203
57
632
Physicians
10,734
1,074
Nurses
13,278
1,326
Medical Providers
8,156
32,168
2,978
NPs, PAs, and Midwives
Source: www.hrsa.gov www.healthdisparities.net
• “CDN has responded to the needs
articulated by clinicians at health
centers…has provided managerial
training and clinical education,
strategies for increased involvement
of clinicians in health center
management and opportunities for
engagement in community-based
primary care research.”
• Practice-based Research
• Education and Training
• Professional Development
Peer Support: Retention/Recruitment
of Clinicians into Health Centers
–
–
–
–
–
–
• “CDN was created in 1985 by a
group of community health center
dental and medical directors with
the encouragement and support of
officials of Region II of the Public
Health Service (PHS).”
578
Dentists
3,479
338
Dental Assistants,
Technicians and Hygienists
8,371
627
Dental Providers
11,850
965
Mental Health Providers
5,694
524
Source: HRSA BPHC UDS, 2013– Special Tabulation
Community Health
Center Patients by
Race/Ethnicity (2013)
Patient Income
Percent of
Poverty Level (2013)
www.CDNetwork.org
Race/Ethnicity (%) National New York
Asian/Pac Island
4.1
5.2
Native American
1.2
0.3
Black
20.3
26.6
White
56.2
32.1
Unknown/NR
14.9
23.0
Hispanic/Latino
34.8
35.3
Source: HRSA BPHC UDS, 2013– Special Tabulation
Community Health Center Patients by Diagnosis, USA (2013)
Selected Diagnoses and Services
National
New York
Hypertension
3,642,869
216,171 (2)
Immunizations
2,699,959
232,287 (1)
Overweight and Obesity
2,228,089
179,258 (4)
NIAID NIMH, HRSA, CDC, AmFAR, BMS, DMP, Roche
MRSA
NCATS
HIT
NIDDK, NCI
CANCER PREVENTION and CONTROL
NCI, AHCPR, PCORI
DEPRESSION
NIDA, SAMHSA, NIMH, PCORI
Diabetes Mellitus
1,882,608
Pap Smear
1,787,256
158,736 (5)
STRESS MANAGEMENT
NIMH, CDC
Depression
1,644,559
94,888 (10)
HYPERTENSION
NHLBI
Contraception
1,221,493
102,963 (8)
DIABETES
HRSA, NIDDK, NIDCR
120,704 (6)
ACADEMIC PARTNERS & CER/PCOR PROJECTS
CDN’S RESEARCH PORTFOLIO
MIXED MODEL
HIV/AIDS
YALE SCHOOL OF PUBLIC HEALTH
•
Centering Pregnancy RCT(NIMH)
DARTMOUTH MEDICAL SCHOOL
•
Cancer Control RCT (NCI; PCORI)
COLUMBIA UNVERSITY
•
•
•
•
•
CAATCH Hypertension in African Americans RCT (NHLBI)
BP Adherence RCT (NHLBI)
Cancer Caregiver Support RCT (NCI)
Web-based Rx Support Tool for HIV (HRSA)
Problem-Solving in Diabetes Management RCT (NIDDK)
College of Physicians and Surgeons
Mailman School of Public Health
RAND CORP & UCLA
•
•
PTSD Among Refugees (NIMH)
PTSD Care Management RCT (NIMH)
UNIVERSITY OF MICHIGAN
•
Periodontal Disease/Diabetes (NIDCR)
•
Stress Management & HIV RCT (3) (NIMH & CDC)
Center for Clinical & Translational Science
•
•
•
•
CA-MRSA Project (NCATS; AHRQ; PCORI)
Bleeding Phenotype (NCATS)
Research Participant Survey (NCATS)
Hepatitis-C Screening & Treatment (NCATS; Helmsley Trust)
NYU Langone School of Medicine
•
•
Hypertension in African Americans RCT (NHLBI)
Cancer Caregiver Support RCT (NCI)
UNIVERSITY OF ROCHESTER
•
•
Technology Enabled Patient Self Management (NCI, PCORI)
BP Visit Intensification Study (NHLBI)
ALBERT EINSTEIN COLLEGE OF MEDICINE
Collaborative Cancer Care Among
Low-Income Urban Women (PCORI)
N2 PBRN - Network of Networks (AHRQ P30)
WEILL CORNELL Medical College
NYC-CDRN (PCORI)
Tobacco Use Disorders
1,181,415
101,650 (9)
IMMUNIZATIONS
CDC, HRSA, Pharma
Anxiety Disorders including PTSD
1,096,079
63,696 (12)
MIGRAINE/HEADACHE
Merck
Asthma
1,092,389
UNIVERSITY OF MIAMI
117,516 (7)
1,079,505
ANEMIA; BLEEDING DISORDERS
Ortho Biotech, NCATS
Miller School Of Medicine
HIV Tests
ASTHMA
EPA, DEP, HRSA
THE ROCKEFELLER UNIVERSITY
HPV SCREENING & VACCINATION
NYC DOHMH
182,227 (3)
Other Mental Disorders
988,999
82,583 (11)
Otitis Media/Eustachian Disorders
841,327
50,483 (14)
Heart Disease
602,687
42,991 (16)
TEEN MENTAL HEALTH SCREENING
Columbia University
Dermatitis/other Eczema
599,743
51,582 (13)
PALLIATIVE CARE
NCI
Mammogram
424,376
41,538 (17)
NUTRITION/PHYSICAL ACTIVITY
RWJ, NYS Atty Gen
Chronic Bronchitis/Emphysema
320,862
17,633 (19)
Hepatitis C Test
PERIODONTAL DISEASE
NIDCR
296,349
46,666 (15)
Hepatitis C
145,309
GENETICS
March of Dimes
11,245 (20)
115,421
19,045 (18)
PREGNANCY/PRENATAL CARE
NIMH
Symptomatic HIV, Asymptomatic HIV
Source: HRSA BPHC UDS, 2013– Special Tabulation)
School of Dental & Oral Surgery & Public Health
MIXED MODEL
CDN RECRUITMENT EXPERIENCE
1992-Present
64,067 Patients enrolled
74 %
Female
49 %
African-American
40 %
Latino/a
Employing the Mixed Model, Significant
Improvements Have Been Achieved In:
CDN has successfully employed the “Mixed Model”
in a variety of experimental and observational studies
conducted in primary care practices serving low-income
and minority communities, including :
–
–
–
–
–
–
•
•
•
•
•
•
•
Community/Migrant Health Centers (CHCs)
Diagnostic and Treatment Centers (DTCs)
Health Department Clinics (DOH)
Public/Voluntary Hospitals (HOSP)
Primary Care Residency Programs (PCRPs)
Managed Care Organizations (MCOs)
Clinical Preventive Services
Disease Management
Health Behavior Change
Integration of Primary Care & Mental Health
Quality of Life
Clinical/Biological Outcomes
Beginning to demonstrate Public Health Impact
www.CDNetwork.org
Drivers of New PBRN Growth
CHALLENGES TO SUSTAINABILTY
WHICH LEAD TO GROWTH OF
NETWORKS
Enormous financial investment
Need for new markets (practices, clinicians)
Saturation of existing practices
Limited bandwidth & competing priorities
Time Constraints
Competition for funding
Inconsistent, partial or poor
translation of research into
practice
Outside demand for expertise & access
Geographic diversity/diverse health needs
POTENTIAL SOLUTIONS
High quality data collection
Simplified, less costly forms
Clinicians who are engaged and
serve as investigators, early adopters
and disseminators
Vigorous communication and
discussion of efficacy and
effectiveness among collaborating
PBRNs
Models of collaboration
Accelerated model of translation
Inter-operable EHR systems
Drivers of Growth & Expansion: Scalable
CDN N2 -PBRN :
Building a Network of Safety Net PBRNs
(“Network of Networks”)
A collaboration among:
◦
◦
◦
◦
◦
◦
◦
◦
◦
Access Community Health Network (ACCESS)
Alliance of Chicago (ALLIANCE)
Association of Asian Pacific Community Health Organization (AAPCHO)
Center for Community Health Education Research and Service (CCHERS)
Clinical Directors Network (CDN) [Lead PBRN]
Community Health Applied Research Network (CHARN)
Fenway Institute (FENWAY)
New York City Research and Improvement Group (NYCRING)
Oregon Community Health Information Network (OCHIN)
Funded by AHRQ Grant: P30 HS 021667
Principal Investigator: Jonathan N. Tobin, PhD (CDN)
Project Officer: Rebecca A. Roper, MS, MPH Director, AHRQ PBRN Initiative
CDN Webcast Partners
•
Fenway Health
•
Fenway Health
•
Chase Brexton Health Services
•
Beaufort-Jasper-Hampton Comprehensive Health Services
•
Academic Partner
•
University of Washington
•
OCHIN
•
Open Door Community Health Center
•
Virginia Garcia Memorial Health Center
•
Multnomah County Health Department
•
OHSU Family Medicine at Richmond
•
Academic Partner
•
Oregon Health and Science University(Academic Partner)
<
•
•
Alliance of Chicago Community Health
Services
•
Alliance of Chicago Community
Health Services
•
Erie Family Health Center, Inc.
•
GLIDE Health Services
•
Heartland Health Outreach
•
Howard Brown Health Center
•
Near North Community Health Center
•
North Country Healthcare
•
Lurie Children’s Hospital/NU
•
Academic Partners:
•
University of Michigan
•
Michigan Public Health Institute
•
Northwestern University
•
Kaiser Permanente Center for Health Research – Data
Coordinating Center
•
Center for Health Research
Association of Asian Pacific Community
Health Organizations(AAPCHO)
•
Asian Health Services Community
Health Center
•
Charles B. Wang Community Health
Center
•
Waianae Coast Comprehensive
Health Center
•
Waimanalo Health Center
•
Academic Partner
•
University of California, Los Angeles
N2 PBRN Academic Partners
Virtual Faculty
• Albert Einstein College of Medicine
of Yeshiva University/Montefiore
Medical Center
• Boston University
• Columbia University
• Dartmouth Medical School
• Harvard University
• Kaiser Permanente Center for Health
Policy Research
• New York University
• Northwestern University
• Oregon Health and Science
University
• RAND Corporation
•
•
•
•
•
•
•
•
•
•
The Rockefeller University
Tufts University
University of California/San Francisco
University of Chicago
University of Illinois at Chicago
University of Miami
University of Michigan
University of Oregon
University of Washington
Yale University
Funded by HRSA
N2 LEARNING COLLABORATIVE
TRACKS
Research Training for Clinical Leaders
The N2 PBRN Online Training Curriculum
Aims to enhance the skills of current PBRN researchers and practicing clinicians who
are interested in participating in clinical research.
1.
PBRN Research Management Innovations (for PBRN Senior Staff)
Tracks:
2.
PBRN Methods (for PBRN Senior Staff & Academic Collaborators)
• Evidence-based practices and best practices demonstrated to be effective at
transforming clinical research into a more clinician-engaged, accelerated research
and translation model, with significant clinical and public health impact
3.
Introduction to Research (for CHC Nodes Staff & New PBRN Staff)
• A “Virtual Faculty” of N2 PBRN Directors and their PBRN-related research
4.
PBRN Study Results (for CHC Nodes, CHC Partners, PBRN Senior
Leadership & Staff, Academic Partners)
• N2 PBRN Academic Partners “Virtual Faculty” and their PBRN-related research
2012-2013
•
– To enable practicing clinicians to develop their research interests and skills, through
didactics on the scientific and statistical aspects of study design as well as through
hands-on experience in preparing and implementing a research project
•
Epidemiology and Biostatistics
– To develop and provide oral and written research dissemination/presentation skills at
local, regional and national forums
•
IRB/Human Subjects Protection
– IRB Application
– Informed Consent
•
• Training in research methodology for practicing clinicians who wish to become
more active and engaged in practice-based research
• New content added on Pragmatic Clinical Trials, CER & PCOR Research methods
Study Design and Implementation
Grant Writing
– To provide technical assistance in grant-writing and identifying potential funding
sources, including training exercises and assistance in developing budgets, staffing plans,
work-scopes, and timelines
•
60 CME/CNE/CDE Credits for Participation
Funded in part by AHRQ Grant: P30 HS 021667
ENCORE: Community Health Center
Patient Centered Outcomes Research (PCOR) Training Program
(Funded by a PCORI Eugene Washington Engagement Award - NCHR 1000-30-10-10 EA-000)
Key Partners:
• Access Community Health Network
• Association of Asian Pacific Community Health Organizations (AAPCHO)
• Clinical Directors Network (CDN) [JN Tobin, PI; M Dziok, PD]
• Community Health Applied Research Network (CHARN)
• Institute for Community Health (ICH) at Harvard University
• National Association of Community Health Centers (NACHC) [M.Proser, Co-PI]
• South Carolina Primary Healthcare Association (SCPHA)
ENCORE: Community Health Center Patient Centered
Outcomes Research (PCOR) Training
(Funded by a PCORI Eugene Washington Engagement Award NCHR 1000-30-10-10 EA-000)
Goal:
To adapt, enhance, and implement an existing year-long training curriculum
designed to educate and engage health center teams including patients,
clinical and administrative staff in PCOR
Objectives:
• Build infrastructure to strengthen research capacity of health centers as
they develop or expand their own research infrastructure and engage in
PCOR
• Develop, implement, and disseminate broad innovative training content
and delivery approaches
• targeted to and accessible at no cost to all health centers and other
primary care practices
• content will prepare health center patients, staff, and researchers in
the conduct of community-led PCOR
• Evaluate, refine, and disseminate training resources to health centers
nationally
THE POWER OF
RESEARCH NETWORKS
CDN N2
Case Presentations of CDN & N2-PBRN Studies:
• Prevention Care Management for Improving
Cancer Early Detection (NCI, AHRQ, PCORI)
• CA-MRSA Projects
– CAMP1 ((NCATS)
– CAMP/PBRN (AHRQ)
– CAMP2 CER RCT (PCORI)
Prevention Care Management (PCM) Projects
to Improve Cancer Screening in Primary Care
Framework: Prevention Care Management (PCM) Projects
(2000-2012)
Efficacy
PCM1 CONSORT: Health Centers
Recruitment
Timeline:
PCM1, PCMT, PCM2 –MMCO & PCM3-MH Projects
November 2001 October 2002
Principal Investigator:
Allen Dietrich, MD
Geisel School of Medicine at Dartmouth
Follow-up:
Co-Principal Investigator:
Jonathan N. Tobin, Ph.D.
Clinical Directors Network (CDN)
Funded by:
NCI Grants R01-CA87776 (PCM1, PCMT)
& R01-CA119014 (PCM2)
PCORI IH-12-11-4522
AHRQ 1 P30-HS-021667
Efficacy
Effectiveness
Dissemination &
Implementation
PCM1
(2000-2004)
PCMT
(2003-2005)
PCM2
(2006-2012)
18 months after
recruitment; all
follow-up completed
by April 2004
Dietrich AJ, Tobin JN, Cassells A, Robinson CM, Greene MA, Sox CH, Beach ML, DuHamel KN, Younge, RG. Telephone Care Management To Improve Cancer
Screening among Low-Income Women. Ann Intern Med. 2006; 144:563-571.
Funded by NCI Grants R01-CA87776 & RO1-CA119014
(A. Dietrich, PI; J.N. Tobin, Co-PI)
Dissemination &
Implementation
Effectiveness
PCMT CONSORT: MMCO (n=1)
Screening Outcomes
PCM1
PCM2 CONSORT: MMCO (n=3)
18 months: Up-to-Date
Pap, mammogram
1 Year HFOBT
5 Years: Sigmoid
10 Years: Colonoscopy
By Chart Review
Efficacy
PCMT
8 months: Up-to-Date
Pap, mammogram
1 Year HFOBT
5 Years: Sigmoid
Barium Enema
10 Years: Colonoscopy
PCM2
18 months: Up-to-Date
1 Year HFOBT
5 Years: Sigmoid
Barium Enema
10 Years: Colonoscopy
By MMCO Claims Data
Effectiveness
By MMCO Claims Data
Dietrich AJ, Tobin JN, Cassells A, Robinson CM, Reh M, Romero KA, Flood AB, Beach ML. Translation of an Efficacious Cancer-Screening Intervention to
Women Enrolled in a Medicaid Managed Care Organization. Ann Fam Med. 2007; 5:320-327.
Dissemination &
Implementation
Dietrich AJ, Tobin JN, Robinson CM, Cassells A, Greene MA, Dunn VH, Falkenstern KM, De Leon R, Beach ML. Telephone Outreach to Increase Colon Cancer
Screening in Medicaid Managed Care Organizations: A Randomized Controlled Trial. Ann Fam Med. 2013; 335-343.
PCM Intervention Delivery
PCM Intervention Components
Organizational Characteristics
Intervention Implementation
Organizational Characteristics
PCM1
Total Number of
Participants
N (%) Reached
PCMT
PCM2
696
663
562
633 (91%)
268 (40%)
340 (60%)
PCM1
Study Period
Mail clinician recommendation
letter to patient
18 months
Research Staff at CDN
8 months
Health Plan Staff
18 months
Heath Plan Staff
Targeted Cancers
Breast, Cervical and Colorectal
Breast, Cervical and Colorectal
Breast, Cervical and Colorectal*
Identification of Eligible
Participants
• Medical records review
• Administrative claims data
• Administrative claims data
Mail activation card to patient
(excluded women who were
up-to-date for breast, cervical and
colorectal cancer screening)
Mean # of calls (range)
Average call length
(support was given in no more than
3 calls)
Subsequent
17(6-48)
−
14 (1-53)
14(1-62)
−
7(1-21)
√
√
Schedule screening appointments
√
Reminder calls
√
Reminder letters
52
√
√
[# minutes (range)]
Initial
√
Confirmed and updated
screening dates
3
PCMT
PCM2
2000-2004
2003-2005
2006-2012
Medicaid
80
100
100
Medicare
21
-
-
Employer/other
9
-
-
No Insurance
5
0
0
Insurance of Study Participants (%)
Mail screening test-specific
educational material to patient
Discuss and provide support on
barriers using script
Phone Calls
PCM1
PCM2
Intervention Components
Intervention Period
Staff
4 (range 1 to 20)
PCMT
√
−
−
−
√
√
√
Practice Types Involved (%)
√
Community Health Center (publicly funded)
√
√
√
−
√ (as needed)
−
√
−
√
100
100
45
Diagnostic & Treatment Center (publicly funded)
0
0
37
Private Practice
0
0
18
Primary Care Clinicians at All Centers per Study
Total Clinicians, n
116
-
364
Family Practitioners (%)
26
-
12
General Internists (%)
35
-
35
Nurse Practitioners and Physician's Assistants (%)
39
-
15
“-” = data not available
53
54
Patient Characteristics
PCM1
PCMT
1390
1316
2240
Age Inclusion Criteria
50-69
40-69
50-63
Age at Baseline - Mean
58.1
50.0
English
36.9%
49.6%
69.3%
Spanish
62.8%
9.4%
24.8%
Other
0.3%
0.5%
6.0%
<3
28.5%
57.8%
>3
68.3%
42.2%
-
Unknown
3.2%
0.0%
-
Diabetes
37.8%
-
29.0%
Hypertension
70.9%
-
60.8%
High Cholesterol
39.6%
-
37.5%
Current
17.6%
-
18.6%
Former
13.0%
-
13.8%
Never
63.9%
-
67.6%
Primary Language (%)
Meta-analysis of Odds Ratios
from 3 CDN PCM RCTs
Statistical Methods for Meta-Analysis
of 3 PCM RCTs
PCM2
Total Number of Participants
55.8
*
• Unadjusted Comparisons of the main effects for the three
PCM RCTs
• Random effects meta-analysis
• Random effects meta-regression model using the aggregate
level data on the log scale was used to estimate a decrease in
effectiveness over the three trials
Years Receiving Care at CHC/Practice (%)
-
Comorbidities at Baseline (%)
Smoking Status (%)
32
-
30
Normal (%)
11.4%
-
20.0%
Overweight (%)
27.3%
-
34.6%
Obese (%)
51.3%
-
44.9%
PCM1
PCMT
– More complete data were available for PCM1 and PCM2
– PCM1 & PCM2 were combined to provide a covariate-adjusted
estimate using logistic regression models
Body Mass Index
Mean kg/m2
Forest Plot
PCM2
• p-value < 0.05 (2-tailed) statistical significance
• 95% confidence intervals are reported
- = data unknown/not available
I2 = 54.8%, p =0.109
55
56
57
Odds Ratios Stratified by Language:
Proportion of Spanish Speakers
Interpretation
Heterogeneity of Treatment Effects
• While the effect sizes for PCM1 versus PCM2 appear to be different, they are
not
Proportion of Spanish Speakers - PCM1 vs PCM2
• The distribution for Spanish and English speakers differs between
PCM1 (64%) and PCM2 (27%)
70
60
64%
• This language effect drives the difference in ORs
% Spanish Speakers
50
• The difference between 1.69 (PCM2) versus 1.31 (PCM1) is best explained by
language differences
40
• This represents Simpson’s Paradox:
30
•
27%
20
•
10
NS: PCM1 vs. PCM2
Sig: Eng vs. Span
•
0
PCM1
PCM2
+ P <0.10
* P < 0.05
** P <0.01
*** P<0.001
The possibility that a measure of association may reverse
direction upon stratification by a third variable
Simpson's paradox can occur in meta-analysis because the sum of the data or results from a
number of different studies may be affected by confounding variables that have been excluded
by design features from some studies but not others
It is an extreme extreme violation of COLLAPSIBILITY, in which results of the data analysis in
every mutually exclusive stratum or subgroup are the opposite of the crude results. (see also
CONFOUNDING BIAS)"
58
Source: M. Porta, A Dictionary of Epidemiology (University Press, 2008)
SCALE-UP
NYC DOHMH Colo-rectal Cancer Screening
Patient Navigator Program
Source: 2008 C5
SCALE-UP
NYC DOHMH Colo-rectal Cancer Screening
Patient Navigator Program
Source: 2008 C5
Source: 2008 C5
Source: 2014 C5
P30 Curriculum, Web Portals
and Resource Library Development
For Patients and Clinicians
www.CDNetwork.org/RussianCRC
Funding:
NYC DOHMH, NYS DOH, CDC
Next Steps: Using Collaborative Care
to Reduce Depression and Increase Cancer Screening
Among Low-Income Urban Women Project
NYC Colonoscopy Screening Data Booklet, 2010 Community Health Survey, C5
Source: 2008 C5
Source: 2014 C5
Collaborative Care to Reduce Depression and Increase
Cancer Screening Among
Low-Income Urban Women Project (PCM3-MH)
A collaboration among:
Clinical Directors Network (CDN) - Jonathan N. Tobin, PhD, Andrea Cassells, MPH, TJ Lin MPH
Albert Einstein College of Medicine - Elisa Weiss, PhD, Nan Xue, PhD
Montefiore Family Care Center - Elisabeth Ihler, MD
Morris Heights Health Center - Alison Maling, LCSW
Urban Health Plan - Alejandra Morales, PsyD
NYCRING – Claudia Lechuga, MPH
BronxWorks - John Weed, LMSW
Good Shepherd Services - Ellen O’Hara-Cicero, LCSW
Geisel School of Medicine at Dartmouth University – Allen Dietrich, MD
Bronx Partners
N2 PBRN: NYCRING
• The New York City Research and Improvement Networking Group is
a partnership of thirty-five practices
• Exclusively focuses on the urban underserved
• NYCRING provides visits to over 600,000 low income, minority
primary care patients
• Access to research, data, clinical and administrative resources made
available through the Albert Einstein College of Medicine and
Montefiore Medical Center
Funding:
PCORI IH-12-11-4522
AHRQ 1 P30-HS-021667
www.nycring.org
Prevention Care Management – PCM
Bronx Partners
1 Montefiore
Family Care
Center
2 Morris Heights
Health Center
3 Urban Health
Plan
4 BronxWorks
5 Good Shepherd
Services
6 Albert Einstein
College of
Medicine
Goals and Objectives
• To determine whether addressing and reducing depression
are necessary steps to increase rates of cancer screening
among low-income depressed women ages 50-64 across
3 Bronx health centers
• We implemented a CER/PCOR study comparing the
effectiveness of two year-long interventions for:
– 756 women ages 50-64
– screen positive for depression (PHQ-9 > 8)
– have not completed recommended screenings for
cervical, breast, and/or colorectal cancer
(Comparison Arm)
• In the PCM condition, the Care Manager will focus on cancer
screening, providing
–
–
–
Education
Patient navigation
Motivational support to overcome screening barriers and form favorable attitudes
towards screening
• Patients in the PCM condition will be referred to their primary
care clinicians for their depression, if they are not in treatment
CDN Online Tools: Staff Intervention Training Resources
at NCI/SAMHSA Cancer Control Planet RTIPS
• Comparing the Effectiveness of:
1) Collaborative Care Intervention (CCI) that addresses Depression and
Cancer Screening needs simultaneously
2) Prevention Care Management (PCM) Patient Navigation Cancer
Screening Intervention
http://rtips.cancer.gov/rtips
http://rtips.cancer.gov/rtips/viewProduct.do?viewMode=product&prod
uctId=295815
CDN Online Tools:
Clinician Training Resources (CME)
Collaborative Care Intervention (CCI)
• Collaborative Care Intervention
facilitates decision-making and action
to engage in screening AND reduce
depression. A Care Manager (CM) will:
– educate patients about cancer screening and
depression;
– provide patient navigation to improve access to
and use of cancer screening services, and
connect patients to outside services
– provide depression care management and
motivational support (includes addressing
barriers) for self-care with respect to screening,
depression, and other conditions
and
– act as a critical link between primary care,
mental health care provider, and the patients,
helping to develop and implement a treatment
plan
www.CDNetwork.org
PCM1
1 Year HFOBT
5 Years: Sigmoid
10 Years: Colonoscopy
Three Component Model (TCM)
Screening Outcomes
18 months: Up-to-Date
Pap, mammogram
By Chart Review
Efficacy
PCMT
8 months: Up-to-Date
Pap, mammogram
1 Year HFOBT
5 Years: Sigmoid
Barium Enema
10 Years: Colonoscopy
By MMCO Claims Data
Effectiveness
http://prevention.mt.gov/suicideprevention/13macar
thurtoolkit.pdf
PCM2
18 months: Up-to-Date
Pap, mammogram
12 months: Up-to-Date
Pap, mammogram
By MMCO Claims Data
1 Year HFOBT
5 Years: Sigmoid
10 Years: Colonoscopy
Dissemination &
Implementation
WWW.CDNetwork.org
CME accredited through AAFP
PCM3
1 Year HFOBT
5 Years: Sigmoid
Barium Enema
10 Years: Colonoscopy
By Electronic Health
Records
(2012-2015)
75
Pragmatic Clinical Trial:
All EHR-based Cancer Screening, Mental Health,
Treatment Data,
Process and Outcomes Measures
– Past history of medication use for mental health
– Past history of psychotherapy
– Present medication use (names and reported side
effects)
– Barriers to medication or psychtherapy use
– Present psychotherapy/counseling and frequency
– Initiation of medication or psychotherapy while
enrolled
Results and Lessons Learned
CONCLUSIONS
Results
Prevention Care Management (PCM) intervention
• Both FQHCs and Community Based Organizations (CBOs) are
now significantly engaged in project implementation activities
• Key facilitators to study implementation include presence of a
study champion, a robust Electronic Health Record (EHR)
system and a multi-disciplinary team
• Challenges include bureaucratic systems that slow the hiring
of study staff, competing priorities and lack of a central IRB
1.
2.
3.
4.
5.
6.
Conclusions
7.
• This study is designed to increase our understanding of
integrating mental health and cancer screening in primary
care, and how to best support this population in making
screening decisions
Addresses multi-level barriers to screening
Effective at increasing CRC screening rates
Impact is greater for the Latina population
Can be translated and implemented successfully across a wide range of
clinical settings in medically underserved communities
Is robust and transferable across CHC, DTC and MMCO settings
Is an important strategy to be implemented in primary care systems to
be effective and sustainable
May need to add CCI components added to address depression and
other mental health, but care management framework may enhance
outcomes for both mental health and cancer screening
78
Policy Implications
Examples
1. CHCs, DTCs, PCPs and other primary care practices with
large numbers of Spanish speaking patients can benefit
from the PCM intervention
2. PCM is an innovative and effective strategy that can be
implemented in MCOs, ACOs, and PCMHs to enhance
CRC screening rates and reduce cancer health disparities
3. PCM is transferrable and can be adapted into cancer
early detection Quality Improvement (QI) Initiatives
4. PCM can be generalized to address mental health needs
of underserved populations ?
CDN N2
79
Case Presentations of CDN & N2-PBRN Studies
• Prevention Care Management for
Cancer Early Detection (NCI, AHRQ, PCORI)
• CA-MRSA Project (NCATS, AHRQ, PCORI)
www.CDNetwork.org
The Rockefeller University
Center for Clinical and Translational Science
Clinical Directors Network
CHC Partnership
Conducting CER/PCOR with
Embedded Mechanistic Studies
Supported in part by grant # UL1 TR000043 from the National Center for Advancing Translational Sciences
(NCATS, National Institutes of Health (NIH) Clinical and Translational Science Award (CTSA) program
PCORI CER 1402 10800
The Community-Associated Methicillin-Resistant
Staphylococcus aureus (CA-MRSA) Project (CAMP1):
Establishing a CA-MRSA Surveillance Network
Translational Science
Embedded Mechanistic
Studies
Comparative
Effectiveness
Research (CER) /
Patient Centered
Outcomes
Research (PCOR)
Dissemination and
Implementation
Research
A collaboration among:
Public Health
The Rockefeller University
Center for Clinical & Translational Science (CCTS)
BRONX
Impact
Effectiveness
Research
CA-MRSA Project (CAMP1) Team
Rockefeller-Clinical Directors NetworkCommunity Health Centers
Clinical Directors Network (CDN)
Community Health Centers (CHCs)
Efficacy Research
Pre-Clinical/Phase I & II Research
Funded by The Rockefeller University Center for Clinical and Translational Science (CCTS) Pilot Grants and an
NIH Administrative Supplement (NIH-NCATS Grant #8 UL1 TR000043) and AHRQ Grant # P30 HS 021667
Stakeholder Engagement and Study Design
Diagnosis
Total
Average # per Year
Average # per Month
Average # over 6 Months
50% Consent / recruitment
Internist
20%
Nutritionist
1%
2. EHR Extraction of Prevalence data (2008 – 2010):
Inflammatory Disease of Breast
Carbuncle and furuncle
Cellulitis and abscess of finger and toe
Cellulitis/abscess
Impetigo
Infection of skin/subcutaneous NOS
Folliculitis
Hydaradenitis
Other skin and soft tissue infections
Pediatrician
16%
Nurse
Nurse 5%
practitioner
26%
Optometrist
1%
Family
physician
9%
Podiatrician
1%
Obstetricia
ns &
Gynecologi
sts
3%
Cumulative # Diagnoses (2008-2010) from 3 CHCs
Urban Health
Open Door Family
ICD-9-CM code
Total
Plan
Health Center
373
139
130
611
680
18
18
0
681
77
77
0
682.8
31
0
0
791
0
487
684
267
110
45
686.9
642
0
320
704.8
705.83
333
208
50
683 (acute lymphadenitis), 686
(pyoderma),728 (myosistis),
771.4 (omphalitis of the
newborn),
771.5
(neonatal infective mastitis)
Hudson River
Health Care
104
0
0
31
304
112
322
75
88
1
0
87
2620
873
73
437
553
184
1032
344
1035
345
15
92
46
29
172
86
29
173
86
218
Workflow Exercise Worksheet
Dentist
3%
Laboratory/Microbiological Results:
S. aureus clones (n=129)
CAMP1 Results
•
–
–
–
–
–
–
Lesion Location (n=152)
•
–
–
–
–
–
–
–
–
Retrospective
Recurrence: History of
SSTIs /MRSA before
enrollment
T1: Recurrent Infection
42 MRSA isolates ST8-USA 300 (28 wounds + 14 colonization sites)
3 MRSA isolates ST30-USA 1100 “SouthWest Pacific clone” (2 wounds + 1
colonization site)
2 MRSA isolates ST8-NY cloneV (2 colonization site)
1 MRSA isolate ST5-USA 100 “NewYork/Japan clone” (1 wound)
1 MRSA isolate ST 72 (1 wound)
5 MRSA isolates to be typed
37 MSSA isolates ( 17 wounds + 20
colonization sites)
T1: Received treatment
of this lesion from other
doctors before
Wound and colonizing isolates share identical phenotypes of
heterogeneous beta-lactam resistance
7 MSSA isolates ST8-USA 300 (4 wounds + 3 colonization
sites)
8 MSSA isolates ST30-USA 1100 “SouthWest Pacific
clone” (4 wounds + 4 colonization sites)
2 MSSA isolates ST8-NY cloneV (1 wound + 1 colonization
site)
4 MSSA isolates ST5-USA 100 “NewYork/Japan clone” (2
wounds + 2 colonization sites)
7 MSSA isolates ST15 (2 wounds + 5 colonization sites)
2 MSSA isolates ST121 (1 wound + 1 colonization site)
1 MSSA isolate USA 400 (1 colonization site)
1 MSSA isolate to be typed
UHP/CAMP-016— wound
spa type
MLST
mecA
SCCmec
pvl
ACME
Wound
t008
ST 8
+
IVa
+
type I
Nasal
t008
ST 8
+
IVa
+
type I
UHP/CAMP-016-nasal-homo*
UHP/CAMP-016-wound-homo*
1.00E+10
UHP/CAMP-016-w
UHP/CAMP-016-n
1.00E+11
1.00E+09
UHP-16-w-homo*1
1.00E+10
UHP-016-n-homo*1
1.00E+08
UHP-16-w-homo*2
1.00E+09
UHP-016-n-homo*2
1.00E+07
UHP-16-w-homo*3
1.00E+06
UHP-16-w-homo*4
1.00E+05
UHP-16-w-homo*5
1.00E+04
1.00E+03
1.00E+02
UHP-016-n-homo*3
1.00E+07
UHP-016-n-homo*4
1.00E+06
UHP-016-n-homo*5
1.00E+05
UHP-16-w-homo*6
1.00E+04
UHP-16-w-homo*7
1.00E+03
UHP-16-w-homo*8
1.00E+01
1.00E+08
UHP-016-n-homo*6
UHP-016-n-homo*7
1.00E+02
UHP-016-n-homo*8
1.00E+01
UHP-16-w-homo*9
1.00E+00
0
0.75 1.5
3
6
12.5 25
Oxacillin (µg/ml)
50
100 200 400 800
UHP-16-w-homo*10
UHP-016-n-homo*9
1.00E+00
0
0.75 1.5
3
6
12.5
25
50
100 200 400 800
UHP-016-n-homo*10
Oxacillin (µg/ml)
T3: Previously
documented MRSA
infection or colonization
Prospective Recurrence: Subsequent
incident of SSTIs/MRSA after
enrollment
T3: Re-occurring complaint of SSTI at
more recent primary care visit
USA 300
UHP/CAMP-016— nasal
Inclusion Criteria
Exclusion Criteria
•The patient presents with signs
and symptoms of a SSTI
•7 to 70 years of age
•Fluent in English or Spanish
•Plans to receive care in this
community health center
during the next year
•The patient is unwilling to
provide informed consent
•The patient is acutely sick (for
example, crying, wheezing,
bleeding, screaming or shaken)
and unable to participate in a
discussion about the study
•The patient is unable to
understand the information
shared about the study
Treatment and Recurrence
of Staph aureus cases (n=75)
54 MRSA isolates ( 36 wounds + 18 colonization
sites)
CFU/ml
5 CHCs; 72 attendees
Elements:
• Active discussions between scientists & healthcare providers
• Agreed incision & drainage of infection site is a simple & effective
treatment
• Emphasized importance of community hygiene
Challenges recognized:
• Tracking infected patients
• Therapy commonly used for CA-MRSA in a CHC setting
Other
7%
CFU/ml
Medical
Assistant
4%
Physician
Assistant School
4%
Health
1. Continuing Medical Education (CME) accredited sessions:
Stakeholder Engagement and Study Design
CHC CME Attendees
Study Start-Up:
Fisher’s Exact Test:
P= 2.206E-04
p-value = 0.0040
CAMP Dissemination
Hospital-Acquired MRSA (HA-MRSA) Pilot Project:
Expanding the CA-MRSA Surveillance Network
Practice Based Research Networks Conduct the Full Spectrum of Translational
Research Studies of CA-MRSA Treatment and Recurrence in Community Health Centers
Goals:
• To study the clinical and microbiological characteristics of HA-MRSA in the
same communities as the CHCs, in order to allow for simultaneous
phenotypic and genotypic comparisons of both HA-MRSA and CA-MRSA
clones
• To understand the increasing occurrence of CA-MRSA strains in
nosocomial settings and HA-MRSA strains appearing in individuals who are
not exposed to hospitals
Received
Special
Recognition
during the
Poster Tour
Session on
Returning
Travelers.
Presented at the 2014 PBRN Conference held by the North American
Primary Care Research Group, June 30 – July 1, Bethesda, MD by:
Maria Pardos de la Gandara, MD, PhD
Postdoctoral Associate
Laboratory of Microbiology and Infectious Diseases
The Rockefeller University
1) Lincoln Medical Center, Bronx, NY
2) Lutheran Medical Center, Brooklyn, NY
Presented at SCTS Translational Science Conference 2013,
(Washington, DC ) by:
•
Shirish Balachandra, MD
Section Head, Walk-In Dept.
Urban Health Plan, Inc.
•
Presented by: Nancy Jenks, FNP
Director of Internal Medicine
Hudson River Community Health
Scott Salvato, PA
Clinical Coordinator
Urban Health Plan, Inc.
Expanding the Study of SSTIs/CA-MRSA To Barbershops and Beauty Salons in NYC
Recurrent Furunculosis in a
Community-Acquired S. aureus
Infection Caused by a Strain Belonging
to the USA300 Clone of MRSA
•
Previous studies have shown the receptiveness of male barbershop owners,
employees, and patrons to learning more about disease prevention and
occupational safety and health
•
SSTIs/lesions are often observed on face, scalp, head, neck, arms, hands
•
About 20% of CAMP participants’ lesions presented in these locations
•
Barbers and their clients were highly receptive to inquiries and information about
MRSA
•
Barbers welcome an in-depth public health education in the barbershop setting
Clinical Directors
Network
(CDN)
South Texas Ambulatory
Research Network
(STARNet)
+
Hudson Brookdale Open Urban
River Family Care Door Health
Family Plan
Center
Health
Health
Care
Center
Section Head, Walk-In Dept.
Urban Health Plan, Inc.
Key:
Maria Pardos de la Gandara, MD, PhD
Postdoctoral Associate
Laboratory of Microbiology and Infectious Diseases
The Rockefeller University
CHC
CHC
CHC
CHC
CHC
CHC
Brooklyn
Family
Care
Center
Hudson
River
Health
Care
Manhattan’s
Physician
Group 95 St.
Manhattan’s
Physician
Group 125 St.
Urban
Health
Plan
n=2
n=34
n=6
n=14
Open
Door
Family
Health
Center
n=23
CHCs
n=12
PATIENTS
n=159
SPECIMENS
n=318
• Protocol
• Consent
oEnglish
oSpanish
• Methods
• Database
• Ontology
• Biospecimen
Repository
Hair Braiding
Eyebrow Threading
Cosmetics
Infection Prevention Knowledge: Paired T-Test (p-value)
Baseline to T1: 2.59 (0.0135)
Baseline to T2: 4.12 (0.0003)
N2 PBRN: STARNet
San Antonio TX
CDN (New York)
CAMP
Nail Salon
Unisex Beauty Salon
Waxing
CDN PBRN2
PBRNs
n=4
Barberhop
MRSA Knowledge: Paired T-Test (p-value)
Baseline to T1: 6.81 (<.0001)
Baseline to T2: 6.25 (<.0001)
n=50
StarNet
ACCESS
LFHC*
(Texas)
(Chicago)
(New York)
CHC
CHC
CHC
CHC
CHC
CHC
Treviño
Family
Clinic
University
Health
System
Kling Adult
Medicine
Madison
Adult
Medicine
LFHC
(Family
Physician)
LFHC
(Park
Slope)
n=8
n=7
n=0
n=0
n=0
n=8
*Incubator PBRN
CAMP
Incision/ Drainage
Specimens & Nasal
Specimens
BioReference Labs
(Culture & Sensitivity)
(Antibiograms)
(Purified Sub-Cultures)
(+)
MRSA
&
MSSA
Rockefeller/
Tomasz Lab
for Molecular EPI &
Whole Genome Seq
• The South Texas Ambulatory Research Network is composed
of small group practices or solo clinicians.
• Members are primary care physicians, clinical staff, medical
students who provide service for patients from the San
Antonio area to the Lower Rio Grande Valley and Corpus
Christi communities.
PBRN Pilot
Local
Clinical
Labs
(Culture &
Sensitivity)
https://iims.uthscsa.edu/STARNet/home
Manhattan’s
Physician
Group 95th
Street
Manhattan’s
Physician
Group 125th
Street
4 PBRNs
12 CHCs
159 Patients
318 Specimens
University
Health
System
CAMP
Lutheran Family
Health Centers
(LFHCs)
Incubator PBRN
Access Community
Health Network
(ACCESS)
+
Trevino
Family
Clinic
Community Health Centers
Hospitals
Presented at SCTS Translational Science Conference 2013,
(Washington, DC) by:
•
Shirish Balachandra, MD
Maria Pardos de la Gandara, MD, PhD
Postdoctoral Associate
Laboratory of Microbiology and Infectious Diseases
The Rockefeller University
N2 PBRN: Network of Networks
Community-Engaged Research Pilot Project:
CAMP Dissemination
•
Recurrent Furunculosis in a
Community-Acquired S. aureus
Infection Caused by a Strain Belonging
to the USA300 Clone of MRSA
Presented at
the 13th
Conference of
the
International
Society of Travel
Medicine,
May 19-23,
2013,
Maastricht, The
Netherlands,
Method:
To engage and recruit two hospitals in the Greater New York Metropolitan
Area to enroll in-patient (HA-MRSA) and out-patient (CA-MRSA) patients for
clinical and microbiological analyses, and expand our CA-MRSA Surveillance
Network to a wider range of healthcare providers
Participating Hospitals:
CAMP Dissemination
Cases of Community-Acquired MRSA
(CA-MRSA) Among Immigrants Seen in
NYC Community Health Centers
+
Kling Adult
Medicine
Madison
Family
Health
Incision/ Drainage Specimens &
Nasal Specimens
BioReference Labs (Culture &
Sensitivity) (Antibiograms)
(Purified Sub-Cultures)
(+) MRSA &
MSSA
Park
Slope
LFHC
Family
Physician
LFHC
PBRN Pilot
Local Clinical
Labs
(Culture & Sensitivity)
Rockefeller/
Tomasz Lab
for Molecular EPI & Whole
Genome Seq
Funded in part by AHRQ Grant: P30 HS 021667
N2 PBRN: Access Community Health
CHICAGO IL
• Composed of 40 health centers that provide preventive care,
chronic disease management, and support services to underserved
communities
• Advance a continuum of care by partnering healthcare providers
with outreach staff, case managers, social workers, and substance
abuse counselors
• Largest provider of primary care for Medicaid beneficiaries in Illinois
http://www.accesscommunityhealth.net/
N2 PBRN: Lutheran Family Health
Centers Network
CAMP Town Halls & Focus Groups:
BROOKLYN NY (incubator PBRN)
Qualitative Findings Demonstrated Convergence of
CER/PCOR Interests
• The Lutheran Family Health Centers (LFHC) network provides high
quality, affordable outpatient primary health care and support
services close to home.
• As one of the largest Federally Qualified Health Center (FQHC)
networks in the nation, LFHC includes 9 primary care sites, 28
school based health/dental clinics and numerous social support
services. With approximately 86,000 patients, the LFHC network
handles nearly 530,000 visits annually
Pragmatic Clinical Trial Infrastructure (PCTi) Use Case:
CA-MRSA RECURRENCE PREVENTION CER/PCOR Study
To compare outcomes, for patients presenting with SSTIs and diagnosed with CAMRSA, randomized to one of two interventions:
• Patients: Responses from the RPPS patient focus group indicated that many
patients participated in the CAMP study in order to contribute to knowledge
about CA-MRSA transmission and recurrence. Outcomes that patients were
most concerned about include: recurrence, pain and inability to work.
[1] Standard CDC-Guidelines Directed Usual Care,
including incision, drainage, and oral antibiotics
• Clinicians: “[It is assumed that] colonization is ongoing, because we’ve had
patients return with recurrent infections. …If you just use systemic antibiotics,
the nasal colonization persists. Another question to consider is if the source is
in the house. We can take all measures to decolonize the person but if the
infection is still in the house (pet, towel, sheets, etc), then it’s a huge factor.” –
Dr. Balachandra
[2] CDC-Guidelines-directed Usual Care combined with
interventions conducted in the home setting to reduce
re-infection and transmission to family/household
members
• Laboratory Investigators: “Does the MRSA recurrent phenotype reflect a
single or multiple genotypes?
https://www.lutheranhealthcare.org
• Clinical Investigators: 31% of MRSA+ wounds and 28% of MSSA+ wounds are
recurrent
Funded by
PCORI CER 1402 10800
(01/01/2015)
CAMP2 Specific Aims & Logic Model
Team Grant-writing Tasks
Each Team consisted of:
– CHC Clinician
– Rockefeller Investigator
– CDN PBRN Staff Member
Group Discussion (30 minutes)
–
–
–
–
Brainstorming and writing
Discussion, Review
Editing
References added by CDN Staff
CDN
Efficacy
Reach
Effectiveness
N2
Effectiveness
Dissemination &
Implementation
CDN N2 PCORnet
Task One: Home Assessment
1. Community Health Worker
Training Module
2. Identifying Household
Members
3. Approach and Consent
4. Conducting Patient Education
Task Two: Home Intervention
1. Administering Questionnaire
2. Self-Sampling for CA-MRSA
Carriage
3. Environmental Sampling for
MRSA Contamination
4. Specimen Transport
NYC-CDRN
Dissemination &
Implementation
Scale-Up
PCORnet
Scale-Up
Sustainability
CDN PBRN & N2 -PBRN
• Adaptation of Existing Templates
• Models of Stakeholder Engagement
–
–
–
–
–
Aim 1: To evaluate the comparative effectiveness of a CHW/Promotora-delivered home intervention
(Experimental Group) as compared to Usual Care (Control Group) on the primary patient-centered
and clinical outcome (SSTI recurrence rates) and secondary patient-centered and clinical outcomes (pain, depression, quality of life,
care satisfaction) using a two-arm randomized controlled trial (RCT).
Aim 2: To understand the patient-level factors (CA-MRSA infection prevention knowledge, self-efficacy, decision-making autonomy,
prevention behaviors/adherence) and environmental-level factors (household surface contamination, household member
colonization, transmission to household members) that are associated with differences in SSTI recurrence rates.
Aim 3: To understand interactions of the intervention with bacterial genotypic and phenotypic variables on decontamination,
decolonization, SSTI recurrence, and household transmission.
Aim 4 [Exploratory]: To explore the evolution of stakeholder engagement and interactions among patients and other community
stakeholders with practicing community-based clinicians and academic laboratory and clinical investigators over the duration of the
study period.
• Scalability
www.CDNetwork.org
Building a Learning Healthcare System Requires
Designing Studies with these Principles:
• Analyzing, reviewing & providing feed-back of EHR data
to practices and clinicians at multiple levels:
– patient
– clinician
– practice
• Disseminating and implementing research on evidencebased (EB)/effective interventions and best practices
• Linking routine workflow with EB-interventions
• Carrying this out within each clinical practice nested
within multiple Healthcare Systems
• Aligning incentives
Communities
Clinicians
Patients
Researchers
Policy-makers
NYC-CDRN Key Collaborators
Health Systems
•
•
•
•
•
•
•
PI:
Clinical Directors Network (CDN)
Columbia/P&S
Montefiore/Einstein
Mount Sinai/Icahn
New York-Presbyterian
NYU/Langone
Weill Cornell (Lead Organization)
Rainu Kaushal, MD MPH
Weill Cornell Medical College
Co-PI: Jonathan N. Tobin, PhD
CDN/Rockefeller University
Co-PI: George Hripcsak, MD MS
Columbia University
Key Scientific/Technical Partners
• The Rockefeller University Hospital
• NY Genome Center (NYGC)
• Biomedical Research Alliance of NY (BRANY)
• HealthIX
• Bronx RHIO (BRIC)
Clinical Research Data
• Demographics
• Diagnoses
• Procedures
• Medications
• Test Results (Labs, Radiologic Scans)
• Health Insurance Claims
• Omics
• Patient-Reported Outcomes
Successful PBRNs = Power of Connectivity
Implications for Clinical Care, Teaching,
Research & Public Health
•
•
•
Acceleration of study conduct and implementation of results
Integration of all activities across the full translational
research spectrum
Development of high performing workforce, including
•
•
•
•
PCORnet Organizational Structure
•
109
Exploring the Use of Social Network Analysis to Measure
Stakeholder Engagement: CAMP Team Connectivity
Source: “Introducing PCORnet: The National Patient-Centered Clinical Research Network,” http://pcornet.org/resource-center/other-resources/
CDN eLearning
• CDN weekly listserv course announcements reaches
25,135 Clinicians, Clinical Researchers and Healthcare Policy-makers
• As of February 2015:
– 815 Webcasts
– 640 Hours of CME/CDE
CECH/CESW Credits awarded
– 30,110 Total Participants
Each dot (node) represents one individual and the line (edge) between them represents a connection between those individuals. The darkness
of the edges between nodes indicates a stronger connection between the two nodes. The strongest connections between individuals are
clustered in the center of the graph, and include stakeholders representing The Rockefeller University, CDN and the CHCs. This network
visualization includes data from a period of three years, and represents the cumulative total of opportunities for the network of stakeholders
to build connections to each other (since interim communications, such as those via small-group face-to-face, telephone and email are not
represented, the densities may actually underestimate the level of connectivity across stakeholders).
Summary: Participating in PBRNs
and Learning Healthcare Initiatives
• 20,200 Live Participants
• 9,910 Library Participants
new types of clinician-investigators who spend most of their career
seeing patients in practice-based settings
carrying out research in practice-based settings
engaging clinicians as investigators who design, conduct, analyze,
disseminate and implement studies
Real-time flow of data and information extracted from care
settings used for population health planning and evaluation,
as well as individual patient treatment
Increasing patient engagement in decision-making and
governance
Summary:
Learning Healthcare Initiatives
Why Efforts are Working
• Strong Academic-PBRN Partnerships
• Strong Community-PBRN Partnerships
• Strong PBRN-PBRN Partnerships
Keys to Success
• Diverse topic offerings
• Protocol specific topic offerings
• Offer timely, relevant Continuing Education (CME, CNE, CDE, CECH, CESW)
Key Barriers
•
•
•
•
Clinical demands/productivity protected time
Competing Priorities (JCAHO, PCMH, MU, ACO)
ACA Uncertainties
Lack of clear linkage between QI & Research
Jonathan N. Tobin, Ph.D.
President/CEO
CLINICAL DIRECTORS NETWORK, INC. (CDN)
Enhances
Retention and Recruitment
Professional Development
Training and Education
Role Diversification
Job Satisfaction
Improves
Clinical Skills
Clinical Guidelines and Best Practices Adoption
Clinical Quality
Decreases
Implementation Time
Stress & Burnout
Co-Director for Community Engaged Research & Adjunct Professor
Allen and Frances Adler Laboratory of Blood and Vascular Biology
Center for Clinical and Translational Science
THE ROCKEFELLER UNIVERSITY
Professor, Department of Epidemiology & Population Health
ALBERT EINSTEIN COLLEGE OF MEDICINE OF YESHIVA UNIVERSITY
Clinical Directors Network (CDN)
5 West 37th Street, 10th Floor
New York, NY 10018 USA
TEL 212-382-0699 ext. 234
FAX 212-382-0669
[email protected]
www.CDNetwork.org
www.eClinician.org
TRANSLATING RESEARCH INTO PRACTICETM
WWW.CDNETWORK.ORG
Clinical Directors Network, Inc. (CDN) is dedicated to the continuing training and education of clinicians in
Health Centers and other practices serving low-income and minority populations.
Winter/Spring 2015
Free CME-Accredited Programs available to everyone via webcast at www.CDNetwork.org
To register for a live webcast, visit Upcoming Webcasts
To view an on-demand webcast, click on Webcast Library and use our tracks to choose from hundreds of archived webcasts
March 2015 WEBCASTS
The 2015 Beatrice Renfield Lecture in Research Nursing NextGen Health Care: The Stars are
Aligned
Presented by: Afaf I. Meleis, PhD, Dr. P.S. (hon), FAAN, Dean Emerita and Professor of Nursing and
Sociology at University of Pennsylvania School of Nursing
Sponsored by: The Beatrice Renfield Foundation and The Rockefeller University University Center for
Clinical and Translational Science
Tuesday, March 3, 2015, 6:00-7:00 PM EST
Discovering the Microbiome of New York City
Presented by: Christopher Mason, PhD, Principal Investigator at Mason Labs, Assistant Professor of
Physiology and Biophysics and an Assistant Professor in the Institute for Computational Biomedicine at
Weill Cornell Medical College
Sponsored By: The Rockefeller University Center for Clinical and Translational Science, N2 PBRN Virtual
Training Series (AHRQ, Grant No. 1 P30-HS-021667), Patient-centered CER Study of Home-based
Interventions to Prevent CA-MRSA Infection Recurrence (CAMP-2) ( PCORI, Grant No. CER 1402 10800)
Wednesday, March 4 2015, 11:30 AM – 12:30 PM EST
April 2015 WEBCASTS
Engaging Patients to Inform Community Health Research within a Practice Based Research
Network
Presented By: Kay Dickerson, BA, Patient Engagement Panel Co-Founder, Lynn Robbins, Patient
Engagement Panel Co-Founder Kathy Norman, MS, Patient Engagement Panel Co-Founder, Nate Warren,
MPH, Patient Engagement Coordinator
Sponsored By: N2 PBRN Virtual Training Series (AHRQ, Grant No. 1 P30-HS-021667) featuring the
Oregon Community Health Information Network (OCHIN)
Wednesday, April 8, 2015, 4:00-5:00 PM EST
RECENT WEBCASTS
Viral Hepatitis and Opportunities for Action
Presented By: Nicole Smith, PhD, MPH, MPP CAPT US Public Health Service, Associate Director,
Policy Office, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and
TB Prevention, Centers for Disease Control and Prevention
Sponsored by: N2 PBRN Virtual Training Series (AHRQ, Grant No. 1 P30-HS-021667)
A Multi-Level Community Engaged Study Exploring Barriers to Clinical Trials and Cancer
Care Among Black Bostonians
Presented by: Linda Sprague Martinez, PhD, Assistant Professor, Public Health and Community
Medicine, Research Director, Center for Community Health Education Research and Service, Inc.
(CCHERS), Elmer R. Freeman, MSW, Executive Director, Center for Community Health, Chidinma
Osuagwa, B.A.Sc., Research Assistant, CCHERS, Elizabeth Ann Powell, MPH, Program Manager ,
Cancer Care Equity Program at Massachusetts General Hospital, Karen M. Winkfield, MD, PhD,
Assistant Professor, Department of Radiation Oncology, Harvard Medical School, Director,
Hematologic Services, Radiation Oncology, Massachusetts General Hospital
Sponsored by: N2 PBRN Virtual Training Series, (AHRQ, Grant No. 1 P30-HS-021667)
Using Technology for Patient Engagement: Examples from the Charles B. Wang Community
Health Center
Presented by: Lynn Sherman, CFO, Charles B. Wang Community Health Center
Sponsored by: N2 PBRN Virtual Training Series (AHRQ, Grant No. 1 P30-HS-021667) featuring
the Association of Asian Pacific Community Health Organizations (AAPCHO)
THE ROCKEFELLER UNIVERSITY CENTER FOR CLINICAL AND TRANSLATIONAL
SCIENCE (CCTS) WEBCAST SERIES
Diet Versus Bariatric Surgery In Obesity And Type 2 Diabetes Treatment
Presented by: Ana Emiliano, MD, Instructor in Clinical Investigation, The Rockefeller University
Programmable Bacteria for Cancer Diagnostics and Therapy
Presented by: Tal Danino PhD, MIT, Bhatia Koch Institute for Integrative Cancer Research Lab
Understanding the Research Participant’s Experience: Outcome Measures to Improve
Clinical Research
Presented by: Rhonda G. Kost, MD, Clinical Research Officer, The Rockefeller University Center
for Clinical and Translational Science (CCTS)
Maximizing the Effectiveness of Therapy against Hepatitis C Infection
Presented by: Donald Kotler, MD, Chief of the Division of Gastroenterology and Liver Disease at
St. Luke's-Roosevelt Hospital
Visit www.CDNetwork.org/Rockefeller. Funded by The National Institutes of Health - National Center for
Advancing Translational Sciences (NIH-NCATS) Grant No. 8 UL1 TR000043 and the 2011 CTSA
Administrative Supplement Award. Contents are solely the responsibility of the authors and do not
necessarily represent the official view of NIH or NCATS.
CDN can help you disseminate your research, conduct your own web-based training, and provide
Continuing Education accreditation. Call us at (212) 382 0699 x 243.
WEBCAST SERIES
The Rockefeller University Center for
Clinical and Translational Science
(CCTS) Series
www.rockefeller.edu/ccts/communityengagement
www.CDNetwork.org/Rockefeller
AIDS Education and Training Center
National Multicultural Center
Howard University College of Medicine
www.CDNetwork.org/AETCNMC
RCHN Community Health Foundation
Webcast Series
Hospital Community Benefit Obligations:
Implications Centers and Communities
www.rchnfoundation.org
www.CDNetwork.org/RCHN
National Association of Community Health
Centers (NACHC)
Risk Management Series
www.NACHC.com
www.CDNetwork.org/NACHC
Health Care Acquired Infection (HAI)
Prevention Training for Ambulatory Surgical Centers
(ASCs) & Train-the-Trainer Workshop
www.CDNetwork.org/HAI
HIV/HEPATITIS C WEBCAST LIBRARY
Further webcasts on these topics are available in our Webcast Library at www.CDNetwork.org
Taking a History of Sexual Health- Opening the Door to Effective HIV Prevention and Care
Presented by: Harvey J. Makadon MD, Director, National LGBT Health Education Center, The Fenway Institute, Fenway
Health, Clinical Professor of Medicine, Harvard Medical School
Sponsored by: N2 PBRN Virtual Training Series (AHRQ, Grant No. 1 P30-HS-021667)
Ending LGBT Invisibility in Health Care: Obtaining Data on Sexual Orientation and Gender Identity in Clinical
Settings
Presented by: Harvey J. Makadon MD, Director, National LGBT Health Education Center, The Fenway Institute, Fenway
Health, and Clinical Professor of Medicine, Harvard Medical School
Sponsored by: N2 PBRN Virtual Training Series (AHRQ, Grant No. 1 P30-HS-021667)
Young African American Men and HIV: An Interactive Response to a Community Health Issue
Presented by: John Schneider, MD, MPH, Infectious Disease, Access Grand Blvd. Health and Specialty Center, Milton
“Mickey” Eder, PhD, Director of Research and Evaluation, Access Community Health Network
Sponsored by: N2 PBRN Virtual Training Series (AHRQ, Grant No. 1 P30-HS-021667)
Maximizing the Effectiveness of Therapy Against Hepatitis C Infection
Presented by: Donald Kotler, MD, Chief of the Division of Gastroenterology and Liver Disease at St. Luke's-Roosevelt
Hospital
Sponsored by: The Rockefeller University Center for Clinical and Translational Science (CCTS) and N2 PBRN Virtual
Training Series (AHRQ, Grant No. 1 P30-HS-021667)
ENHANCING COMMUNITY HEALTH CENTER PCORI ENGAGEMENT (EnCoRE)
This work was partially supported through a Patient-Centered Outcomes Research Institute (PCORI) Program Award (NCHR
1000-30-10-10 EA-0001). With support from: N2PBRN – Building a Network of Safety Net PBRNs Funded by: Agency for
Healthcare Research and Quality (AHRQ) Grant # 1 P30 HS 021667.
Session 3: Community Engagement in Research
Presenters: Michelle Jester, Research Manager, National Association of Community Health
Centers Rosy Chang Weir, Director of Research, Association of Asian Pacific Community
Health Organizations (AAPCHO)
Session 4: Measurement, Measurement Error, and Descriptive Statistics
Presenter: Vicki M. Young PhD, Chief Operating Officer, South Carolina Primary Health Care
Association
Session 5: Sample Size, Power and Sampling Methods
Presenters: Jonathan N. Tobin, PhD, FACE, FAHA, President/CEO, Clinical Directors Network,
Inc., Professor, Department of Epidemiology & Population Health, Albert Einstein College of
Medicine of Yeshiva University; MaryAnn McBurnie, PhD Senior Investigator, Kaiser
Permanente Center for Health Research Steering Committee Chair, Community Health
Applied Research Network (CHARN)
For more information on the EnCoRE curriculum and to view new additions
to the Live Session Library, visit www.CDNetwork.org/EnCoRE
Clinical Directors Network, Inc. (CDN)
5 West 37th St. 10th FL. • New York, NY 10018 USA • TEL 212-382-0699 ext. 242 • FAX 212-382-0669
[email protected]
www.CDNetwork.org
www.eClinician.org