What You Need to Know to be a Health Services Researcher durhamm

What You Need to Know to be a Health Services Researcher Mary L. Durham, PhD Vice President, Kaiser Permanente Director, TCHR A NEGOTIATOR • I need to be able to put together complex collaborative arrangements that involve multiple institutions. That means negotiating for entré into diverse settings, for multiple Institutional Review Board reviews, and for virtually every step of the work. A DIPLOMAT • Forget the idea of the solitary scientist working alone or with a few select colleagues. I must be able to satisfy the often-conflicting demands of far-flung Pis and Co-PIs, their deans or directors, IRBs, HIPAA privacy officers, and many others. A POLITICIAN • The days of adequate funding are gone – if they ever existed. Now I must be able to make the 20% budget cut the funder requires. When one of the sites has to be eliminated and no one wants to cut the scope of work, I get to use my best political maneuvering to get the job done. A METHODOLOGIST • I must be able to rely on my knowledge of flexible methods that suit the occasion but don’t bury the opportunity to do the work with my busy clinicians partners. (I actually like this part of the work best because it has become one of the few things that resemble the science I was originally trained to do!) A PUBLICIST OR ON CAMERA TALENT • You want me to do interviews with the press??? Today’s researchers must be able to explain complex topics to the public and be able to hand reporters great quotes so they get it right. (All I really want to do is write papers and let my work speak for itself.) A CHANGE AGENT • More and more research requires applying my fledgling understanding of community-based practice research principles so that I can be a good partner with the organization/s where the work is conducted. Instead of pursuing my own personal research agenda, sometimes I’ll be designing projects that focus on an organization’s priority work. AN HISTORIAN • Introducing and engineering short-term change in an individual or organization is not enough. Now I must do work that can be sustained over time. A FUTURIST • ―Show me the data.‖ I am called upon to imagine the future and do the research before healthcare systems take a chance on change. Building the Bridge Between Research and Clinical Practice: Tips for Health Services Researchers Adrianne C. Feldstein, MD, MS, Assistant Medical Liaison for Research, Kaiser Permanente Northwest Affiliate Investigator, Center for Health Research Presentation Goals  Describe existing frameworks and key elements for successful translation of research into practice (TRIP)  Briefly describe 2 projects with TRIP learnings  Describe key TRIP learnings for health services researchers highlighting ―Change agent‖, ―Air traffic controller‖ and ―Historian‖ work What do we know? - Useful Models Community-Based Participatory Research (AHRQ 7-04 Evidence Report) – Community participation in all aspects of research - question, design,implementation, analysis – Co-learning and reciprocal transfer of expertise – Shared decision-making power – Mutual ownership products and processes Useful Models Organization Change / Diffusion of Innovation (e.g. Commonwealth Fund, AHRQ TRIP) Four Key Domains – Characteristics of Innovation – Characteristics of Adopting Organizations – Dissemination Infrastructure – External Environment Useful Models Chronic Care Model (Wagner et al)  Community  Health system leadership  Delivery system design  Clinical information systems  Clinician decision support  Patient self management support Useful Models RE-AIM evaluation framework (Glasgow et al)  Reach (to diverse patient groups)  Effectiveness  Adoption (by practice settings and clinicians)  Implementation (consistency of use by various staff)  Maintenance of practices and results over the long term. Useful models  PRISM (Feldstein et al)- ―Change Agent‖ model Safety in Prescribing (SIP)  Specific Aims – Measure the effect patient-specific EMR alerts on risky prescribing – Measure the effect of adding a brief educational outreach program  Outcome measures / Analysis – Monthly prescribing rates, time series design, segmented regression analyses Target Areas  Medications (generally) to avoid in the elderly  Dose adjustment for renal insufficiency  Drug interactions SIP Community Based Participation  Organizational Patient Safety Strategy  Strong Management and Clinical Leadership  Qualitative Work with Prescribers – Structured interviews – Discount usability testing  Local and National Committees (IT/ pharmacist/ physician )- ―Air Traffic Control‖ work – Research questions – Clinical content – Coordination and Implementation Visit Date: 10/03/2003 Overlapping Prescriptions for Warfarin and 5 Drugs SIP Additional Success Factors  Alerts continue and extended to 9000 clinicians – Maintenance pre-planned- ―Historian‖ work  Data on effectiveness strong (outcomes data weak)  Limited cultural change  Relationships strong – bridge researchers REFIT: The Re-Fracture Intervention Trials (Phase 1+2) The results of a randomized controlled trial to improve the management of osteoporosis after a fracture and their translation into practice Study Population / Intervention / Outcomes Population: Women over age 50 who sustained clinical fracture associated with osteoporosis, no BMD or treatment Study Design/Intervention 1.RCT comparing UC with EMR Reminder and EMR+Patient Reminder 2. Nurse outreach pilot 3. Time series evaluation implementation combined intervention Primary Outcome: Pharmacologic treatment for osteoporosis or completion of a BMD measurement by 6 months post-fracture REFIT Community-based Participation  Senior management support  Guided by quality improvement committee from design  funding  implementation  maintenance  Strong physician champions Patient Name (Health Record #) KPNW, EIGHT (6173-98-02) Sex: Female DOB: 8/6/1952 Age: 50 Age: 50 Sex: Female DOB: 8/6/1952 Dear Dr. _________________ Your patient, Eight Kpnw, has been identified by the KPNW Osteoporosis Work Group as being at high risk for osteoporosis based on the person’s age and a previous fracture (since 1997) and may benefit from further testing and medical therapy. Prior fracture is the strongest predictor of future fracture, and treating osteoporosis will reduce future fracture risk by 30-50%. Clinical guidelines recommend that older individuals who sustain a low-impact fracture (e.g. a fall from standing height or less) of a site representing increased risk for osteoporosis (all sites except skull, facial, fingers and toes) should receive specific medical follow up. They should receive either 1) an evaluation for secondary osteoporosis and direct pharmacological treatment or 2) bone mineral density testing (BMD) followed by evaluation and pharmacological treatment if indicated by BMD. This notification is based on electronic information that may not reflect care that is very recent. Please ignore this notice if you have already addressed this with the patient. Please see our guidelines on the intranet home pate at: www.http:///internal.or.kp.org/cpg/resource/R20903.HTML Additional information is found in the NIH Consensus Statement on Osteoporosis at: http://odp.od.nig.gov/consensus/cons/111/111_intro.htm To order bone mineral density by dual-energy x-ray absorptiometry enter IR bone on Order Summary in EpicCare. If you have questions, please E-mail me. Thank you, Dr. _________________ REFIT patient outreach pilot Nurse care management per standing orders/guidelines  17/19 patients initiated osteoporosis medication Women 67+ with Fractures (2001-2005) Treatment Year N Medication BMD Both (Medication and Scan) Total Treatment 2001 979 275 18 27 320 % 28.1% 1.8% 2.8% 32.7% 2002 1010 284 22 26 332 % 28.1% 2.2% 2.6% 32.9% 2003 1202 339 37 39 415 % 28.2% 3.1% 3.2% 34.5% 2004 1259 399 77 72 548 % 31.7% 6.1% 5.7% 43.5% 2005 710 318 72 43 433 % 44.8% 10.1% 6.1% 61.0% REFIT Additional Success Factors  Strong evidence base  Limited cultural change  HEDIS measure – strong external pressure Outcome  Reminders and outreach continue Success Factors Characteristics of Innovation (Organizational perspective) – – – – – – – – Readiness Strength of evidence base Addresses barriers of frontline staff Coordination across departments and specialties Burden (complexity and cost) Usability and adaptability Trialability and reversibility Ability to observe results Success Factors Characteristics of Innovation (Patient perspective) – – – – – – – Patient centeredness Providing patient choices Addresses patient barriers Seamlessness of transition- program elements Service and access Burden (complexity and cost) Feedback of results Success Factors Characteristics of Recipients (Organization-leaders, managers, staff) – Organizational health and culture – Management support and communication – Clinical leadership – Systems and training – Data and decision support – Staffing and incentives – Expectation of sustainability – Perceived net benefit – Knowledge and beliefs – Perceived risk – Prior experience Success Factors Characteristics of Recipients (Patient) – – – – – – – Demographics Disease burden Competing demands Perceived net benefits Knowledge and beliefs Perceived risks Prior experience Success Factors Implementation-Sustainability Infrastructure Performance data Dedicated team Adopter training and support Relationship and communication with adopters (Bridge researchers) – Protocols and procedures – Plan for sustainability (QA structure, existing staff and systems) – – – – Success Factors External Environment – Payor satisfaction – Competition – Regulatory environment – Reimbursement – Community resources Thanks We look forward to hearing about your experiences! AcademyHealth: Becoming Media Savvy Michelle Ponte Kaiser Permanente From Stats to Cosmo Magazine? • Media Is Important for Your Career! • Expectations of Researchers Are Changing. • What Exactly Does the Term ―Media‖ Mean? Five Reasons Why Researchers Must Be Media Savvy 1. 2. 3. 4. 5. Funding Impact on Clinical Care Organizational Reputation Don’t Let Someone Else Tell Translational Research Your Story. Learn Media Skills. It isn't Always Intuitive! • A desire to communicate • Enthusiasm • Good Listening Skills • Speak Common English. • Be a Persuader. • Be a Spokesperson Understanding the Media Cycle • Presenting Vs. Publishing • When to do a Press Release • Understanding How Reporters Work With Embargo Dates What Reporters Want From You • New Information • Interesting • Easily Translated Understand Your Audience • Your Audience Is not Just the Reader. • Different Audiences Need Different Things. • How Does Your Work Relate to a Particular Audience? Help the Reporter Get the Story Right • Work With Your Media Relations Colleagues. • Be Available Just Prior to the Embargo! • Be Prepared to Discuss the Most Important Findings. Help the Reporter Get the Story Right • Be Brief! • Be Able to Explain Relevance • Always Think: Juicy Quote. Help the Reporter Get the Story Right • Make it Interesting. • Lose the Details. • Assume Nothing. Help the Reporter Get the Story Right • Develop Talking Points. • Be Available! • What Does Off the Record Really Mean? • Offer to Review the Facts. Important Tips • What You Say Will Be Taken Out of Context. • Understand Issues Around Methodology. • Anticipate Tough Questions. • Speak in Positive Terms. • Deflect When Necessary. • Respond to Follow-up Questions. AcademyHealth Mark Hornbrook, PhD Chief Scientist The Center for Health Research Northwest, Southeast & Hawaii A Negotiator: Use Case #1 • For testing ways of translating research findings into practice, I need to approach health plan executives, medical directors, clinical chiefs, dept. managers, nursing managers, and individual MDs and RNs about adopting new programs that have been shown to generate better health outcomes for patients. • But change is difficult. Clinicians sometimes aren’t convinced by statistics—probabilities are not certainties—and they want to know who is going to pay for the extra work! A Negotiator: Use Case #2 • I want to administer a survey to physicians who provided care to a sample of cancer patients who are research participants. • To obtain MD cooperation: – – – – – Letter from head of NCI Letter from president of specialty society E-mails from their medical director & clinical chief Modest financial incentive Choice of paper or web-based response modes A Diplomat: Use Case #1 • I want to work with community based organizations to develop a research program in smoking and weight management. • But the CBO leaders already know that one commercial program is the preferred approach and want my research project to pay for membership fees so they can prove the program works in their communities. • CBOs may not understand the technical requirements for fundable community-based research. A Diplomat: Use Case #2 • A Federally-Qualified Health Clinic is interested in conducting research on health issues that are most prevalent in its clinic population. • FHQC doctors are not research trained and do not have time out of clinic to conduct research. • An HMO research center is interested in conducting practicebased research with diverse populations. • By bringing the HMO research and FHQC leaders together, a collaborative vision is created and steps for moving forward on writing proposals for joint studies are identified. A Politician: Use Case #1 • One of my collaborating research sites is asking for twice as much money as any other site. The request derives from a combination of a location with higher costs of living, proposed team members with higher ranks and longer tenure, and higher levels of effort to perform the work. • Should I replace this site, which means losing the collaboration of a scientist I have worked with for many years? Or insist on less-experienced staff at the given effort levels, or lower effort allocations in recognition of the higher levels of experience of the proposed team members? A Politician: Use Case #2 • NIH is replacing General Clinical Research Centers (GCRCs) with Clinical and Translational Science Awards (CTSAs). • Building a CTSA proposal requires negotiating changes in long-standing infrastructure support for basic biological and biomedical research (bench labs, beds, exam rooms, microarrays, etc.) to make room to support population sciences (clinical/utilization data) and TRIPP research.