PPRNet - Primary (Care) Practices Research Network
Dissemination of the PPRNet Model for Improving Medication Safety in Primary Care
(PPRNet-MS-2 10/01/2010 - 09/30/2013)
Implementation of Alcohol Screening, Intervention and Treatment in Primary Care
(AMTRIP 09/20/2008 - 09/19/2013)
Enhancing Comparative Effectiveness Research Capabilities in PPRNet
(08/01/2010 – 07/31/2012)
Reducing Inappropriate Prescribing of Antibiotics by Primary Care Clinicians
(ABX-TRIP 08/24/2009 - 07/22/2012 )
Medication Safety in Primary Care Practice - Translating Research into Practice
(09/30/2007 - 09/30/2010)
Colorectal Cancer Screening in Primary Care Practice (C-TRIP)
(06/01/2006 - 04/30/2010)
Implementation and Evaluation of Standing Orders Using Health Information Technology
(SOTRIP 07/01/2008 - 06/30/2010)
Facilitating Alcohol Screening of Hypertensive Patients - AATRIP
(07/01/2004 - 08/31/2007)
Accelerating Translation of Research Into Practice - ATRIP
(09/30/2002 - 09/30/2006)
Primary and Secondary Prevention of CHD and Stroke (TRIP II Project)
(10/01/2000 - 09/30/2003)
Impact of Direct to Consumer Pharmaceutical Advertising
(06/30/2003 to 05/31/2006)
DTC Advertising Effect on Adherence to Statin Therapy
(07/01/2004 - 05/31/2007)
Dissemination of the PPRNet Model for Improving Medication Safety in Primary Care
(PPRNet-MS-2 10/01/2010 - 09/30/2013)
Citation: Wessell, A. M., S. M. Ornstein, et al. (2013). "Medication Safety in Primary Care Practice: results from a PPRNet quality improvement intervention." Am J Med Qual 28(1):16-24.
Abstract: Reducing medication errors is a fundamental patient safety goal; however, few improvement interventions have been evaluated in primary care settings. The Medication Safety in Primary Care Practice project was designed to test the impact of a multi-method quality improvement intervention on 5 categories of preventable prescribing and monitoring errors in 20 Practice Partner Research Network (PPRNet) practices. PPRNet is a primary care practice–based research network among users of a common electronic health record (EHR).The intervention was associated with significant improvements in avoidance of potentially inappropriate therapy, potential drug-disease interactions, and monitoring of potential adverse events over 2 years. Avoidance of potentially inappropriate dosages and drug-drug interactions did not change over time. Practices implemented a variety of medication safety strategies that may be relevant to other primary care audiences, including use of EHR-based audit and feedback reports, medication reconciliation, decision-support tools, and refill protocols.
Implementation of Alcohol Screening, Intervention and Treatment in Primary Care
(AMTRIP 09/20/2008 - 09/19/2013)
Citation: Ornstein, SM, Miller, PM, Wessell, AM, Jenkins, RG, Nemeth, LS, Nietert, PJ. Integration and Sustainability of Alcohol Screening, Brief Intervention, and Pharmacotherapy in Primary Care Settings. J Stud Alcohol Drugs 2013 Jul;74(4):598-604.
Abstract: At-risk drinking and alcohol use disorders are common in primary care and may adversely affect the treatment of patients with diabetes and/or hypertension. The purpose of this article is to report the impact of dissemination of a practice-based quality improvement approach (Practice Partner Research Network-Translating Research into Practice [PPRNet-TRIP]) on alcohol screening, brief intervention for at-risk drinking and alcohol use disorders, and medications for alcohol use disorders in primary care practices.
Method: Nineteen primary care practices from 15 states representing 26,005 patients with diabetes and/or hypertension participated in a group-randomized trial (early intervention vs. delayed intervention). The 12-month intervention consisted of practice site visits for academic detailing and participatory planning and network meetings for "best practice" dissemination.
Results: At the end of Phase 1, eligible patients in early-intervention practices were significantly more likely than patients in delayed-intervention practices to have been screened (odds ratio [OR] = 3.30, 95% CI [1.15, 9.50]) and more likely to have been provided a brief intervention (OR = 6.58, 95% CI [1.69, 25.7]. At the end of Phase 2, patients in delayed-intervention practices were more likely than at the end of Phase 1 to have been screened (OR = 5.18, 95% CI [4.65, 5.76]) and provided a brief intervention (OR = 1.80, 95% CI [1.31, 2.47]). Early-intervention practices maintained their screening and brief intervention performance during Phase 2. Medication for alcohol use disorders was prescribed infrequently.
Conclusions: PPRNet-TRIP is effective in improving and maintaining improvement in alcohol screening and brief intervention for patients with diabetes and/or hypertension in primary care settings.
Citation: Wessell AM, Nemeth LS, Jenkins RG, Ornstein SM, Miller PM. Medications for Alcohol Use Disorders in a Primary Care Practice-Based Research Network Implementation Study. Alcoholism Treatment Quarterly 2014; 32(1):58-66.
Abstract: National Institute on Alcohol Abuse and Alcoholism recommendations encourage clinicians to consider the use of alcohol medications (ARx), acamprosate, disulfiram, naltrexone, or topiramate, for patients with alcohol use disorders (AUD). These recommendations have not yet been implemented in U.S. primary care practices. This mixed-methods substudy reports overall ARx use and facilitators to ARx use observed during a group-randomized trial in 19 practices. Nine percent of patients with a documented AUD diagnosis (n = 149 patients) received an ARx prescription. Facilitators to ARx use were exposure to evidence, limited referral options, receptive patients, successful outcomes, low cost of oral naltrexone, and familiarity with topiramate. Findings may affect the development of future primary care implementation programs.
Citation: Nemeth, LS, Miller, PM, Nietert, PJ, Ornstein, SM, Wessell, AM, Jenkins, RG. Organizational Attributes and Screening and Brief Intervention in Primary Care. Addict Behav. 2013 Jun 14;38(11):2639-2642.
Abstract: Overconsumption of alcohol is well known to lead to numerous health and social problems. Prevalence studies of United States adults found that 20% of patients meet criteria for an alcohol use disorder. Routine screening for alcohol use is recommended in primary care settings, yet little is known about the organizational factors that are related to successful implementation of screening and brief intervention (SBI) and treatment in these settings. The purpose of this study was to evaluate organizational attributes in primary care practices that were included in a practice-based research network trial to implement alcohol SBI. The Survey of Organizational Attributes in Primary Care (SOAPC) has reliably measured four factors: communication, decision-making, stress/chaos and history of change. This 21-item instrument was administered to 178 practice members at the baseline of this trial, to evaluate for relationship of organizational attributes to the implementation of alcohol SBI and treatment. No significant relationships were found correlating alcohol screening, identification of high-risk drinkers and brief intervention, to the factors measured in the SOAPC instrument. These results highlight the challenges related to the use of organizational survey instruments in explaining or predicting variations in clinical improvement. Comprehensive mixed methods approaches may be more effective in evaluations of the implementation of SBI and treatment.
Citation: Ornstein, SM, Jenkins, RG, Litvin, CB, Wessell, AM, Nietert, PJ. Preventive Services Delivery in Patients With Chronic Ilnesses: Parallel Opportunities Rather Than Competing Obligations. Ann Fam Med. 2013 Jul-Aug;11(4):344-9.
Abstract: Whether patients with 1 or more chronic illnesses are more or less likely to receive recommended preventive services is unclear and an important public health and health care system issue. We addressed this issue in a large national practice-based research network (PBRN) that maintains a longitudinal database derived from electronic health records.
Methods: We conducted a cross-sectional study as of October 1, 2011, of the association between being up to date with 10 preventive services and the prevalence of 24 chronic illnesses among 667,379 active patients aged 18 years or older in 148 member practices in a national PBRN. We used generalized linear mixed models to assess for the association of being up to date with each preventive service as a function of the patient’s number of chronic conditions, adjusted for patient age and encounter frequency.
Results: Of the patients 65.4% had at least 1 of the 24 chronic illnesses. For 9 of the 10 preventive services there were strong associations between the odds of being up to date and the presence of chronic illness, even after adjustment for visit frequency and patient age. Odds ratios increased with the number of chronic conditions for 5 of the preventive services.
Conclusions: Rather than a barrier, the presence of chronic illness was positively associated with receipt of recommended preventive services in this large national PBRN. This finding supports the notion that modern primary care practice can effectively deliver preventive services to the growing number of patients with multiple chronic illnesses.
Citation: Ornstein SM, Nietert PJ, Jenkins RG, Litvin CB: The Prevalence of Chronic Diseases and Multimorbidity in Primary Care Practice: A PPRNet Report. J Am Board Fam Med 2013 Sept-Oct; 26 (5):518-524.
Abstract: Multimorbidity (multiple chronic illnesses) greatly affects the delivery of health care and assessment of health care quality. There is a lack of basic epidemiologic data on multimorbidity in the United States. This article addresses the prevalence of 24 chronic illnesses and multimorbidity from primary care practices across the United States.
Methods: This cross-sectional study was conducted in the PPRNet, a practice-based research network among 226 practices in 43 states that maintains a clinical database derived from a common electronic health record. Practices providing data as of October 1, 2011, and their active adult patients comprised the population used for analyses. The prevalence of each chronic illness and multimorbidity were calculated.
Results: Included in these analyses were 148 practices with 667,379 active patients. Median prevalence across practices ranged from 35.8% for hypertension to 0.23% for Parkinson disease, with wide variability among practices for all conditions. Multimorbidity increased steeply with age, leveling off at age 80; overall, 45.2% of patients had more than one chronic illness.
Conclusion: Multimorbidity is a prevalent problem in primary care practice, a finding with implications for health care delivery and payment, quality assessment, and research.
Citation: Litvin, CB, Ornstein, SM, Wessell, AM, Nemeth, LS, Nietert, PJ. Use of an Electronic Health Record Clinical Decision Support Tool to Improve Antibiotic Prescribing for Acute Respiratory Infections: The ABX-TRIP Study. J Gen Intern Med. 2013 Jun;28(6):810-6.
Abstract: Antibiotics are often inappropriately prescribed for acute respiratory infections (ARIs).
Objective: To assess the impact of a clinical decision support system (CDSS) on antibiotic prescribing for ARIs.
Design: A two-phase, 27-month demonstration project.
Setting: Nine primary care practices in PPRNet, a practice-based research network whose members use a common electronic health record (EHR).
Participants: Thirty-nine providers were included in the project.
Intervention: A CDSS was designed as an EHR progress note template. To facilitate CDSS implementation, each practice participated in two to three site visits, sent representatives to two project meetings, and received quarterly performance reports on antibiotic prescribing for ARIs.
Main Outcome Measures: 1) Use of antibiotics for inappropriate indications. 2) Use of broad spectrum antibiotics when inappropriate. 3) Use of antibiotics for sinusitis and bronchitis.
Key Results: The CDSS was used 38,592 times during the 27-month intervention; its use was sustained for the study duration. Use of antibiotics for encounters at which diagnoses for which antibiotics are rarely appropriate did not significantly change through the course of the study (estimated 27-month change, 1.57% [95% CI, -5.35%, 8.49%] in adults and -1.89% [95% CI, -9.03%, 5.26%] in children). However, use of broad spectrum antibiotics for ARI encounters improved significantly (estimated 27 month change, -16.30%, [95% CI, -24.81%, -7.79%] in adults and -16.30 [95%CI, -23.29%, -9.31%] in children). Prescribing for bronchitis did not change significantly, but use of broad spectrum antibiotics for sinusitis declined.
Conclusions: This multi-method intervention appears to have had a sustained impact on reducing the use of broad spectrum antibiotics for ARIs. This intervention shows promise for promoting judicious antibiotic use in primary care.
Citation: Litvin, CB, Ornstein, SM, Wessell, AM, Nemeth, LS, Nietert, PJ. Adoption of a clinical decision support system to promote judicious use of antibiotics for acute respiratory infections in primary care, International Journal of Medical Informatics, Volume 81, Issue 8, August 2012, Pages 521-526. PMID:22483528.
Abstract: Overuse of antibiotics for acute respiratory infections (ARIs) in primary care is an established risk factor for worsening antimicrobial resistance. The “Reducing Inappropriate Prescribing of Antibiotics by Primary Care Clinicians” study is assessing the impact of a clinical decision support system (CDSS) on antibiotic prescribing for ARIs using a multimethod intervention to facilitate CDSS adoption. The purpose of this report is to describe use of the CDSS, as well as facilitators and barriers to its adoption, during the first year of the 15-month intervention.
Methods: Between January 1, 2010 and December 31, 2010, 39 providers in 9 practices in US states participated in this study. Quarterly EHR based audit and feedback, practice site visits for academic detailing, performance review and CDSS training, and “best-practice” dissemination during two meetings of study participants were used to facilitate CDSS adoption. Mixed methods were used to evaluate adoption of the CDSS. Using data extracted from the EHR, CDSS use for ARI was calculated. To determine facilitators and barriers of CDSS adoption, semi-structured group interviews were conducted with providers and staff at each practice.
Results: During the first year of implementation, the ABX-TRIP CDSS was used 14,086 times for ARI encounters. Overall, practice use of the CDSS during ARI encounters ranged from 39.4% to 77.2%. Median use of the CDSS for adult patients was 58.2% and 68.6% for pediatric patients. Key factors associated with CDSS adoption include the perception by providers that it assists with decision making and stimulates patient discussions, engagement of non-physician staff and an iterative CDSS development process.
Conclusions: Adoption of a custom designed CDSS in the first year of implementation is promising. Successful implementation of such technology requires a focus not only on the technological solution itself, but on its integration with the entire clinical workplace.
Citation: Wessell, A. M., S. M. Ornstein, et al. (2013). "Medication Safety in Primary Care Practice: results from a PPRNet quality improvement intervention." Am J Med Qual 28(1): 16-24.
Abstract: Reducing medication errors is a fundamental patient safety goal; however, few improvement interventions have been evaluated in primary care settings. The Medication Safety in Primary Care Practice project was designed to test the impact of a multimethod quality improvement intervention on 5 categories of preventable prescribing and monitoring errors in 20 Practice Partner Research Network (PPRNet) practices. PPRNet is a primary care practice–based research network among users of a common electronic health record (EHR). The intervention was associated with significant improvements in avoidance of potentially inappropriate therapy, potential drug-disease interactions, and monitoring of potential adverse events over 2 years. A voidance of potentially inappropriate dosages and drug-drug interactions did not change over time. Practices implemented a variety of medication safety strategies that may be relevant to other primary care audiences, including use of EHR-based audit and feedback reports, medication reconciliation, decision-support tools, and refill protocols
Citation: Wessell AM, Litvin C, Jenkins RG, Nietert PJ, Nemeth LS, Ornstein SM. Medication Prescribing and Monitoring Errors in Primary Care: A Report From the Practice Partner Research Network. Qual. Saf. Health Care 2010.
Abstract: Medication errors have been associated with poor patient outcomes and pose significant public health consequences. Establishing medication safety quality indicators is crucial to capturing the pervasiveness of preventable errors and is a fundamental first step in the process of improvement. A set of medication prescribing and monitoring quality indicators were developed, and adherence to them was assessed among a group of US primary care practices in the PPRNet, practice-based research network.
Methods: Twenty Practice Partner Research Network practices in 14 US states with 94 clinicians and 52 246 active adult patients participated in the study. All practices use a common electronic medical record with dosing, interaction and monitoring decision support features. A consensus development process was used to select indicators in the categories of inappropriate treatment, dosing, drug-drug and drug-disease interactions, and monitoring of potential adverse events. Data extracted electronically from practices’ electronic medical record were used to assess practice-level adherence with the indicator set as of 1 July 2008.
Results: Thirty medication safety indicators were selected. Across all practices, inappropriate treatment, dosing, drug-drug and drug-disease interactions were avoided in 75%, 84%, 98% and 86% of eligible patients, respectively; monitoring of preventable adverse drug events occurred in 75% of patients. There was wide variability in practice adherence with the indicators. Discussion: The consensus development process was successful in selecting a broad set of primary care medication safety quality indicators. Although aggregate adherence was relatively high in this group of practices, opportunities exist to improve potential errors in treatment selection, dosing and monitoring.
Citation: Ornstein SM, Nemeth LS, Jenkins RG, Nietert PJ: Colorectal Cancer Screening in Primary Care – Translating Research into Practice, Medical Care, 48(10):900-906
Abstract: Colorectal cancer (CRC) screening is recommended for all adults 50 to 75 years old, yet only slightly more than one-half of eligible people are current with screening. Because CRC screening is usually initiated upon recommendations of primary care physicians, interventions in these settings are needed to improve screening.
Objectives: To assess the impact of a quality improvement intervention combining electronic medical record based audit and feedback, practice site visits for academic detailing and participatory planning, and "best-practice" dissemination on CRC screening in primary care practice.
Research Design:Two-year group randomized trial.
Subjects: Physicians, midlevel providers, and clinical staff members in 32 primary care practices in 19 States caring for 68,150 patients 50 years of age or older.
Measures: Proportion of active patients up-to-date (UTD) with CRC screening (colonoscopy within 10 years, sigmoidoscopy within 5 years, or at home fecal occult blood testing within 1 year) and having screening recommended within past year among those not UTD.
Results: Patients 50 to 75 years in intervention practices exhibited significantly greater improvement (from 60.7% to 71.2%) in being UTD with CRC screening than patients in control practices (from 57.7% to 62.8%), the adjusted difference being 4.9% (95% confidence interval, 3.8%-6.1%). Recommendations for screening also increased more in intervention practices with the adjusted difference being 7.9% (95% confidence interval, 6.3%-9.5%). There was wide interpractice variation in CRC screening throughout the intervention.
Conclusions: A multicomponent quality improvement intervention in practices that use electronic medical record can improve CRC screening.
Citation: Nemeth LS, Jenkins RG, Nietert PJ, Ornstein SM: Colorectal Cancer Screening in Primary Care: Theoretical Model to Improve Prevalence in the Practice Partner Research Network, Health Promotion Practice, 2009, March 18.
Abstract: Colorectal cancer (CRC) is the second leading cause of cancer death in the United States (US). Half of Americans above age 50 are not current with recommended screening; research is needed to assess the impact of interventions designed to increase receipt of CRC screening. The Colorectal Cancer Screening in Primary Care (C-TRIP) study is a theoretically-informed group randomized trial within 32 primary care practices. Baseline median proportion of active patients aged 50 years or older up-to-date with CRC screening among the 32 practices was 50.8% (N=55,746). Men were more likely to be screened than women (52.9% vs. 49.2% respectively). Patients 50–59 years of age were less likely to be up-to-date with screening (45.4%) than those in the 60–69 year and 70–79 years groups (58.5% in both groups). Opportunities exist to increase the proportion of CRC screening received in adults age 50 and older. C-TRIP evaluates the effectiveness of a model for improvement for increasing this proportion.
Citation: Nemeth LS, Nietert PJ, Ornstein SM: High performance in screening for colorectal cancer: a Practice Partner Research J Am Board Fam Med. 2009 Mar-Apr;22(2):141-6.
Abstract: Introduction: Colorectal cancer (CRC) screening is recommended for average-risk adults age 50 and older, yet half of eligible US adults are not current. This case study of highest performing practices within the Colorectal Screening in Primary Care study (C-TRIP) explains practice strategies used and provides a model for improving CRC screening in primary care.
Methods: A case study design was used to analyze practice performance data and qualitative data obtained from site visits, network meetings, and correspondence. The Practice Partner Research Network (PPRNet) Translating Research into Practice (TRIP) Quality Improvement (QI) model provided an analytic framework to evaluate the 5 highest-performing practices in the C-TRIP intervention. Practice strategies were grouped within the concepts: prioritize performance (PP), redesign delivery system (RDS), electronic medical record tools (EMR), and activate the patient (AP).
Results: Thirteen specific practice strategies were exemplified within these four concepts (PP, RDS, EMR, AP). Most or all of these strategies were used by practices that achieved the highest proportion (up to 78%) of adults screened for CRC.
Conclusions: Primary care practices achieving a high proportion of CRC screening use systematic processes in the organization of their care. This case study provides a framework to organize systems that increase early detection and prevention of colorectal cancer.
Citation: Nietert PJ, Jenkins RG, Nemeth LS, Ornstein SM (2009). An application of a modified constrained randomization process to a practice-based cluster randomized trial to improve colorectal cancer screening. Contemporary Clinical Trials, 30:129-132.
Abstract: When designing cluster randomized trials, it is important for researchers to be familiar with strategies to achieve valid study designs given limited resources. Constrained randomization is a technique to help ensure balance on pre-specified baseline covariates.
Methods: The goal was to develop a randomization scheme that balanced 16 intervention and 16 control practices with respect to 7 factors that may influence improvement in study outcomes during a 4-year cluster randomized trial to improve colorectal cancer screening within a primary care practice-based research network. We used a novel approach that included simulating 30,000 randomization schemes, removing duplicates, identifying which schemes were sufficiently balanced, and randomly selecting one scheme for use in the trial. For a given factor, balance was considered achieved when the frequency of each factor's sub-classifications differed by no more than 1 between intervention and control groups. The population being studied includes approximately 32 primary care practices located in 19 states within the U.S. that care for approximately 56,000 patients at least 50 years old.
Results: Of 29,782 unique simulated randomization schemes, 116 were determined to be balanced according to pre-specified criteria for all 7 baseline covariates. The final randomization scheme was randomly selected from these 116 acceptable schemes.
Conclusions: Using this technique, we were successfully able to find a randomization scheme that allocated 32 primary care practices into intervention and control groups in a way that preserved balance across 7 baseline covariates. This process may be a useful tool for ensuring covariate balance within moderately large cluster randomized trials.
Citation: Nemeth LS, Ornstein SM, Jenkins RG, Wessell Am, Nietert PJ. Implementing and Evaluating Electronic Standing Orders in Primary Care Practice: A PPRNet Study. Journal of the American Board of Family Medicine Sept-Oct 2012, Volume 25, Issue 4, 594-604.
Abstract: A standing order (SO) authorizes nurses and other staff to carry out medical orders per practice-approved protocol without a clinician’s examination. This study implemented electronic SOs into the daily workflow of primary care practices; identified methods and strategies; determined barriers and facilitators; and measured changes in quality indicators resulting from electronic SOs.
Methods: Within 8 practices using the Practice Partner® electronic health record (EHR), a customized health maintenance template provided SOs for screening, immunization, and diabetes measures. EHR data extracts were used to calculate the presence and use of these measures on health maintenance templates and performance over 21 months. Qualitative observation/interviews at practice site visits, network meetings, and correspondence enabled synthesis of implementation issues.
Results: Improvements in template presence, use, and performance were found for 14 measures across all practices. Median improvements in screening ranged 6% to 10%; immunizations, 8% to 17%, and diabetes, 0% to 18%. Two practices achieved significant improvement on 14 of the 15 measures. All practices significantly improved on at least 3 of the measures.
Conclusions: A small sample of primary care practices implemented SOs for screening, immunizations and diabetes measures supported by PPRNet researchers. Technical competence and leadership to adapt EHR reminder tools helped staff adopt new roles and overcome barriers.
Facilitating Alcohol Screening of Hypertensive Patients - AATRIP
(07/01/2004 - 08/31/2007)
Citation: Miller PM, Stockdell R, Nemeth L, Feifer C, Jenkins R, Nietert PJ, Wessell A, Liszka H, Ornstein S: Initial steps by nine primary care practices to implement alcohol screening guidelines with hypertensive patients: The AA TRIP project, 2006, Substance Abuse, 27(1/2):61-70
Abstract: Many medical conditions are caused or exacerbated by heavy drinking, necessitating alcohol screening and discussion in primary care practices. This is particularly true of hypertension, the most common primary diagnosis in the United States, which has been linked to the regular consumption of 3 or more standard alcoholic beverages a day. The Accelerating Alcohol Screening-Translating Research into Practice (AA-TRIP) project was designed to improve detection and management of alcohol problems in primary care patients with hypertension. Medical providers are being trained using the Practice Partner Research Network's- Translating Research into Practice (PPRNet-TRIP) quality improvement model. This includes a multi-method intervention (electronic medical records, on-site academic detailing, practice feedback reports and annual network meetings) to help practices increase adherence to clinical guidelines. Qualitative analyses of initial steps taken by nine primary care practices toward the routine implementation of alcohol screening guidelines are presented. Organizational factors and provider and patient characteristics all influenced the method and consistency of alcohol screening and intervention. Perceived time constraints, patient sensitivity to questions about alcohol, and possible stigma associated with a diagnosis of alcoholism were also relevant barriers requiring problem solving.
Citation: Feifer C, Nemeth L, Nietert PJ, Wessell AM, Jenkins RG, Roylance LF, Ornstein SM: Different Paths to High-Quality Care: Three Archetypes of Top Performing Practice Sites. Annals of Family Medicine, 5(3): 233-241, 2007
Abstract: Primary care practices use different approaches in their quest for high-quality care. Previous work in the Practice Partner Research Network (PPRNet) found that improved outcomes are associated with strategies to prioritize performance, involve staff, redesign elements of the delivery system, make patients active partners in guideline adherence, and use tools embedded in the electronic medical record. The aim of this study was to examine variations in the adoption of improvements among sites achieving the best outcomes.
Methods: This study used an observational case study design. A practice-level measure of adherence to clinical guidelines was used to identify the highest performing practices in a network of internal and family medicine practices participating in a national demonstration project. We analyzed qualitative and quantitative information derived from project documents, field notes, and evaluation questionnaires to develop and compare case studies.
Results: Nine cases are described. All use many of the same improvement strategies. Differences in the way improvements are organized define 3 distinct archetypes: the Technophiles, the Motivated Team, and the Care Enterprise. There is no single approach that explains the superior performance of high-performing practices, though each has adopted variations of PPRNet’s improvement model.
Conclusions: Practices will vary in their path to high-quality care. The archetypes could prove to be a useful guide to other practices selecting an overall quality improvement approach.
Citation: Ornstein SM, Jenkins RG, Nietert PJ, Feifer C, Roylance LF, Nemeth L, Corley S, Dickerson L, Bradford WD, Litvin, C: Multi-Method Quality Improvement Intervention to Improve Cardiovascular Care: A Cluster Randomized Trial, Annals of Internal Medicine, 2004; 141(7):523-532
Abstract: Research is needed to validate effective and practical strategies for improving the provision of evidence-based medicine in primary care.
Objective: To determine whether a multimethod quality improvement intervention was more effective than a less intensive intervention for improving adherence to 21 quality indicators for primary and secondary prevention of cardiovascular disease and stroke.
Design: 2-year randomized, controlled clinical trial with the practice as the unit of randomization.
Setting: 20 community-based family or general internal medicine practices in 14 states. All used the same electronic medical record.
Participants: 44 physicians, 17 midlevel providers, and approximately 200 staff members; data from the electronic medical records of 87,291 patients.
Interventions: All practices received copies of practice guidelines and quarterly performance reports. Intervention practices also hosted quarterly site visits to help them adopt quality improvement approaches and participated in 2 network meetings to share "best practice" approaches.
Measurements: The percentage of indicators at or above predefined targets and the percentage of patients who had achieved each clinical indicator.|
Results: Intervention practices improved 22.4 percentage points (from 11.3% to 33.7%) in the percentage of indicators at or above the target; control practices improved 16.4 percentage points (from 6.3% to 22.7%). The 6.0-percentage point absolute difference between the intervention and control group was not statistically significant (P > 0.2). Patients in intervention practices had greater improvements than those in control practices for diagnoses of hypertension (improvement difference, 15.7 percentage points [95% CI, 5.2 to 26.3 percentage points]) and blood pressure control in patients with hypertension (improvement difference, 8.0 percentage points [CI, 0.0 to 16.0 percentage points]).
Limitations: The study involved a small number of practices and lacked a pure control group.
Conclusions: Primary care practices that use electronic medical records and receive regular performance reports can improve their adherence to clinical practice guidelines for cardiovascular disease and stroke prevention.
Citation: Bradford W, Kleit A, Nietert P, Steyer T, McIlwain T, Ornstein S: How direct to consumer television advertising for osteoarthritis drugs affects physicians' prescribing behavior, 2006, Health Affairs, 25(5):1371-1377
Abstract: This study examined how direct to consumer advertising has affected physicians' prescribing behavior for osteoarthritis patients. Monthly clinical information on fifty-seven primary care practices during 2000-2002, matched to monthly brand specific advertising data for local and network television, was analyzed. DTC advertising of Vioxx and Celebrex increased the number of osteoarthritis patients seen by physicians each month. DTC advertising of Vioxx increased the likelihood that patients received both Vioxx and Celebrex, but Celebrex ads only affected Vioxx use.
Citation: Bradford WD, Kleit AN, Nietert PJ, Ornstein SM: Effects of Direct-to-Consumer Advertising of Hydroxymethylglutaryl Coenzyme A Reductase Inhibitors on Attainment of LDL-C Goals, 2006, Clinical Therapeutics, 28(12): 2105-2118
Abstract: Although highly controversial, directto-consumer (DTC) television advertising for prescription drugs is an established practice in the US health care industry. While the US Food and Drug Administration is currently reexamining its regulatory stance, little evidence exists regarding the impact of DTC advertising on patient health outcomes. OBJECTIVE: The objective of this research was to study the relationship between heavy television promotion of 3 major hydroxymethylglutaryl coenzyme A reductase inhibitors ("statins") and the frequency with which patients are able to attain low-density lipoprotein cholesterol (LDL-C) blood-level goals after treatment with any statin.
Methods: We used logistic regression to determine achievement of LDL-C goals at 6 months after statin treatment, using electronic medical record extract data from patients from geographically dispersed primary care practices in the United States. We identified LDL-C blood levels as being at or less than goal, as defined by risk-adjusted guidelines published by the National Heart, Lung, and Blood Institute from the Adult Treatment Panel III (ATP III) data. A total of 50,741 patients, identified from 88 practices, were diagnosed with hyperlipidemia and had begun therapy with any statin medication during the 1998-2004 time period. In addition, total dollars spent each month on television advertising at the national and local levels for atorvastatin, pravastatin, and simvastatin were obtained. DTC advertising data were merged by local media market where the physician practice was located and by the month in which the patient was first prescribed a statin. The models were run for all patients who initiated therapy, and also on a subsample of patients who continued to receive prescriptions for the drugs for at least 6 months. Logistic regressions were used to predict the likelihood that each patient attained the ATP III LDL-C blood-level goals as a function of DTC advertising and other factors. Results: High levels of national DTC advertising when therapy was initiated were found to increase the likelihood that patients attained LDL-C goals at 6 months by 6% (P < 0.001)-although the effect was concentrated among patients with the least-restrictive ATP III LDL-C goals (<or=160 mg/dL). This result was found in both the entire set of patients as well as the restricted sample of patients who maintained therapy for at least 6 months.
Conclusions: The results of this study suggest that higher levels of DTC television advertising of statin treatment were significantly associated with improvements in the likelihood of attaining cholesterol-management goals for at least some patients. While this paper does not address the impact of DTC advertising on the costs of care or on unnecessary switching between statin treatments, the results do suggest that DTC advertising can have beneficial effects, which should be a factor when additional restrictions on DTC advertising are considered. This result-that DTC ad vertising might have beneficial effects-should be weighed against existing studies that have found that patients' suggestions (conceptually which could be induced by DTC advertising) may be associated with overprescribing (eg, in the case of the use of antidepressants for adjustment disorder).
The Impact of Electronic Medical Records on Primary Care Practice
Citation: Wager KA, Lee FW, White AW, Ward DM, Ornstein SA. Impact of an Electronic Medical Record System on Community-Based Primary Care Practices. J Am Board Fam Pract 2000;13:338-48
The purpose of this study was to examine the organizational and economical impact of electronic medical records on community-based, primary care practice. Six PPRNet practices that had converted from paper records to electronic medical records within the past five years participated. The final report was a narrative description and an analysis of themes that emerged. Included were similarities and differences in perspectives between different user groups and different sites regarding changes that occurred in practice that may be attributed to the electronic medical record. The report included changes in costs associated with maintaining paper versus electronic medical record systems, while controlling for patient volume, inflation, and changes in reimbursement rates over time. The study findings were important in furthering our understanding of how electronic medical records have changed physician practice through the perspectives of experienced users.
Abstract: The purpose of this study was to examine the organizational and economical impact of electronic medical records on community-based, primary care practice. Six PPRNet practices that had converted from paper records to electronic medical records within the past five years participated. The final report was a narrative description and an analysis of themes that emerged. Included were similarities and differences in perspectives between different user groups and different sites regarding changes that occurred in practice that may be attributed to the electronic medical record. The report included changes in costs associated with maintaining paper versus electronic medical record systems, while controlling for patient volume, inflation, and changes in reimbursement rates over time. The study findings were important in furthering our understanding of how electronic medical records have changed physician practice through the perspectives of experienced users.
Quality of Care for Asthma, Coronary Disease, Diabetes Mellitus and Hypertension in the Practice Partner Research Network
Citation: Ornstein SM, Jenkins RG: Quality of Care for Chronic Illness in Primary Care: Opportunity for Improvement in Process and Outcome Measures. The American Journal of Managed Care. 1999; 5(5):621-627
Abstract: To describe adherence to a number of quality indicators and clinical outcomes for asthma, diabetes mellitus, hypertension, coronary heart disease, atrial fibrillation, and cerebrovascular disease in the primary care practices of the Practice Partner Research Network (PPRNet).
Study Design: Cross-sectional epidemiologic design.
Patients and Methods: PPRNet is a national research network of ambulatory, mostly primary care practices that use the Practice Partner Patient Records electronic medical records. Participating practices send anonymous clinical data on patients to the PPRNet data center monthly. Standard database management and statistical software are used to compile practice reports. These reports include measures of adherence to process and outcome measures for chronic illnesses, the subject of this report.
Results: Forty-eight PPRNet practices provided data for the first quarter of 1998. A total of 336,401 patients were active in these practices during this quarter. At least 2000 active patients had each of the conditions studied. Wide variation in guideline adherence among PPRNet practices was present for each of the performance measures. Better performance was present for physical examination measures and laboratory monitoring than for treatment interventions. Overall performance was excellent for blood pressure monitoring, poor for lipid monitoring in patients with CHD, and intermediate for glycosylated hemoglobin monitoring in patients with diabetes mellitus.
Conclusion: The findings of this study are comparable to others in documenting that most clinical practice guidelines for chronic illness are not followed for a majority of patients and that large majorities do not reach desired clinical outcomes.
Citation: Hueston WJ, Mainous AG, Ornstein S, Pan Q, Jenkins RG: Antibiotics for Upper Respiratory Infections. Follow-up Utilization and Antibiotic Use. Arch Fam Med. 1999; 8:426-430
Abstract: To examine the effects of antibiotic prescribing during an initial visit for viral respiratory tract infections on future care seeking and the cost of care.
Materials and methods: Retrospective analysis of recorded visits for viral respiratory tract infections (N = 49,862) between January 1, 1995, and December 31, 1997, to practices in a large network of affiliated practices that use the same electronic medical record.
Results: Patients receiving antibiotics at the initial visit were less likely to return for a second visit, but this difference was small (15.4% vs 17.4%, P < .001). When returning for the second visit, those who received an antibiotic on the initial visit were prescribed more expensive antibiotics than those who had not received an antibiotic on the initial consultation. Overall, cost from initial antibiotic use outweighed any benefit from reduced utilization in adults and children.
Conclusions: Antibiotic prescribing at an initial contact for a viral respiratory tract illness may reduce the likelihood that an individual will return for a subsequent visit, but adds substantial costs to care for the initial antibiotic and for more expensive antibiotics used on subsequent visits.
Citation: Hueston WJ, Ornstein SM, Jenkins RG, Pan Q, Wulfman JS: Treatment of Recurrent Otitis Media After a Previous Treatment Failure - Which Antibiotics Work Best? The Journal of Family Practice. 1999; 48(1):43-46
Abstract: Recurrent infection after an episode of otitis media is common in pediatric patients. If a patient experienced primary treatment failure in a preceding episode, physicians often feel pressured to prescribe a broad-spectrum, second-line agent for the next episode rather than a first-line drug. The purpose of our study was to determine whether using a second-line drug resulted in fewer treatment failures in a recurrent otitis episode following an episode of apparent resistance.
Methods: The Practice Partner Research Network database, a national research network of practices that use the same electronic medical record, was reviewed to identify all primary episodes of otitis media over a 2-year period (N = 7807). From this, 1416 pediatric patients with presumed treatment failures were identified. The subset of those with a second otitis media episode more than 90 days after the index episode (N = 343) was selected for study. Of this group, 236 (69%) received first-line antibiotics (amoxicillin, ampicillin, penicillin, or sulfamethoxazole-trimethoprim) and the remaining 107 received a broader-spectrum, second-line antibiotic. The primary outcome was the need for an additional antibiotic for otitis media within the next 45 days.
Results: Patients receiving first- and second-line antibiotics did not differ in sex or age. However, those receiving second-line antibiotics had a shorter duration between episodes (231 vs 280 days, P = .007). Failure rates for first- and second-line antibiotics in recurrent episodes were not significantly different (13% vs 19%, P = .20). Because the duration between episodes could have affected failure rates, we stratified the time between episodes into short, intermediate, and long duration. Second-line antibiotics were not superior to first-line drugs in any stratum.
Conclusions: For a new otitis media episode in a patient with a previous treatment failure, first-line drugs (amoxicillin, ampicillin, penicillin, or sulfamethoxazole-trimethoprim) are just as effective as broader-spectrum, more expensive, second-line antibiotics.
Citation: Jenkins RG, Ornstein SM: Preventive Services in the Primary Care Practices of the Practice Partner Research Network. Topics in Health Information Management 2000; 20(3):80-84
Abstract: Despite the emphasis of primary care on preventive services over the past decade, and the reminder systems that are available to promote the provision of these services, many patients still do not receive needed services. This study describes the preventive services that the primary care practices of the Practice Partner Research Network (PPRNet) monitors, and documents adherence to them. Preventive services monitored in PPRNet practices and the levels of adherence to them vary by practice and service. The lower-than-desired levels of adherence offer opportunities for improvement interventions.
Wager KA, Ornstein SM, Jenkins RG: The Perceived Value of Computer Based Patient Records Among Clinician Users. MD Computing, September 1997; 14(5)