PPRNet Completed Research
Implementation of Alcohol Screening, Intervention and Treatment in Primary Care (AMTRIP)
(09/20/2008 - 09/19/2013) Principal Investigators: Peter Miller, PhD, Professor, Dept. of Psychiatry and Behavioral Sciences and Steve Ornstein, MD, Professor, Dept. of Family Medicine.
A prime reason that alcohol screening of patients in primary care has been recommended is that heavy alcohol use can worsen medical conditions such as hypertension and diabetes mellitus. This project examines the effectiveness of the Practice Partner Research Network's (PPRNet) Accelerating Alcohol Screening-Translating Research into Practice (AATRIP) model to improve the detection, brief intervention, treatment (including pharmacotherapy and medical management) of alcohol problems by primary care physicians.
a) To compare the AATRIP model (with 10 primary care practices throughout the United States) to a control condition (10 primary care practices). b) Increase the use of NIAAA guidelines for alcohol screening, diagnosis, brief intervention, and pharmacotherapy treatment by primary care medical practices for adult patients. c) To further examine the influence of alcohol screening and intervention on the course of alcohol-sensitive medical diseases prevalent in primary care (i.e. hypertension and diabetes).
Practice Site Visits were conducted by PPRNet Faculty who have extensive experience with academic detailing, Practice Partner Patient Records, and Quality Improvement in practice. Practice members (one clinician and one lead nursing staff member) participated in three once-yearly network meetings.
Enhancing Comparative Effectiveness Research Capabilities in PPRNet
(08/01/2010 – 07/31/2012) Principal Investigator: Steven Ornstein, MD. Funded by AHRQ the intent of the proposed work is to greatly enhance the capability of an existing, successful primary care practice based research network (PBRN) and develop sophisticated computer algorithms to enhance the ability of researchers to identify patients with any of 20 chronic medical conditions.
09/01/2007 - 08/31/2011) Investigators: Steven Ornstein, MD, Ruth Jenkins, PhD, David Bradford,
Specific Aims: a) Infrastructure development including a set of activities intended to expand PPRNet to at least 250 practices. b) The primary research project was a cross-sectional epidemiologic study, comparing the delivery of recommended preventive services among patients with no chronic illness, one chronic illness, and multiple chronic illnesses. c) Research addressed this issue and findings leading to a variety of investigations designed to improve preventive services delivery to patients with multiple chronic illnesses.
Enhancing PPRNet membership was be implemented through a combination of web-based tools with webinar's, web-based survey tools, video sharing, and social networking sites such as facebook, twitter and wikis.
Reducing Inappropriate Prescribing of Antibiotics by Primary Care Clinicians
(ABX-TRIP) (08/24/2009 - 07/22/2012) Principal Investigator: Andrea Wessell, PharmD.
This project assessed the facilitators and barriers to use, as well as the impact on antibiotic prescribing, of a clinical decision support system (note template) for diagnosis and management of acute respiratory tract infections.
Specific Aims: a) Facilitate the initiation of a clinical decision support system for diagnosis and management of acute respiratory tract infections and its incorporation into daily workflow in nine primary care practices, identifying best methods and strategies utilized b) Determine barriers and facilitators to the uptake and sustained use of a clinical decision support system that incorporates diagnosis and treatment information as well as delayed prescription strategies for acute respiratory tract infections in these practices. c) Document changes in antibiotic prescribing for acute respiratory tract infections resulting from the use of the clinical decision support system.
d) Disseminate findings to the rest of the research network and to publish results in a peer-reviewed medical journal.
Practice Site Visits - Practice site visits were conducted by PPRNet Faculty who have extensive experience with academic detailing, Practice Partner Patient Records, and Quality Improvement in practice.
Network Meetings - Intervention practice members (one clinician and one lead nursing staff member) participated in two once-yearly network meetings (travel, accommodations, and some meals paid by the grant funds). A project meeting was held August 2012 in Charleston, SC.
Effect of FDA Boxed Warnings and Public Information on Pharmaceutical Use
(09/01/2007 to 08/31/2011) Principal Investigator: Ruth Jenkins. Source: DHHS/Agency for Healthcare Research and Quality
Public concern has grown about the safety of the U.S. pharmaceutical supply due to well-publicized drug withdrawals or adverse reactions. The Institute of Medicine recently conducted a study of the oversight options available to the Food and Drug Administration (FDA) and concluded that substantial improvements are required in the way that post-marketing drug safety issues are identified and handled. The most restrictive labeling tool used by the FDA is mandating a boxed warning. However, boxed warnings are issued in the midst of a complex information environment that includes direct to consumer advertising (DTCA), general news media coverage, scientific journal publications, and direct to physician marketing.
No research had been conducted to determine how the alternative sources of information on safety work simultaneously to prompt changes in prescribing behavior and whether the boxed warning mechanism has any marginal effect on pharmaceutical use.
This research aimed to identify conditions under which the boxed warning program can be effective, and suggested alternative approaches for assuring the safe use of pharmaceutical products where necessary.
The three goals of this project were to examine: 1) The effects of public information and black box warnings on the flow of patients into physician offices 2) The effects of public information on the likelihood of appropriate drug prescribing 3) The impact of FDA issued boxed warning on the likelihood of appropriate prescribing for specific medications
Ambulatory Safety and Quality Program: Improving Quality Through Clinician Use of Health IT - Medication Safety in Primary Care Practice (MS-TRIP)
(09/30/2007 - 09/30/2010) Investigators: Steve Ornstein, M.D. and Andrea Wessell, PharmD, Department of Family Medicine, MUSC
Funded by the AHRQ, this project was designed to improve safe medication use in PPRNet practices. More specifically, the aims were to define a set of medication safety quality indicators, incorporate these into PPRNet performance reports and assess the impact of PPRNet-TRIP quality improvement model on the indicators. Read more in the MUSC Catalyst press release.
The MS-TRIP project has developed a set of medication safety measures relevant for primary care and incorporated these measures in practice performance reports sent quarterly to participating practices. Over the three years of this project the measures assessed the impact of on the incidence of these errors and improved medication safety in primary care.
The three main goals of the MS-TRIP project were:
1) Develop a set of PPRNet medication safety indicators based on literature, refined to reflect cumulative expertise of members. 2) Incorporate PPRNet medication safety indicators in quarterly practice reports distributed to twenty participating practices. 3) Assess the impact of PPRNet-TRIP QI model on medication safety indicators in participating practices.
The MS-TRIP project implemented these goals into practice settings through a combination of:
a) Practice Performance Reports - Posted quarterly show, for each measure, historical performance, performance at the present time, the median performance of all PPRNet practices, the 90th percentile among PPRNet practices, and national benchmarks. b) Practice Site Visits - Two practice site visits each during years 2 and 3 of the project. Site visits have been conducted by Andrea Wessell, PharmD who has extensive experience with academic detailing, Practice Partner Patient Records, and Quality Improvement in practice. c) Network Meetings - Practice members (one clinician and one lead nursing staff member) participated in the final network meeting held in Charleston, SC.
Web-Based Tools - Practice clinicians and clinical staff have completed anonymous surveys throughout the project.
Publication: 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
Colorectal Cancer Screening in Primary Care Practice (C-TRIP)
(06/01/2006 - 04/30/2010) Investigators: Steve Ornstein, M.D., Department of Family Medicine, & Lynne Nemeth, PhD., College of Nursing, MUSC
The National Cancer Institute (NCI) funded this four-year randomized trial project awarded to the Practice Partner Research Network (PPRNet) entitled "Colorectal Cancer Screening in Primary Care Practice (C-TRIP)." The purpose of the activities in the project were to assess whether PPRNet-TRIP can improve colorectal cancer screening in primary care.
PPRNet’s quality improvement model for successfully translating research into practice termed PPRNet-TRIP, has demonstrated effectiveness in improving cardiovascular disease prevention and treatment in primary care practice. PPRNet-TRIP incorporates prioritization of evidence-based quality philosophies, involving all staff (teamwork), delivery system redesign, patient activation, and EMR tools for individualized and population-based medicine. See (TRIP) II Model for details.
The three main goals of the C-TRIP project were: 1) Ascertain the extent of colorectal cancer screening in thirty PPRNet primary care practices across the United States and systematically incorporate this information in each practice’s electronic medical record and the PPRNet longitudinal database 2) Assess the impact of the PPRNet-TRIP model on improving clinician recommendation of colorectal cancer screening 3) Assess the impact of the PPRNet-TRIP model on improving patient receipt of colorectal cancer screening.
The PPRNet improvement model was disseminated through this three-component intervention:
a) Practice Reports - Posted quarterly showed, for each measure, historical performance, performance at the present time, the median performance of all PPRNet practices, the 90th percentile among PPRNet practices, and national benchmarks. Intervention group practices received a supplemental report on CRC screening. b) Site Visits - Four practice site visits (approximately every 6 months) during the 2 year intervention were conducted by Drs. Ornstein and Nemeth who have extensive experience with academic detailing, Practice Partner Patient Records, and Quality Improvement in practice. c) Network Meetings - Practice members (one clinician and one staff member) participated in two annual network meetings.
Topics included: a) Project updates b) "Best Practice" presentations c)Small group workshops, among participants with similar roles in their practices (Clinicians, nurses, back office staff)
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
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.
Nemeth LS, Nietert PJ and Ornstein SM: High Performance in Screening for Colorectal Cancer: A Practice Partner Research Network (PPRNet) Case Study. Journal of the American Board of Family Medicine, 2009, 22: 141-146, PMCID: PMC2696281 - NIH Public Access Link to Article
Implementation and Evaluation of Standing Orders Using Health Information Technology (SOTRIP)
(07/01/2008 - 06/30/2010) Investigators: Steve Ornstein, MD, Lynne Nemeth, PhD
This was a contract funded by the Agency for HealthCare Research and Quality (AHRQ). A standing order in an outpatient medical practice authorizes nurses and other staff to carry out a medical order (test, vaccination, etc) according to a practice approved protocol, without a provider's exam. When the clinicians empower staff to carry out standing orders, practice efficiency improves and quality of care improves.
Specific Aims of the Project were: 1) Facilitate the initiation of an electronic standing order system and its incorporation into daily workflow in eight primary care practices, identifying best methods and strategies utilized. 2. Determine barriers and facilitators to the uptake and sustained use of electronic standing orders in these practices.
3. Document changes in quality of care indicators and practice time management resulting from the use of electronic standing orders.
Practice Site Visits - Practice site visits were conducted by PPRNet Faculty who have extensive experience with academic detailing, Practice Partner Patient Records, and Quality Improvement in practice.
Network Meetings - Intervention practice members (one clinician and one lead nursing staff member) participated in two once-yearly network meetings (travel, accommodations, and some meals paid by the grant funds).
Facilitating Alcohol Screening of Hypertensive Patients - AATRIP
(07/01/2004 - 08/31/2007) Principle Investigator: Peter Miller, PhD.
The primary objective of this study was to utilize the Practice Partner Research Network's Translating Research into Practice (PPRNet-TRIP) model to improve detection and management of excessive drinking among primary care patients with hypertension.
Publication: 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
Accelerating Translation of Research Into Practice - ATRIP
(09/30/2002 - 09/30/2006) Investigators: Steve Ornstein, MD.
This Partnership for Quality demonstration project was funded by AHRQ. The goal of this study was to disseminate the PPRNet-TRIP model of quality improvement to a broader number of PPRNet practices. The project addressed practice guidelines for priority conditions and improvement approaches advocated in the Institute of Medicine (IOM) report and Healthy People 2010 activities. The project expanded PPRNet’s approach to quality improvement to 100 primary care practices in 36 States with more than 500 clinicians and nearly 850,000 patients. Improvement activities focused in eight clinical areas: prevention and treatment of cardiovascular disease and diabetes, cancer screening, adult immunization, respiratory and infectious disease, mental health and substance abuse, obesity and nutrition, and safe medication prescribing in the elderly. All practices received PPRNet performance reports, 64% participated in practice-site visits, and 59% in network meetings. Across all practices, a summary measure of care across all the clinical indicators improved an absolute value of 2.43% annually (p < 0.0001 for trend over time), and clinically and statistically significant improvements occurred for 29 of the 36 individual quality measures.
Publication: 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
Primary and Secondary Prevention of CHD and Stroke (TRIP II Project)
(10/01/2000 - 09/30/2003) Principal Investigator: Steve Ornstein, MD.
TRIP-II was a three-year grant funded by The Agency for Healthcare Research and Quality (AHRQ) entitled "Primary and Secondary Prevention of Cardiovascular Disease and Stroke." The long-term objective of the research was to validate a method implementing evidence-based medicine in primary care, using an approach combining information tools and behavioral change theory. Twenty non-academic primary care practices in 14 U.S. states with 61 health care professionals and over 87,000 patients participated. The control group practices only received PPRNet reports, while the intervention group practices also participated in practice-site visits and network meetings. Improvements were found in both groups, with evidence of greater improvement in the intervention group.
Publication: 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
Impact of Direct to Consumer Pharmaceutical Advertising
(06/30/2003 to 05/31/2006) Principal Investigator: David Bradford, PhD.
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.
Publication: 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
DTC Advertising Effect on Adherence to Statin Therapy
(07/01/2004 - 05/31/2007) Principal Investigator: David Bradford, PhD.
This grant was funded by the National Heart, Lung, and Blood Institute. The goal of this research was to assess the effect of direct to consumer advertising for prescription of cox-2 inhibitors and statins on the cost and the cost effectiveness of pharmacological care for treatment of hyperlipidemia.
Other Completed Research:
Coxibs and Blood Pressure
PPRNet participated in a study funded by Pharmacia, “The Effects of Vioxx® (Rofecoxib) and Celebrex® (Celecoxib) on Ambulatory Care Patients' Blood Pressure.” The goal of the study was to compare the effects of Rofecoxib and Celecoxib on blood pressure and other outcomes in a PPRNet practices
This study described the preventive services that are monitored in PPRNet primary care practices and measures patient adherence with USPSTF recommendations.
The Impact of Electronic Medical Records on Primary Care Practice
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.
Publication: 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
Quality of Care for Asthma, Coronary Disease, Diabetes Mellitus and Hypertension in the Practice Partner Research Network
The purpose of this study was to study adherence with practice guidelines for chronic disease PPRNet practices. The focus was on adherence to quality indicators for asthma, coronary disease (CHD), diabetes mellitus (DM), and hypertensive in the fourth quarter of 1997.
Publication: 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
Congestive Heart Failure in the Practice Partner Research Network
Collaborators: Douglas Smucker, MD, Steven Ornstein, MD, Ruth Jenkins, MS.
This study was conducted by Dr. Smucker, from the Department of Family Medicine at the University of Cincinnati. Dr. Smucker used PPRNet data to study the epidemiology of congestive heart failure in patients > 50 years of age.
Antibiotics for Upper Respiratory Infections: Follow-up Utilization and Antibiotic Use
Collaborators: William J. Hueston, M.D., Arch G. Mainous III, Ph.D., Steven Ornstein, M.D., Ruth G. Jenkins, M.S., Qin Pan, M.S.
This study assessed the impact of antibiotic prescribing during an initial visit for viral respiratory infections on future care seeking and the cost of care. Patients who received antibiotics at the index visit were slightly less likely to return for a follow-up visit (15.4% vs. 17.4%). Those who received antibiotics on the first visit were prescribed more expensive antibiotics in follow-up. The cost of initial antibiotic use outweighed any benefit from reduced utilization.
Publication: : Arch Fam Med. 1999; 8:426-430
Treatment of Recurrent Otitis After a Preceding Resistant Case: Which antibiotics work best?
Collaborators: William J. Hueston, M.D., Steven Ornstein, M.D., Ruth G. Jenkins, M.S., Qin Pan, M.S., and Jeffery Wulfman, M.D.
The purpose of this study was to examine if the use of a second-line drug resulted in fewer treatment failures in a recurrent otitis episode following an episode of otitis media resistant to first-line antibiotics. 343 patients with an otitis media episode more than 90 days after an episode of resistant otitis media were selected for study. Of this group, 236 (69%) received first line antibiotics (amoxicillin, ampicillin, penicillin or sulfa-trimethoprim) and 107 (31%) received a second line antibiotic. The primary outcome was the need for an additional antibiotic for otitis media within the next 45 days. Failure rates for first and second line antibiotics in recurrent episodes were not significantly different (13% vs. 18%, p=0.20). We concluded that for a new otitis media episode in a patient with a previous resistant otitis, amoxicillin or sulfa-trimethoprim are just as effective as broader spectrum, more expensive antibiotics.
Publication: The Journal of Family Practice. 1999; 48(1):43-46
PPRNet Members Use of CPR Systems in Practice
This study describes the use of CPR systems among PPRNet physician practices and highlights the many advantages realized by system users. In general, the PPRNet member practices viewed their use of the PMSI computer-based patient record as very positive, particularly in improving the overall quality of the patient record and as a tool in providing patient care.
Publication: Wager KA, Ornstein SM, Jenkins RG: The Perceived Value of Computer Based Patient Records Among Clinician Users. MD Com
Publication: Preventive Services in the Primary Care Practices of the Practice Partner Research Network. Topics in Health Information Management 2000; 20(3):80-84