Community based research in primary care: a parable

1. Community based research in primary care: a parable New opportunities for family medicine research WREN annual meeting 2008

2. Research (as we know it) is new • Prior to the 1950’s much research was case reports, case series, expert opinion and the methods were primitive. • Medical journals in the 40’s and 50’s were heavily surgical technique as medical treatments were new. • Potions, notions, tonics and were popular as “new medicine”

4. Austin Bradford Hill and the RCT • used randomization for the first time in1948 and described method of randomized controlled trial in 1952 • Used streptomycin to treat tuberculosis in randomized patients • Dealt with the issues of treatment vs. no treatment

5. Sir Richard Doll and smoking • Found increased incidence of lung cancer in newly diagnosed patients who smoked over those that didn’t in 1950 • The British doctor’s study, a longitudinal cohort study from early 50’s found similar relationship using statistical methods – correlational studies

8. First twenty years for family medicine • We studied what we did • Educational research • Residents, students, doctor/patient • We measured what we could • Descriptive work was first – what did family doctors do?? • We followed the money • Title VII, RWJ funding for faculty development • AHCPR became AHRQ

9. What we didn’t do • Collaborate • Within academic medicine (we became our own worst enemy) • With each other – no networked research, no comparative studies. • We didn’t value our own (first class vs. coach) • REALLY study what we did • Short term educational outcomes for residents, students and faculty – survey research • We would rather do it than study it • Describe our role in the health system • No policy, Clinical Health Services research

10. We didn’t have the right tools • No tools to count with (computer punch cards, data entry, surveys) • Weren’t sure what to count – the denominator obsession • No tools to measure results – intermediate measures of health – national data, not practice data (the Virginia Study) • We were not able to visualize the forest

11. But is wasn’t ALL our fault • Family medicine departments lacked intellectual venture capital • We were treated like Bible salesmen in academic medical centers • MPH was only avenue to research training • MPH is not a research degree • Epidemiology is not the godhead • We only had one product to sell…graduates

12. But a lot of it was….. • We had no academic tradition, journals or incentives in our systems • We had no research pipeline • We were led by results-oriented, publically responsive founders • We kept looking internally rather than externally • We wallowed in our anti-intellectualism and waited until the rest of education came to us, except….

13. ….they didn’t

14. Things changed, as they always do • Fellowship training with research emphasis – NRSA for primary care • “Research” could be said out loud • Academic journals required better quality work and our work appeared in other journals • Young faculty found friendly mentors – in other departments • The research money for primary care came with HMO’s

16. The umtyumpth health care crisisto be continued in 2009 • Cost • Safety • Quality

17. New opportunities for family medicine • Focused research training led to funding • Areas of “expertise” such as prevention, chronic disease, AODA, • Beginning to network across departments • Beginning to link practice with research • We began to do research on things that matter to the public

18. NIH funding (Rabinowitz Ann Fam Med) • From $18 million to >30 million in 10 years (2003) (is >$50 2007) • Half were in family medicine core departments (others in other fields such as cancer, health services, etc) • Half were PhD’s • Most new career development awards were family physician PI’s

19. But….. • Percentage of overall NIH funding had not changed though amounts had • AHRQ funding was flat to down • Connection with non-core family medicine may mean that relevance is harder to see • Departments were divided into haves and have nots (50% had grants) • What is the future metric???

20. The Ketchup bottle theory of changethe “bloop” of the “naughts” • The NIH Roadmap and Clinical Translational Research • Public health is struggling for relevance and needs partners • Public/public partnerships • Medicine is looking outside of the walls of medical schools and discovering applied research • We are pushing national health care up the hill again

21. Clinical Translational Science Award (CTSA) • NIH funding for translational research to improve clinical practice and increase quality of patient care • Community involvement is a requirement in grant development • Infrastructure support for clinical research • Opportunities to address improving health disparities

22. Family medicine is crucial to success of CTSA awards • We have links to and are trusted by communities • We understand translational research better than others • We have experience with research networks • We know how to listen

23. One reason that medical care may have less influence over community health than one might expect is a health care organization’s limited view of disease in a community. That is, most of the health care needs of a community never come to the attention of most health care providers.

24. Society

25. Clinical Population Health • includes health outcomes, • patterns of health determinants, • policies and interventions that link these two. • Begins with the practice but MUST include the community to be useful

26. Population-Based Health Service Delivery Model Capabilities of Organization or System Needs of Population Feasible Community Health Services Environmental Influences

27. We have new tools for research • A Ubiquitous world • My first (palm) Pilot study • Not just registries but population based knowledge • From health systems, public health and practices • Electronic Health Records • GIS and Health – health mapping • Community health mashups

36. New tools: WEB 2.0 technology • The practice as a social network • Patient subgroups on the Practice website • Education, social support • Portable web based EHR • Google • The Shared Care Plan of Whatcom County

37. New resources to fund ideas • State, county, local health departments • CDC • Public Health Emergency preparedness • Large Health Systems • Clinical Translational Research through NIH • Large employers