Wednesday, January 4, 2012

Clinical Research Oriented Workshop (CROW) Meeting: December 22, 2011

Present: Ben Littenberg, Charlie MacLean, Connie van Eeghen

Guest: Tim Burdick, MD

1. Start Up: The effect of provider attitude on patient care encounters, especially motivational interviewing.

2. Rodger: Web-Based Self-Management Intervention for Multi-Morbidity R01, with co-PIs of Rodger and a colleague with much R01 experience. This grant has been under discussion for two years as the result of a conference not about collaborative care but health behavior interventions in medical disease.

a. NIH interest, through the Heart, Lung, Blood Institute. T his announcement came out in November regarding primary care patient with multi-morbid conditions, including mental health and substance abuse disorders. There was interest in alternative study methods to RCTs, including quasi-experimental design. The R01 announcement specifically calls for the development of an intervention. This application will be sent to the Dissemination and Implementation review session.

b. Progress on methods: The Oregon Research Institute has developed a track record and a web based tool, “MyPath,” a health risk appraisal with scoring/ranking and EBP patient support resulting in a plan with possible strategies and automated interventions (electronic reminders, journaling). Rodger has developed a positive working relationship with this Institute, proposing that bi-directional data sharing with provider based EHRs is an important addition. This study proposed to study MyPlan with depression, interaction with the EHR, and applying it in two models (dyadic primary care and collaborative care). (John Wasson at Dartmouth has done work with a health risk appraisal, barrier assessment, and visit planner print out for next appointment, accessible by patient and provider.) LOI needed followed by live presentation on January 4 (audio-visual web conferencing). Decision to be made about a week later.

c. In-depth discussion followed on us of the following design alternatives:

i. Usual care (no MyPath), all with EHR for a period of time

1. Patient portal exists and used

2. Behavioral health management application, with increasing use by patients over time (a threat to validity to be addressed by side analysis)

ii. MyPath in a traditional practice

iii. MyPath in a collaborative care BHC supported practice (pre-existing “patient centered behavioral health” aka PCBH)

iv. MyChart – the EPIC portal

1. with PCBH

2. without PCBH

v. Collaborative care with no MyPath (pre-existing PCBH)

1. studying ii and iii doesn’t prove anything about MyPath

2. studying i and ii looks at MyPath but doesn’t provide the “live coach” that Rodger is interested in

3. studying i and iii might show the highest impact but have the least explanatory ability

4. studying i and v, offering them both MyPath looks at all possible alternatives and needs the most number of practices (~300 per arm)

vi. Proposed design: study i and ii and iii, measuring by reaim

1. Reach: sign-ons created (may be contaminated by usual care patients with access to other patient portals)

2. Effective: PHQ-9, ER utilization

a. Measures: QUALI and composite measure

i. Euroqol 6D (how to obtain from usual care group, at least a sample; not obtainable from the experimental group who don’t access the portal)

ii. Better to use EHR based measures

1. ER utilization

3. Adapt: qualitative methods

4. Implement: qualitative methods – is this what NIH cares about most?

5. Maintenance: utilization of portal

vii. Recommendation: consider three arms and focus on what primary outcomes are

d. Process for exceeding the $500K cap (we didn’t get to this point, but it sounds interesting)

3. Next Workshop Meeting(s): Thursday, 12:30 p.m. – 2:00 p.m., at Given Courtyard Level 4

a. Dec 29: UVM closed

b. Jan 5: Journal Club; start new meeting time from 1:00 – 2:30 on Thursdays

c. Future agenda to consider:

i. Ben: budgeting exercise for grant applications

ii. Rodger: Mixed methods article; article on Behavior’s Influence on Medical Conditions (unpublished); drug company funding

iii. Amanda: presentation and interpretation of data in articles

iv. Future: Review of different types of journal articles (lit review, case study, original article, letter to editor…), when each is appropriate, tips on planning/writing (Abby)

Recorder: C. van Eeghen

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