Wednesday, May 9, 2012

Clinical Research Oriented Workshop (CROW) Meeting: May 3, 2012

Present: Kairn Kelley, Amanda Kennedy, Rodger Kessler (by phone), Ben Littenberg

1.                  Presentation: Rodger on discussion of patient generated health assessment, as the next evolution past behavioral health risk appraisal in primary care
a.       Presentation:
                                                  i.      Précis: ISO behavioral health screening data for about 15 years; FAHC now ready to act via PRISM and related resources.  Rodger has been developing new concepts regarding this topic with Wilson Pace, along the lines of Larry Weed’s work, automating diagnostic support systems through structured patient questions. 
                                                ii.      Prior to PHQ/GAD questionnaires, practitioners asked/recorded questions taking 11-15 minutes to arrive at a reasonably accurate diagnosis.  This is beyond what PCPs can devote to this work, resulting as PHQ9/GAD7/ETOH “The Audit” (brief measures developed by Kronke).  Issue: the search for valid outcomes with fewer questions: PHQ2 and GAD2 (ultra brief screens) – high level of false positives but decent sensitivity.
                                              iii.      PRISM initially offered 4 fields for these data.  Rodger worked with NIH (Cancer Institute, Russ Glasgow re: on-the-ground research) for ~3 years: behavioral risk assessment (previously shared with this group: 8 dimensions, 14 questions, beyond mental health and substance abuse). 
1.      Criteria for a measure: valid, brief (3 items), actionable, integratable into EHR
2.      Interest to Rodger: beyond depression and anxiety, including activity, health behavior, and something else.
3.      Phase 1: Milton; Phase 2: other FAHC practices
4.      FAHC primary care leaders: identify the features of patient function and what to engage to improve healthcare, what to monitor
a.       No mechanism for patients to provide data on multiple dimensions of health, readiness to change, preference to kind of interventions…
b.      How to overlay these core measures with the measures implied above
                                              iv.      Efforts to do behavioral risk assessment is trapped in a mental model about MH, separate from primary care.
1.      Key topics related: collaboration and integration
2.      New services are supposed to be adjunctive to primary care, within the same office (but not part of the practice of primary care)
3.      Aesculapius: produces referrals for anxiety and depression, but doesn’t help practice deal with behavioral health/medical comorbidities that affect the effectiveness of medicine (reasons: referrals are reactive, clinician is inherently limited in terms of service domain, …)
4.      Integration: processes and procedures that affect patient care are seamless within the practice.  Panel based integration describes protocol driven care rather than provider driven referral. 
5.      Integration has grown to mean (for Rodger) the integration of BH and PC questions that assess the patient across these traditional boundaries. 
b.      Dialogue:
                                                  i.      For the most part the kind of data Rodger is looking for is a function of informal provider initiated questions.  There is no current model for collecting “patient preferences” in general.
                                                ii.      Rodger has looked at generalized health assessments (NCQA standards, patient-based goal setting), for which there is some interest but more resistance due to the dynamics of change currently in place at FAHC.
                                              iii.      Rodger has just received permission to create a formal work group at FAHC to develop this idea.
1.      Robert Gibbons, biostatistician, looking at MH issues and the development of questions leading to differential diagnosis of various MH diagnoses. 
2.      Focus: comprehensive health assessment: highest risk areas and highest interest/readiness areas
                                              iv.      Goal is to work both on how to research what happens in practice and how to measure what happens clinically.  Research choice
1.      Least number of questions to identify MH issues
2.      Least number of questions to identify patient issues (health status, health function, and patient activation) (this is what Rodger wants to study)
                                                v.      Ben: “The perfect assessment is the enemy of a good assessment” – start small.
1.      Starting with BH assessments in PRISM in 3 weeks
2.      Consider alternate models of the end goal of comprehensive assessment: CATI – computer-intelligent testing based on respondent choices. 
                                              vi.      Kairn’s research: many words in the dichotic word test; need a shorter, simpler, quicker test.  Similar assessment issue.
                                            vii.      Rodger’s choices:
1.      Referral model to BH clinician is limiting in scope, types of referrals, types of patients, and exists outside of the relationship involved in the medical care provider (Aesculapius)
2.      Primary care/BH consultant model: a model like the integrated pharmacist (a better team approach to primary care), with the pharmacist as a consultant, not as a front line provider.
a.       The clinician has a specified role
b.      The practice (and beyond) that determines where care happens and the outcomes that result  (Rodger’s focus: health services research in primary medical and behavioral care)

2.                  Summer Session
a.      Not Mondays, Tues 1-4, Thurs 1-4 (Amanda’s summer schedule)
b.      Not Tues or Wed (Kairn’s and Ben’s summer schedule)
c.       Doodle poll on its way – Connie to send out

3.                  Kairn update:
a.      Tomorrow: update on inter-rater reliability and The Avengers
b.      Next: proposal on dissertation topic for committee meeting next Thursday for their approval/rejection (the formal proposal was originally due Aug 1).  Agenda:
                                                  i.      Introductions
                                                ii.      Research Domain Overview
1.      Define key terms
                                              iii.      Research Question: What is the prevalence (or role?) of Dichotic Listening Deficit in kids with ADHD? 
1.      Specific Study Questions (the questions that result in a paper)
a.      #1 What is the prevalence of abnormal tests in ADHD – Brief Design
b.      #2 What is the prevalence of abnormal scores in three groups (subtypes) of children – Brief Design
c.       #3 How to evaluate different tests, e.g. what is the reliability of SSW, what is its accuracy, and what is the prevalence of abnormal SSW in ADHD – Brief Design (in which the goal is cheap, fast, reliable, accurate, and safe)
c.       Finish/submit article (which contributes to the dissertation question but is not the same thing) and finish comps by end of August

4.                  Workshop Goals for 2012:
a.       Journal club: identify UVM guests and articles; invite to CROW ahead of time
b.      Research updates: share work-in-process

5.                  Next Workshop Meeting(s): Thursday, 1:00 p.m. – 2:30 p.m., at Given Courtyard Level 4. 
a.       May 10: Connie – From Dissertation to Publication - draft article with two questions: Does it read sufficiently like a journal article (if not, what to change) and are the results presented clearly?
b.      May 17: Abby – TBA (last scheduled session of the semester)
c.       Future agenda to consider:
                                                  i.      Ben: budgeting exercise for grant applications
                                                ii.      Ben: Writer’s workshop on the effect of the built environment on BMI (Littenberg & Austin Troy)
                                              iii.      Journal Club: “Methods and metrics challenges of delivery-system research,” Alexander and Hearld, March 2012 (for later in the year?)
                                              iv.      Rodger: Mixed methods article; article on Behavior’s Influence on Medical Conditions (unpublished); drug company funding.  Also: discuss design for PCBH clinical and cost research.
                                                v.      Amanda: presentation and interpretation of data in articles
                                              vi.      Sharon Henry: article by Cleland, Thoracic Spine Manipulation, Physical Therapy 2007

Recorder: Connie van Eeghen

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