Clinical Research Oriented Workshop (CROW) Meeting: Sept 20, 2012

Present: Whitney Calkins, MD, Abby Crocker, Kairn Kelley, Mark Kelly, Amanda Kennedy, Rodger Kessler, Ben Littenberg, Charlie MacLean, Connie van Eeghen

1.                  Start Up:  Introductions and welcome to Whitney Calkins from Family Medicine.

2.                  Presentation: Rodger: The Department of Family Medicine has invited research proposals as part of the Transformation project, to be presented to Academy of Family Practice (1 year), to be followed by a broader project (2 years).  Goal: engage FM faculty in research. 

a.       Can patient engagement and population adherence to EBM guidelines be affected by development and implementation of a patient-centered 'MyActionPlan' that builds upon technology through large-scale health assessment data collection?"

                                                  i.      My Action Plan is an EMR generated document for the patient to take home, in support of shared decision making, e.g. to take cardiovascular medications, etc.  Probably exists as a separate tab from the AVS (After Visit Summary) to highlight what was most important to the patient in support of good health.

                                                ii.      Long term: Wilson Pace is bringing together investigators across the NRN who are building similar assessment tools.

b.      Question:  Can we develop and implement a tool within PRISM  to improve both population care and patient engagement specifically improving reliability of cardiovascular disease management. (To be implemented in one FM practice for this study.)

                                                  i.      Specific focus: CV goals (medications, smoking) with some clinical goals, either object (blood pressure) or categorical (better, worse, the same). 

                                                ii.      Research goal is to develop and implement in one site. 

                                              iii.      The evaluators/funders (Tom and John) are in support of this product development focus.  Resource: .25 FTE protected faculty time, with the support of PRISM developers to the extent needed.  This depends significantly on organizational decision making.

                                              iv.      Consider the construct: does goal setting affect behavior?  This can be tested on paper and does not necessarily depend on an EMR intervention (e.g. SMART goal setting; Excel spreadsheet 10 year projections related to patient risk factors).  There are also current web based interventions: MyHealth.com

1.      The current literature indicates that goal setting in the provider office has limited support in connection with health outcomes.

2.      Self-efficacy literature does support links to positive outcomes, which links this work to a larger model of prevention effectiveness. 

                                                v.      Possible focuses (#1 below grew to be highest in interest):

1.      Collect data for patient goal setting and report – is this Novel?  Maybe good for infrastructure, if not of national interest.  Should be publishable.

a.       30 minute visit

b.      Structure conversation, e.g. SMART

c.       Specific to the patient’s selected issue (EtOH,…) – select which THIS project will focus on

2.      Report/plan goes with patient

3.      Report in PRISM

4.      Self-efficacy: patient belief/feeling about their ability to change

5.      Develop a SmartForm to support EBP patient care and generate an action plan (clinical decision support).  Test as to whether it has an effect on patients.

a.       Physician use of SmartForm likely to be low

                                              vi.      Approach

1.      Develop on the conference table/role plan

2.      Pilot in one clinic with one/few providers

3.      Develop as a PRISM specification (in the future)

                                            vii.      Evaluate

1.      Validation by patients in response to whatever the focus is producing, e.g. a standard goal setting exercise

2.      Identify a measure for change in “patient engagement”

3.      Include measures that matter to your future audiences: cost, time, and utilization

c.       Aims

                                                  i.      Develop 'MyAction Plan'

1.      develop an health assessment for patient-generated data

2.      use that date to develop an individualized self-management plan

                                                ii.      Implement My Action Plan in one FM practice

1.      develop EBM Cardiovascular content

2.      develop the CV SmartForm

3.      integrate SmartForm elements with the Action Plan incorporating data from health assessment

                                              iii.      Measure and Assess

                                              iv.      If there is time, develop a comprehensive set of SmartForms that include other chronic diseases

d.      Further research.  Generalize the My Action Plan beyond CVD first to other FA sites and then in a larger trial

e.       Next steps: narrow the focus and declare boundaries by early next week.  Proposal is due by next Wednesday. 

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

a.       Sept 27: Charlie on ways to analyze and understand narcotic prescribing in VT through various data sources and various ways to summarize and present data that are useful to clinicians. This generalizes to other medication categories as well and overlaps with Amanda's Medication Management Project. (No Amanda)

b.      Oct 4:

c.       Future agenda to consider:

                                                  i.      Kairn – review of draft article on IRR  

                                                ii.      Ben: budgeting exercise for grant applications; NHANES – lower female mortality for women taking birth control medications

                                              iii.      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.  Also: Prezi demo. 

                                              iv.      Amanda: presentation and interpretation of data in articles

Recorder: Connie van Eeghen

Clinical Research Oriented Workshop (CROW) Meeting: Sept 13, 2012

Present: Abby Crocker, Rodger Kessler, Connie van Eeghen

1.                  Start Up:  We all agree: we love our beautiful home on Given Courtyard 4S!

2.                  Presentation: Abby: Draft Table 1 on her study on infants exposed to opiates in-utero

a.       Abby has written the background and methods sections of her manuscript.  She provided a draft table 1 with 24 variables, each of which may have a different “n” as the denominator value for that variable.  (That is, some birth records are missing some fields of data, and this varies by variable.  Furthermore, some variables are natural subsets, like whether the mother was in treatment or not, and necessarily have smaller n’s.)  These variables are also the predictors in the study she is doing to find predictors of NAS (Neonatal Addiction Syndrome).

b.      The question: what is the best way to present such a long table, especially since the n’s changes so much.  Suggestions:

                                                  i.      Add a column for every variable to present the real n

                                                ii.      Group variables into 4 tables, each representing a concept (infant, environment, mother, substance abuse), with the infant as the starting point

                                              iii.      Tell the story using the tables

c.       We had an ongoing side-bar conversation about how the thinking process necessary to keep all these variables “in focus” might or might not be assisted by using the presentation software Prezi.  Rodger agreed to work through a demo of Prezi and bring it to CROW sometime in the near future.

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

a.       Sept 20: Rodger on Family Medicine Research Project 

b.      Sept 27: Charlie on ways to analyze and understand narcotic prescribing in VT through various data sources and various ways to summarize and present data that are useful to clinicians. This generalizes to other medication categories as well and overlaps with Amanda's Medication Management Project.

c.       Oct 4:

d.      Future agenda to consider:

                                                  i.      Kairn – review of draft article on IRR  

                                                ii.      Ben: budgeting exercise for grant applications; NHANES – lower female mortality for women taking birth control medications

                                              iii.      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.  Also: Prezi demo. 

                                              iv.      Amanda: presentation and interpretation of data in articles

Recorder: Connie van Eeghen

Clinical Research Oriented Workshop (CROW) Meeting: Sept 6, 2012

Present: Abby Crocker, Kairn Kelley, Amanda Kennedy, Rodger Kessler, Ben Littenberg, Connie van Eeghen

1.                  Start Up:  Charlie attended a good initial meeting of a Health Dept advisory group on pain management – a receptive group, with a new and very interested analyst.  New limitation of VPMS: the largest prescriber in the state (of opiates) is FAHC, unspecified.  (This probably refers to ED discharges and resident patients.)  This is because the vendor drops the identifying information in the provider field. 

2.                  Presentation: Kairn: what does probability mean in the context of inter-rater agreement

a.       Probability has 2 schools of thought (per Ben):

                                                  i.      Traditional: A probability is a fact, that is represented by the average and standard deviation of real world trials.  Usual example: coin toss.

                                                ii.      Bayesian: A probability is an opinion, or a prediction, about the world, that is more/less well informed.  Each is conditional, based on other probabilities.  Usual example: card game.

b.      Kairn presented an “ice cream cone” graphic to present the relationships that are possible of the two raters in her study in their agreement, resulting in “pass rate” outcomes

                                                  i.      Each of the 200 words can be evaluated based on the goodness of their inter-rater agreement (there were 34 subjects, each rated by two raters)

                                                ii.      We can hypothesize an ideal level of agreement (97% based on the mean in this data set) to evaluate the goodness of the word in auditory testing (within child agreement).  Note: none of the words rated worse that random agreement.

                                              iii.      Bland-Altman plots the difference of the pass-rate from each word for both raters over all the children rated. (Difference in average pass rates per word.)

                                              iv.      Outliers could be tested with Kairn’s data, in “decile” slices. 

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

a.       Sept 13: Abby: draft manuscript (minus analysis, at this point) (starting at 2:30) (No Ben, Kairn)

b.      Sept 20: Charlie on ways to analyze and understand narcotic prescribing in VT through various data sources and various ways to summarize and present data that are useful to clinicians. This generalizes to other medication categories as well and overlaps with Amanda's Medication Management Project.

c.       Sept 27:

d.      Oct 4:

e.       Future agenda to consider:

                                                  i.      Kairn – review of draft article on IRR  

                                                ii.      Ben: budgeting exercise for grant applications; NHANES – lower female mortality for women taking birth control medications

                                              iii.      Journal Club: “Methods and metrics challenges of delivery-system research,” Alexander and Hearld, March 2012 (for later in the year?).  UVM authors who have published interesting design articles (Kim, Osler)

                                              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