Clinical Research Oriented Workshop (CROW) Meeting: Jan 24, 2013

Present: Abby Crocker, Kairn Kelley, Rodger Kessler, Ben Littenberg, Charlie MacLean, Connie van Eeghen

1.                  Start Up:    Honeybell tangelos can be found on Given Courtyard 4^th floor South, if you ask the right person.

2.                  Future CROW group project

a.       In a recent CROW session, the group decided to learn more about multi-level modeling through a team-based research study. The ideal project will result in a publication. The team is considering a research topic centered on opiates, categorized by long acting/short acting prescription choices (or no pain management prescription at all) for opiate-naïve adults less than age 65 who have had a musculo-skeletal injury.  Our question is whether there is a difference in ER utilization based on category of opiate and dosage (in morphine equivalents).

b.      Using VHCURES (no Medicare yet), we are limited to what was paid for by insurance over the last five years (started in 2007).  Other issues to keep in mind:

                                                  i.      Provider IDs are difficult, as they have more than one name assigned and more than one MPI.  One solution is to build a master unique ID list that connects all assigned names and MPIs.  Also, claims do not identify referring providers, so inferences have to be made about what visit caused what procedure. 

                                                ii.      Patient IDs are very difficult: every insurer and prescription management company uses a different unique ID for its subscribers/members.  Sometimes they overlap (encrypted SSN or name or encrypted subscriber SSN or name), but since encrypted fields have to be exact matches, this doesn’t help if all we have are names.  Otherwise some fuzzy matching will be needed, including date of birth, zipcode, and clinically related data (diagnosis or procedure with prescribed medication).  Medicaid is simpler as it pays for its own pharmaceuticals, but harder because member turnover is thought to be high.

c.       Connie received copies of the data dictionary (the data sets) and the field values (the codebook).  She will share these with the group.  Next step: Steve Kappel will come to CROW on Feb 7. 

3.                  Presentation: Abby’s policy paper on breastfeeding for babies with opiate exposed mothers.  Abby asked the group to help complete a conceptual framework for a paper based on the socio-ecological model to identify breastfeeding influencers, barriers, and aids.  Opiate dependent mothers have a much lower rate of breastfeeding than the national rate (76%) and current protocols don’t respond to this specific issue.  Completing the model requires considering both the mother and NAS (neonatal abstinence syndrome) infant.

a.       Basic framework of nested categories, starting with the largest: (items in red are NAS specific)

                                                  i.      Social (policy and cultural norms):

1.      Breast feeding in public

2.      Breast feeding at work

3.      Insurance reimbursement

a.       WIC

b.      VNA home visits?

4.      Community attitudes towards breastfeeding

                                                ii.      Community (organization):

1.      Hospital

a.       Staffing challenges for lactation support

b.      P4P (lack of incentive – may be an aid, rather than a barrier)

c.       Structural: policies & procedures; standing orders

                                                                                                                          i.      Referral bias, i.e. the OB high risk

d.      Cultural: healthy baby initiative hospital, breastfeeding friendly, default bottle feeding)

e.       Education/staff

2.      Health care providers (OB, Pediatrician, SA counselor, SW…)

a.       Attitudes & skills

b.      Uncertainty of mother’s ongoing use of drugs

3.      Post-discharge

a.       Home health visits – avoided by mothers of NAS infants

4.      Transportation – multiple NAS related appointments; trade-offs with managing work, multiple appointments and breastfeeding

                                              iii.      Interpersonal (relationships; emotional support):

1.      Family

a.       Attitude

2.      Friends

3.      Spouse

                                              iv.      Individual:

1.      Baby:

a.       Medical (preemie)

b.      NAS (irritability)

2.      Mother

a.       Active user of drugs

b.      Attitudes & knowledge

c.       Insufficient nutrition (500-600 calories/day extra)

d.      Fear of relapse

b.      Visual interpretation of this model:

c.       Each barrier and issue can be addressed in a solution set for policy interventions in a “bundled way”

                                                  i.      Coordination among providers (including lactation support) with transportation support; preemies in hospital bundle; PCMH based program

                                                ii.      Social norming: Group meetings for new mothers; creating expectations r/t breastfeeding

                                              iii.      Consider a hierarchy of interventions: if the provider doesn’t like it, it won’t happen

                                              iv.      Consider two phases – in which case the model is different for each phase

1.      Breastfeeding initiation – in the organization; connection with post-discharge support groups and providers

a.       Preemie initiation

b.      Non-preemie initiation

2.      Breastfeeding maintenance – in the community

a.       Early (1^st 4 weeks)

b.      First 6 months

c.       First year

d.      Structure of paper

                                                  i.      Breastfeeding is good; national rates; NAS rates

                                                ii.      Identify issues for this group (the red issues above); issues are specific to NAS beyond those already known as barriers to breastfeeding

                                              iii.      Recommended policy interventions for NAS population (as opposed to policy interventions beyond the NAS population?); a checklist for all the variables/issues for providers/organizations (a branching logic flowsheet)

1.      Mothers in a treatment program

2.      Mothers not in a treatment program (who are these: high risk but not anymore? Or relapsed?  Needs regular monitoring?)

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

a.       Jan 31: Kairn: F31 update

b.      Feb 7: Steve Kappel: Understanding/using VHCURES

c.       Feb 14: Abby:

d.      Future agenda to consider:

                                                  i.      Christina Cruz, 3^rd year FM resident with questionnaire for mild serotonin withdrawal syndrome?

                                                ii.      Peter Callas or other faculty on multi-level modeling

Recorder: Connie van Eeghen