Present: Abby
Crocker, Kairn Kelley (by phone), Amanda Kennedy, Rodger Kessler, Ben
Littenberg, Charlie MacLean, Prema Menon, Connie van Eeghen
1.
Start Up: News from Rodger: instructions from study
section leader – all applications start with a score of 5 (middle of the range).
This is the result of clustering at the low (better) end.
2.
Presentation: Future
CROW group project
a. In
a recent CROW session, the group had agreed
that it would be interesting to discuss a broad outline of a group research
project with roles organized around investigator, analyst, and reviewer. One of our goals is to learn more about multi-level modeling through
a team-based research study. The ideal project will result in a
publication.
b. Possible
topics:
i.
Benzos: currently topical due to an FDA announcement on
Monday restricting prescription dosages for women. High prevalence; alternative treatments are
present in data bases.
ii.
Stimulants for children with ADHD (short-acting vs.
long-acting)
c. Data
sources:
i.
Data are available now from VHCURES without Medicare
age group; may be missing many clinical co-variates (limited to what is paid
for by insurance). Submit a request to
Liz and work with Liz and Steve Kappel to organize. IRB moves quickly and Steve runs the data.
Almost five years of data (started in 2007).
1. Is
the denominator patients or prescribers?
Patients will have incomplete histories based on cash payments and
out-of-state services. There may be problems with unique patient identifiers,
as insurance companies have different patient codes.
2. Topics
must be exclusive of geriatrics and hospital admissions. Medications and procedures only. Does have ED
visits. Does not have zipcodes.
ii.
IRIS: many more co-variates (entire clinical record);
no claims from VHCURES with more extensive med list. PRISM med list is smaller and less accurate;
patients may be getting care that is invisible to IRIS.
d. Research
topic: “what is the association of x to y while controlling for z.” We’re interested in topics that are not just driven
by the main predictor but cluster by certain variables (e.g. providers). Therefore, a larger sample size isn’t as
important as the number of providers, and the sample sizes within those
clusters. This phenomenon can appear at
many levels: practice, county, and within patient (for repeated events, such as
cardiac care visits). Consider picking a
homogenous population to provide a good template for this type of research
study and a predictor with greatest opportunity to learn about different analytical
models.
i.
Motivation for Kairn, who started us down this road:
each child is tested more than once, from a specific class, on a specific day
of week. Different analytical models
produce different results; when to use which?
ii.
Possible predictors: geography, type of practice
(primary, specialty), medication (hypnotic meds [benzos] dose category, short
acting opiates, babies on opiates, multi-prescriber opiates, stimulants
long/short)
1. The
team is considering opiates, categorized by long/short, length of time (<
and > 60 days). Could have a
systematic intervention (duration limits on short-acting Rx)
iii.
Possible outcomes: ED visits, use of medications
(atypicals, benzos, opiates), event related to medication, surgeries, diagnosis
codes related to procedures, cost/utilization in a defined time period,
fall/fractures, dose progression, persistence of drug therapy (point
prevalence), drug substitution, clinical momentum (continued use of drugs on
auto-pilot)
1. The
team is considering ED visits
iv.
Variables to control: time (secular trends in
prescribing)
v.
Lines of inquiry:
1. How
much of the variation of x is explained by provider vs. patient.
2. Comparative
effectiveness
3. Penetration
of interventions
4. Dose/response
effect: benzos and ED visits
a. Classify
into high/med/low dose
b. Adults
only (age restriction)
c. Analyze
event rates for three dosage categories
5. Natural
history of drug use
vi.
Next step: VHCURES code book; Steve Kappel – Connie to
follow up
a.
Jan 24: Abby: breast feeding paper
b.
Jan 31: Kairn: F31 update
c.
Feb 7: Abby:
d.
Feb 14:
e. Future
agenda to consider:
i.
Christina Cruz, 3rd year FM resident with
questionnaire for mild serotonin withdrawal syndrome on 12/6 or 12/13
ii.
Peter Callas or other faculty on multi-level modeling
Recorder: Connie van Eeghen
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