Community based research Community based research in primary care: a parablein primary care: a parable

New opportunities for family New opportunities for family medicine researchmedicine researchWREN annual meeting 2008WREN annual meeting 2008

Research (as we know it) is newResearch (as we know it) is new

Prior to the 1950’s much research was Prior to the 1950’s much research was case reports, case series, expert opinion case reports, case series, expert opinion and the methods were primitive.and the methods were primitive.

Medical journals in the 40’s and 50’s were Medical journals in the 40’s and 50’s were heavily surgical technique as medical heavily surgical technique as medical treatments were new.treatments were new.

Potions, notions, tonics and were popular Potions, notions, tonics and were popular as “new medicine”as “new medicine”

Austin Bradford Hill and the RCTAustin Bradford Hill and the RCT

used randomization for the first time used randomization for the first time in1948 and described method of in1948 and described method of randomized controlled trial in 1952randomized controlled trial in 1952

Used streptomycin to treat tuberculosis in Used streptomycin to treat tuberculosis in randomized patientsrandomized patients

Dealt with the issues of treatment vs. no Dealt with the issues of treatment vs. no treatmenttreatment

Sir Richard Doll and smokingSir Richard Doll and smoking

Found increased incidence of lung cancer Found increased incidence of lung cancer in newly diagnosed patients who smoked in newly diagnosed patients who smoked over those that didn’t in 1950over those that didn’t in 1950

The British doctor’s study, a longitudinal The British doctor’s study, a longitudinal cohort study from early 50’s found similar cohort study from early 50’s found similar relationship using statistical methods – relationship using statistical methods – correlational studiescorrelational studies

First twenty years for family First twenty years for family medicinemedicine

We studied what we did We studied what we did – Educational researchEducational research

Residents, students, doctor/patientResidents, students, doctor/patient

We measured what we couldWe measured what we could– Descriptive work was first – what did family Descriptive work was first – what did family

doctors do??doctors do??

We followed the moneyWe followed the money– Title VII, RWJ funding for faculty developmentTitle VII, RWJ funding for faculty development– AHCPR became AHRQAHCPR became AHRQ

What we didn’t doWhat we didn’t do

CollaborateCollaborate– Within academic medicine (we became our own worst Within academic medicine (we became our own worst

enemy)enemy)– With each other – no networked research, no With each other – no networked research, no

comparative studies.comparative studies.– We didn’t value our own (first class vs. coach) We didn’t value our own (first class vs. coach)

REALLY study what we didREALLY study what we did– Short term educational outcomes for residents, Short term educational outcomes for residents,

students and faculty – survey research students and faculty – survey research – We would rather do it than study itWe would rather do it than study it

Describe our role in the health systemDescribe our role in the health system– No policy, Clinical Health Services researchNo policy, Clinical Health Services research

We didn’t have the right toolsWe didn’t have the right tools

No tools to count with (computer punch No tools to count with (computer punch cards, data entry, surveys)cards, data entry, surveys)

Weren’t sure what to count – the Weren’t sure what to count – the denominator obsessiondenominator obsession

No tools to measure results – intermediate No tools to measure results – intermediate measures of health – national data, not measures of health – national data, not practice data (the Virginia Study)practice data (the Virginia Study)

We were not able to visualize the forest We were not able to visualize the forest

But is wasn’t ALL our faultBut is wasn’t ALL our fault

Family medicine departments lacked Family medicine departments lacked intellectual venture capitalintellectual venture capitalWe were treated like Bible salesmen in We were treated like Bible salesmen in academic medical centersacademic medical centersMPH was only avenue to research trainingMPH was only avenue to research training– MPH is not a research degreeMPH is not a research degree– Epidemiology is not the godheadEpidemiology is not the godhead

We only had one product to sell…We only had one product to sell…graduatesgraduates

But a lot of it was…..But a lot of it was…..

We had no academic tradition, journals or We had no academic tradition, journals or incentives in our systemsincentives in our systems

We had no research pipelineWe had no research pipeline

We were led by results-oriented, publically We were led by results-oriented, publically responsive foundersresponsive founders

We kept looking internally rather than externallyWe kept looking internally rather than externally

We wallowed in our anti-intellectualism and We wallowed in our anti-intellectualism and waited until the rest of education came to us, waited until the rest of education came to us, except….except….

…….they didn’t.they didn’t

Things changed, as they always doThings changed, as they always do

Fellowship training with research emphasis – Fellowship training with research emphasis – NRSA for primary careNRSA for primary care

““Research” could be said out loudResearch” could be said out loud

Academic journals required better quality work Academic journals required better quality work and our work appeared in other journalsand our work appeared in other journals

Young faculty found friendly mentors – in other Young faculty found friendly mentors – in other departmentsdepartments

The research money for primary care came with The research money for primary care came with HMO’s HMO’s

The umtyumpth health care crisisThe umtyumpth health care crisisto be continued in 2009to be continued in 2009

CostCost

SafetySafety

QualityQuality

New opportunities for family New opportunities for family medicinemedicine

Focused research training led to fundingFocused research training led to funding– Areas of “expertise” such as prevention, Areas of “expertise” such as prevention,

chronic disease, AODA, chronic disease, AODA,

Beginning to network across departmentsBeginning to network across departments

Beginning to link practice with researchBeginning to link practice with research

We began to do research on things that We began to do research on things that matter to the publicmatter to the public

NIH funding NIH funding ((Rabinowitz Ann Fam MedRabinowitz Ann Fam Med))

From $18 million to >30 million in 10 years From $18 million to >30 million in 10 years (2003) (is >$50 2007)(2003) (is >$50 2007)

Half were in family medicine core Half were in family medicine core departments (others in other fields such as departments (others in other fields such as cancer, health services, etc) cancer, health services, etc)

Half were PhD’sHalf were PhD’s

Most new career development awards Most new career development awards were family physician PI’swere family physician PI’s

But…..But…..

Percentage of overall NIH funding had not Percentage of overall NIH funding had not changed though amounts hadchanged though amounts had

AHRQ funding was flat to downAHRQ funding was flat to down

Connection with non-core family medicine Connection with non-core family medicine may mean that relevance is harder to seemay mean that relevance is harder to see

Departments were divided into haves and Departments were divided into haves and have nots (50% had grants)have nots (50% had grants)

What is the future metric???What is the future metric???

The Ketchup bottle theory of changeThe Ketchup bottle theory of changethe “bloop” of the “naughts” the “bloop” of the “naughts”

The NIH Roadmap and Clinical Translational The NIH Roadmap and Clinical Translational ResearchResearchPublic health is struggling for relevance and Public health is struggling for relevance and needs partnersneeds partnersPublic/public partnershipsPublic/public partnershipsMedicine is looking outside of the walls of Medicine is looking outside of the walls of medical schools and discovering applied medical schools and discovering applied researchresearchWe are pushing national health care up the hill We are pushing national health care up the hill againagain

Clinical Translational Science Award Clinical Translational Science Award

(CTSA(CTSA) )

NIH funding for translational research to NIH funding for translational research to improve clinical practice and increase improve clinical practice and increase quality of patient carequality of patient care

Community involvement is a requirement Community involvement is a requirement in grant developmentin grant development

Infrastructure support for clinical researchInfrastructure support for clinical research

Opportunities to address improving health Opportunities to address improving health disparitiesdisparities

Family medicine is crucial to success of Family medicine is crucial to success of CTSA awardsCTSA awards

We have links to and are trusted by We have links to and are trusted by communitiescommunities

We understand translational research We understand translational research better than othersbetter than others

We have experience with research We have experience with research networksnetworks

We know how to listenWe know how to listen

One reason that medical care may One reason that medical care may have less influence over community have less influence over community health than one might expect is a health than one might expect is a health care organization’s limited view health care organization’s limited view of disease in a community. That is, of disease in a community. That is, most of the health care needs of a most of the health care needs of a community never come to the attention community never come to the attention

of most health care providers.of most health care providers.

Public Health

Family Medicine And Communities

BiomedicineBench to beside

Society

Clinical Population HealthClinical Population Health

includes health outcomes,includes health outcomes,

patterns of health determinants,patterns of health determinants,

policies and interventions that link these policies and interventions that link these two. two.

Begins with the practice but MUST include Begins with the practice but MUST include the community to be usefulthe community to be useful

Population-Based Health Population-Based Health Service Delivery ModelService Delivery Model

Feasible Community

Health Services

Needs of Population

Environmental Influences

Capabilities of Organization or

System

We have new tools for researchWe have new tools for research

A Ubiquitous worldA Ubiquitous world– My first (palm) Pilot study My first (palm) Pilot study

Not just registries but population based Not just registries but population based knowledgeknowledge– From health systems, public health and From health systems, public health and

practicespractices

Electronic Health RecordsElectronic Health RecordsGIS and Health – health mappingGIS and Health – health mappingCommunity health mashupsCommunity health mashups

New tools: WEB 2.0 technologyNew tools: WEB 2.0 technology

The practice as a social networkThe practice as a social network

Patient subgroups on the Practice websitePatient subgroups on the Practice website– Education, social supportEducation, social support

Portable web based EHR Portable web based EHR – GoogleGoogle– The Shared Care Plan of Whatcom County The Shared Care Plan of Whatcom County

New resources to fund ideasNew resources to fund ideas

State, county, local health departmentsState, county, local health departments

CDCCDC

Public Health Emergency preparednessPublic Health Emergency preparedness

Large Health SystemsLarge Health Systems

Clinical Translational Research through Clinical Translational Research through NIHNIH

Large employersLarge employers