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Department of Family Medicine, VCU Medical Center, Virginia Commonwealth University Department of Family Medicine and Population Health Virginia Commonwealth University VCU Medical Center

VCU Department of Family Medicine

Research

Completed projects

The following projects and initiatives have been completed by the Department of Family Medicine and Population Health:

Promoting Use of a Personal Health Record for Prevention

Start Date: June 15, 2010
Principal Investigator: Alexander H. Krist, MD, MPH
Sponsor: Agency for Healthcare Research and Quality (AHRQ)

Description

Exploratory and developmental grant to improve health care quality through health information technology.

Quality Performance Measurement

Start Date: Oct. 1, 2007
Principal Investigator: Daniel L. Longo, ScD
Sponsor: Agency for Healthcare Research and Quality (AHRQ)

Aims

This contract’s main objective is to produce a comprehensive report on issues involved in supporting primary care practices in collecting and reporting quality performance data, current effective strategies that practices have implemented to collect and report quality data, and potential innovations in the field as described in the tasks and sub-tasks in AHRQ’s Task Order Number Four. We are identifying barriers and facilitators to data reporting and collecting, as well as potential solutions and strategies for primary care offices. AHRQ Conference on Health Care Data Collection and Reporting: Collecting and Reporting Data for Performance Measurement serves as the task order’s foundation and guides the final report format.

Description

The Virginia Ambulatory Care Research Outcomes Network intervention is using a combination of comprehensive literature review, on-site focus group visits and consultative and peer mentoring approaches. To guide our work and analyses, our task order project utilizes a conceptual framework derived from three lines of inquiry including quality of care with an emphasis on performance reporting and provider behavior change, diffusion of innovation theory and competing demands in primary care practice. Nine ACORN practices are undergoing detailed assessment regarding data measurement and utilization, and staff and consultants work with six small practices selected from the nine. Using qualitative research methods, we are developing six case studies including “member checks,” conducting an in-depth literature review and synthesis, performing environmental scanning and synthesizing all project findings. Finally, we are focusing on the results of the task order’s identification, examination and recommendations on current challenges, strategies for overcoming barriers and facilitating solutions in collecting and reporting data for performance measurement. Innovative dissemination strategies using case studies are employed in a variety of venues to reach practicing primary care clinicians, administrative and office staff and policy-makers.

An Interactive Preventive Health Record (IPHR) to Promote Patient-Centered Care

Start Date: September 2007
Principal Investigator: Alexander H. Krist, MD, MPH
Sponsor: Department of Health and Human Services, Agency for Healthcare Research and Quliaty (AHRQ)

Hypothesis

We posit that an interactive preventive health record, designed to provide patients with preventive health information from their clinician’s electronic medical records and link patients to educational resources, decision aids and a tailored list of prevention recommendations, will increase the delivery of recommended screening tests, immunizations and counseling. We propose to test four specific aims in a randomized controlled trial.

Aims

Our study evaluates whether an invitation from a patient’s primary care clinician to use the IPHR, versus the usual delivery of preventive care, results in the following outcomes for adult patients:

  1. Increased delivery of age- and gender-appropriate clinical preventive services.
  2. Use of the IPHR.
  3. Increased shared decision-making for preventive services.
  4. Improved clinician-patient communication about preventive needs.
Description

We are conducting a randomized controlled trial involving 5,500 patients (2,750 intervention and 2,750 control patients) randomly selected from the practice population. Intervention patients receive a tailored postal request from their personal clinician to visit the IPHR for assistance with managing their preventive care, while control patients receive usual preventive care. Outcomes being investigated include both the delivery of preventive care (whether patients are up-to-date on age- and gender-appropriate preventive services) and specific domains of patient-centered care (the patient’s perspective on the care experience). Outcomes are assessed from two separate patient postal surveys (a Preventive Services Survey to assess delivery of preventive care and the CAHPS Clinician and Group Survey to evaluate patient-centered care measures), EMR data queries and automated reports from the IPHR about patient and clinician use of the HIT tool. To limit survey length and ensure adequate response rates, we are selecting two separate cohorts of study participants for outcomes measurement. We are mailing each cohort a different postal survey — the Preventive Services Survey for 4,500 patients and the CAHPS Survey for 1,000 patients — in January 2008 (baseline), January 2009 (six months after the intervention) and January 2010 (18 months after the intervention). We plan a pre-post cohort analysis of outcomes, comparing the change from baseline to six and 18 months for the intervention and control groups. Patient and practice perspectives about implementation of the IPHR are further assessed by qualitative analysis of focus groups.

Colorectal Cancer Screening Barriers Study

Start Date: May 5, 2005
Principal Investigators: Steven H. Woolf, MD, MPH, Resa M. Jones, PhD, project director
Sponsor: National Cancer Institute and Agency for Healthcare Research and Quality (AHRQ)

Hypothesis

Colorectal cancer is the second leading cause of cancer-related deaths in the U.S. An estimated 148,610 new cases of CRC and 55,170 deaths will occur in 2006. Screening for all Americans aged 50 and older is uniformly recommended by at least one of four screening options: fecal occult blood testing, flexible sigmoidoscopy, colonoscopy or double-contrast barium enema. A major factor limiting screening effectiveness is the low proportion of the eligible population that undergoes screening. Understanding the relative importance of screening determinants is essential to prioritize potential public health, clinical and policy strategies to enhance CRC screening.

Description

The primary aim of this study is to describe the factors that patients identify as their reason(s) for not undergoing screening for CRC and the relative importance they assign to each factor. The primary outcome of this study is a profile of CRC screening barriers that patients identify in their responses to the postal survey.

QuitLink: A Leveraging Solution to Tobacco Counseling

Start Date: May 2005
Principal Investigator: Stephen F. Rothemich, MD, MS

Hypothesis

Providing a new configuration of existing tools to identify smokers and connect them with community resources will increase rates of smoking-cessation counseling provided in primary care settings and will increase the number of smokers who receive community-based counseling to stop smoking.

Aim 1

To test whether delivery of A3-5 (Assess, Assist, Arrange) will be enhanced by a practice support system that combines (1) an expanded smoking as a vital sign intervention, (2) fax referral of preparation-stage patients for telephone counseling and (3) feedback to the provider.

Aim 2

To assess contextual factors that might affect implementation of the intervention and account for its ultimate success or failure. In particular, to assess: 1) environmental and practice-level factors that affect practices’ ability to successfully implement and use the intervention and 2) patient characteristics beyond readiness to change (i.e., age, gender, race/ethnicity) that affect willingness to use the quit line and complete counseling.

Description

The primary purpose of this project is to test whether the delivery of A3-5 (Assess, Assist and Arrange) is enhanced by a system that combines (1) an expanded vital sign intervention with (2) fax referral of preparation-stage patients for telephone counseling provided by the American Cancer Society (ACS) and (3) feedback to the provider. The question is examined in a randomized trial, with practices as the unit of analysis and with a control intervention consisting of a conventional vital sign intervention. The experiment therefore compares what intervention and control practices accomplish beyond simply identifying patients who use tobacco. The secondary purpose of this study is to assess contextual factors that might affect implementation of the intervention and account for its ultimate success or failure. In particular, to assess: (1) environmental and practice-level factors that affect practices’ ability to successfully implement and use the intervention and (2) patient characteristics beyond readiness to change (i.e., age, gender, race/ethnicity) that affect willingness to use the quit line and complete counseling. The study is conducted at 16 diverse family practices in Virginia.

Comprehensive Practice-Friendly Model for Promoting Healthy Behaviors

Date: 2005-2009
Principal Investigators: Steven H. Woolf, MD, MPH, Alexander H. Krist, MD, MPH, project director
Sponsor: Robert Wood Johnson Foundation

Description

Six affiliated practices adopted a brief, three-minute routine to deliver A1-3 (Ask, Advise, Agree) in the office and offered patients four options for intensive assistance (Assist [A4], Arrange [A5]) outside the office. Patients could select nine months of online, telephone or group counseling, or usual care. An electronic health record expedited the in-office intervention and referrals. Outcome measures included health behaviors, derived from 7,200 surveys administered pre-intervention and three and nine months post-exposure, and implementation, derived from EHR data, “counselee” surveys and patient/staff interviews.

Colonoscopy Screening Frequency

Date: November 2006-December 2007
Principal Investigators: Alexander H. Krist, MD, MPH, Resa M. Jones, PhD
Sponsor: Not funded

Question

To what extent are endoscopists’ recommendations on repeat colonoscopy concordant with the most current (2006) guidelines on post-polypectomy surveillance and screening?

Background

Colonoscopy possesses the highest sensitivity of available screening tests for colorectal cancer and polyps, but it also carries risks. Appropriate intervals for repeating colonoscopy are important to ensure that the benefits of screening and surveillance are not offset by harms. The study objective was to examine whether endoscopists’ recommendations for repeat colonoscopy, as communicated to primary care clinicians after the procedure, adhered to published guidelines.

Method

Analysts abstracted medical records at ten primary care practices in Virginia and Maryland in 2006. The records of a random sample of men and women (300 per practice) aged 50 to 70 years were reviewed. The sample included patients who had a colonoscopy and a written report from an endoscopist, and who lacked designated risk factors. The main outcome was concordance between endoscopists’ recommendations and published guidelines regarding repeat colonoscopy.

Results

Of 3000 charts reviewed, 1,282 (42.7 percent) included records of a colonoscopy and 1,021 (34 percent) included an endoscopist’s report. In 64.9 percent of communications, the endoscopist specified when retesting should occur. Recommendations were consistent with contemporaneous guidelines in only 39.2 percent of cases and with current guidelines in 36.7 percent of cases. The adjusted mean number of years in which repeat colonoscopy was recommended was 7.8 years following normal colonoscopy and 5.8 years and 4.4 years, respectively, when hyperplastic polyps or one to two small adenomatous polyps were found.

Conclusion

Endoscopists often recommended repeat colonoscopy at shorter intervals than are advised either by current guidelines or by guidelines in effect at the time of the procedure. Endoscopists’ communications to primary care clinicians often lacked contextual information that might explain these discrepancies. Unless appropriate caveats apply, adhering to endoscopists’ recommendations may incur unnecessary harms and costs.

Promoting Healthy Behaviors in Primary Care Research Networks

Date: July 1, 2003-Oct. 31, 2004
Principal Investigator: Steven H. Woolf, MD, MPH
Sponsor: Robert Wood Johnson Foundation

Hypothesis

Primary care patients who visit a specially designed, practice-sponsored Web site will exhibit a greater shift toward readiness to change behaviors in relation to diet, physical activity, smoking and problem drinking than occurs under usual care.

Aims

To test the effectiveness and feasibility of using a practice-sponsored Web site to help primary care clinicians promote healthy diet, physical activity, tobacco cessation and healthy alcohol use among their patients.

Description

This 16-month study employed a pre-post design to study effectiveness and feasibility in four intervention and two control practices in Northern Virginia. The aim of the Web site was to link patients with the information, resources and services that were most likely to facilitate behavior change but that were difficult to identify or arrange at the conventional office visit, or at other times when patients needed them. The Web site hosted a comprehensive array of resources regarding healthy behaviors.

Conclusion

The intervention increased the rate at which patients were referred for intensive behavioral counseling compared to current practice norms. Given the evidence that intensive counseling is more effective in promoting behavior change, implementing eLinkS could have substantial public health benefits.

Collaboration between clinicians and community resources presents a “win-win” scenario for patients, clinicians and community programs. Patients obtain more intensive assistance, while clinicians welcome an easy means to connect patients with the help they need. Community programs, which often struggle to attract clients through media and advertising, appreciate the influx of referrals from the medical community.

This formula has implications that extend beyond behavioral counseling. A system like eLinkS that facilitates systematic screening and referrals could, with some modification, help clinicians arrange screening tests and chronic disease management. Clinician-community collaboration has long been advocated for these purposes, but applying modern technology to make collaboration easy holds considerable promise.

Does Checking Smoking Status as a Vital Sign Increase Physician Counseling? A Practice-Level Randomized Controlled Trial

Dates: 1998-2005
Principal Investigator: Stephen F. Rothemich, MD
Sponsor: Robert Wood Johnson Foundation’s Generalist Physician Faculty Scholars Program

Purpose

Guidelines encourage primary care clinicians to document smoking status when obtaining vital signs, but whether this promotes cessation counseling is unclear. We examined whether the vital sign intervention influenced patient-reported frequency and intensity of tobacco-cessation counseling.

Methods

Cluster-randomized controlled trial in . Nursing staffs at intervention practices were instructed to assess the tobacco status of every adult patient and record it with the traditional vital signs. Control practices used no systematic tobacco screening or identification system. Outcomes were the proportion of smokers reporting clinician counseling of any kind and the frequency of two counseling subcomponents — simple quit advice and more intensive discussion.

Results

A total of 6,729 adult patients, including 1,149 smokers, at 18 primary care practices completed exit surveys during a six-month comparison period. Among 561 smokers at intervention practices, 61.9 percent reported receiving any counseling compared with 53.4 percent of the 588 smokers at control practices (difference 8.6 percent, p=0.04). The effect was largely restricted to simple advice, which was reported by 59.9 percent of intervention patients and 51.5 percent of control patients (p=0.04). There was no significant increase in more extensive discussion: 32.5 percent and 29.3 percent at intervention and control practices respectively (p=0.18).

Conclusions

The vital sign intervention promotes tobacco counseling at primary care practices through a modest increase in simple advice to quit. Implemented as a single intervention, it does not appear to increase intensive counseling.

Tobacco Use in Primary Care Practice Populations: A Pilot Cohort Study

Date: 2003-2004
Principal Investigators: Stephen F. Rothemich, MD, MS, Diane B. Wilson, EdD
Sponsor: Massey Cancer Center, Virginia Commonwealth University

Hypothesis
  1. The proposed postal methodology for longitudinal follow-up of prior in-office survey participants will result in at least a 50 percent participation rate.
  2. The resulting longitudinal data will be of sufficient volume and quality to estimate tobacco cessation, initiation and relapse rates in practice populations.
  3. The resulting longitudinal data will be of sufficient volume and quality to perform additional exploratory data analyses as described in the second aim.
Aims
  1. Demonstrate the feasibility of using a postal survey methodology to collect longitudinal patient-provided data in multiple primary care practices on health behaviors, functional health status, demographics and receipt of evidence-based screening tests for subsequent use in larger, longer cohort studies.
  2. Using longitudinal data collected from patient responses to a mailed survey, linked to participants’ administrative data and previous in-office survey responses, perform statistical analyses to examine tobacco cessation and relapse in this population, including associations with demographics, comorbidities, health status and other health behaviors, such as diet and exercise.
Description

Sequential mailing method of a survey to more than 2,500 patients in two practices who had completed a similar in-office survey at least 12 months previously. The initial survey mailing included a cover letter of invitation, consent information, a $2 participation incentive and a postage-paid pre-addressed return envelope. One week after the first mailing a reminder postcard was sent to each recipient of the initial mailing. A second survey mailing was sent to non-respondents at three weeks past the initial mailing.

Outcomes

The response rate was 56 percent, which was deemed successful in this setting. The methods used in this sequential mailing have served as the model for other studies that involved a postal survey. Analysis of respondents’ changes in responses compared to their previous in-office survey has not yet been completed.

A Preventive Care Website to Promote Primary and Secondary Prevention of Cancers

Date: April 2005-March 2006
Principal Investigator: Alexander H. Krist, MD, MPH
Sponsor: Massey Cancer Center, Virginia Commonwealth University

Hypothesis

This pilot study seeks to evaluate whether patients and physicians will use a cancer preventive care website prior to a health maintenance examination. Ultimately the Web site has the potential to improve the delivery of cancer preventive services.

Aims
  1. To develop a cancer preventive care website for patients that would effectively integrate multiple tools proven to improve primary and secondary cancer prevention, such as tailored health messages, reminder systems, decision aids and risk-assessment instruments.
  2. To evaluate perceived value and use of such a Web site by primary care clinicians and patients.
Description

A cancer preventive care website, www.MyPreventiveCare.net, was developed. More than 500 patients presenting for a health maintenance examination were asked to use the Web site prior to their next office visit. Participants were surveyed about their experience.

Outcomes

Of the patients instructed to use the Web site prior to their office visit, 78 percent did so. Among patients and physicians who used the website, there was satisfaction with the information provided. Helpful information about desired Web site format and content was learned and will be used in redesigning future versions of MyPreventiveCare.

Primary Care Practice-Based Research Networks: Network Defining Data

Dates: February-August 2002
Principal Investigator: Stephen F. Rothemich, MD, MS
Sponsor: Agency for Healthcare Research and Quality (AHRQ)

Objectives

This study was done in parallel with 18 other practice-based research networks across the country as part of the AHRQ Primary Care Practice-Based Research Network Initiative.

 
  1. Providing benchmark data to practices for visit data not otherwise available in ’s core data set, such as reason for encounter, health counseling/education services, medications and visit duration.
  2. Establishing an initial data set of provider and practice characteristics for the core data set.
  3. Making it possible to compare to other PBRNs and determine in what ways is similar or unique both for planning collaborative studies with other PBRNs and for speaking to the generalizability of research findings through comparison with national data.
  4. For data elements that do overlap with those collected through other means in , such as patient self-reported race/ethnicity and demographic, insurance status, diagnoses and procedural data from administrative data, providing an opportunity for making comparisons between these two data sources at the individual level as well as at the aggregate level as means of characterizing practices.
  5. Helping us focus on classification and translation of data we currently obtain, such as the practice’s designation of primary insurance type for visits, but had yet to organize in ways that allow us to make comparisons between practices or collapse the data into meaningful categories.
Description

Of 93 clinicians in 12 practices, 100 percent were invited to participate in the study, as well as 29 providers. They were asked to complete a survey form about themselves and, if willing, to record 30 encounters on a different survey form. The survey was developed in collaboration with the other 18 networks in the study, with many data elements based upon the content of the National Ambulatory Medical Care Survey from the Center for Health Statistics.

Outcomes
  1. contributed to AHRQ’s national inventory of practice-based research networks.
  2. Elements from the practice and provider surveys were incorporated into ’s yearly inventory.