Practice-based Quality Improvement/Research Networks: Full Speed Forward Steven Kairys, MD, MPH; Richard Wasserman, MD; Wilson Pace, MD From the Department of Pediatrics, Jersey Shore University Medical Center, Neptune, NJ (Dr. Kairys); Department of Pediatrics, University of Vermont, Burlington, Vt (Dr. Wasserman); and University of Colorado, Aurora, Colo (Dr. Pace) The views expressed in this report are those of the authors and do not necessarily represent those of the US Department of Health and Human Services, the Agency for Healthcare Research and Quality or the American Board of Pediatrics Foundation. The authors declare that they have no conflict of interest. Publication of this article was supported by the Agency for Healthcare Research and Quality and the American Board of Pediatrics Foundation. Address correspondence to Steven Kairys, MD, MPH, Department of Pediatrics, Jersey Shore University Medical Center, 1945 New Jersey 33, Neptune Township, NJ 07753 (e-mail: [email protected]).
ACADEMIC PEDIATRICS 2013;13:S12–S13
TRADITIONALLY THERE HAS been a recognized difference between practice-based research and quality improvement (QI). Research is discovery and new knowledge; QI is application of what is known. Research is preplanned and scientifically rigorous; it studies a specific population by means of a highly standardized model of investigation. QI tailors a model of improving service delivery to individual sites, seeks to reach the broadest population, and uses an iterative process to continuously refine the model. Both, however, are dependent on accurate data, and both aim to improve health outcomes and alter the way care is delivered. The emergence of electronic health records (EHRs) has increased the capacity to abstract data from patient records across an entire practice population. The greater availability of such data obtained outside of research-specific collection and a developing science of QI implementation have begun to blur the traditional distinction between research and QI. Moreover, the distinction between the two may be too fine for application, as research without practice-based connections may be perceived as irrelevant to practitioners.1 The limits of our current efforts to more rapidly translate research findings into practice call for new ways to expedite the translation of discovery to delivery of care. We highlight in this commentary the potential value of practice-based research networks (PBRNs) and quality improvement networks (QINs) as vehicles for translation. PBRNs and QINs can bridge the research/QI chasm. PBRNs have the capacity to develop new knowledge and to spread that knowledge at the practice level. Currently, a diverse group of 143 primary care PBRNs span the medical landscape. Networks are also now collaborating more extensively, and the Agency for Healthcare Research Quality (AHRQ) is promoting this consortium approach via the recent PBRN Centers of Excellence awards. Mold and Peterson1 write that when designing projects and innovation, it is important to determine whether the new tool or process can work in the real day-to-day world of primary care practices. Hundreds of great and proven ACADEMIC PEDIATRICS Copyright ª 2013 by Academic Pediatric Association
innovations exist solely in the journals that published the results. This failure of many research-proven activities to be effective in practice has led to an interesting duality of innovation approaches. Classic research develops interventions under highly controlled environments and then tests for generalizability. QI approaches implement interventions in real-world settings, assesses them for impact, and then may further dissect the intervention using research methodologies.2,3 Some PBRNs do focus primarily on research questions, but many are hybrids that have the capacity for combined research and QI work. Often research and QI methods are combined within a single study. Similarly, there are a number of QINs at the national, state, or academic level. The QINs prioritize the spread and application of new knowledge, guidelines, measures, or tools. Even so, more of their results are getting published and their work is achieving greater rigor through specific research designs. A major difference between a QIN and a PBRN is that PBRN studies are likely to include a control or different level of intervention and will randomize at the practice level, whereas a QIN will have all sites test the targeted intervention. New federal priorities such as comparative effectiveness research may provide additional platforms for the research/QI hybrid model. PRBNs’ potential for research and dissemination makes them true research and development organizations— perhaps the first of their kind in health care. The translation of research into practice demands involving practicing clinicians in the research design. This participatory approach can lead directly to ready incorporation of results into the culture of the practice and then to the spread throughout an organization. Recent studies have documented that these changes can be sustainable.4 Many networks encourage participatory membership and seek topics and projects from clinicians. This inclusive approach may be a major reason for their success in translating new ideas and processes into day-to-day practice. PBRNs’ and QINs’ participatory structure also supports the membership becoming active learners and joining learning communities. Practices in each network type
S12
Volume 13, Number 6S November–December 2013
ACADEMIC PEDIATRICS
PRACTICE-BASED QUALITY IMPROVEMENT/RESEARCH NETWORKS
use teams of doctors, nurses, and front-line staff to accomplish their objectives. The sought-after changes are practice-wide, and the staff are actively involved in the new approaches. These team-based processes are critical for the office system changes required for meaningful use of EHRs, participatory patient involvement, and community collaboration. Most PBRNs have proven to be highly sustainable, with reports of only 4 networks disbanding since 2008, despite difficulties in acquiring infrastructure support. PBRN start-up has been supported in the recent past by AHRQ with infrastructure grants, PBRN earmarks, master contracts, and now centers of excellence. With a greater focus on translation and pragmatic trials, the National Institutes of Health has also increased its support of PBRNs. Many challenges to the future success of PBRNs and QINs remain. Funds are now more scarce than ever. AHRQ funding for investigator-initiated activities is diminished. There are no national funding sources for QINs, and most of the networks operate from grant to grant, with limited resources for infrastructure. For pediatric research, there is a shortage of skilled primary care investigators. One survey reported that only 25% of doctors had any formal training in research.5 Practice-level barriers are many, but the top two are excessive clinical demands and a personal lack of research training. The 3 commentators for this article have found that the arrival of the Maintenance of Certification (MOC) has distracted some providers, who have little time to devote to external projects and data collection. The 3 also note that the active movement of pediatricians from independent practitioners to employees has increased the layers of system approvals, which often negatively affects participation. Optimistically, enabling factors can encourage participation, particularly having access to mentors and sharing ideas with other collaborators, as well as the increased
S13
morale that can occur with the inclusion of their staff in the projects. The ability to offer MOC IV credit for network projects has also helped attract participants. These factors need to be marketed at the state and national level to promote the benefits of participating in a network. PBRNs and QINs have proven their potential for creating real-time change in care delivery. Network leaders continue to expand the scope and strategies of the networks. Many believe that the networks could be the infrastructure to support the reforms in health care that are still in their infancy, with PBRNs morphing into health-improvement networks. The future may show us that networks can do it all: perform research, disseminate the results, and translate that research as well as QI efforts into sustainable improvements in health outcomes.6 The future is upon us.
REFERENCES 1. Mold JW, Peterson KA. Primary care practice-based research networks: working at the interface between research and quality improvement. Ann Fam Med. 2005;3:S12–S20. 2. Solberg LI, Elward KS, Phillips WR, et al. How can primary care cross the quality chasm? Ann Fam Med. 2009;7:164–169. 3. Kottke TE, Solberg LI, Nelson AF, et al. Optimizing practice through research: a new perspective to solve an old problem. Ann Fam Med. 2008;6:459–462. 4. Rhyne R, Sussman AL, Fernald D, et al. Reports of persistent change in the clinical encounter following research participation: a report from the Primary Care Multiethnic Network (PRIME Net). J Am Board Fam Med. 2011;24:496–502. 5. Bakken S, Lantigua RA, Busacca LV, et al. Barriers, enablers, and incentives for research participation: a report from the Ambulatory Care Research Network (ACRN). J Am Board Fam Med. 2009;22: 436–446. 6. Williams RL, Rhyne RL. No longer simply a Practice-based Research Network (PBRN) health improvement networks. J Am Board Fam Med. 2011;5:485–488.
ACADEMIC PEDIATRICS 2013;13:S12–S13
TRADITIONALLY THERE HAS been a recognized difference between practice-based research and quality improvement (QI). Research is discovery and new knowledge; QI is application of what is known. Research is preplanned and scientifically rigorous; it studies a specific population by means of a highly standardized model of investigation. QI tailors a model of improving service delivery to individual sites, seeks to reach the broadest population, and uses an iterative process to continuously refine the model. Both, however, are dependent on accurate data, and both aim to improve health outcomes and alter the way care is delivered. The emergence of electronic health records (EHRs) has increased the capacity to abstract data from patient records across an entire practice population. The greater availability of such data obtained outside of research-specific collection and a developing science of QI implementation have begun to blur the traditional distinction between research and QI. Moreover, the distinction between the two may be too fine for application, as research without practice-based connections may be perceived as irrelevant to practitioners.1 The limits of our current efforts to more rapidly translate research findings into practice call for new ways to expedite the translation of discovery to delivery of care. We highlight in this commentary the potential value of practice-based research networks (PBRNs) and quality improvement networks (QINs) as vehicles for translation. PBRNs and QINs can bridge the research/QI chasm. PBRNs have the capacity to develop new knowledge and to spread that knowledge at the practice level. Currently, a diverse group of 143 primary care PBRNs span the medical landscape. Networks are also now collaborating more extensively, and the Agency for Healthcare Research Quality (AHRQ) is promoting this consortium approach via the recent PBRN Centers of Excellence awards. Mold and Peterson1 write that when designing projects and innovation, it is important to determine whether the new tool or process can work in the real day-to-day world of primary care practices. Hundreds of great and proven ACADEMIC PEDIATRICS Copyright ª 2013 by Academic Pediatric Association
innovations exist solely in the journals that published the results. This failure of many research-proven activities to be effective in practice has led to an interesting duality of innovation approaches. Classic research develops interventions under highly controlled environments and then tests for generalizability. QI approaches implement interventions in real-world settings, assesses them for impact, and then may further dissect the intervention using research methodologies.2,3 Some PBRNs do focus primarily on research questions, but many are hybrids that have the capacity for combined research and QI work. Often research and QI methods are combined within a single study. Similarly, there are a number of QINs at the national, state, or academic level. The QINs prioritize the spread and application of new knowledge, guidelines, measures, or tools. Even so, more of their results are getting published and their work is achieving greater rigor through specific research designs. A major difference between a QIN and a PBRN is that PBRN studies are likely to include a control or different level of intervention and will randomize at the practice level, whereas a QIN will have all sites test the targeted intervention. New federal priorities such as comparative effectiveness research may provide additional platforms for the research/QI hybrid model. PRBNs’ potential for research and dissemination makes them true research and development organizations— perhaps the first of their kind in health care. The translation of research into practice demands involving practicing clinicians in the research design. This participatory approach can lead directly to ready incorporation of results into the culture of the practice and then to the spread throughout an organization. Recent studies have documented that these changes can be sustainable.4 Many networks encourage participatory membership and seek topics and projects from clinicians. This inclusive approach may be a major reason for their success in translating new ideas and processes into day-to-day practice. PBRNs’ and QINs’ participatory structure also supports the membership becoming active learners and joining learning communities. Practices in each network type
S12
Volume 13, Number 6S November–December 2013
ACADEMIC PEDIATRICS
PRACTICE-BASED QUALITY IMPROVEMENT/RESEARCH NETWORKS
use teams of doctors, nurses, and front-line staff to accomplish their objectives. The sought-after changes are practice-wide, and the staff are actively involved in the new approaches. These team-based processes are critical for the office system changes required for meaningful use of EHRs, participatory patient involvement, and community collaboration. Most PBRNs have proven to be highly sustainable, with reports of only 4 networks disbanding since 2008, despite difficulties in acquiring infrastructure support. PBRN start-up has been supported in the recent past by AHRQ with infrastructure grants, PBRN earmarks, master contracts, and now centers of excellence. With a greater focus on translation and pragmatic trials, the National Institutes of Health has also increased its support of PBRNs. Many challenges to the future success of PBRNs and QINs remain. Funds are now more scarce than ever. AHRQ funding for investigator-initiated activities is diminished. There are no national funding sources for QINs, and most of the networks operate from grant to grant, with limited resources for infrastructure. For pediatric research, there is a shortage of skilled primary care investigators. One survey reported that only 25% of doctors had any formal training in research.5 Practice-level barriers are many, but the top two are excessive clinical demands and a personal lack of research training. The 3 commentators for this article have found that the arrival of the Maintenance of Certification (MOC) has distracted some providers, who have little time to devote to external projects and data collection. The 3 also note that the active movement of pediatricians from independent practitioners to employees has increased the layers of system approvals, which often negatively affects participation. Optimistically, enabling factors can encourage participation, particularly having access to mentors and sharing ideas with other collaborators, as well as the increased
S13
morale that can occur with the inclusion of their staff in the projects. The ability to offer MOC IV credit for network projects has also helped attract participants. These factors need to be marketed at the state and national level to promote the benefits of participating in a network. PBRNs and QINs have proven their potential for creating real-time change in care delivery. Network leaders continue to expand the scope and strategies of the networks. Many believe that the networks could be the infrastructure to support the reforms in health care that are still in their infancy, with PBRNs morphing into health-improvement networks. The future may show us that networks can do it all: perform research, disseminate the results, and translate that research as well as QI efforts into sustainable improvements in health outcomes.6 The future is upon us.
REFERENCES 1. Mold JW, Peterson KA. Primary care practice-based research networks: working at the interface between research and quality improvement. Ann Fam Med. 2005;3:S12–S20. 2. Solberg LI, Elward KS, Phillips WR, et al. How can primary care cross the quality chasm? Ann Fam Med. 2009;7:164–169. 3. Kottke TE, Solberg LI, Nelson AF, et al. Optimizing practice through research: a new perspective to solve an old problem. Ann Fam Med. 2008;6:459–462. 4. Rhyne R, Sussman AL, Fernald D, et al. Reports of persistent change in the clinical encounter following research participation: a report from the Primary Care Multiethnic Network (PRIME Net). J Am Board Fam Med. 2011;24:496–502. 5. Bakken S, Lantigua RA, Busacca LV, et al. Barriers, enablers, and incentives for research participation: a report from the Ambulatory Care Research Network (ACRN). J Am Board Fam Med. 2009;22: 436–446. 6. Williams RL, Rhyne RL. No longer simply a Practice-based Research Network (PBRN) health improvement networks. J Am Board Fam Med. 2011;5:485–488.
