Primary Care Practice-based Research Network Research Articles

Adapting and implementing breast cancer follow-up in primary care: protocol for a mixed methods hybrid type 1 effectiveness-implementation cluster randomized study

BackgroundAdvances in detection and treatment for breast cancer have led to an increase in the number of individuals managing significant late and long-term treatment effects. Primary care has a role in caring for patients with a history of cancer, yet there is little guidance on how to effectively implement survivorship care evidence into primary care delivery.MethodsThis protocol describes a multi-phase, mixed methods, stakeholder-driven research process that prioritizes actionable, evidence-based primary care improvements to enhance breast cancer survivorship care by integrating implementation and primary care transformation frameworks: the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework and the Practice Change Model (PCM). Informed by depth interviews and a four round Delphi panel with diverse stakeholders from primary care and oncology, we will implement and evaluate an iterative clinical intervention in a hybrid type 1 effectiveness-implementation cluster randomized design in twenty-six primary care practices. Multi-component implementation strategies will include facilitation, audit and feedback, and learning collaboratives. Ongoing data collection and analysis will be performed to optimize adoption of the intervention. The primary clinical outcome to test effectiveness is comprehensive breast cancer follow-up care. Implementation will be assessed using mixed methods to explore how organizational and contextual variables affect adoption, implementation, and early sustainability for provision of follow-up care, symptom, and risk management activities at six- and 12-months post implementation.DiscussionStudy findings are poised to inform development of scalable, high impact intervention processes to enhance long-term follow-up care for patients with a history of breast cancer in primary care. If successful, next steps would include working with a national primary care practice-based research network to implement a national dissemination study. Actionable activities and processes identified could also be applied to development of organizational and care delivery interventions for follow-up care for other cancer sites.Trial registrationRegistered with ClinicalTrials.gov on June 2, 2022: NCT05400941.

Maternal Preconception Body Mass Index and Early Childhood Nutritional Risk

BackgroundRisk factors for problematic child eating behaviors and food preferences are thought to begin during the preconception period. It is unknown if maternal preconception body mass index (BMI) is associated with child nutritional risk factors (eg, poor dietary intake and eating behaviors). ObjectivesWe aimed to determine whether maternal preconception BMI was associated with child nutritional risk. MethodsIn this longitudinal cohort study, a secondary data analysis of children ages 18 mo to 5 y were recruited from The Applied Research Group for Kids (TARGet Kids!), a primary care practice-based research network in Canada. The primary exposure was maternal preconception BMI. The primary outcome was parent-reported child nutritional risk score, measured using the Nutrition Screening for Every Preschooler/Toddler (NutriSTEP), an age-appropriate validated questionnaire. Fitted linear mixed effects models analyzed associations between maternal preconception BMI and child nutritional risk after adjusting for covariates. ResultsThis study included 4733 children with 8611 repeated NutriSTEP observations obtained between ages 18 mo to 5 y. The mean (standard deviation [SD]) maternal preconception BMI was 23.6 (4.4), where 73.1% of mothers had a BMI ≤24.9 kg/m2, and 26.9% had a BMI ≥25 kg/m2. The mean (SD) NutriSTEP total score was 13.5 (6.2), with 86.6% at low risk (score <21) and 13.4% at high risk (score ≥21). Each 1 unit increase in maternal preconception BMI was associated with a 0.09 increase in NutriSTEP total score (95% confidence interval [CI]: 0.05, 0.12; P ≤ 0.001). After stratification, each 1 unit increase in maternal BMI was associated with a 0.06 increase in mean NutriSTEP total score (95% CI: 0.007, 0.11; P = 0.025) in toddlers and 0.11 increase in mean NutriSTEP total score (95% CI: 0.07, 0.15; P < 0.001) in preschoolers. ConclusionHigher maternal preconception BMI is associated with slightly higher NutriSTEP total scores. This provides evidence that the preconception period may be an important time to focus on for improving childhood nutrition.This study was registered at clinicaltrials.gov as NCT01869530.

Factors associated with research participation in a large primary care practice-based pediatric cohort: Results from the TARGet Kids! longitudinal cohort study.

All longitudinal cohort studies strive for high participant retention, although attrition is common. Understanding determinants of attrition is important to inform and develop targeted strategies to improve study participation. We aimed to identify factors associated with research participation in a large children's primary care cohort study. In this longitudinal cohort study between 2008 and 2020, all children who participated in the Applied Research Group for Kids (TARGet Kids!) were included. TARGet Kids! is a large primary care practice-based pediatric research network in Canada with ongoing data collection at well-child visits. Several sociodemographic, health, and study design factors were examined for their associations with research participation. The primary outcome was attendance of eligible research follow-up visits. The secondary outcome was time to withdrawal from the TARGet Kids! study. Generalized linear mixed effects models and Cox proportional hazard models were fitted. We have engaged parent partners in all stages of this study. A total 10,412 children with 62,655 total eligible research follow-up visits were included. Mean age at enrolment was 22 months, 52% were male, and 52% had mothers of European ethnicity. 68.4% of the participants attended at least 1 research follow-up visit. Since 2008, 6.4% of the participants have submitted a withdrawal request. Key factors associated with research participation included child age, ethnicity, maternal age, maternal education level, family income, parental employment, child diagnosis of chronic health conditions, certain study sites, and missingness in questionnaire data. Socioeconomic status, demographic factors, chronic conditions, and missingness in questionnaire data were associated with research participation in this large primary care practice-based cohort study of children. Results from this analysis and input from our parent partners suggested that retention strategies could include continued parent engagement, creating brand identity and communication tools, using multiple languages and avoiding redundancy in the questionnaires.

Discriminative Accuracy of the CAPTURE Tool for Identifying Chronic Obstructive Pulmonary Disease in US Primary Care Settings

Chronic obstructive pulmonary disease (COPD) is underdiagnosed in primary care. To evaluate the operating characteristics of the CAPTURE (COPD Assessment in Primary Care To Identify Undiagnosed Respiratory Disease and Exacerbation Risk) screening tool for identifying US primary care patients with undiagnosed, clinically significant COPD. In this cross-sectional study, 4679 primary care patients aged 45 years to 80 years without a prior COPD diagnosis were enrolled by 7 primary care practice-based research networks across the US between October 12, 2018, and April 1, 2022. The CAPTURE questionnaire responses, peak expiratory flow rate, COPD Assessment Test scores, history of acute respiratory illnesses, demographics, and spirometry results were collected. Undiagnosed COPD. The primary outcome was the CAPTURE tool's sensitivity and specificity for identifying patients with undiagnosed, clinically significant COPD. The secondary outcomes included the analyses of varying thresholds for defining a positive screening result for clinically significant COPD. A positive screening result was defined as (1) a CAPTURE questionnaire score of 5 or 6 or (2) a questionnaire score of 2, 3, or 4 together with a peak expiratory flow rate of less than 250 L/min for females or less than 350 L/min for males. Clinically significant COPD was defined as spirometry-defined COPD (postbronchodilator ratio of forced expiratory volume in the first second of expiration [FEV1] to forced vital capacity [FEV1:FVC] <0.70 or prebronchodilator FEV1:FVC <0.65 if postbronchodilator spirometry was not completed) combined with either an FEV1 less than 60% of the predicted value or a self-reported history of an acute respiratory illness within the past 12 months. Of the 4325 patients who had adequate data for analysis (63.0% were women; the mean age was 61.6 years [SD, 9.1 years]), 44.6% had ever smoked cigarettes, 18.3% reported a prior asthma diagnosis or use of inhaled respiratory medications, 13.2% currently smoked cigarettes, and 10.0% reported at least 1 cardiovascular comorbidity. Among the 110 patients (2.5% of 4325) with undiagnosed, clinically significant COPD, 53 had a positive screening result with a sensitivity of 48.2% (95% CI, 38.6%-57.9%) and a specificity of 88.6% (95% CI, 87.6%-89.6%). The area under the receiver operating curve for varying positive screening thresholds was 0.81 (95% CI, 0.77-0.85). Within this US primary care population, the CAPTURE screening tool had a low sensitivity but a high specificity for identifying clinically significant COPD defined by presence of airflow obstruction that is of moderate severity or accompanied by a history of acute respiratory illness. Further research is needed to optimize performance of the screening tool and to understand whether its use affects clinical outcomes.

Challenges in Use of Practice-based Research Networks for a Medical Device Trial to Detect SARS-CoV-2.

Primary care practice-based research networks (PBRNs) participated in a point of care (POC) device study funded by by the National Institutes of Health and led by the University of Massachusetts Chan Medical School (UMass) to speed the development, validation, and commercialization of POC tests to detect SARS-CoV-2. The purposes of this study were to describe the characteristics of participating PBRNs and their respective collaborators in this device trial and describe complications challenging its execution. Semi-structured interviews were conducted with lead personnel from participating PBRNs and UMass. Four PBRNs and UMass were invited to participate and 3 PBRNs and UMass participated. This device trial recruited 321 subjects in 6 months; 65 subjects from PBRNs. Each PBRN and the academic medical center site enrolled and recruited subjects differently. Main challenges identified were having adequate clinic personnel to enroll and aid in consent and questionnaire completion, frequently changing inclusion/exclusion criteria, use of the digital electronic data collection platform, and having access to a -80°C freezer to store supplies. This trial involved numerous researchers, primary care clinic leaders and staff, and academic center sponsored program staff and attorneys resulting in a resource-intensive endeavor to enroll 65 subjects in the real-world clinical setting of primary care PBRNs with the academic medical center enrolling the rest. Multiple obstacles to standing up the study were encountered by the PBRNS. Primary care PBRNs rely largely on the goodwill established between academic health centers and participating practices. For future investigations involving device studies, collaborating PBRN leaders should assess whether recruitment criteria may change, obtain detailed lists of equipment needed, and/or know if the study is likely to be halted suddenly to appropriately prepare their member practices.

Association of Late Preterm Birth and Size for Gestational Age With Cardiometabolic Risk in Childhood

The long-term cardiometabolic consequences of late preterm birth (34-36 weeks' gestation) are not well understood. To assess whether late preterm birth and size for gestational age are associated with cardiometabolic risk (CMR) in childhood. This retrospective cohort study included 1742 children born in Ontario, Canada, between April 1, 2006, and September 30, 2014, and followed up until September 30, 2019. Data from children enrolled in The Applied Research Group for Kids (TARGet Kids!) primary care practice-based research network were linked to administrative health care data at ICES (formerly known as the Institute for Clinical Evaluative Sciences). Participants were excluded if they had conditions affecting growth (eg, failure to thrive or cystic fibrosis), any acute or chronic conditions (other than asthma and high-functioning autism), severe developmental delay, or families who were unable to communicate in English. Late preterm birth, gestational age as a continuous measure, and size for gestational age. The primary outcome was composite CMR score (overall age- and sex-standardized z score of CMR components, including waist circumference, log triglyceride level, glucose level, systolic blood pressure, and high-density lipoprotein cholesterol level). Secondary outcomes were the individual CMR components. Multivariable linear regression analysis was used to separately evaluate the associations of late preterm birth, continuous gestational age, and size for gestational age with CMR at ages 3 to 12 years. Among 2440 eligible children, 1742 (mean [SD] age, 5.6 [2.2] years; 951 boys [54.6%]) were included in the final cohort. Overall, 87 children (5.0%) were born moderately preterm (<34 weeks' gestation), 145 (8.3%) were born late preterm (34-36 weeks' gestation), 455 (26.1%) were born early term (37-38 weeks' gestation), and 1055 (60.6%) were born full term (≥39 weeks' gestation). Compared with children born full term, those born moderately preterm (adjusted β = 0.50; 95% CI, 0.24-0.75) and late preterm (adjusted β = 0.27; 95% CI, 0.06-0.47) had higher CMR scores. Each additional gestational week was associated with a 0.06 U (adjusted β; 95% CI, -0.08 to -0.03 U) decrease in CMR. In this study, children born late preterm and moderately preterm had higher CMR. These results suggest that screening and early-life interventions for these children may prevent cardiometabolic outcomes.

Patient Research Interest Differences by Gender and Race/Ethnicity: A North Texas Primary Care Practice-Based Research Network (NorTex) Study.

Recruiting and increasing participation of women and racial/ethnic groups remains an ongoing struggle despite the National Institutes of Health Revitalization Act mandating the inclusion of these populations. This study examined gender and racial/ethnic differences in research interest in participating in Practice-Based Research Network studies focused on cardiovascular disease (CVD), diabetes, cancer, and mental health research. A total of 1348 participants and 18 NorTex clinics from the North Texas Primary Care Registry Project (NRP) database were included in this cross-sectional study. Participants who signed up through the registry to participate in future research projects and self-reported as non-Hispanic White, Hispanic, or non-Hispanic Black were included. Research interest in heart disease, high cholesterol, high blood pressure and heart failure were categorized as CVD; depression and anxiety were categorized as mental health; diabetes and cancer research were coded as single item dependent variables. Of registry participants, 72% were female, 34.5% were Black, and 24.4% were Hispanic. Of participants, 70% (n = 942) were interested in CVD research, the leading area of interest. Mental health research (56.3%, n = 755) was the second highest area of interest, while cancer had the least interest (38.4%, n = 515). After controlling for age, smoking, and having a diagnosis of the medical condition, gender did not predict interest in CVD, diabetes, cancer, or mental health research. However, race/ethnicity significantly predicted interest in diabetes and cancer research. Results indicate there are racial/ethnic differences in interest in specific research topics among our registry participants. This information may be helpful to develop successful recruitment strategies.

Children\u2019s screen use and school readiness at 4-6 years: prospective cohort study

BackgroundThe primary aim of this study was to determine if screen use in early childhood is associated with overall vulnerability in school readiness at ages 4 to 6 years, as measured by the Early Development Instrument (EDI). Secondary aims were to: (1) determine if screen use was associated with individual EDI domains scores, and (2) examine the association between screen use and EDI domains scores among a subgroup of high screen users.MethodsThis prospective cohort study was carried out using data from young children participating in a large primary care practice-based research network in Canada. Logistic regression analyses were run to investigate the association between screen use and overall vulnerability in school readiness. Separate linear regression models examined the relationships between children’s daily screen use and each separate continuous EDI domain.ResultsA total of 876 Canadian participants participated in this study. Adjusted logistic regression revealed an association between increased screen use and increased vulnerability in school readiness (p = 0.05). Results from adjusted linear regression demonstrated an association between higher screen use and reduced language and cognitive development domain scores (p = 0.004). Among high screen users, adjusted linear regression models revealed associations between increased screen use and reduced language and cognitive development (p = 0.004) and communication skills and general knowledge domain scores (p = 0.042).ConclusionsScreen use in early childhood is associated with increased vulnerability in developmental readiness for school, with increased risk for poorer language and cognitive development in kindergarten, especially among high users.

Association Between Physical Activity, Screen Time and Sleep, and School Readiness in Canadian Children Aged 4 to 6 Years.

School readiness is strongly associated with a child's future school success and well-being. The primary objective of this study was to determine whether meeting 24-hour movement guidelines (national physical activity, sedentary behaviors, and sleep recommendations) was associated with school readiness measured with mean scores in each of the 5 developmental domains of the Early Development Instrument (EDI) in Canadian children aged 4 to 6 years. Secondary objectives include examining the following: (1) the association between meeting 24-hour movement guidelines and overall vulnerability in school readiness and (2) the association between meeting individual physical activity, screen use and sleep recommendations, and overall school readiness. A prospective cohort study was performed using data from children (aged 4-6 years) who participated in a large-scale primary care practice-based research network. Of the 739 participants (aged 5.9 + 0.12 years) in this prospective cohort study, 18.2% met the 24-Hour Movement Guidelines. Linear regression models (adjusted for child/family demographic characteristics, number of siblings, immigration status, and annual household income) revealed no evidence of an association between meeting all 24-hour movement guidelines and any of the 5 domains of the EDI (p > 0.05). Adjusted linear regression models revealed evidence of an association between meeting screen use guidelines and the "language and cognitive development" (β = 0.16, p = 0.004) domain, and for the sleep guideline, there was a statistically significant association with the "physical health and well-being" (β = 0.23, p = 0.001), the "language and cognitive development" (β = 0.10, p = 0.003), and the "communication skills and general knowledge" (β = 0.18, p < 0.001) domain. Early lifestyle interventions targeting screen use and sleep may be beneficial for improving a child's readiness for school.

Improving Iowa Research Network Patient Recruitment for an Advance Care Planning Study.

Introduction/ObjectivesIn February 2019, recruitment began in Iowa Research Network offices for a Patient-Centered Outcomes Research Institute (PCORI) funded Advance Care Planning (ACP) study to be conducted in 7 primary care practice-based research networks across the United States and Canada. The main study trained clinicians and nursing staff in serious illness care conversations and requested they refer eligible patients. Eligible patients were those with serious illness or frailty expected to live 1 to 2 years. Clinicians indicated it was difficult to identify eligible patients. This study aimed to find better methods for increasing patient recruitment for the ACP study.MethodsResearch staff brainstormed and implemented strategies to increase patient referrals from clinicians. Participating offices used Epic for their medical record and the Gagne Index was used to generate a list of eligible patients in Epic SlicerDicer. When patients from the Epic SlicerDicer report appeared on the schedule, clinicians and nursing staff were notified that they might be eligible for ACP. Clinicians and nursing staff were asked to complete a survey identifying their perception of implemented strategies. A Wilcoxon signed-rank test was conducted to compare referral numbers before and after the Gagne Index/Epic SlicerDicer intervention.ResultsSeven clinicians referred patients prior to and 11 after the Gagne Index/Epic SlicerDicer intervention. Clinicians referred a total of 120 patients; 31 patients prior to and 89 patients after the Gagne Index/Epic SlicerDicer implementation (P = .002). Survey results indicated that several strategies facilitated clinician referrals, including patients identified as potentially appropriate on the schedule, quarterly meetings with researchers, and e-mails with a list of potentially eligible patients.ConclusionsNotifying clinical staff about potential study participants increased patient referrals in this ACP study. Research staff must have time, funding, and patience to support clinical staff who are expected to refer patients to studies.

Practice-Based Primary Care Clinical Research During the COVID Pandemic.

Practice-Based Primary Care Clinical Research During the COVID Pandemic Barbara P Yawn Acknowledgments. Thank you to the investigators, research staff and Practice Based Research Network (PBRN) staff and practices in the CAPTURE trial. Funding. This work is funded by the lung division of the National Heart Lung and Blood Institute. All clinical research became challenging early in 2020 with the first surge of the SARS-CoV-2 (COVID) pandemic. All multi-centered academic clinical trials faced many challenges. Our study based not in academic centers or practices, but in primary care practice-based research networks (PBRNs) seemed to have added layers of challenges to identify, understand, and overcome. Our project enrolled primary care practices and then patients directly in their primary care practices for a single in-person visit. Before COVID, the clinical staff of the practices were invited to a lunch session that provided a 45-minute online review of the clinical topic. Patient participants completed the questionnaires and spirometry and peak flow testing required for this study at the time of their visit to their primary care office for another reason. 12-month follow up was done with an online, telephone or mailed patient survey, and from review of the past 12 months of health care use from participant's medical record abstraction and designed to be completed in about 50% of participants. Beginning in early March 2020, the practice sites and all of our practice-based research networks halted all research. Over the next few months, the sites allowed some COVID-related research to begin or resume. Our study did not fit that category. Over the summer months of 2020, some other studies that could be accomplished via virtual interactions like telephone or online surveys were allowed to restart. We did not meet that standard either since we need spirometry and peak flow testing. Most of our work had to be refocused from completing enrollment to identifying safety protocols and procedures for the consent and questionnaires. The spirometry and peak flow procedures, which were considered a nebulizing procedure, were a very large concern in the summer of 2020. The primary care clinics saw them as potentially viral spreading procedures. We were working with six PBRNs spread around the country with different periods of "surge" and very different oversight of practice-based primary care research. In some PBRNs, the requirements for safety were set by the PBRN's affiliated academic medical center. For other PBRNs, requirements were set, or also set, by regional health care systems. All practices needed to work with the local practices to understand their concerns, educate them on levels of risk, and address safety needs unique to that site. Obtaining personal protective equipment (PPE) was difficult since our study was not being completed in the hospital setting and was often not directly associated with an academic medical center. Once we obtained PPE through the AMA, SGIM, and AAFP programs, we needed to work on "fit testing" for the N95 masks, which is not readily available at all primary care practices or PBRNs (e.g., those based in rural areas). We needed to develop "cleaning and re-use" policies that fit with the academic and CDC guidance but were realistic for our broad spectrum of sites. [End Page 22] One approach that appeared to be acceptable to several primary care practices and research oversight groups was to offer visits virtually. While virtual enrollment and visit completion would have been a nice solution, our academic pulmonology investigators and the experts on our DSMB did not feel that at home pre- and postbronchodilator spirometry could be done with sufficient accuracy to meet the needs of our study. So, we developed the concept of "mixed" research visits—part virtual and part in person. Virtual visits, however, required a change in consenting to online or e-consent. For many sites, the use of e-consent was a barrier requiring new formats, new tools, and in some cases, extensive work with local IRBs to approve not only specific e-consent tools but also garner support for the concept of e-consent, even for our minimal risk study. IRBs expressed concerns that potential participants would not understand or be engaged...

Parenting stress during infancy is a risk factor for mental health problems in 3-year-old children

BackgroundAlthough research on the relationship between parent and child mental health is growing, the impact of early parenting stress on preschool-aged children’s mental health remains unclear. The objective was to evaluate the association between parenting stress during infancy and mental health problems in 3-year-old children.MethodsA prospective cohort study of healthy preschool-aged children recruited from 9 primary care practices in Toronto, Canada was conducted through the TARGet Kids! primary care practice-based research network. Parenting stress was measured when children were between 0 to 16 months of age, using the Parent Stress Index Short Form, PSI-SF. Parent-reported child mental health problems were measured at 36 to 47 months using the preschool Strengths and Difficulties Questionnaire, total difficulties score (TDS). Hierarchical linear regression analysis was used to investigate the association between standardized PSI-SF and TDS, adjusted for child age, sex, temperament, sleep duration and household income. To strengthen clinical interpretation, analysis was repeated using adjusted multivariable logistic regression (TDS dichotomized at top 20%).ResultsA total of 148 children (mean ± SD age, 37.2 ± 1.7 months, 49% male) were included in the analysis. Parenting stress during infancy (11.4 ± 3.1 months of age) was significantly associated with mental health problems in 3-year-old children (β = 0.35; 95% CI = 0.20–0.49, p < 0.001). Higher parenting stress was also associated with increased odds of higher TDS (OR = 2.26, 95% CI = 1.69–2.83, p < 0.01).ConclusionHealthy preschool-aged children with parents reporting parenting stress during infancy had a 2 times higher odds of mental health problems at 3 years.

The Changing Face of Primary Care Research and Practice-Based Research Networks (PBRNs) in Light of the COVID-19 Pandemic.

The COVID-19 outbreak is a stark reminder of the ongoing challenge of emerging and reemerging disease, the human cost of pandemics and the need for robust research.1 For primary care, the advent of COVID-19 has forced an unprecedented wave of practice change. In turn, Practice-Based Research Networks (PBRNs) must rapidly pivot to address the changing environment and the critical challenges faced by primary care. The pandemic has also impacted the ability of PBRNs to deploy traditional research methods such as face-to-face patient and provider interactions, practice facilitation, and stakeholder engagement. Providers need more relevant, patient-centered evidence and the skills to effect change. These skills will become more important than ever as primary care practices evolve in response to the current COVID-19 pandemic and the disparities in health outcomes highlighted by COVID-19 and the global Black Lives Matter social movement for justice. Throughout this issue, authors detail the work conducted by PBRNs that demonstrate many of these evolving concepts. Articles explore how PBRNs can evaluate COVID-19 in primary care, the role of PBRNs in quality improvement, stakeholder engagement, prevention and chronic care management, and patient safety in primary care.

Multimorbidity and patient-reported diagnostic errors in the primary care setting: multicentre cross-sectional study in Japan

ObjectivesThere is lack of evidence for the association between multimorbidity and diagnostic errors. Information on diagnostic errors from patients’ perspectives is crucial to improve the diagnostic process. In this study,...

Embedding "Smart" Disease Coding Within Routine Electronic Medical Record Workflow: Prospective Single-Arm Trial.

BackgroundElectronic medical record (EMR) chronic disease measurement can help direct primary care prevention and treatment strategies and plan health services resource management. Incomplete data and poor consistency of coded disease values within EMR problem lists are widespread issues that limit primary and secondary uses of these data. These issues were shared by the McMaster University Sentinel and Information Collaboration (MUSIC), a primary care practice-based research network (PBRN) located in Hamilton, Ontario, Canada.ObjectiveWe sought to develop and evaluate the effectiveness of new EMR interface tools aimed at improving the quantity and the consistency of disease codes recorded within the disease registry across the MUSIC PBRN.MethodsWe used a single-arm prospective trial design with preintervention and postintervention data analysis to assess the effect of the intervention on disease recording volume and quality. The MUSIC network holds data on over 75,080 patients, 37,212 currently rostered. There were 4 MUSIC network clinician champions involved in gap analysis of the disease coding process and in the iterative design of new interface tools. We leveraged terminology standards and factored EMR workflow and usability into a new interface solution that aimed to optimize code selection volume and quality while minimizing physician time burden. The intervention was integrated as part of usual clinical workflow during routine billing activities.ResultsAfter implementation of the new interface (June 25, 2017), we assessed the disease registry codes at 3 and 6 months (intervention period) to compare their volume and quality to preintervention levels (baseline period). A total of 17,496 International Classification of Diseases, 9th Revision (ICD9) code values were recorded in the disease registry during the 11.5-year (2006 to mid-2017) baseline period. A large gain in disease recording occurred in the intervention period (8516/17,496, 48.67% over baseline), resulting in a total of 26,774 codes. The coding rate increased by a factor of 11.2, averaging 1419 codes per month over the baseline average rate of 127 codes per month. The proportion of preferred ICD9 codes increased by 17.03% in the intervention period (11,007/17,496, 62.91% vs 7417/9278, 79.94%; χ21=819.4; P<.001). A total of 45.03% (4178/9278) of disease codes were entered by way of the new screen prompt tools, with significant increases between quarters (Jul-Sep: 2507/6140, 40.83% vs Oct-Dec: 1671/3148, 53.08%; χ21=126.2; P<.001).ConclusionsThe introduction of clinician co-designed, workflow-embedded disease coding tools is a very effective solution to the issues of poor disease coding and quality in EMRs. The substantial effectiveness in a routine care environment demonstrates usability, and the intervention detail described here should be generalizable to any setting. Significant improvements in problem list coding within primary care EMRs can be realized with minimal disruption to routine clinical workflow.

Association of Physical Activity and Cardiometabolic Risk in Children 3-12Years.

This study aimed to examine the association between physical activity (PA) and a total cardio metabolic risk (CMR) score in children aged 3-12years. Secondary objectives were to examine the association between PA and individual CMR factors. A longitudinal study with repeated measures was conducted with participants from a large primary care practice-based research network in Toronto, Canada. Mixed effects models were used to examine the relationship between parent-reported physical activity and outcome variables (total CMR score, triglycerides, glucose, high-density lipoprotein cholesterol, systolic blood pressure, waist circumference, weight-to-height ratio, and non-high-density lipoprotein cholesterol). Data from 1885 children (6.06y, 54.4% male) with multiple visits (n = 2670) were included in the analyses. For every unit increase of 60minutes of PA, there was no evidence of an association with total CMR score (adjusted: -0.02 [-0.014 to 0.004], P = .11]. For the individual CMR components, there was evidence of a weak association between PA and systolic blood pressure (-0.01 [-0.03 to -0.01], P < .001) and waist-to-height ratio (-0.81 [-1.62 to -0.003], P < .001). Parent-reported PA among children aged 3-12years was not statistically associated with total CMR, but was weakly associated with systolic blood pressure and waist-to-height ratio.

Rapid Deployment of a Statewide COVID-19 ECHO Program for Frontline Clinicians: Early Results and Lessons Learned.

In a pattern repeated around the country, Oregon reported its first coronavirus patient on February 28, 2020.1 A week later, the governor declared a state of emergency.2 While the media initially focused on efforts to address COVID-19 in large cities, many rural communities were working in parallel to prepare. In these rural areas, there was an increasing concern that the burden of COVID-19 may be particularly dire due to factors such as older populations, higher prevalence of chronic diseases and poverty, and less health care access.3-6 Rural clinicians, especially those working in outpatient settings, are caring for patients during the pandemic with few resources and many questions. There was, and continues to be, an urgent need for the rapid dissemination of emerging public health and treatment best practices, scientific evidence, and available resources for rural clinicians. Project ECHO (Extension for Community Healthcare Outcomes) provides an ideal model for the rapid dissemination of pertinent information to rural clinicians during a crisis. Developed at the University of New Mexico in 2003, Project ECHO is a telementoring education model that expands primary care clinicians’ ability to manage complex health conditions. An interdisciplinary expert faculty, an “all teach, all learn” approach, and a combination of didactic and case-based learning characterize ECHO programs.7-9 Since 2016, the Oregon ECHO Network (OEN) has provided telementoring to rural and urban clinicians through a variety of ECHO programs, including substance use disorders, adult and pediatric psychiatry, and smoking cessation. The OEN is housed within a statewide primary care practice-based research network, the Oregon Rural Practice-based Research Network (ORPRN).10-12 Shortly after the first COVID-19 case, OEN, ORPRN staff and consultants realized Project ECHO could provide a unique and valuable tool to connect and share emerging information with clinicians across the state. While OEN leadership initially wondered whether we had the resources to create and implement a COVID-19 program in just a few days, we could not sit on the sidelines when we had a successful, well-established Project ECHO program that could bring together public health and health care experts to share timely information in response to this novel situation. The process of creating the COVID-19 ECHO program for frontline clinicians, along with results from the first 4 weekly sessions, confirm crucial factors and strategies that we believe allowed us to support clinicians, especially in rural areas, in this pandemic. Our experience can provide guidance for others in future health crises. A few days after OEN and ORPRN leadership brought their idea to the state, the governor's office made a request to OEN on March 13, 2020: Create a COVID-19 Response ECHO for health care providers to launch on March 19, 2020. Two key challenges presented: (1) how to rapidly prepare and (2) how to accommodate a much larger number of participants than normal. OEN programs typically take 3 to 6 months of planning, including identifying faculty, developing curricula, securing accreditation to provide continuing medical education (CME), and recruiting participants. Our programs usually accept no more than 35 participants to maximize interactions. We had less than a week to prepare, and we anticipated over 500 participants. With this short timeframe, OEN's previously established systems and relationships were paramount. They allowed us to widely promote the COVID-19 ECHO, register participants through an established registration portal (though to maximize participation, registration was not required), identify highly qualified and credible faculty experts, develop a secure process for evaluation, and offer CME. Adapting for the high volume of participants necessitated certain deviations from the traditional ECHO model. It was important to create a format that was more interactive and responsive than a traditional webinar, but still feasible with a large audience. Quickly striking that balance required using the participant chat box feature in multiple ways. We did a real time reading, synthesizing and asking of key questions during each session, as well as an iterative process of debriefing after each session, utilizing a close reading through the entire chat box (15 to 20 pages of text) along with postsession survey responses. This allowed us to make week-by-week adjustments in both the content and format of the sessions. A total of 737 individuals participated in the first COVID-19 Response ECHO; mean participation across the first 4 sessions was 718. As of April 15, 2020, 1,110 individuals had registered for the ECHO series. Although registration was not required to attend, participants were incentivized to register because OEN uploaded resources (eg, session recordings, chat box history) to the registration website. In addition, participants received CME by registering and completing postsession surveys. We sent postsession surveys to all registrants, and 413 unique individuals (a subset of registrants) returned at least 1 postsession survey by the week following the fourth session. The demographics between all registrants and those who completed a postsession survey are similar, as seen in Table 1. Over 25% of participants reported practicing in either a rural or frontier area (comparable to Oregon's rural population13), and over 75% provide direct patient care. Each COVID-19 ECHO session began with a public health update, given by Oregon's Chief Medical Officer and members of her team and a local County Health Officer. The update included the latest information about cases, hospital capacity, personal protective equipment, testing, telehealth, and treatment. After this update and an initial round of questions from the chat box moderator (a family physician), expert presenters, such as infectious disease specialists, gave updates on clinical features of COVID-19. Each session also featured a community presenter sharing their on-the-ground experience regarding best practices and lessons learned. We selected community presenters and topics based on feedback from ECHO participants. For example, 1 urban and 1 rural provider presented on changes to their workflows and staffing during the fourth session after numerous participants requested more information about the experiences of primary care settings. Other community presentations included guidance on telehealth, advanced care planning and end-of-life care, and best practices for nursing home care in rural areas. Beyond the content of the formal session, participants constantly asked questions of and learned from each other through the chat box. Additional OEN staff monitored the chat box in real-time to answer questions about registration, how to access information and resources following the session, and to post links into the chat box from presenters’ slides. We assessed satisfaction with the sessions via an email survey sent to all registrants. Over 200 participants returned postsession surveys each week (mean 213). Participants rated these first 4 sessions highly, with 94% rating the sessions good, very good, or excellent. There were no significant differences between rural and urban participants. We also asked participants to answer several open-ended questions in the postsession surveys, including “What did you like best about this ECHO session?” and “Changes in my practice I'm going to make.” As demonstrated in Table 2, preliminary qualitative results suggest that rural participants appreciated up-to-date, locally relevant information. They also valued being able to connect with fellow health care providers from around the state, and learn from shared experiences. Table 3 describes sample quotes regarding the actions rural respondents planned to make. These included: disseminating knowledge to colleagues, implementing clinic changes, and improving discussions with patients. Through implementing the COVID-19 Response ECHO, OEN is learning important lessons about what health care clinicians need during a public health crisis, especially in small rural practices. Each week we consistently found that participants were hungry for credible, up-to-date and honest information, regardless of their geographic location. Although we could not offer a traditional ECHO program with dialogue, the 700 participants each week still found a way to connect via ideas, stories, experiences, and suggestions, as well as questions, in the chat box. For rural health care providers, in particular, being able to connect virtually with peers from across the state also served to ease feelings of isolation during an incredibly stressful time. We were initially uncertain if we could create and implement a COVID-19 ECHO program in less than a week. In reviewing our actions from that week, we found 3 key factors were essential to our ability to quickly respond and create this program. First, we already had an established ECHO support system, including a project manager, IT support, and a registration/communication platform. Prior to launching the COVID-19 ECHO program, over 780 unique health professionals, including primary care providers from 225 practices, had participated in previous ECHO programs. Second, OEN's existence within ORPRN further expanded our reach and strengthened the trust Oregon clinicians had with us. Since 2002, ORPRN has worked with 350 primary care practices statewide on diverse technical assistance, quality improvement, and research projects. Finally, OEN had spent 5 years strengthening relationships and building trust with diverse health leaders through our OEN Advisory Board. This Board consists of partners from the Oregon Health Authority, an academic medical center, 6 Coordinated Care Organizations (Medicaid Accountable Care Organizations), and 1 large health system. Having relationships with leaders in state government and across Oregon allowed us to successfully enlist key public health officials and others to participate in the ECHO program. Overall, having the existing foundation of strong systems and relationships is vital to succeed in rapidly responding to a health crisis. Fast-moving public health emergencies necessitate the rapid delivery of high-quality information to health care professionals, including those practicing in rural communities. The Project ECHO model and a modified process was an effective vehicle to meet these urgent needs and reach a large proportion of the state. In order to mount a timely response, however, systems and relationships must already be in place.

Results of Engineering, Primary Care, Oncology Collaborative Regarding a Survey of Primary Care on a Re-Engineered Survivorship Care Plan.

Survivorship care plans (SCPs) may facilitate cancer survivorship care shared between oncologists and primary care, particularly for patients more likely to receive care across healthcare systems such as rural patients. However, limited research has addressed primary care clinicians' information or workflow needs with regard to SCPs. This study's objective was to assess primary care clinicians' perceived usefulness with a re-engineered SCP previously developed by applying engineering approaches and informed by primary care preferences. An emailed survey of primary care clinicians assessed perceived usefulness with the re-engineered SCP. Clinicians were recruited across the USA from primary care practice-based research networks (PBRNs) with high concentrations of rural practices. Over 90% of respondents (n = 111) agreed that (1) the re-engineered SCP was useful (n = 95) and (2) they would want to receive a similar SCP (n = 93). The majority demonstrated high agreement regarding the SCP's relevance, understandability, content, and ability to help provide better survivorship care. Perceived usefulness was consistent between rural and non-rural clinicians. Suggested improvements involved decreased length, addition of a bulleted list, and electronic health record integration. Results indicate that the majority of primary care clinicians perceive the re-engineered SCP as useful. However, primary care clinicians indicated continued barriers despite end-user specific alterations. Future research should investigate additional strategies to support primary care survivorship-related workload, provide essential SCP content, and improve survivorship care delivery.

Prevalence of documented alcohol and opioid use disorder diagnoses and treatments in a regional primary care practice-based research network

BackgroundMost people with alcohol or opioid use disorders (AUD or OUD) are not diagnosed or treated for these conditions in primary care. This study takes a critical step toward quantifying service gaps and directing improvement efforts for AUD and OUD by using electronic health record (EHR) data from diverse primary care organizations to quantify the extent to which AUD and OUD are underdiagnosed and undertreated in primary care practices. MethodsWe extracted and integrated diagnosis, medication, and behavioral health visit data from the EHRs of 21 primary care clinics within four independent healthcare organizations representing community health centers and rural hospital-associated clinics in the Pacific Northwest United States. Rates of documented AUD and OUD diagnoses, pharmacological treatments, and behavioral health visits were evaluated over a two-year period (2015–2016). ResultsOut of 47,502 adult primary care patients, 1476 (3.1%) had documented AUD; of these, 115 (7.8%) had orders for AUD medications and 271 (18.4%) had at least one documented visit with a non-physician behavioral health specialist. Only 402 (0.8%) patients had documented OUD, and of these, 107 (26.6%) received OUD medications and 119 (29.6%) had at least one documented visit with a non-physician behavioral health specialist. Rates of AUD diagnosis and AUD and OUD medications were higher in clinics that had co-located non-physician behavioral health specialists. ConclusionsAUD and OUD are underdiagnosed and undertreated within a sample of independent primary care organizations serving mostly rural patients. Primary care organizations likely need service models, technologies, and workforces, including non-physician behavioral health specialists, to improve capacities to diagnose and treat AUD and OUD.

325. Cancer Screening Disparities among Persons Living with HIV (PLWH)

BackgroundCancer is now the leading cause of mortality for persons living with HIV (PLWH) in the United States, but it is uncertain whether PLWH access cancer screening that could lower this burden. We sought to assess cancer screening for breast, cervical, and colon cancer among PLWH compared with the HIV-uninfected population at a multicenter healthcare system over the past two decades.MethodsData were obtained from a prospective, observational HIV clinical care cohort comprised of PLWH engaged in care in the Partners Healthcare System. Patients eligible for cancer screening between the years 2002 and 2016 were included. Patients were matched in a maximum of 1:4 ratio with HIV-uninfected patients from the Massachusetts General Primary Care Practice-Based Research Network based on age, sex, race, year of study entry, and length of follow-up. The mean proportion of time in which eligible patients were guideline concordant for cervical, breast, and colon cancer screening was assessed. Non-parametric tests were used to compared screening rates between PLWH and HIV-infected and on the basis of multiple clinical and sociodemographic factors.ResultsDuring the observation period, a total of 495 PLWH were eligible for breast cancer screening, 1011 for cervical cancer screening, and 1965 for colon cancer screening. For each screening group, the majority of PLWH were on antiretroviral therapy (ART) and had relatively high CD4 cell counts (Table 1). Screening rates for PLWH compared with controls were 67.3% vs. 82.8% (P < 0.0001) for breast cancer, 49.0% vs. 73.3% (P < 0.0001) for cervical cancer, and 92.7% vs. 91.2% (P = 0.96) for colon cancer (Figure 1). Among PLWH, factors significantly associated with lower rates of screening guideline concordance were older age, lower CD4 count, HIV-1 RNA >1000 copies/mL, and HIV duration < 5 years for breast cancer, and older age, white race, English language, and lack of ART use for cervical cancer.ConclusionAmong patients engaged in longitudinal care, PLWH had significantly lower rates of screening for breast and cervical cancer than HIV-uninfected. Disparity is not explained by racial or primary language differences. Further work to improve access to cancer screening for PLWH is needed. Disclosures All authors: No reported disclosures.