Primary Care Research

Studies funded by AHRQ's Primary Care Practice-Based Research Networks (PBRNs) identify ways to improve patient care and report medical errors

Primary care practice-based research networks (PBRNs) involve practicing clinicians with academic researchers in asking and answering clinical and organizational questions about primary health care. In 2000, AHRQ launched an initiative to support the growth and development of PBRNs, recognizing the importance of this work and the potential of PBRNs to improve the health of Americans by engaging clinicians in quality improvement activities and fostering an evidence-based culture in primary care practice.

Since the inception of the program, AHRQ has awarded over $16 million to more than fifty PBRNs across the country for studies focusing on a diverse range of health services issues and the care of a variety of medical conditions.

Four recent AHRQ-funded PBRN studies are summarized below. The first two studies focused on primary care patients and found that adults who were at risk for developing diabetes were more likely to be physically active when they made exercise a priority, and adults at risk for developing chronic illnesses could benefit from nutrition-related screening and services (HS13521). The third study revealed that physicians' use of electronic medical records (EMRs) to print medication information did not seem to compromise counseling their patients verbally on medication indications and side effects (HS14406 and HS14552). Finally, according to the fourth study, error reporting systems in physicians' offices will need specific improvements to better motivate family physicians to report medical errors (HS13554).

Donahue, K.E., Mielenz, T.J., Sloane, P.D., and others (2006, October). "Identifying supports and barriers to physical activity in patients at risk for diabetes." Preventing Chronic Disease 3(4), pp. 1-12.

Researchers at the North Carolina Family Practice-Based Research Network analyzed survey responses from several network practices of 258 patients who were considered at high risk for developing diabetes. The patients were asked about what helped and prevented them from engaging in physical activity. High-risk patients scored 10 points or higher on the American Diabetes Association risk test. They typically were patients who were older, overweight or obese, had a family history of diabetes or history of gestational diabetes, and were sedentary. Only 56 percent of these high-risk patients engaged in the recommended 150 minutes or more of moderate to vigorous activity per week. More individuals who had graduated from high school or attended college education met the recommended activity levels than those who did not graduate from high school (Figure 1).

Individuals were 55 percent less likely to be physically active if they viewed activity as a low priority, 58 percent less likely to be active if they were worried about injury, and 62 percent less likely to be active if they had difficulty finding time for activity. Individuals most enjoyed walking (70 percent), gardening (39 percent), stretching (24 percent), swimming, (12 percent) and biking (11 percent). In the past year, 69 percent of this high-risk group had discussed physical activity with their health care provider.

Gaskins, N.D., Sloane, P.D., Mitchell, C.M., and others (2007, March). "Poor nutritional habits: A modifiable predecessor of chronic illness? A North Carolina Family Medicine Research Network (NC-FM-RN) study." Journal of the American Board of Family Medicine 20, pp. 124-134.

Researchers found that patients at known risk for chronic illness, such as those with prediabetes, were found to have poorer nutritional habits than those who had the disease. Therefore, patients in high risk categories may be particularly appropriate targets for nutrition-related screening and services. Of the primary care patients cared for by four North Carolina Family practices in this study, 40 percent reported engaging in no regular physical activity, 24 percent were current smokers, 18 percent had diabetes, 42 percent had hypertension, and 13 percent had a history of heart disease. Forty-one percent were obese and 40 percent scored as high-risk on a diabetes risk screen.

The researchers surveyed 1,788 ethnically diverse adult patients (mean age of 48) in the practice waiting rooms, which included a 7-item nutrition screen. In addition, the study gathered data on disease and functional status, race/ethnicity, health habits, and demographic factors. Overall, 30 percent of those surveyed reported eating three or more fast food meals weekly; 29 percent drank three or more high-sugar beverages weekly; 22 percent ate three or more high-fat snacks weekly; 36 percent ate three or more desserts weekly; 11 percent reported eating "a lot" of margarine, butter, or meat fat; 62 percent ate two or fewer fruits or vegetables daily; and 42 percent reported consuming protein less than two times a week.

Total scores were worse for patients with prediabetes than those with diabetes, for young adults than older persons, and for persons reporting good/excellent health versus fair/poor health. These results probably indicate better nutritional awareness and motivation among people who suffer from chronic diseases, note the researchers. As family medicine focuses more on chronic disease care and prevention, the role of the family medicine office in promoting nutritional health, physical activity, and other healthy habits may well increase. This study's results indicate that the primary care office may be a particularly appropriate place for nutrition education to prevent chronic illness, since persons at high risk tend to have particularly poor nutritional habits.

Kuo, G.M., Mullen, P.D., McQueen, A., and others (2007, March). "Cross-sectional comparison of electronic and paper medical records on medication counseling in primary care clinics: A Southern Primary-care Urban Research Network (SPUR-Net) study." Journal of the American Board of Family Medicine 20, pp. 164-173.

Physicians' use of electronic medical records (EMRs) to print medication information does not seem to compromise their oral counseling of patients on medication indications and side effects compared with paper medical records (PMRs). With PMRs, physicians typically write medication prescriptions and give them to patients to fill at the pharmacy.

In contrast, an EMR with computerized physician order entry can print the prescription and store all medical-related records in the computer. Many can print medication information handouts for patients. In this study, the researchers compared the frequency of oral counseling and written information by primary care physicians at two PMR clinics and two EMR clinics.

There was less written plus oral counseling for medication indications and side effects in PMR clinics (2 percent) than EMR clinics (20 percent). Rates of oral counseling were similar in PMR and EMR clinics. However, PMR clinics provided more oral counseling only for indications (69 percent) than EMR clinics (53 percent). The impact of receiving oral or written counseling on patients' reports of having questions about their medications was inconclusive. The researchers call for more studies to address patient recall and to evaluate the quality and content of medication counseling.

Elder, N.C., Graham, D., Brandt, E., and Hickner, J. (2007, March). "Barriers and motivators for making error reports from family medicine offices: A report from the American Academy of Family Physicians National Research Network (AAFP NRN)." Journal of the American Board of Family Medicine 20, pp. 115-123.

Researchers conducted 18 focus groups with 139 physicians, nurse practitioners, physician assistants, nurses, and staff of 8 family medicine practices that were part of the American Academy of Family Physicians National Research Network. The groups focused on testing process errors, since tests are ordered during 39 percent of primary care visits.

The focus groups revealed that staff and physicians at busy family practice offices across the U.S. were willing to identify and submit reports of testing process errors. When they perceived benefits to themselves, their practices, and their patients, they were willing to take the time to submit reports. However, the time needed to complete the reports, as well as confusion about what information and what type of error should be reported, were barriers to the usefulness and quality of the reports. Many participants said they learned about errors just by making the reports.

Making the reports also helped some deal with the frustration and guilt of having made or discovered errors. For an error reporting system to maintain itself, it will have to provide ongoing benefits such as emotional support, regular feedback, and perceived quality improvement to those reporting errors. Also, the system should make clear what is needed in a report and who should make reports. It should also provide feedback useful to error reporters and take into account error severity and personal responsibility for the error. Assurance of reporters' anonymity and confidentiality are also important issues.

Editor's Note: In addition to funding opportunities, AHRQ is supporting PBRNs through a national resource center, an annual national conference, peer learning groups, an electronic PBRN research repository, and a dedicated community extranet. More information on AHRQ's PBRN initiative can be found at http://www.ahrq.gov/research/pbrn/pbrninit.htm.

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