Annual Report
2001-2002
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Research
RESEARCH SECTION
RESEARCH SECTION
WWAMI RURAL HEALTH RESEARCH CENTER
WWAMI CENTER FOR HEALTH WORKFORCE STUDIES
URBAN RESEARCH FOCUS GROUP (URG)
THE CLINICAL GUIDELINE FOCUS GROUP
INDIVIDUAL INVESTIGATOR-GENERATED RESEARCH
FELLOWSHIP TRAINING PROGRAMS—NATIONAL RESEARCH SERVICE AWARD (NRSA)
WASHINGTON FAMILY PHYSICIANS COLLABORATIVE RESEARCH NETWORK
STUDENT RESEARCH PROGRAMS
Organized in October of 1977 by former Chairman Dr. Theodore Phillips, the Research Section continues to flourish as one of the largest family medicine research enterprises in North America. Dr. Thomas Taylor served as the Director of the Research Section during the 2001-2002 academic year.
The Research Section is the administrative structure through which Family Medicine research efforts are conducted. The section assists in budgetary and scientific review during proposal development and is responsible for post-award management of most Departmental externally funded grants and contracts. The Rural Health Research Center, the Center for Health Workforce Studies, the Urban Research Group, and the Clinical Guideline Research Group serve as the foci for conceiving and implementing the section’s research agendas. Individual investigators also develop research ideas and receive funding outside these group structures. A number of projects previously funded were in operation during the past year, and several applications were submitted and funded. Appendix L summarizes funded research activity for the 2001-2002 academic year.
WWAMI RURAL HEALTH RESEARCH CENTER
The Washington, Wyoming, Alaska, Montana, Idaho (WWAMI) Rural Health Research Center (RHRC) is one of six rural research centers funded by the federal Office of Rural Health Policy to perform policy-oriented research on issues related to rural health care. Established in 1988, the RHRC has been refunded through 2004. The RHRC is based in the Department of Family Medicine and has close working relationships with other departments, schools, the Washington State Department of Health, and numerous academic, community, and government agencies. The core research team consists of Gary Hart, director and principal investigator; Roger Rosenblatt, co-investigator; Laura-Mae Baldwin, co-investigator; Denise Lishner, associate director for administration; and Eric Larson, deputy director. Many other faculty members and support personnel are actively involved in RHRC-sponsored studies.
The WWAMI RHRC focuses on the following major areas of inquiry:
Projects recently completed or currently underway:
Current or recently completed projects funded by other sources (the National Cancer Institute, Department of Defense, National Library of Medicine, federal Department of Education, and Office for the Advancement of Telehealth):
Studies to be performed in the upcoming year:
RHRC staff members also have made numerous presentations at regional and national meetings and conferences and have sponsored rural health workshops in such areas as studies of rural health care quality and quality of care for acute myocardial infarction in rural and urban U.S. hospitals.
WWAMI CENTER FOR HEALTH WORKFORCE STUDIES
The WWAMI Center for Health Workforce Studies (CHWS) is one of five health workforce centers funded by the Health Resources and Services Administration (HRSA) through the Bureau of Health Profession's National Center for Health Workforce Information and Analysis. The Center was established at the University of Washington in October 1998, and has been refunded through 2006. The CHWS brings together a multidisciplinary team of researchers from medicine, nursing, dentistry, public health, and the allied health professions to perform applied research on the distribution, supply, diversity and competence of health care providers, with emphasis on workforce issues in underserved rural and urban areas of the WWAMI region. The core research team for the Center consists of Gary Hart, director and principal investigator; Sue Skillman, deputy director; Roger Rosenblatt, co-investigator; Laura-Mae Baldwin, co-investigator, Eric Larson, co-investigator; Denise Lishner, research coordinator; and Heather Deacon, program coordinator.
The WWAMI CHWS:
Congressional Appropriation in 2002:
In addition to its core funding from the HRSA Bureau of Health Professions, the WWAMI CHWS received a $500,000 U.S. Congressional appropriation in 2002 to collect and analyze health workforce information in Washington State.
Ongoing Research Studies:
Recently Completed Studies:
Examples of WWAMI CHWS Partnership Activities with States:
Washington
Wyoming
Alaska
Montana
Utah
Nebraska
WWAMI CHWS investigators have presented results of Center studies at numerous national and regional conferences and meetings around the country, and publish results as Center working papers as well as in peer-reviewed journals.
Workforce Related Projects:
The Pacific Islands Continuing Clinical Education Program (PICCEP) conducts health workforce assessments and delivers continuing medical education (CME) to the six U.S.-associated jurisdictions in the Pacific (Guam, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Palau, and the Republic of the Marshall Islands). PICCEP has involved many medical, dental, and nursing faculty from the University of Washington, as well as other clinical colleagues in the Northwest and in Hawaii.
URBAN RESEARCH FOCUS GROUP (URG)
The Urban Research Group (URG) began as a Departmentally sanctioned focus group during the 1998-99 academic year, and has evolved into a research group supporting the work of investigators who are clinically active at Harborview Medical Center from within the Department of Family Medicine. The URG has served to advance the process of creating new research on the urban underserved in the Department of Family Medicine. At the same time, it has served to further the evolution and cohesion of the newly established residency satellite based at Harborview Medical Center. Although the URG no longer has dedicated funding for its activities, its intellectual and collegial activities continue to be of value to the participants.
Members of the group are Bob Crittenden, Mark Doescher, Alvin Goo, Jane Huntington, Roger Rosenblatt, Barry Saver, Freya Spielberg, and Abigail Halperin. Fellows and residents affiliated with the Department of Family Medicine attend periodically. During this last year, Drs. Laura-Mae Baldwin, Steve Taplin, and Tom Taylor participated while Dr. Rosenblatt was on sabbatical.
The major activity during the 2001-2002 academic year has been a monthly seminar at Harborview Medical Center, in which investigators have had the opportunity to do strategic planning for Department efforts in research on urban issues, to review and discuss work in progress, to determine individual and collective responses to new funding opportunities, and to invite and listen to other experts in the area.
URG members were successful in competing for a number of extramural grants. Mark Doescher and Barry Saver continue work on two Robert Wood Johnson Foundation (RWJF) grants testing interventions to increase perinatal tobacco cessation rates among women receiving prenatal care in a number of different clinical settings in Washington State, and to improve asthma care for high-risk pediatric patients attending community and migrant health centers.
Drs. Saver and Doescher also continued work on two grants funded by the Agency for Healthcare Research and Quality (AHRQ) and the RWJF to study issues related to prescription benefits in the elderly. In related work, Dr. Doescher completed an Advanced Research Training grant awarded by the American Academy of Family Physicians that focused on the health consequences of cost sharing among elderly Medicare recipients.
Dr. Saver is also the recipient of an AAFP Advanced Research Training Grant for training in the area of qualitative research methods and racial/ethnic disparities in health. During the past year, he took coursework and did independent study in qualitative research methods, and developed a grant proposal involving qualitative methods to investigate health disparities.
Freya Spielberg continues to work on several projects associated with her five-year K08 career development award from the National Institute on Drug Abuse (NIDA) in the area of behavioral interventions for HIV prevention, and has several grants pending. She is currently beginning work on a new CDC funded project to develop an interactive HIV/STD computer counseling program, and is assisting the pre-doctoral section in developing a new curriculum to teach medical students how to do brief effective patient centered HIV/STD counseling. She continues as the medical director of the People of Color Against AIDS Network (POCAAN) “Health on Wheels” program, a group dedicated to extending HIV/STD counseling, testing, and referral for people of color in the Seattle metropolitan area.
Abigail Halperin completed work on a grant from the American Legacy Foundation to support her work in tobacco control on college campuses. She is also receiving funding, as co-PI, from a four-year NCI-funded Randomized Intervention Trial to reduce smoking among college students. In addition, she is working on a grant sponsored by the Associated Schools of Public Health to develop a tobacco studies in public health curriculum for the Masters in Public Health program at the University of Washington School of Public Health and Community Medicine.
THE CLINICAL GUIDELINE FOCUS GROUP
The activities of the clinical guideline focus group have focused on a four-year National Institute on Aging (NIA) grant funded from 1998-2002. Dr. Thomas Taylor serves as the principal investigator for this grant. The aims of this project are to create and evaluate a web-based decision support for women making decisions about the use of hormone replacement therapy and other issues related to menopause and life after menopause.
The decision support system is based on three years of focus group analysis, structured interviews, and surveys of physicians and patients in a four-state region of the Pacific Northwest. These studies led to the description and independent validation of a multi-stage decision process that underlies this complex set of decisions. Six papers have already recorded this preliminary work and others are in process.
The focus group members are collaborating with a team of information scientists and software engineers in the Center for Health Systems Research and Analysis at the University of Wisconsin at Madison. The first three years were focused on developing content for the decision support system, concentrating on all aspects of menopause. The decision support system covers both symptom management and long-term prevention and includes information on both conventional and alternative treatments. It is being used by patients in the Harvard Pilgrim and Fletcher Allen health plans, and being reviewed by the Mayo Clinic for possible use. A large-scale efficacy trial based in Seattle and in Milwaukee, involving 414 subjects, has been completed and extensive analyses are almost complete. A budget supplement of $75,000 was granted by the NIA in 2001 to cover unanticipated costs of recruiting minorities for the efficacy trial.
Members of the group consist of Thomas Taylor and Barry Saver, supported by Susan Casey. The project involves collaboration with Dean Nancy F. Woods and Dr. Aileen McLaren of the School of Nursing.
INDIVIDUAL INVESTIGATOR-GENERATED RESEARCH
Allies Against Asthma:
Dr. Sharon A. Dobie served as the principal investigator for a Robert Wood Johnson Foundation, Allies Against Asthma Program Grant that funded the King County Asthma Forum to engage in a community-based planning process targeting low income children with asthma. The Forum used these funds to enlarge the coalition, to engage the community in planning interventions to improve the health of low income children with asthma, and to submit an application for a three year intervention project. The planning year included analyses of secondary data, focus groups from representative constituencies, asthma summits, planning retreats, and community education and support meetings. The subsequent grant application was funded by the Robert Wood Johnson Foundation, with significant matching funds from a variety of other sources. Because of her work in the initial phase of this project, Dr. Dobie was honored with the American Lung Association of Washington's Philanthropy award for best research project.
ACCORD (Action to Control Cardiovascular Risk in Diabetes):
Allan Ellsworth, PharmD, is the local site principal investigator for this randomized, multi-center, double 2X2 factorial design study of the effects of aggressive glycemia, lipid, and/or blood pressure control on macrovascular disease in 10,000 patients with type 2 diabetes mellitus. One hundred and fifty patient subjects will be enrolled and followed at the Family Medical Center, University of Washington Medical Center. The study is funded by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health.
The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial is designed to test the effects on major cardiovascular disease events of 1) intensive glycemia control, 2) treatment to increase HDL-cholesterol and lower triglycerides (in the context of good LDL-cholesterol and glycemia control), and 3) greater blood pressure control (in the context of good glycemia control). The study investigators hope the results will enhance the options for reducing the persistent high rate of major morbidity and mortality from cardiovascular disease that accompanies type 2 diabetes.
The trial has completed its vanguard phase of recruitment (10% of total enrollment). First year data has been analyzed and NHLBI has approved subsequent funding for the full phase trial, with recruitment slated to begin Jan 2003, and follow-up scheduled to end December, 2008. Primary results will be announced by the end of 2009.
Are Highly Concentrated Health Care Markets Bad for Health Care?
Dr. George Wright is directing an eighteen month study funded by the Robert Wood Johnson Foundation’s Health Care Financing and Organization (HCFO) program to assess the impact of the market power exercised by health plans and provider networks on physicians’ working conditions as well as the quality and intensity of care received by patients. Increasing financial pressure on both health plans and providers has led to acrimonious conflicts over contracts, and some provider groups have been able to force substantial increases in reimbursement. Two policy questions are posed. Are these recent developments positive or negative? What benefits and costs to society does greater provider market power imply? The study is using the Community Tracking Study’s (CTS) national physician and household surveys in 60 rural and urban areas linked to detailed market structure data. Key research questions include: 1) Countervailing market power:
Across markets, are concentrations of market share among a few health plans correlated with the grouping of providers in a few dominant organizations? 2) Physician work life: Do physicians in markets with a few dominant provider organizations report lower work hours, higher income, and more career satisfaction? 3) Service utilization: What are the relative effects of provider and health plan concentration on the intensity and specialty-orientation of health care as reported by patients? 4) Quality of care: What are the relative effects of provider and health plan concentration on the quality and convenience of care?
Rural Models for American Health Care: Is Our Problem the Solution?
Dr. George Wright has teamed up with Dr. Ira Moscovice of the University of Minnesota on a two-year project to reexamine rural health care from a new perspective. The co-principal investigators hypothesize that America’s rural areas have evolved cost-effective, high-quality models that deserve careful attention, not only as models for other rural communities, but for urban systems as well. The project will test the hypothesis that small-scale health care organized into effective networks, provides an attractive model to the current trajectory of ever agglomerating mega-organizations. The Robert Wood Johnson Foundation has awarded a Senior Policy Investigator Grant to these co-investigators to: 1) review the literature on the cost and quality of rural health care, 2) reanalyze existing sample surveys for evidence of systematic geographic variations in system performance, 3) use existing Medicare data to identify areas with high-performing health systems, and 4) sample these systems for four case studies to understand better their sources of strength and whether they can be replicated elsewhere. The goal is to use the Dartmouth Atlas combined with data from the new Primary Care Service Areas (PCSA) to identify high-performing small-scale rural health care systems. The site visits will focus on understanding their key features that can be implemented elsewhere.
Rural Community Hospital Development:
Dr. John Coombs (Phillips Professor in Family Medicine) is the Principal Investigator for the Rural Community Hospital Development (RCHD) program, which started in 1991. Clinical Associate Professor Peter House and Amy Hagopian manage this program. RCHD is a family of self-supporting activities that serve organizations in the Northwest on small projects. Since 1991, the program has completed over 115 projects with a total income of over $400,000. In 2001-2002, we facilitated a training session and board retreat for the Washington Academy of Family Physicians, partnered with the Alaska Center for Rural Health to prepare community assessments in Petersburg and Wrangell, Alaska, and facilitated the annual board retreat for Beartooth Hospital and Health Center in Red Lodge, Montana.
FELLOWSHIP TRAINING PROGRAMS—NATIONAL RESEARCH SERVICE AWARD (NRSA)
The Department of Family Medicine participates in a joint National Research Service Award with the Departments of Medicine and Pediatrics at the University of Washington. This two year fellowship, administered through the Division of Medicine, Health Resources and Services Administration, is aimed at training individuals for primary care faculty roles. The program includes a Master of Public Health degree and experience in research with faculty mentors. During the 2001-2002 academic year, Dr. Joe Lemaster completed the program. He is currently an acting assistant professor in the Department of Family and Community Medicine, University of Missouri, Columbia. Dr. Daniel Aukerman is the 2002-2004 year fellow. Dr. Thomas R. Taylor directs the Family Medicine component of the NRSA fellowship.
WASHINGTON FAMILY PHYSICIANS COLLABORATIVE RESEARCH NETWORK
Although federal funding through Title 780 of the Division of Medicine, Health Resources and Service Administration has ended, the Network has continued to function in collaboration with the Research Committee of the Washington Academy of Family Physicians. It has been extensively involved in the preparatory studies for the web-based decision support project (see the Clinical Guideline Focus Group work) for women making decisions about the use of hormone replacement therapy. Part of the network is currently participating in the efficacy trial portion of this project.
The primary student research program in the School of Medicine, formally known as Independent Study in Medical Science (ISMS), is now called III (Independent Investigative Inquiry). The great majority of students in this program, involving all four years in the medical school, are supervised by a School of Medicine committee chaired by Dr. Thomas Taylor. Drs. William Phillips and Mike Gordon serve as III committee members.
The Department of Family Medicine’s student research program is administered with the Predoctoral Program under the direction of Dr. William Phillips. A large number of students participated in the 2001-2002 year with support from the School of Medicine, Washington Academy of Family Physicians, and the Department of Family Medicine predoctoral grant. In addition to projects conducted under the sponsorship of individual faculty members in the Department of Family Medicine, medical students also participated in research through the Rural/Underserved Opportunities Program (RUOP). Five students pursued Medical Student Research Training Program (MSRTP) projects using RUOP as a base, and an additional 20 students explored community projects in a new, community oriented, primary care component of RUOP that also satisfied the school's newly revised research requirements. More details can be found in the RUOP report in the Predoctoral section of this report. All student projects and faculty sponsorship are noted in the Predoctoral Section of this report.
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