(left to right) Bijal Balasubramanian, MBBS, MPH, epidemiologist; Jill Kelly, LPN, chart auditor; Denalee O'Malley, BA, project director; Anna Looney, PhD, practice facilitator; Benjamin Crabtree, PhD, principal investigator, UMDNJ-Robert Wood Johnson Medical School
Embracing Complexity for Translating Research into Practice
s a social worker and community volunteer, Alice has devoted her life to helping people with their problems, but she has not had much success with her own problem of living with diabetes. Alice was diagnosed with diabetes seven years ago at the age of 45. When she talks about having diabetes, her stories center around her struggle with weight, issues surrounding food, and the technical aspects of daily glucose monitoring and insulin injections. While medical science has made enormous progress over the past 50 years, each year the prevalence of obesity and chronic disease increases, and a growing number of people like Alice feel that advances in diagnostics and
therapies have not been enough to change their lives.
Alice’s type 2 diabetes predisposes her to developing significant heart
disease. Cardiovascular disease is largely preventable by reducing risk factors such as diabetes mellitus, elevated blood pressure and elevated blood cholesterol, especially through the modification of unhealthy behaviors such as tobacco use, sedentary lifestyle and poor diet. A strong foundation of research has led to clear guidelines for the primary and secondary prevention of cardiovascular disease and related risk factors; however, despite the existence of these evidence-based guidelines and widespread attempts to disseminate them, the translation of clinical guidelines into practice has been a frustrating challenge. Since most adults with type 2 diabetes seek their care from family physicians, general internists or general practitioners—accounting for 76% of all outpatient visits provided to adults with diabetes—translating theoretically sound strategies that work in research settings into real world primary care practices could have a tremendous impact. Our research focuses on discovering more effective care delivery models and strategies for successfully integrating technological advances and new
therapies into everyday primary care practices.
| Figure 1. Just having the tools (such as EMR) does not translate into better patient care. Figure showing that practices without EMRs performed significantly better in aspects of diabetes care.
| Figure 2. Everyday Family Practice with critical needs of relationship building
Like most primary medical care practices, Everyday Family Practice, where Alice receives her care, is still rooted in a care delivery model optimized for delivering acute care in 10 to 15 minute visits. In fact, two-thirds of all U.S. physicians work in similar semi-autonomous solo or small group practices. Such practices now face tremendous challenges responding to increasing numbers of patients with chronic and mental health issues. Like patients, medical practices have also been offered technological solutions such as electronic medical records (EMR), flow sheets, disease registries, and reminder systems. Unfortunately, practice transformation has been difficult and many new technologies are either not adopted or have not lived up to their promise.
The Department of Family Medicine at UMDNJ-Robert Wood Johnson Medical School has been at the forefront in developing organizational change models for enhancing the quality of care in primary care practices. This program of research has spanned more than 15 years and involves close collaborations of investigators from Case Western Reserve University (Kurt Stange, MD, PhD), Lehigh Valley Hospital (William Miller, MD, MA), University of Colorado (Paul Nutting, MD, MSPH), University of Texas at Austin (Reuben McDaniel, Jr, EdD) and University of Texas Health Sciences Center at San Antonio (Carlos Jaen, MD, PhD). These colleagues and our team of investigators have completed a series of descriptive and intervention studies of physician practices encompassing a wide range of topics, including approaches for enhancing chronic disease management, tobacco cessation assessment and counseling, and delivery of cancer related preventive services. Studies by our collaborative team have been funded by NCI, NIDDK, NIMH, NHLBI, and the Robert Wood Johnson Foundation.
Our efforts to understand the organization of primary care practices are guided by an emerging theoretical model that conceptualizes practices as complex adaptive systems that continually evolve over time. This model is derived from complexity science and understands that the environments, cultures, and interconnected network of relationships within a particular practice shape how these organizations deliver care and adapt to changes. This model challenges the underlying assumption of many widely used interventions that focus on individual physicians or isolate specific health problems. We feel it is critical to understand that physicians and their practices are part of larger systems and that specific health problems are not independent of the whole complex range of problems experienced by patients and cared for in primary care practices. Thus, while improving practice has traditionally focused on having well-defined problems and using tactics such as continuous quality improvement, hiring effective people, and implementing evidence-based guidelines, our program of research shows that one of the best strategies for improving practice is to pay attention to improving relationships among stakeholders in and related to the practice.
Our research group currently uses facilitated Reflective Adaptive Process or RAP teams to enhance relationships, encourage action-reflection cycles, develop facilitative leadership, and stimulate collaborative team creation. RAP teams generally consist of a physician leader, the practice manager, representatives from each part of the practice (i.e. billing, front desk, nursing staff, etc.), and a patient. These teams meet for one hour every week, review the practice vision and develop and implement strategies for prioritized practice issues and problems. The RAP process helps the practice develop trust, mutual respect, and mindfulness, and helps to establish more diverse connections among practice members. Practices become more improvisational and better able to continually adapt to the ever changing health care environment.
We are currently funded by NHLBI and NCI to conduct practice level interventions targeting multiple chronic illnesses and cancer screening. These studies use group-randomized intervention designs in which practices are randomized into intervention and control groups, with the intervention practice clinicians and staff participating in facilitated RAP teams and other strategies to enhance teamwork, relationships, leadership, and collaboration. Currently more than 60 New Jersey Family Medicine Research Network practices are participating including Everyday Family Practice where Alice is a patient. Pending grants focus on implementing electronic medical records and other technologies to enhance cardiovascular disease prevention and management. The long-term goal of this program of research is to significantly impact the quality of care delivered in New Jersey, with a particular focus on the delivery of more effective strategies for addressing complex lifestyle change issues.
Benjamin F. Crabtree, PhD, a medical anthropologist, is professor and director of research, Department of Family Medicine, UMDNJ-Robert Wood Johnson Medical School. Dr. Crabtree has contributed more than 100 peer-reviewed manuscripts and is recognized for his expertise in qualitative research. He has co-edited two books, Doing Qualitative Research, now in its 2nd Edition, and Exploring Collaborative Research in Primary Care. He has been principal investigator on major grants from AHRQ, the Robert Wood Johnson Foundation, NHLBI, and NCI.