South Texas Psychiatric Practice-Based Research Network Meeting March 10th, 2010

Transcription

1 South Texas Psychiatric Practice-Based Research Network Meeting March 10th, 2010 Attendees: Drs. Don Howe, Boyce Elliot, Randy Sellers, Jeff Cordes, Stephen Gelfond, Mel Cohen, Maria Sweeney, Heather Regwan, Jon Zeber and Laurel Copeland. Dr. Jose Garcia via video conference from Laredo Director: Dr. Cervando Martinez. Staff: Holly Hayes and Stephanie Reyes. I. Welcome and Introductions A. The Director Cervando Martinez opened the meeting with a summary of the meeting with 14 in attendance.. The second card study was discussed and it was decided that the research subcommittee, comprised of Drs. Sellers, Gelfond, Cohen and Salazar would meet to decide on whether to do a card study based on Hahn s Difficult Doctor-Patient Relationship Questionnaire (DDPRQ) (Hahn, 2001) or based on the negative positive reaction scale created by the group. II. Approval of Minutes A. The minutes were approved by all in attendance III. Research Subcommittee report on the next card study. A. The Subcommittee met on February 10 th, 2010 and decided to use the Hahn s DDPRQ version for the next card study because it would be comparable to the past primary care studies done with Hahn s DDPRQ. In Addition, the group would be breaking new ground since this particular survey has never been tested in a Psychiatric setting. Please see attached card. The subcommittee decided to recruit 20 Psychiatrists to participate in this next study to maximize the amount of data collected as well as to help the Network get closer to achieving official PBRN status. 1. Dr. Sellers expressed that they worked on making this card study short, simple and feasible. When Dr. Garcia asked if the Hahn s DDPRQ scale could possibly be modified Dr. Sellers explained that they wanted to keep the survey exactly the same to maintain data integrity and ability for comparisons to be made. 2. Dr. Sellers went on to discuss that they will also be able to compare the demographic information collected from each Psychiatrist to the data collected from the patients in the study. 3. The Dr. Cervando Martinez clarified that the data on both sides of the card will be collected on each patient, regardless of their Likert scale score. 4. There was a discussion on whether to collect 50 consecutive cards or to choose one day a week to collect cards. Dr. Gelfond had originally wanted the cards numbered 1-50 to see if the practitioner reaction corresponded to a particular part of the day. Cervando asserted that they are heterogeneous group who see different numbers of patients in a given week. There was the feeling that data collection on one particular day a week may be more feasible and less taxing for some of the Psychiatrists. It was decided that the method of data collection (consecutive vs. one day a week) would be left to the discretion of the participating Psychiatrist. Directions will be specific to those two methods so as to eliminate any conscious or unconscious discrimination in data collection. 5. Dr. Mel Cohen suggested that every participating psychiatrist do a satisfaction survey after the study asking which method of data collection they chose, how time consuming they thought it was, if they would like to participate in another study and any recommendations they have. Holly said she would follow up with that suggestion using an existing survey template and forwarding it to Dr. Cohen.

2 **The following section has been contributed by research experts Drs. Laurel Copeland and Jon Zeber ** B. We were very appreciative to be invited to attend the Psychiatric PBRN meeting and have the opportunity to discuss your work. Some of the issues brought up during the meeting merit further discussion and elaboration. John and I are happy to respond to any questions anyone in the Psychiatric PBRN may have (Zeber@CZResearch.com; Copeland@CZResearch.com). In addition, here are some more thoughts that were stimulated by the Psychiatric PBRN meeting. 1. Some of the feedback on the study card from the black box duo was related to survey format, some was related to content, and some was related to study design. a. The format issues included use of white space, ordering of questions (this can affect the data you end up with), and the structure of item responses. Item responses were the issue when the question came up about the use of the line connecting the values 1 through 7 for the single item asking about difficult patients, and the discussion of the anchor terms. Anchoring each value with words such as markedly and severely helps the respondent choose an answer, but if s/he feels that the anchor words are out of order (e.g., that #6 severely should be ranked lower than #5 markedly ), this can result in responses that are higher or lower than the surveyors expect. To determine whether the anchors mean different things to different people, the researcher can do the field-testing of survey items that I mentioned, where the card is given to a psychiatrist (not in the actual study, so not in the Psychiatric PBRN) to complete while envisioning some particular patient, and then the researcher debriefs the respondent to determine what the question and its responses brought to mind. The goal is to find out whether the respondent is answering the question that the researcher is trying to ask. The reason I brought up this process is that one of the psychiatrists in last night s meeting questioned the anchor terms. Generally speaking, if one in a group of 10 thoughtful persons has a concern about an item, other respondents may also. b. When we were considering the content, we wanted to know, what are the research questions, and which question is most important to the clinicianresearchers to answer first? Then we considered whether the items on the card could yield information to answer the chosen research question(s). c. The study design aspects we considered were primarily (a) assessing all patients on all items vs. assessing most items only on difficult patients; (b) diurnal, day-of-the-week, and week-to-week variation in the type of patients seen / assessed; and (c) sample size. Last night we also discussed (d) confounding of patient type with provider. On issue (a) we favored assessing all patients so that a comparison group is assessed at the same

3 time as the group of primary interest (the difficult patients). On issue (b) we rely on the clinicians to decide which part of the day, which days of the week, and which part of the month will yield the most typical patients for their practice, and then to assess patients at those times. One wants to avoid choosing only the difficult patients, choosing only the easy patients, or otherwise introducing bias into the sample through the selection of patients. Assessing 50 sequential patients is desirable because none are omitted and they may be scheduled without respect to their diagnoses and personalities. However, a busy clinic day can interfere unexpectedly. That s the nature of the process. The different patient loads of the clinicians may warrant adjusting the schedule of assessment, such as having 25% of the target assessed each week for 4 weeks, or it may not warrant adjusting the schedule. The clinicians in the Psychiatric PBRN know best. The study will yield unique and valuable data, regardless of irregularities in the data collection schema. Keeping track of deviations from the plan is all that is needed so that a future reader can understand how the study proceeded, and can consider the results in that context. All studies have limitations; it is not necessary to be perfect. 2. The study can be described as a feasibility study or a pilot study, and the sample can be described as a convenience sample. The study design may be described as observational and cross-sectional. 3. Dr Cordes asked what we might learn from this current study. Hahn et al 1996 found differences in the DDPR score by type of mental illness, which we could affirm or dispute in the Psychiatric PBRN practices. Hahn et al reported no differences on DDPR score by demographic measures (age, sex, race) which The Psychiatric PBRN could either support or dispute. The Psychiatric PBRN can augment the knowledge base on the difficult patient by assessing whether there are DDPR score differences by language issue? Yes/no or by number of meds prescribed (similar to the Hahn finding that that higher DDPR scores were associated with higher health care utilization). As Dr Sellers noted, this study will also provide a chance to determine how highly the single item how difficult is this patient correlates with the 10-item DDPR score. If the correlation is very high, then in future studies the concept of the difficult patient could be assessed by just the 1 item in lieu of the 10-item scale, leaving more room on the card for other research constructs. 4. Another product of the research can be process measures, where you keep track of how the study was implemented and what the clinician-researchers thought about that process. Some possible questions to consider or to gather data on include: a. How easy was it to stick the proposed schedule of assessing 50 consecutive patients? b. How stressful was the study for the clinician-researcher? c. How many patients did each clinician actually assess? d. Was it helpful to have the cards pre-numbered? What would be better?

4 e. Was it easy to keep track of the blank and completed cards? What would help? f. How difficult was it to complete a card between each set of 2 patients? g. How often did you (the clinician-researcher) have to put off completing a card until later? How much do you think that affected your ability to rate the patient accurately? h. How much variability was there in the number of days required for each clinician to complete 50 cards? i. Is 50 cards too many? j. Was it boring after the first day? k. What ideas for card studies came to mind as you (the clinician-researcher) were completing these cards? IV. Infrastructure discussion and strategic planning retreat A. The group voted to have the retreat on Tuesday April 6 th from 6:00PM 8:30 PM, in the Psychiatry Department on the 7 th floor of the School of Medicine building in room 710L. All members are asked to bring a colleague new to the Network to help expand membership. At this retreat the Network s research agenda will be set for the next year and serve as documentation of the Network s growth. Please RSVP by Monday April 5 th. PBRN Resource Center Coordinator Holly Hayes opened this discussion by asking everyone what was one thing they would like to accomplish at this retreat. The following were contributed by the group: 1. Dr. Martinez: Discussion about the possible role the Network could have in the upcoming field trials of for the DSM 5, working with the Translational research center, discussion about process to approve investigator-initiated studies, interaction with VA network, and hearing from PBRN expert Dr. Michael Parchman. 2. Dr. Mel Cohen: To have Research guidance on data collection, statistics etc. hear about other PBRNs and explore possible interdisciplinary work with PBRNs such as STARNet. 3. Dr. Randy Sellers: Hear stories from a successful mature PBRN and also hear about lessons learned from failed studies. 4. Holly Hayes: Discussion of Network recruitment and marketing its value to new and existing members. 5. Dr. Stephen Gelfond: A discussion on how projects can be funded. B. Holly wrote the following brainstorming questions for members to keep in mind for the retreat: 1. I wonder if is related to? 2. Why do patients with usually present with symptom? 3. Are patients with condition more likely to have/develop/present?

5 4. How common is in my patient population? V. As of there are 19 members who are IRB or CITI trained and ready to start the card study at the beginning of April. It is not too late to complete the short IRB training for non-va members. VA members CITI training is longer, however if you take a module a day you will be done in time to participate in the study. Both links will be on the to which these minutes are attached. VI. The meetings will now be scheduled the first Tuesday of every month unless otherwise specified.