FPs Put Research Into Practice

Practice-based research is becoming a two-way street. As family physicians and their staff members conduct research, they reap the rewards of providing better patient care; improving their office systems; and, sometimes, obtaining new equipment and expanded reimbursement.

During the past five years, FP researchers have learned how to blend quality improvement and research, said Wilson Pace, M.D., director of the AAFP National Research Network. The network has collaborated with other groups in sponsoring depression-and-QI and spirometry studies. These two research projects, plus another not related to the AAFP network, are in the final report-writing phase. Taken together, the three studies show how research leaves its footprints in grass-roots practices; FPs learn through the projects, and the lessons stick long after their practices have completed the research work.

FPs Ron Mansolo, M.D., and Elizabeth Burnell-Mansolo, M.D., a husband-and-wife team in Leander, Texas, and nurse practitioner Megan Passe, R.N., who works with them, took part in a 2004-06 study on depression and quality improvement. They tested the usefulness of a patient health questionnaire (PDF file: 2 pages / 42 KB. More about PDFs.) for determining whether patients are depressed, and they are finding the lessons learned from the research invaluable for enhancing their patient care.

"I knew one patient was depressed, but he wasn't real open about how he was feeling," said Burnell-Mansolo. She had him fill out the questionnaire, and his answers indicated a more serious degree of depression than she had suspected. "At that point, I increased the medication, and at the next visit, the patient was better," she said.

Patients eventually build up a reservoir of questionnaires, said Burnell-Mansolo. "Sometimes I pull out old questionnaires and let patients see how much they're improving."

The practice found the questionnaire so valuable that Mansolo created similar tools on conditions such as attention-deficit/hyperactivity disorder, cancer, chronic illness and diabetes; another is issued to patients coming in for a general physical exam.

As part of the depression study, the practice also created a QI team that then multiplied. Representatives from billing and the front office and the practice's medical assistants now hold regular sessions to trouble-shoot, and all staff members, including the physicians and Passe, meet each month for team-building.

The team meetings help define problems and solutions for everyone in the office. "The biggest problem patients had was holding on the phone too long," said Marilynn McAlister, office manager. By looking at the problem in the team setting, everyone was encouraged to get involved in solving it. "Now whoever answers the phone tries to really listen instead of putting the patients on hold at first," said McAlister. When getting an answer to a question will take awhile, staff members promise to call the patient back within two hours. "And we do," said McAlister.

Mansolo, Burnell-Mansolo and Passe also took part in a 2004-05 spirometry study that tested whether FPs and their staff members could do accurate pulmonary function tests, or PFTs, and whether in-office spirometry would change FPs' assessment of the severity of patients' asthma or chronic obstructive pulmonary disease -- thus, changing their care plan for the patient. Study FPs received spirometers to keep and use at their practices, and, during the study, pulmonologists checked their spirometry interpretations.

The addition of this service again helped Burnell-Mansolo and Mansolo enhance their patient care. "A woman I saw recently was complaining of shortness of breath, but I didn't hear her wheezing when I examined her," said Burnell-Mansolo. She started the patient on medication and, within a few days, had Passe give the patient a PFT. The results indicated the patient needed more assistance, so Burnell-Mansolo ordered inhaled steroids. "The PFT helps with diagnosis and treatment," she said.

The addition also helped boost the practice's accounts receivable. Insurance companies pay for the PFTs, Mansolo said. "Being able to treat our patients in our office saves money" for the health care system as a whole, he added.

FP Raj Kachoria, M.D., of Macedon, N.Y., chair of the family physicians' section of the eight-county Rochester (N.Y.) Independent Physicians Association, or RIPA, is another participant in the spirometry study who discovered its financial benefits. Kachoria shared information about the spirometry study, as well as the manual for study participants, with RIPA members and then with an HMO that contracts with RIPA. "The study information and the manual backed us up on the value of doing spirometry in our offices," said Kachoria. "We now have a guideline from the HMO for primary care physicians to do spirometry, and we're not getting questions when we bill for it."

Agreeing to take part in a retinopathy study funded by the American Diabetes Association led to better patient care for the FPs at 15 clinics in the Salud Family Health Centers system in Colorado. They participated in a 2002-04 study on diabetic retinopathy that examined primary care physicians' ability to read retinal photographs. The grant paid for two cameras for the clinics and a photographer to take pictures of about 2,500 patients with diabetes. For the study, the Salud FPs read the photographs, and an ophthalmologist "over-read" them to check the FPs' interpretation.

"We found out family docs can read retinal photographs, and we discovered about 8 percent of our diabetic patients had severe diabetic retinopathy and needed to see ophthalmologists for that," said FP Tillman Farley, M.D. Farley, who practices in Fort Lupton, Colo., is the Salud clinics' medical director and is writing the research report discussing the study's findings.

He emphasized the retinopathy study's patient care benefits. "Instead of referring all our diabetic patients for screening and treatment, we are now only referring those patients with significant disease," he said. "The screening and treatment are now just part of our program. We've put the research into practice."