Research practice improvement ideas are generated by community clinicians practicing in Northern New England. The COOP Governing Board and staff develop the research ideas as they work through the "pipeline." Some ideas will never be funded. The work of developing any idea helps educate the members about research methods, increases enthusiasm for practice and stimulates new ideas. Any clinician who has participated in COOP research is eligible to present ideas at the Annual meeting or develop an "interactive insert" which is part of a quarterly newsletter.
The COOP Project has also moved to systematically improving care and speeding up the process.
Current funded research projects supporting the COOP office practices and staff are:
The goal of the Primary Care Anxiety Project is to develop a comprehensive picture of anxiety disorders in patients seen in primary care settings, both closed-panel health maintenance organizations and private primary care practices. The study will focus on panic disorder with and without agoraphobia, generalized anxiety disorder, social phobia, post traumatic stress disorder and mixed anxiety depression.
The study has four main goals:
PCAP has been designed as a cohort study of 650 patients. Study subjects will be drawn from patients seen in primary care practices. Participating practices include several practices within 25 miles of Hanover, NH, affiliated with the Dartmouth COOP practice-based research network, the Codman Square Health Center in Boston, a primary care practice at the University of Massachusetts in Worcester, MA, and two family-practice-model centers of Harvard Pilgrim Health Care, in Swansea and Plainville, MA. Patients who are unselected, not-psychotic, English-speaking, at least 18-year-old, and established patients in each of the participating sites will complete a self-administered screening questionnaire. Those screening positive for any anxiety disorder will be offered a detailed interview. The interview will be conducted by a trained rater and will incorporate a battery of instruments including a structured interview for diagnosing psychiatric illness according to DSM-IV (SCID-IV), a medical history questionnaire, and other instruments designed to collect information on psychosocial functioning, patient demographics, and life events. Patients will be contacted for follow-up interviews at six months, 12 months, and 24 months after intake. These interviews will also be conducted in person by a trained rater and will incorporate similar instruments to those used at intake.
The knowledge gained from this study will complement and extend the only existing database on anxiety disorders, the Harvard Brown Anxiety Disorders Research Program (HARP). HARP is a cohort study of 711 patients with anxiety disorders carried out in tertiary care psychiatric facilities on patients in treatment with psychiatrists, psychologists, and other mental health providers. The proposed study will extend our knowledge for the first time to the general medical setting where most patients with anxiety disorders are evaluated and treated. It will allow us to take advantage of the less selected patient population and look at patients with more moderate and perhaps different illnesses seen in primary care settings. This study, combined with the HARP study, will form a comprehensive approach to understanding anxiety disorders in the general American population.
The essential feature of this research is studying patients with anxiety disorders in the primary care setting. It will provide us with the first prospective longitudinal study of the course outcome and naturalistic treatment of anxiety disorders in primary care. It will also be the first study of reasons why primary care clinicians choose to prescribe specific treatments and why patients seek and take treatments prescribed by physicians for emotional disorders. Finally, it will lay the ground work for additional studies of specific treatments and other aspects of the care of patients with anxiety disorders in primary care settings.
Pain is an extremely common symptom presented to primary care physicians and accounts for significant suffering on the part of patients, billions of lost work days per year, and increasing rates of disability and health care utilization. Unfortunately, pain is a problem frequently not helped by the standard medical interventions often because:
The primary objective of this project is to design the best, most efficient rapid assessment and management approach for pain in busy community practice settings by developing an Intervention model that utilizes the Dartmouth COOP Clinical Improvement System and a telephone-based, Nurse-Educator Intervention. This is a feasibility (pilot) project of 12 months duration. Four-hundred-fifty patients aged 21-69 with significant pain being treated by one of ten New England physicians will be randomly assigned to the Intervention (n=350) or serve as Controls (n=100). The Intervention will consist of two levels:
We hypothesize that the rapid assessment and intervention approach will result in:
The Dartmouth COOP Project is currently involved in the Primary Care Management of Prostate Disease Study. This controlled trial is a substudy of the Patient Outcomes Research Team (PORT) for Prostate Diseases that is funded by the Agency for Health Care Policy and Research (AHCPR). In two interrelated investigations, the PORT/COOP team is addressing this key question: how, in a busy primary care office setting, can informed, cost-effective decisions about prostate disease be made for the greatest benefit of the patient? The main objectives of the studies are stated as follows:
Fifty physicians in 33 practices from 2 geographic regions (New England and Arkansas) are currently participating. Initial patient questionnaires were sent to approximately 10,000 men age 50 and above to gather information about their general health, urinary tract symptoms and prostate-related conditions. A subset of 2400 men was randomly selected (stratified by physician) for outcomes assessment in the 18-month trial. Intervention physicians received educational materials developed by the Dartmouth COOP/PORT II team. These materials included the Comprehensive Primary Care of Prostate Disease Physician Reference Manual, a Companion "Quick" Guide for physicians, 3 patient brochures: The Prostate Gland, The PSA Test, and BPH,; and 2 linear videotapes developed in conjunction with and distributed by the Foundation for Informed Medical Decision Making (FIMDM) at Dartmouth: The PSA Decision: What YOU Need to Know, and Benign Prostatic Hyperplasia: Choosing Surgical or Nonsurgical Treatment. Additionally, other materials such as those released by AHCPR related to the BPH Practice guideline (both Patient and Clinician Guides) were made available to practices. Throughout the trial, physicians have been encouraged to make use of the materials and tailor this use to fit their practice needs and style. Patients of intervention practices also received educational materials directly from the Dartmouth COOP/PORT II team after completing and returning their baseline surveys.
Data from the patient Male Health Survey has undergone preliminary analysis with results reported at and published by the Society of General Internal Medicine (SGIM) annual meeting in the spring of 1997: Barry MJ, Wasson JH, Hammond Cs, et al. Prostatic Symptoms, Problems, Concerns, and Interventions Among Older Men in Primary Care Practices. J Gen Int Med 12 (supplement 1):17, 1997. Follow-up data collection and final analysis will be completed in early 1998 followed by reporting of results, distribution of intervention materials to control sites, and packaging and dissemination of any materials and information from this trial to the broad primary care community. Opportunities for future trials will also be carefully addressed and developed into project proposals as warranted.
