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Pending Research Funding

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Responded to: National Institute on Alcohol Abuse and Alcoholism RFA

Teen Screen and Advise: Underage Drinking Project

Abstract:

The “TEEN SCREEN AND ADVISE; Underage Drinking Project“ seeks to study alcohol risk screening of youth and the impact of implementing the NIAAA’s Alcohol Screening Guide for Children and Adolescents”. This study will be conducted in VT and NH, two states with the highest rates of youth alcohol use in the nation. It will be conducted in the Dartmouth CECH/COOP primary care practice-based research networks that have established comprehensive electronic adolescent health risk screening (DartScreen) at all health visits for both research and clinical purposes. We will establish routine clinician alcohol screening and intervention based on the recently available NIAAA Clinician Guide, followed by recruitment of a cohort of over 2000 11-18 year olds that will be surveyed three times post visit.

We will conduct an effectiveness study to determine how the new NIAAA alcohol screening questions and counseling guide actually perform in real world settings by assessment of both population outcomes and clinical processes. In Aim 1 we will: a) Examine the prevalence of the NIAAA risk status groups, and determine the extent to which these risk groups predict alcohol-related harms at screening and in the year following initial screening at health visits (1-month, 6-month, and 12-month outcomes); and b) Determine if clinician use of the NIAAA clinical counseling protocol alters adolescent drinking patterns for at risk and drinking adolescents. In addition we will determine how this is influenced by changes in teen attitudes, motivation, effectiveness of counseling.

For Aim 2) we will determine the extent to which the NIAAA alcohol screening risk groups at different developmental stages predict co-morbid significant mental health issues and health risk behaviors. While some primary care data exists on other health risks for drinking in the past month and bingeing, this information for the new developmentally based alcohol risk groups is lacking. This will inform clinicians about the complexity and range of issues they are likely to encounter when implementing the new NIAAA Clinician Guide. We will utilize the capacity of the DartScreen to centrally collect cross-sectional de-identified data on a wide range of health risks (alcohol use, emotional issues, social conduct, sexual behaviors, tobacco and substance use) on 5000 early, mid and late adolescents screened at health visits.

During the process of practices implementing the new guide, it is important to learn if a teleconferencing-based training prepares clinicians to effectively use the guide, as well as how clinician and practice factors, influence implementation. Thus, Aim 3) seeks to explore the factors that facilitate and impede primary care clinician implementation of the NIAAA recommended approach to youth alcohol screening and intervention. We will follow the clinical implementation process using quantitative and qualitative surveys of clinicians and adolescent assessment of the counseling received.


Responded to: Request from Northwestern University, Department of Preventive Medicine to participate as partner in NHLBI PBRN Grant

VIEW of Your Heart Trial

The Value of Imaging in Enhancing the Wellness of Your Heart (VIEW) trial
(The CO-OP was invited to participate in this study by Phillip Greenland, MD from Northwestern and proposal was submitted last October to the NHLBI.)

Abstract:

Observational studies have shown that coronary artery calcium (CAC) score measured by computed tomography (CT) can improve risk prediction of cardiovascular disease (CVD) events. It has been suggested, therefore, that CAC testing may be useful to help guide preventive therapy, but this contention has not been evaluated in a randomized controlled trial (RCT).

The Value of Imaging in Enhancing the Wellness of Your Heart (VIEW) trial is designed as an RCT in 30,000 participants, men 45 to <70 years old and women 55 to <80 years old, at “low” (5% to <10% ten-year) risk of future coronary heart disease (CHD) events based on Framingham risk score. In an effectiveness trial, we will test the primary hypothesis that randomization to a CVD risk management strategy using statin therapy in persons with CAC is associated with lower risk of major CVD events than usual care among individuals at relatively low risk who are not currently eligible for guideline-based lipid-lowering drug therapy.

The primary outcome is a composite of non-fatal myocardial infarction (MI), resuscitated cardiac arrest, probable or definite angina with revascularizations, non-fatal stroke (not transient ischemic attack), or death due to any CVD (MI, stroke, other CVD). Secondary outcomes include total mortality, the components of the primary outcome, an expanded CVD composite including all revascularizations, CVD-free survival, incident cancer, cost-effectiveness and health-related quality of life.

We estimate 89.9% power using intention to treat to detect a hazard ratio of 0.785. Randomization will be 1:1 to usual medical care (standard risk assessment + usual preventive care) versus CAC-informed care (CAC testing + atorvastatin therapy when CAC results indicate presence of subclinical atherosclerosis). Recruitment will occur through established practice-based research networks, HMOs, integrated health care systems, and contract research sites. Follow-up will occur largely via coordinating center efforts using telephone, email, and mail. Total study duration is 8 years with 1 year of start-up, 2.5 years of recruitment, follow-up lasting 3.5 years (average of 4.75 years), and a year of closeout, data analysis, manuscript writing, and presentations. Two clustered applications are submitted, a Clinical Coordinating Center at Northwestern and a Data Coordinating Center at Wake Forest.

This trial will fill a critical gap in our knowledge regarding the role of CAC testing in the prevention of CVD. The cost and radiation exposure involved in CT scanning require demonstrating the effectiveness of the proposed approach if we are to allocate resources wisely in promoting cardiovascular health. Due to the widespread burden of CVD and the challenges in correctly identifying persons at risk for a first CVD event, the identification of a cost-effective adjunct to current risk assessment methods would have major impact on public health and healthcare expenditures.

Dartmouth CO-OP Project Principal Investigator will be Blair Brooks, MD.


FUNDED April 26, 2010

Completed June 2012

Responded to: AAFP PBRN Stimulation Grant Application

A Comparison of Cesarean Section Outcomes for Rural Obstetricians and Family Physicians

ABSTRACT

The proposed study is a retrospective descriptive study to compare the specific and overall complications of Cesarean sections performed in rural hospitals by family physicians and obstetricians.  Data will be obtained by chart abstraction and billing data.  The first phase of the study will be a pilot study in two New England community hospitals. At one hospital, all Cesareans are performed by family physicians. At a nearby hospital with similar patient demographics, obstetricians perform all C-sections. The 125 most recent C-sections will be studied in each hospital.  This will represent 2-5 years experience at the selected hospitals.

Outcomes data to be studied will be: maternal death, fetal death, Apgar score, newborn transfer to NICU, hemorrhage requiring transfusion, hemorrhage requiring Cesarean-hysterectomy, post-op infection, bowel injury, bladder injury, wound dehiscence, length of stay, length of procedure, and decision to incision time.  Basic demographic data will be obtained to confirm appropriate controls, including age, parity, insurance status, race and maternal medical conditions. Data will be collected by the principal investigator or her designee, following appropriate training in chart review and billing data collection techniques.  Data will be analyzed using standard statistical methods.



FUNDED September 30, 2010

Responded to: RFA-HS-10-014

The Teen Mental Health Project

ABSTRACT

Adolescence is a time when mental health issues are common. Half of all lifetime mental health disorders emerge by age 14. Despite the majority of adolescents being seen every year in primary care, only a third of depressed teens are identified in the usual health visit without use of a screening tool. One in every twelve teens in rural New England at health visits screen at risk for depression or suicide. Evidence exists that a collaborative care system where teens are screened for depression, providers receive training and supports to
assess teens, and office staff are trained to provide follow up and referral will lead to better outcomes. The US Preventive Services Task Force recommends this approach. However, most clinicians, especially in small rural practices, find it overwhelming to change usual care and lack resources to establish enhanced office care linked to mental health services. Linking clinicians through the practice research network has provided regional practices with the support to implement innovative changes to enhance patient care.

Through AHRQ support the Dartmouth CO-OP Project and CECH Practice-Based Research Networks (PBRNs) will partner with Dartmouth Hitchcock and regional mental health key stakeholders to establish the structure to train clinicians and their office staff, enhance mental health counseling options, provide clinicians with adolescent psychiatric input, and support office changes to respond to teen depression. The Dartmouth CO-OP Project will provide the tools and staff to assist practices in quality improvement with the office and form an ongoing group of practices and stakeholders to sustain improvements in the delivery of primary care adolescent mental health services.


Responded to:
The Dartmouth Center for Clinical and Translational Science – Pilot Grant ApplicationChild Well-Being Project

ABSTRACT

Key coping strategies for regulating emotions and handling stress develop during childhood. Inability to handle stress can limit children reaching their full potential and can result in anxiety, somatic complaints, and poor school performance. This pattern can continue into adulthood with emotional and cardiovascular consequences. Currently the healthcare system addresses acute problems and does not provide interventions to foster mental wellness or prevent the side effects of stress.

This pilot proposal seeks to develop and study, in a controlled trial, an innovative community approach to enhance mental wellness in preadolescent children. It will provide school and primary care activities that teach children to use relaxation techniques in their daily lives. This intervention of daily, brief relaxation exercises enhance focus and school performance, will be delivered to 4th/5th children in Walpole, NH by teachers trained by the Benson Mind Body Institute, with a goal of enhancing attention and school performance. Half the children will receive additional reinforcement from one primary care practice to encourage its regular use at home with parents. Evaluation will compare anxiety symptoms, physical health, social and school performance between 83 students in Walpole and 80 students in a control rural community in VT. The additive effect of a primary care component in Walpole will also be determined.

Mindfulness interventions are a priority of the Institute of Medicine’s comparative effectiveness research agenda. This “universal” preventive intervention has the potential for a larger study and wide spread use in rural communities.