Volume 15, Issue 1
Winter 2003
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Feature Article
The Birnbaum nominees:
Group Health teams help translate research into practice
By Katie Saunders
The setting was the downtown Seattle Sheraton Hotel, the occasion was
the third Annual Hilde and Bill Birnbaum Endowed Lecture, and the scene
was reminiscent of the Academy Awards. Group Health Center for Health Studies Associate
Director Dan Cherkin, PhD, opened an envelope and announced the winners of
the Birnbaum Award—the nurses of Group Health’s Breast Cancer
Screening Program. This award, established by CHS and the Group Health
Community Foundation, acknowledges a Group Health delivery system team
that has made extraordinary contributions to successful research at the
Cooperative. The title of the award is significant. Through public service
and generous donations, Group Health consumer leaders Hilde and the late
Bill Birnbaum have long supported the need to integrate new research into
health care delivery.
Toward that end, the annual Birnbaum lecture was instituted in 2000. It
gives Group Health professionals and Foundation donors a chance to
celebrate and learn more about research that benefits the Group Health
delivery system. This year’s speaker was the Center’s own Ed Wagner,
MD, who has achieved national and international recognition for his
efforts toward improving chronic illness care. The Birnbaum award, newly
instituted in 2002, explicitly acknowledges that CHS research does not
exist in a vacuum. "We at CHS recognize that collaboration with our
partners in the Group Health delivery system is essential to our success
as a research organization," says Cherkin.
Center staff were asked to nominate individuals or teams they had
worked with who had demonstrated commitment to research as a way to
improve patient care. The following five groups were nominated:
1) The Breast Cancer Screening Program nurses for their participation
in breast cancer surveillance research;
2) The Central and Eastside gastroenterology teams for their
participation in colorectal cancer control and prevention research;
3) The Northgate Medical Center Cluster C team for its participation in
the Healthy Steps Program (a program focused on integrating child
development into health care);
4) The Northgate Medical Center, Capitol Hill Family Health Center, and
Eastside Primary Care Center teams for their participation in depression
clinical trials; and
5) The Group Health Physical Therapy Department for its participation
in a back pain randomized trial.
CHS scientists voted for one of the five nominees, with the Breast
Cancer Screening Program nurses attaining the majority of the votes. While
there can be only one winner, the Center subscribes to the notion that it’s
an honor to have been nominated!
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The Breast Cancer Screening Program nurses
Group Health’s Breast Cancer Screening Program (BCSP) invites female
Group Health enrollees aged 40 and older to participate in mammography
screening at intervals of one and two years, depending on breast cancer
risk. Early detection leading to a reduction in late-stage disease and
breast cancer-related mortality is the program’s ultimate goal. As part
of the screening program, women complete a survey that asks about
demographics and risk factors related to breast cancer (e.g., family
history, age of menarche). This survey is used by clinicians to help with
the interpretation of mammograms and by researchers seeking to improve
breast cancer care. Data from the survey have provided critical
information to help radiologists evaluate their performance and to
motivate changes in the way care is delivered. For example, women are now
encouraged to undergo screening during the first two weeks of their
menstrual cycle when mammograms are more effective because of lower breast
density.
Over the last 15 years, the BCSP nurses have not only delivered care
through the program centers, but have played a critical role in enhancing
the quality of the survey data. The nurses review data with the women as
they complete the survey, sometimes identifying and correcting erroneous
responses in the process. Also, because of their personal interactions
with program participants, the nurses have been uniquely positioned to
gauge what is working well with the survey, and what isn’t. For example,
the nurses suggested that the question about family history should collect
more detailed information about whether breast cancer was diagnosed in a
first-or second-degree relative.
"The nurses contributed immeasurably to improving the
survey," says Stephen Taplin, MD, a CHS senior investigator and Group
Health family practitioner. "We’ve published more than 25 papers
based on this data, including crucial work that ultimately improves
care." Taplin wishes to acknowledge manager Jo Ellen Callahan and the
following BCSP nurses: Ann Asher, Linda Brender, Ellen Jane Canfield,
Donna Crosby, Mary Dahlstrom, June Dawson, Priscilla Dicarlo, Joanne Caro
Dorschel, Trumaine Greenland, Patti Ann Hurlbut, Caroline Klaport, Linda
Marion, Lynette Murphy, Brenda Oneal, Heidi Pelton, Winona Pietila,
Mulumebet Retta, Nancy Siburg, Michele Simpson, Lisa Stilwell, Marilyn
Vanbrero, Lavana Wood, Susan Woods, and Helene Worsham.
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The Physical Therapy Department
The Group Health Physical Therapy Department, under the direction of
Rick Bocko, participated in a National Institutes of Health-funded
randomized trial of an intervention for patients with back pain. The
collaboration grew out of work that Steve Berry, Physical Therapy Department
Manager, and Michael Von Korff, ScD, the project’s Principal
Investigator, did together to draft guidelines for managing back pain in
primary care settings.
Back pain is a common condition that can lead to personal suffering and
large societal costs due to reduced work productivity and increased health
care expenditures. Researchers hypothesize that back pain patients who
fear that physical activity will increase their pain may avoid certain
activities. This "fear-avoidance" behavior can eventually lead
patients to become out-of-shape and disabled.
The intervention in the back pain randomized trial was designed to
address patients’ fears regarding back pain and support resumption of
usual activities. The intervention was delivered by a study staff
behavior-medicine specialist and one of three volunteer Group Health
physical therapists–Steve Berry, John Maisano, or Bridget Goglia. Over a
one-year period, the physical therapists participated in more than 250
study-related visits—all in addition to their regular case load. The
extra effort appears to have paid off—initial results suggest that the
intervention successfully reduced patients’ back pain-related fears and
activity limitations.
Von Korff views this as an excellent example of how collaboration with
delivery system staff can enhance research. "The physical therapists’
proactive involvement changed the direction of our back pain research,
making our study both more relevant to the Group Health delivery system
and more effective in addressing patient needs," says Von Korff.
"Their involvement has allowed us to develop a care model that could
be fully integrated into existing GHC services for back pain in primary
care and physical therapy."
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The Central and Eastside Gastroenterology teams
Colorectal cancer is the second leading cause of cancer deaths and the
fourth most common cancer in men and women in the United States. Over the
last several years, CHS scientists have conducted research with the goal
of either preventing this disease or improving its early detection.
Examples of studies include: the Screening Markers for Colorectal Cancer
study, designed to identify early, molecular markers for colorectal
cancer; the Soy Isofavone study, designed to evaluate ways to prevent
colon cancer; and the National Colonoscopy Trial, designed to evaluate
colonoscopy screening.
This body of work would not be possible without the collaboration of
the gastroenterology (GI) teams at Central and Eastside Specialty Centers.
Led by Andrew Feld, MD, at Central and Tom Ylvisaker, MD, at Eastside,
these teams play multiple roles in CHS’ colorectal cancer control and
prevention research. They schedule study procedures, perform
colonoscopies, obtain colon biopsies, suggest operational changes, and
encourage recruitment. For example, for each subject in the Soy Isofavone
Study, clinicians performed two colonoscopies over a one-year period and
took an additional 15 study biopsies at each colonoscopy. "Needless
to say, we were quite a presence in the clinic," says Investigator
Katherine Newton, PhD.
Summing up this successful collaboration, investigator Meg Mandelson,
PhD, says, "The collaboration has been an important learning
experience, and has truly exemplified how CHS and the Group Health
delivery system can work together to achieve meaningful research
results."
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The Northgate Medical Center, Capitol Hill Family Health Center, and
Eastside Primary Care Center teams
For the last 15 years, CHS researchers have worked with teams at
Northgate Medical Center, Capitol Hill Family Health Center, and Eastside
Primary Care Center to improve the treatment of patients with depression.
The majority of depressed patients are diagnosed and treated in primary
care, making this a logical setting for intervention studies. In the seven
randomized trials conducted by CHS over the last 15 years, researchers
have focused on pharmacologic and behavioral treatments for depression, as
well as strategies to ensure that patients receive adequate follow-up care
for their condition.
"Our depression clinical trials would not have been possible
without the family practice teams at these clinics," says Elizabeth
Lin, MD, a CHS affiliate investigator and Group Health family
practitioner. The participation rate among the primary care practices at
these three clinics is an astonishing one hundred percent. Providers have
referred patients to studies, participated in training sessions,
contributed to the content of interventions, consulted with study experts
regarding difficult cases, and provided collaborative care with study
psychiatrists and psychologists.
Because of the large scale of these trials—2,000 patients randomized
over 15 years—it is not possible to name all the people who deserve
recognition. "The clinicians are the unsung heroes of our
studies," says Lin.
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Northgate Medical Center Cluster C team
The Healthy Steps for Young Children Program is a national research
project that integrates child development interventions into primary care.
Group Health is one of the sites, with CHS Investigator Robert S.
Thompson, MD, the Principal Investigator.
The program, which targets children from birth to age 3, emphasizes the
importance of a quality parent-child relationship for the healthy
development of the child. One component of the Healthy Steps program is
the "enhanced" well-child visit—a team approach that involves
physicians and clinic staff, as well as a Healthy Steps Specialist (a CHS
staff member). The purpose of the "enhanced" well child visits
is to foster a close relationship between parents and providers in
addressing child development and behavioral issues.
It’s no surprise that the success of the program and its evaluation
depends on the support of the clinicians and staff who provide prenatal
and/or pediatric care at the participating study clinics—Northgate and
Family Health Care. While project staff are grateful to both clinics (and
cluster teams within the clinics), CHS project manager Lynda Tyll, RN, MS,
cites the sustained efforts of Cluster C at Northgate as truly
extraordinary.
Tyll enumerates several examples of Cluster C’s continuing commitment
to the Healthy Steps Project since the program’s inception four years
ago. For example, Sallie Dacey, MD, a Healthy Steps "lead
provider," has been a consistent advocate for the program, devoting
time to attend a four-day training conference in Boston. Karin Madwed, MD,
provided educational training on maternal depression to the Healthy Steps
Specialist. Many providers and staff have enthusiastically facilitated the
program’s implementation and supported the work of the Healthy Steps
Specialists. In addition, providers and staff have willingly attended
periodic training sessions and many clinicians have given feedback on the
program’s content and the best ways to integrate it into practice.
"The sustained spirit of cooperation and participation from
Northgate Medical Center’s Cluster C is a testament to their ongoing
commitment to this research," Tyll says. Members of the Cluster C
team include: Sallie Dacey, MD, Birgit Grimlund, MD, Patricia Kato, MD,
Karin Madwed, MD, Lucia Muller, MD, Shauna Smith, MD, Joyce Brown, MA,
Janey Sloane, MA, Petra Sporseen, MA, Karla Vernon, MA, Gayle Smith, PCR,
Colleen Barker, PCR, Roslyn Latchman, LPN, Pattie Barclay, RN, Nelly
Clader, RN, Mary Pat Thorpe, RN, Sarah Matthews, ARNP, and Denise
Schaefer, ARNP. Tyll also wished to acknowledge the following former
providers of Cluster C: Patricia Boiko, MD, Karl Weyrauch, MD, and the
late Carol Folger, MD.
CHS’ close connection with the Group Health delivery system makes it
that much easier to fulfill the Birnbaum’s vision that research should
lead to improvements in care for actual patients. According to Dan
Cherkin, the U.S. Congress and the National Institutes of Health are
coming around to this way of thinking by acknowledging that research needs
to be more clinically relevant and translatable into practice. This is not
a novel concept for CHS. The Center’s unique relationship with its
delivery-system partners has paved the way for CHS’ long-standing
commitment to "translating scientific knowledge into effective and
efficient clinical practice," Cherkin adds.
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