Pediatric Research in Office Settings (PROS): A National Practice-Based Research Network to Improve Children's Health Care
Objectives. To describe the establishment of a national pediatric primary care research network to improve children's health care—Pediatric Research in Office Settings (PROS), and to evaluate the network's progress toward achieving its objectives.
Setting. Pediatric practices in all 50 states and Puerto Rico.
Participants. Approximately 1400 pediatric practitioners from more than 470 practices.
Results. Beginning in 1986, a core of volunteer pediatrician coordinators from participating American Academy of Pediatrics chapters were identified to oversee local PROS efforts, represent practitioners, and inform the development of proposed research studies. PROS subsequently recruited practitioners from around the country, building a research infrastructure and a system of collaboration between the practitioners, research staff at the AAP, and investigative teams at academic institutions. This PROS collaboration has developed and conducted 10 primary care research studies that have added to the knowledge base of pediatric primary care.
Conclusions. PROS has accomplished two of its initial objectives—development of a structure and process for pediatric practice-based research and provision of research experience to practitioners. Successful and consistent achievement of a third objective—meaningful dissemination of study results to relevant audiences—will depend on meeting several challenges. primary care, health services research, child health, ambulatory care.
In the United States, the vast majority of children receive health care in community-based primary care offices and clinics. The content of child health care delivered in these primary care settings has not, however, been explored adequately and the effectiveness of many of the approaches used in these primary care settings has not been established. The relative paucity of research done in primary care settings has limited the knowledge base available for practitioners to use in improving the health care of children. For this reason, the American Academy of Pediatrics (AAP) Executive Board sanctioned establishment of a network in 1986 to promote pediatric practitioner collaboration in primary care research. This network, now known as Pediatric Research in Office Settings (PROS), has grown since that time to involve >1400 practitioners at more than 470 practice sites in every region of the United States. As of 1998, PROS has performed 10 primary care research projects and has collected data on tens of thousands of subjects. This article 1) reviews the AAP's objectives in establishing PROS; 2) describes progress toward realizing those objectives; and 3) points out areas in which PROS needs to focus additional efforts in the future.
Pediatrics has a long tradition of individual practitioners conducting investigations in their offices and clinics.1–3 In addition, some academic departments of pediatrics, such as the University of Rochester, have developed informal local collaborations between practitioners and academic faculty to produce important research.4 However, formalized networks of primary care practitioners devoted to research first arose in the United States among family physicians.5,,6 Green and Lutz7described these practice-based research networks (PBRNs) as “groups of practices … affiliated with each other … for the purpose of investigating the phenomena of clinical practice occurring in communities.” Christoffel et al8 described the first pediatric PBRN, the Pediatric Practice Research Group of Children's Memorial Hospital in Chicago.
The special strengths and advantages of PBRNs in primary care research have been described in detail elsewhere.7–10 These include access to nonreferred study samples, enhanced follow-up of subjects in longitudinal studies, the opportunity for large sample sizes, and inclusion of broad ranges of practitioners. In addition, given the current emphasis on evidence-based medicine11–13 as the basis for practice, it is critical that the evidence needed for the practice of medicine be gathered in the types of settings where it is most likely to be applied.
The rationale for a national, pediatric PBRN is the requirement for samples of children and/or practitioners that are geographically dispersed, diverse, and/or large enough to address research questions in pediatric primary care that cannot be answered otherwise. The advantages of a national PBRN under the umbrella of the AAP, the largest national organization of pediatricians, include access to comparison samples of nonparticipating pediatric practitioners and the chance to inform policies that affect the health care of children. The mission of PROS is to improve the health of children by conducting collaborative practice-based research to enhance primary care practice.
The objectives for the PROS effort were: 1) establishment of a structure and process to study the care provided children in community-based primary care settings and the effectiveness of that care; 2) provision of investigative experience to a large group of pediatric practitioners on the study of care and treatment issues in practice; and 3) dissemination of study results to pediatricians and other primary care practitioners, public health groups, and groups formulating guidelines, standards, and recommendations so that they might act on this new information. These objectives were delineated in proposals for core funding from the Health Resources and Services Administration/Maternal and Child Health Bureau (HRSA-MCHB).
STRUCTURE AND PROCESS FOR PROS
In 1985, the AAP established a Task Force on Collaborative Research under the leadership of then-president Robert Haggerty, MD, to determine the feasibility of establishing a PBRN of pediatricians. Evan Charney, MD, chaired this task force, which recommended establishment of the network. Doctor Charney served subsequently as the first PROS Steering Committee Chair. HRSA-MCHB provided guidance and critical early support for network activities and has continued to support the network and its research. Several other PBRNs played an important consultative role in network development. Among these, the Ambulatory Sentinel Practice Network, the national family practice network, provided a model for PROS as a national network, and the Pediatric Practice Research Group, as the first pediatric network, provided guidance on working with pediatric practitioners. The network, originally called the Collaborative Research Practice Network, was renamed Pediatric Research in Office Settings (PROS) by a vote of the members in 1987.
Participating practitioners were recruited initially through the efforts of individual pediatricians in each chapter (most chapters represent states or geographical subdivisions of states). These pediatricians, known as PROS Chapter Coordinators, had been identified in each AAP chapter through the chapter leadership. Chapter coordinators in turn identified pediatricians interested in practice-based research through a variety of mechanisms, including personal contacts, recruitment at AAP chapter meetings, or solicitations in chapter newsletters. Nurse practitioners, physician assistants, and family physicians working with pediatricians were also eligible for membership. PROS Chapter Coordinators, who are mostly practicing pediatricians, have many other important network functions (see below). More recently, to increase the pace of growth, PROS has advertised directly for interested practitioners through clip-and-mail notices in the AAP News and Pediatrics.
Description of PROS Practitioners
PROS includes >1400 practitioners in more than 470 practices across the United States. A current map of the location of PROS practices can be seen in Fig 1. To be able to describe the characteristics of its practitioners and compare them to larger samples of practitioners, the network uses questions on practice and practitioner demographics, fielded within the network at 3-year intervals, and fielded regularly to a sample of randomly selected AAP practitioners through the AAP Research Department's Periodic Survey of Fellows mechanism. Practitioner comparisons reported in this article are based on responses from a 1994 to 1995 survey of PROS practitioners and a 1994 Periodic Survey of Fellows.14 The groups were compared on age, gender, time spent in specialty work, practice arrangement, and population setting of the practice. Comparisons were made using goodness-of-fit χ2 tests. If the overall distribution χ2was significant, specific categorical differences were identified with post hoc proportional t tests, using Bonferroni's correction for multiple comparisons.
Data from the 624 PROS practitioners in the network at the time (comprising 91% pediatricians, 8% nurse practitioners, and 1% physician assistants) were compared with 695 AAP direct-patient-care practitioners (all of whom were pediatricians). The response rate for the PROS sample was 87.5%. The response rate of all Periodic Survey respondents was 68.9%. Practitioner demographics included age, gender, and time spent in general pediatrics. Practice demographics included practice arrangement and geographic location.
As Table 1 indicates, slightly more than half of each group was younger than 45. Statistical comparison of the age distributions revealed no significant differences (χ2 = 1.11, ns). Mean ages for the two groups (43.9 for the PROS group versus 44.6 for the AAP group) were not significantly different (t = −1.32, ns). Table 1 also shows the gender distributions for the two groups. Nearly 60% of the practitioners in each group were male. Again, statistical comparison revealed no significant difference (χ2 = 1.05, ns). A third practitioner characteristic examined was the time that practitioners reported spending in general pediatrics versus time spent in specialty-related work. As Table 1 indicates, although both groups spent a clear majority of their time in the practice of general pediatrics, PROS practitioners spent a greater percentage of time, on average, than their AAP direct-patient-care counterparts.
Table 2 displays the results of analyses examining the practice arrangement of the practitioners' primary employment setting. Although a small percentage of practitioners in each group reported their primary employment setting as a solo practice, significantly fewer PROS practitioners (5.3%) reported working in such settings than the AAP direct-patient-care practitioners (17.1%). Higher percentages of PROS practitioners than AAP practitioners reported practicing in group settings.
Table 3 reports on population setting location of practitioners' practices. Slightly more than half of all PROS practitioners (50.3%) are located in suburban practice settings, a significantly higher proportion than that of their AAP counterparts. Also notable is the finding that PROS practitioners are underrepresented in urban inner city locations. Only 9.4% of PROS practitioners were located in such settings, as compared with 17.8% of the AAP practitioners.
PROS is overseen by a steering committee, composed of a chairperson, three practitioner chapter coordinators, the chairperson of the AAP Advisory Committee to the Board on Research, the chairperson of the AAP Council on Pediatric Research, the executive director of the Ambulatory Sentinel Practice Network, up to three consultants, and a liaison from the AAP Section on Epidemiology. Using input from the chapter coordinators and PROS research staff, the steering committee makes all policy decisions for the network (Fig 2).
Under the direction of the PROS Director and the AAP Director of the Division of Primary Care Research, PROS staff at the AAP national office conduct the day-to-day work of the network. These operations include maintenance of a data base of participating practices and practitioners, coordination of communications with chapter coordinators and participating practices, organization of practitioner study recruitment and practitioner training in study protocols, coordination of data collection efforts, monitoring of study progress, management and analysis of PROS study data, planning for PROS meetings, and coordination of study activities with principal investigators and research staff at collaborating institutions. Figure 2 provides a schematic of these relationships.
The core cost for annual network operations is approximately $300 000. These funds cover staff to direct the network, maintain national communications with more than 470 practices, provide travel expenses to meetings for 50+ Chapter Coordinators, and pay for piloting of new network study ideas. This cost does not include the donated time of PROS Coordinators and Steering Committee members or the costs of individual research projects (see below under “PROS Studies”).
A chapter coordinator and alternate coordinator oversee PROS functions in each participating PROS chapter and represent the chapter's practitioners. Coordinators and alternates are appointed by each chapter's president. The coordinator's responsibilities include recruitment of practices into PROS, regular communication both with PROS practices in the chapter and with the PROS central research staff, and attendance at semiannual PROS meetings. Coordinator practices generally are the first practices to take part in new PROS studies, allowing the coordinator to gain additional credibility with which to help recruit and support practitioners in the chapter who might participate.
Any participating PROS practitioner, chapter coordinator, member of the PROS Steering Committee, or member of an AAP committee or council may propose a new study by submitting a brief proposal to the Steering Committee. After an initial Steering Committee review, chapter coordinators review new proposals at one of their semiannual meetings, and the Steering Committee makes a final decision on the basis of chapter coordinator input. Once studies are approved, a principal investigator is officially designated and a study research management group (RMG) is assembled to refine the study and seek outside funding. Principal investigators usually are full-time academic pediatricians who are based at university medical centers around the country. PROS strives to join the pediatric practitioner's wisdom in formulating relevant research questions and developing workable protocols with the sound scientific research methods required to address the questions. To achieve this end, researchers are teamed with one or more practicing pediatricians who serve as coinvestigators on the RMG. Other members of the RMG include the PROS Director, selected PROS research staff at the AAP, and consultants. The RMG develops grant proposals, initial project protocols, and data collection materials.
RESEARCH EXPERIENCE FOR PROS PRACTITIONERS
Practitioners and chapter coordinators directly contribute to the development and refinement of study questions, research protocols, and data collection instruments. This process is accomplished at chapter coordinators meetings (see below), via mailings of draft materials to interested practitioners, and more recently, via the PROS e-mail discussion group known as PROS-NET.
Practitioner and Practice Participation
To begin participation in PROS, practitioners complete questionnaires describing themselves and their practices. Each participating practice designates a contact practitioner, who serves as the focal point for communication with the chapter coordinator and with PROS research staff. Although PROS practitioners are not required to participate in any particular PROS study, they are regularly recruited to join new studies (approximately one per year) as they are developed in the network. Practices may participate in more than one PROS study at a time if one of the studies only entails data collection for a relatively infrequent event. The number of practices participating in individual PROS studies has ranged from as few as 15 to as many as 240.
Protocols and materials for individual studies are distributed by mail. Coordination of PROS study protocols within practices is the responsibility of practice project managers, who may be practitioners, but are more commonly members of the office or clinic staff who oversee the day-to-day details of the project. When funds are available through project-specific grants, practices are reimbursed to cover a portion of the costs in practitioner and staff time that are engendered through participation in the study. Informal estimates of the costs borne by practices for individual studies range as high as $1000 per practice per study.
Prestudy Surveys of Practitioners
At the beginning of PROS studies, practitioners are surveyed regarding attitudes and behaviors related to the subject under study. This same survey is also sent to a random sample of AAP members using the AAP Research Department's Periodic Survey mechanism, as described above. For example, at the beginning of a study on the management of acute asthma, a scenario-based questionnaire addressing practitioner use of asthma-related diagnostic and therapeutic modalities was sent to all PROS participants and also to nearly 800 randomly-selected office-based practitioners.15 This technique allows for detection of biases potentially attributable to differences between PROS practitioners participating in a study and AAP member practitioners, thereby aiding assessment of the generalizability of results from PROS studies. In addition, the assessment of attitudes and behaviors regarding management of particular clinical conditions provides a baseline from which to measure future changes in practitioner behavior. Prestudy surveys have been fielded for 5 of the 10 PROS studies that have completed data collection, although results have not yet been analyzed for all of these.
PROS Coordinators Meetings
Coordinators meet with the PROS research staff, steering committee, and project principal investigators twice a year. At these meetings, they hear progress reports on current studies and provide feedback to study RMGs on study operations. In an effort to enhance the research expertise of the group, continuing medical education presentations devoted to research principles and methodology are a regular feature of these meetings. Finally, meetings provide the opportunity for coordinators to review, critique, and contribute to newly proposed study ideas.
Since its inception, PROS has completed data collection on 10 studies. These include studies of vision screening in preschool children,16 the emergence of secondary sexual characteristics in young girls,17 immunizations in pediatric practice,18,,19 age and gender composition of pediatric practices,20 management of acute gastroenteritis,21,,22 management of acute asthma,23,,24 a survey of practitioners' views of needed research,25 management of very young febrile infants,26 the management of child behavior problems,27 and the referral process in pediatrics.28 Dissemination activities still need to be completed for the last 7 of these studies. Funding to support individual projects has been obtained from the HRSA-MCHB, the Agency for Health Care Policy and Research, the National Institute of Mental Health, the AAP Research in Pediatric Practice Fund and Corporate Friends of Children Fund, and corporate sources. Costs of individual PROS studies are high because of the complexity of gathering data systematically and accurately in so many sites. Direct costs for these studies have ranged from $30 000 to $1.5 million.
DISSEMINATION OF STUDY RESULTS TO RELEVANT AUDIENCES
PROS strives to improve children's health care by using study results in several ways. The first is feeding back practice-specific study results to all practitioners who have participated in a study. For example, in PROS studies on the use of preventive practices, practitioners have been able to compare their own preschool vision screening rates and immunization rates with those of the network as a whole. There is evidence from managed care systems that simple feedback to practitioners about their practice behaviors, especially in comparison with other practitioners, has an impact on clinical behavior.29,,30 Anecdotal reports from practitioners suggest that this simple feedback of information has produced changes in clinician behavior on a local level, and we suspect that this phenomenon is widespread.
PROS also works to improve children's health care by providing information on study results to a variety of audiences. This is accomplished for the network as a whole via the PROS Network News, a semiannual newsletter, via the AAP News (the monthly AAP membership periodical which goes to all AAP members), and through distribution of study manuscripts-in-preparation to all practitioners who have participated in studies. PROS provides information to academic pediatricians via presentations at national meetings, and to large groups of primary care practitioners via publication of findings in peer-reviewed journals. Future plans for dissemination of study results include making results available via an interactive World Wide Web site.
Moreover, PROS directly feeds results of studies to groups formulating guidelines, standards, and recommendations at the AAP through reports to relevant AAP committees. Study results from the PROS vision screening study on the “screen-ability” of 3-year-old children were in part responsible for the recent revised recommendations for vision testing to include that age group.31
In a final step, PROS is attempting to measure improvements in child health care by resurveying, after the conclusion of studies, both PROS study participants and random samples of the AAP membership regarding their reported health care practices relevant to those studies. This complete cycle of prestudy survey, PROS study, dissemination of results, and poststudy resurvey has been accomplished so far only for the topic of preschool vision screening. The 1993 postvision screening study survey of a random sample of AAP practitioners showed no increase in the prevalence of preschool vision screening over a similar survey 5 years earlier.32 It is probably naive, however, to assume that publication of a single study, without broader efforts to disseminate findings and encourage physicians to change their usual practices, would result in a widespread change in physician behavior.33 Similar follow-up surveys are planned for other completed PROS studies, and will likely be preceded by more sophisticated dissemination efforts.
PROS has primarily accomplished the first two objectives laid out above—establishment of a structure and process for practice-based research and to provide investigative experience to a large group of pediatric practitioners. As a national pediatric PBRN, PROS draws strength from four sources: pediatric practitioners, the pediatric academic community, the AAP, and the HRSA-MCHB. Pediatric practitioners form the core of the network. They work to define and refine research questions, design workable study protocols and data collection materials, and generate high quality data on very large sample sizes. Currently, PROS member pediatricians comprise ∼5% of all AAP members who are primary care generalists. Through PROS, many key problems experienced by pediatricians in clinical practice are being identified25 and subjected to research that can be expected to contribute to their resolution.
Members of the pediatric academic community have committed extensive resources and services to PROS. Full-time pediatric academic faculty have served as members of the task force that originally recommended formation of the network, as steering committee members, as chapter coordinators, and as principal investigators on PROS research studies. Academic institutions have benefited, in turn, when studies are funded and the principal investigators from those institutions carry them forward. This easy partnership of pediatric academicians with practitioners is a model for other medical disciplines.
By providing a birthplace and a home for PROS, the AAP was the first professional organization to establish a PBRN. The AAP has continued to nurture the network throughout time with core financial and logistical support. The AAP has in turn benefited from the knowledge that PROS research has produced for pediatricians.
The HRSA-MCHB had the vision to provide core funding support to this effort as a means of improving the health care of children. Core funding is of central importance to a national PBRN, because of the high costs of the required infrastructure (communications, travel, meetings, staff) to conduct research on a national scale. The HRSA-MCHB relationship has provided an ongoing dialogue and incentives to link practice-based research in office settings to the public health arena, to better represent all children.
The elements that are in place—the network of dedicated pediatric practitioners, the alliance with the academic community, and the support of the AAP and HRSA-MCHB—provide a structure and facilitate a process that has generated a considerable amount of new knowledge about pediatric primary care. In the process, a considerable number of PROS practitioners have become quite sophisticated in practice-based research.
The third PROS objective, the dissemination of study results to primary care practitioners and to groups formulating guidelines and standards so that they may act on this new information, is only beginning to be realized. It will best be accomplished as a number of challenges, described below, are met and overcome.
The advantages of a national pediatric PBRN are substantial. Inherent challenges, however, accompany PROS national status. The first is the communications gap between PROS practitioners and PROS researchers. It is physically impossible for all PROS practitioners to have immediate input into PROS studies, as they cannot all attend semiannual PROS meetings. The practitioners who serve as chapter coordinators serve both as a proxy for and as conduits of input from other practitioners. Those practitioners who subscribe to the PROS-NET, the PROS e-mail discussion list, or who respond to feedback clip-and-mail portions of the PROS Network News can also provide regular input regarding studies, but the remainder of practitioners remain at a distance from this process. As a greater percentage of PROS practitioners come to use electronic communications such as e-mail and the World Wide Web, it should be possible for PROS to bridge some of this distance. Bringing PROS practitioners closer to the research in this way will facilitate dissemination of results and provide a climate for discussions of changing the way practitioners practice.
A second challenge for a national network is the difficulty of collecting data that require more intensive work or facilities on the part of the practice. For example, research on the effectiveness of health supervision visits that would require audiotaping of actual visits would be very challenging when collecting data at hundreds of sites that are thousands of miles apart. Studies requiring such data may be beyond the scope of a national PBRN. Nevertheless, it may be possible for PROS to overcome this second limitation through creative collaboration with the regional pediatric PBRNs that are springing up around the country. Using the example cited above, regional networks might be able to audiotape office visits to validate paper-and-pencil measures addressing the content of health supervision, which might then be used in a large scale PROS study. The leadership of PROS and the regional pediatric PBRNs have begun to explore ideas for collaboration that would maximize the strengths of each.
Another challenge involves the representation of relevant populations of children. Because a disproportionate number of PROS practices are found in the suburban United States, PROS currently underrepresents minority and disadvantaged populations. PROS strives to provide an accurate picture of child health care and outcomes in community settings. To the extent that PROS studies lack sufficient information about minority children and/or participation by minority pediatricians, that picture will be incomplete. PROS has been making specific efforts to recruit practitioners who serve these vulnerable populations34 and to affiliate with community health centers and other sites of care for minority and disadvantaged children to correct this deficiency. More recently, PROS has taken a new approach to this problem by collaborating with a group of minority practitioners, the Pediatric Section of the National Medical Association, in a study on the effects of changes in the polio immunization schedule.35
Intervention studies represent yet another challenge to PROS. Until the present, PROS has confined its efforts to observational clinical outcomes studies, most of which have identified factors associated with variations in care and their relation to differences in outcome. These studies can and will continue to make important contributions to improving care. In the future, PROS will need to extend its repertoire to include intervention studies such as randomized clinical trials. Clinical trials will offer substantial logistical challenges for a national PBRN, but PROS will need to solve these challenges to provide the best answers about the effectiveness of specific aspects of child health care.
Finally, although the new knowledge about child health services generated by PROS and other PBRNs is vital and necessary for improving pediatric primary care, it is not sufficient for achieving this objective. PBRNs need to help generate another level of knowledge, ie, to find the best ways to implement study findings and other proven elements of care in clinical settings. PROS has recently launched its first project in this area, aimed at identifying and then testing ways to improve the care of children with chronic asthma in a diverse group of pediatric practices. When PBRNs are routinely conducting studies to identify reliable ways of translating knowledge into delivered health services, they will be fully realizing the objective of improving health care for children.
This work was supported by Grant No. MCJ-177022 from the Health Resources and Services Administration, Maternal and Child Health Bureau.
The authors acknowledge the dedicated work of PROS practitioners and their office staffs in implementing PROS studies, the outstanding efforts of PROS central office staff in study execution and network maintenance, and the sustained strong commitment and input of past and present PROS Chapter Coordinators and PROS Steering Committee members in all aspects of the PROS enterprise.
- Received January 2, 1997.
- Accepted May 6, 1998.
Reprint requests to (R.C.W.) PROS Network—Vermont Office, 111 Colchester Ave, Burgess 421, Burlington, VT 05401.
- AAP =
- American Academy of Pediatrics •
- PROS =
- Pediatric Research in Office Settings •
- PBRN =
- practice-based research networks •
- HRSA-MCHB =
- Health Resources and Services Administration/Maternal and Child Health Bureau •
- RMG =
- research management group
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- Copyright © 1998 American Academy of Pediatrics