The purpose of this K08 AHRQ Patient-Centered Outcomes Research (PCOR) Mentored Clinical Investigator Award is to establish Dr. Anita Misra-Hebert as an independent investigator studying natural experiments in redesigning primary care delivery systems. Her goal is to develop high-level skills in implementation science quantitative and qualitative research methods, with an emphasis on defining contextual factors that may promote success or failure of specific primary care redesign efforts in diverse practice settings. Dr. Misra-Hebert will gain practical expertise in PCOR primary care redesign through both formal and informal educational programs and through close work with her mentors during this project. Dr. Kurt Stange, her primary research mentor, is a recognized expert in the study of contextual factors in primary care practice redesign. Her co-mentors include Dr. David Aron, a recognized expert in implementation science research methods, Dr. Michael Rothberg, an expert in quantitative research methods, specifically related to observational studies with large datasets, and Dr. Adam Perzynski, a sociologist and an expert in qualitative and quantitative research methods. Environment Located in Cleveland, Ohio, Cleveland Clinic is a nonprofit, multispecialty academic medical center that integrates clinical and hospital care with research and education, and one of the largest and most respected hospitals in the country. Cleveland Clinic is structured as a group practice. The physicians on staff are salaried employees and are not in private practice. The practice is structured to complement the group practice model. The Medicine Institute at Cleveland Clinic is leading efforts across the institution to promote value-based care initiatives for patient care. The Medicine Institute Center for Value-Based Care Research specializes in health services and clinical research regarding novel approaches to care that can improve quality, reduce cost, or both. The Center includes 4 primary investigators, nurses, statisticians and research assistants, as well as affiliated health services researchers from across the Cleveland Clinic. Dr. Misra-Hebert will be fully supported in this environment to conduct research to evaluate best practices in primary care redesign efforts. The ability of the Cleveland Clinic and its Medicine Institute to support Dr. Misra-Hebert's research and development is greatly enhanced by the Cleveland Clinical & Translational Science Collaborative, which provides collaborative clinical research support and infrastructure across the institutions represented on her mentoring team. Research Project This goal of this study is to provide evidence of best practices for the delivery of team-based primary care with evaluation of contextual factors in the implementation of primary care redesign efforts. As the complexity of healthcare delivery increases, primary care is moving from a model of care delivery in which individual clinicians provide care to individual patients to team-based care models. To understand whether these new models have actually improved value in care delivery, it will be important to measure outcomes relevant to patients and those specific to team-based care. Team approaches will need to be optimized based on diverse contextual factors. The initial project will focus on the evaluation of contextual factors relevant to a specific team-based redesign effort involving an enhanced role of medical assistants compared to usual care and will include evaluation of patient and provider experience.
The specific aims of the proposed research are as follows:
Aim 1 : To evaluate patient-centered clinical quality of care outcomes in the team-based care-medical assistant model (TBC-MA) compared to usual care.
Aim 2 : To identify contextual factors (patient, provider, practice) that contribute to the sustained implementation of the TBC-MA model.
Aim 3 : To assess patient and provider experience in the TBC-MA model compared to usual care. Later work during the career development award will include study of the longitudinal effects of team-based care, and redesign implementation that involves non-clinician care team members in improving care coordination for primary care patients.

Public Health Relevance

This goal of this study is to provide evidence of best practices for the delivery of team-based primary care. To understand whether new ways to deliver primary care have actually improved care, we will measure the quality of care delivered and will evaluate patient and provider experience. The initial project will focus on the evaluation of a specific team-based primary care model involving an enhanced role of medical assistants compared to usual care.

National Institute of Health (NIH)
Agency for Healthcare Research and Quality (AHRQ)
Clinical Investigator Award (CIA) (K08)
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HSR Health Care Research Training SS (HCRT)
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Willis, Tamara
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Cleveland Clinic Lerner
United States
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Misra-Hebert, Anita D; Kattan, Michael W (2018) Prostate Cancer Screening-A New Recommendation for Meaningful Physician-Patient Conversations. JAMA Oncol 4:1049-1050
Pantalone, Kevin M; Misra-Hebert, Anita D; Hobbs, Todd M et al. (2018) Clinical Inertia in Type 2 Diabetes Management: Evidence From a Large, Real-World Data Set. Diabetes Care 41:e113-e114
Pantalone, Kevin M; Misra-Hebert, Anita D; Hobbs, Todd M et al. (2018) Antidiabetic treatment patterns and specialty care utilization among patients with type 2 diabetes and cardiovascular disease. Cardiovasc Diabetol 17:54
Misra-Hebert, Anita D; Hom, Grant; Klein, Eric A et al. (2018) Testing of a Tool for Prostate Cancer Screening Discussions in Primary Care. Front Oncol 8:238
Havele, Sonia A; Pfoh, Elizabeth R; Yan, Chen et al. (2018) Physicians' Views of Self-Monitoring of Blood Glucose in Patients With Type 2 Diabetes Not on Insulin. Ann Fam Med 16:349-352
Misra-Hebert, Anita D; Hu, Bo; Le, Phuc H et al. (2018) Effect of Health Plan Financial Incentive Offering on Employees with Prediabetes. Am J Med 131:293-299
Misra-Hebert, Anita D; Pantalone, Kevin M; Ji, Xinge et al. (2018) Patient Characteristics Associated With Severe Hypoglycemia in a Type 2 Diabetes Cohort in a Large, Integrated Health Care System From 2006 to 2015. Diabetes Care 41:1164-1171
Pantalone, Kevin M; Misra-Hebert, Anita D; Hobbs, Todd M et al. (2018) Effect of glycemic control on the Diabetes Complications Severity Index score and development of complications in people with newly diagnosed type 2 diabetes. J Diabetes 10:192-199
Misra-Hebert, Anita D (2017) Cervical cancer in African American women: Optimizing prevention to reduce disparities. Cleve Clin J Med 84:795-796
Misra-Hebert, Anita D; Kattan, Michael W (2017) Comment on: Decisional Conflict, Regret, and the Burden of Rational Decision Making. Med Decis Making 37:E360-E361

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