Mold JW, Barton ED.  OAFP starts practice-based resource/research network. J OklahomaState Med Assoc, 1996; 89: 433-434.

The Oklahoma Academy of Family Physicians in collaboration with the University of Oklahoma Health Sciences Center, has established a primary care practice-based research network with thirteen family practice offices currently participating.  The practices are connected to each other and the Health Sciences Center campuses in Oklahoma City and Tulsa by electronic mail and have begun their first research project involving the diagnosis and treatment of brown recluse spider bites in the primary care setting.

Mold JW, Cacy JR, Barton ED.  Patient-Physician E-Mail Communication.  J Oklahoma State Med Assoc, 1998 September.  91(6): 331-334.

Methods: 23 physicians from 14 OKPRN practices enrolled 25 consecutive patients each on two separate days (total N=1068 patients).  Each patient answered 5 questions on the back of a postal card that was then mailed to the OU DFPM. 

Conclusions: A significant number of primary care patients have computer and e-mail.  Approximately half would like to be able to use e-mail to communicate with their PCP.

Cacy J, Mold JW.  The Clinical Characteristics of Brown Recluse Spider Bites Treated by Family Physicians: An OKPRN Study.  The Journal of Family Practice 1999.  48(7): 536-542.

Methods:  Preprinted, postage-paid cards of two types were given to physician members of the Oklahoma Physicians Research Network.  One card was used for recording examination and treatment data, and the other was for tracking the progress of the bite until it was completely healed.  For comparison, similar information was collected from the local poison control center.

Results:  From April 1996 to August 1998, the physicians recorded 149 bites.  Most of the victims were women aged 18 to 65 years, and most sought treatment within 3 days.  Pain was common but not universal.  Most bites were located on the extremities.  Erythema was always present, but necrosis was present in only 40% of the bites.  Some systemic signs or symptoms were common.  The most frequent forms of treatment were systemic antibiotics (66% of cases) and conservative wound management (56%).  Only 1 hospitalization occurred; 43% of the bites healed within 2 weeks; and only 13% resulted in scarring.

Conclusions:  The brown recluse spider bite is a relatively common problem treated by family physicians in Oklahoma .   Most bites are not serious.  More research at the practice level is needed to develop diagnostic criteria and to explore the effectiveness of various treatment options.

Mold JW. Treatment of brown recluse spider bites by family physicians.  Submitted to JABPF (in press)

Methods: Same as for first brown recluse study.  Total N 256 bites.

Results: Predictors of longer healing time:Delay in seeking treatment. Diameter of erythema when first seen. Diameter of necrosis when first seen. Diameter of necrosis when first seenTreatment with dapsone, systemic steroids, or high dose Vitamin C. Predictors of scarring: Diameter of necrosis when first seen. Diabetes mellitusDiameter of necrosis when first seenDiabetes mellitusTreatment with dapsone or high dose Vitamin C

Conclusions: None of the treatment approaches used by OKPRN physicians made any difference in healing time or probability of scarring.  Fortunately most bites (80%) healed without scarring.  The median time to healing was 17 days.

Mold JW and Thompson DM.  Management of brown recluse spider bites in primary care.  JABPF September/October 2004, 17(5): 347-352.

Brown Recluse Spiders Unpublished

Background and Rationale: Little is known about the level of knowledge and experience of Oklahomans with regard to brown recluse spider bites.  There may be a need for additional public education on this subject. 

Methods: All adult (>18 y.o.) patients being seen in the waiting rooms of the Family Medicine Center clinics and individuals shopping at a grocery store in Edmond during predetermined periods of time were approached and asked to answer a series of questions and to pick out a picture of a brown recluse spider from among five pictures of spiders. 

Results: 132 FMC patients and 90 shoppers completed the survey.  Although the mean ages (43.6 vs. 21.4) and gender distribution (67% female vs. 50% female) of the two groups were different, their responses to the survey were practically identical.  46% thought they could identify a BR spider and 44% chose the correct picture.  Twenty-four percent had seen a BR spider in their home in the past year, but only 2% had been bitten by one.   

Conclusion: Brown recluse spiders are common in Oklahoma , but less than 50% of a sample of Oklahomans can recognize them from a picture.  Considering their prevalence, BR spiders only rarely seem to bite people.

Hulson TD, Mold JW, Scheid D, Aaron M, Aspy CB, Ballard NL, Boren N, Gregory ME, Truong TC.  Diagnosing Influenza: The Value of Clinical Clues and Laboratory Tests.  The Journal of Family Practice 2001 December.  50(12): 1051-1056. 

Methods:  Data were collected during 3 consecutive influenza outbreaks over a 2-year period in one 5-man family practice office in Edmond .  The information collected included date of onset, symptoms, vaccine status, WBC and differential counts, ZstatFlu test (antigen test), and influenza culture.  Using culture positivity as the criterion for influenza diagnosis, we compared cases with non-cases on each variable independently and by logistic regression. 

Results:  Culture-positive cases could not be reliably distinguished from those that were culture negative using symptoms or vaccination status.  Both WBC count and ZstatFlu results discriminated fairly well, and their combination did somewhat better.  Differential counts were not helpful.  WBC counts above 8,000 were associated with a low probability of influenza.  The sensitivity and specificity of the ZstatFlu were 65% and 83%, respectively. 

Conclusions:  Our data suggest that symptoms and vaccine status do not reliably identify patients with influenza.  Use of WBC counts and the ZstatFlu test can be helpful.  The sequence, combination, and criteria for use of these tests depend on tradeoffs between under-treatment of influenza cases and the over-treatment of non-influenza cases, and cost and benefit projections for individual patients.

Mold JW, Gregory ME.  Best Practices Research.  Family Medicine 2003 February, 35(2): 131-134. 

This is a description of the “best practices research” method pioneered for use in practice-based research networks by OKPRN.  It is a method used to identify effective methods for managing common primary care processes like lab test results, prescription refills, no-shows, preventive services, etc.  The process of interest is first broken down into to its component parts.  Values and acceptable standards are then agreed upon for each part (to define “most effective”).  Finally, exemplars are sought and identified from within the network for each part, their methods are studied, and the best methods are combined into a complete “best” method.

Mold JW, Cacy DS, Dalbir DK.  Management of Laboratory Test Results in Family Practice.  An OKPRN Study.  The Journal of Family Practice, 2000 August.  49(8): 709-715. 

Methods:  We used a questionnaire guided by a literature review to identify a conceptual model, current practices, and clinicians who reported having an effective method for at least one of 4 steps in the process of managing laboratory test results.  Clinicians with differing methods were selected for each of the steps.  Practice audits and patient surveys were used to determine actual performance.  On the basis of these audits, we constructed a unified best method and conducted time-motion studies to determine its cost. 

Results:  After auditing only 4 practices we were able to identify effective methods for 3 of the 4 steps involved in the management of laboratory test results.  The unified best method costs approximately $5.19 per set of tests for an individual patient. 

Conclusions:  By identifying effective practices within a family practice research network, an effective method was identified for 3 or the 4 steps involved in the management of laboratory test results in primary care settings.

Mold JW, Enright MM, Oehlert WH.  Improving the quality of care for diabetic patients using best practices research and practice enhancement assistants.  In preparation. 

Methods: Exemplars identified from previous OFMQ audits were interviewed regarding their diabetes management methods.  Six common principles were discovered.  These principles were then taught to 20 OKPRN physicians who were also provided with a practice enhancement assistant to help them make changes.  A PDA-based program was also available to use by choice.  Pre- and 3 mo. Post-intervention audits were done.

Conclusions: Use of the best practices research approach in combination with a PEA resulted in significant short-term improvements in quality of diabetes care.

Roberts M and Mold JW. Primary care network survey.  Presented at OKPRN Convocation 2/2003. 

Methods: The PRINS surveys were designed by the Agency for Healthcare Research and Quality and primary care practice-based research network directors.  They were intended to capture information on the clinicians and practices involved in primary care practice-based research networks and a sample of their patient encounters, and to compare them to other clinicians and practices using other available data sets.  Overall, 1500 PRINS 1 surveys were completed by clinicians in 19 networks across the country, and PRINS 2 information was captured on 26,649 encounters.  In OKPRN, a total of 248 clinicians, including 98 faculty members, 100 second and third year residents, and 50 community practitioners, completed the PRINS 1 survey (clinician and practice information), and 40 faculty, 52 residents, and 26 community practitioners completed data on approximately 30 encounters each, capturing data on a total of 3535 encounters.  

Results: PRINS 1: (OKPRN compared to Family Physicians nationally)Community Practitioners: OKPRN practitioners were more likely to be younger, male, and Native American; they were less likely to be Hispanic and black.  Faculty: OKPRN faculty were more likely to be younger and female.Residents: OKPRN resident members were younger, female, and Native American; they were less likely to be African American.PRINS 2: (OKPRN compared to PCPs in the National Ambulatory Medical Care Survey)Community Practitioners: On average, OKPRN physicians see more Native Americans and Medicare patients, and fewer Hispanics, Medicaid, and HMO patients.  They do less non-illness care and more ambulatory surgery.   Faculty: OKPRN faculty physicians see a higher percentage of female, Native American, Medicaid, and HMO patients and fewer Hispanic patients.  They do less non-illness care and more ambulatory surgery than PCPs surveyed for NAMCS.Residents: OKPRN residents see more female, Black, Native American, Medicaid, self pay, and HMO patients and many fewer Caucasian and Medicare patients.  They do more non-illness care than NAMCS PCPs. 

Conclusions: While OKPRN clinicians are similar to national samples, they differ in several important ways.  Within OKPRN, residents see a very different spectrum of patients than faculty and particularly community physicians do.

Mold JW, Mathew MK, Belgore S, DeHaven M.  Prevalence of night sweats in primary care patients.  An OKPRN and TAFP-Net collaborative study.  The Journal of Family Practice 2002 May, 51(5): 452- 456. 

Methods:  OKLAHOMA Studies pilot year data.  799 patients 65 years of age and older from the practices of 23 OKPRN physicians within 75 miles of OKC.  Patients completed and extensive questionnaire that was reviewed with them by a research nurse. 

Results:  Of the 2267 patients who participated, 41% reported experiencing night sweats within the last month, including 23% with pure night sweats and an additional 18% with day and night sweats.  The prevalence of night sweats in both men and women was highest in the group aged 41 years to 55 years.  In multivariate analyses, factors associated with pure night sweats in women were hot flashes and panic attacks; in men, sleep problems.  Variables associated with night and day sweats in women were increased weight, hot flashes, sleep disturbances and use of antihistamines, selective serotonin reuptake inhibitors (SSRIs) and other (non-SSRI, non-tricyclic) antidepressants; in men, increased weight, hot flashes, and greater alcohol use.   A majority of patients had not reported their night sweats to their physicians, even when frequent and severe. 

Conclusions:  Night sweats are common and under-reported.  Pure night sweats and night and day sweats may have different causes.  With regard to the etiologies of pure night sweats, panic attacks and sleep disorders need further investigation.

Mold JW, Aboshady HM, and Roberts AM. Prevalence and predictors of night sweats, day sweats, and hot flashes.  Annals of Family Medicine 2004 September/October, 2(5): 391-397 

Methods:  A cross-sectional study of patients over 64 years old recruited from the practices of 23 family physicians.  Variables included socio-demographic information, health habits, chronic medical problems, symptoms, quality of life (QOL), and the degree to which patients were bothered by night sweats, daytime sweating, and hot flashes. 

Results:  Among the 795 patients, 10% reported being bothered by night sweats, 9% day sweats, and 8% hot flashes.  Eighteen percent reported at least one of these symptoms.  The three symptoms were strongly correlated.  Factors associated with night sweats in the multivariate models were age (O.R.0.94/yr; C.I.: _95%: 0.89, 0.98), fever (O.R. 12.60; C.I. _95%: 6.58, 24.14), muscle cramps (0.R. 2.84; C.I. _95%: 1.53, 5.24), numbness of hands and/or feet (O.R. 3.34; C.I. _95%: 1.92, 5.81), impaired vision (O.R. 2.45; C.I. _95%: 1.41, 4.27), and hearing loss (O.R.1.84; C.I. _95%: 1.03, 3.27).  Day sweats were associated with fever (O.R. 4.10; C.I. _95%: 2.14, 7.87), restless legs (O.R. 3.22; C.I. _95%: 1.76, 5.89), lightheadedness (O.R. 2.24; C.I. _95%: 1.30, 3.88), and diabetes (O.R. 2.19; C.I. _95%: 1.22, 3.92).  Hot flashes were associated with non-Caucasian race (O.R. 3.10; C.I. _95%: 1.60, 5.98), fever (O.R. 3.98; C.I. _95%: 1.97, 8.04), bone pain (O.R. 2.31; C.I. _95%: 1.30, 4.08), impaired vision (O.R. 2.12; C.I. _95%: 1.19, 3.79), and nervous spells (O.R. 1.87; C.I. _95%: 1.01, 3.46).  All three symptoms were associated with reduced QOL. 

Conclusions:  Night sweats, day sweats, and hot flashes are reasonable common symptoms in elderly primary care patients.  Presumably related to autonomic reactions to emotional or physical distress, they are, no doubt, more noticeable and distressing to some than to others.  Though relatively non-specific, their presence should probably prompt additional questions about febrile illnesses, diabetes, anxiety, depression, somatic and visceral pain, sensory deficits, and restless legs syndrome in addition to standard, recommended evaluations for uncommon serious diseases such as tuberculosis and malignancies.

Mold JW, Wooley J, and Nagykaldi Z. Associations between night sweats and sleep disturbances.  In Press, Annals of Family Medicine 

METHODS:  Cross-sectional study of consecutive adult patients seen in 10 primary care physicians’ offices.  Data collected and transmitted by PDA included demographic variables, height, weight, and blood pressure, occurrence of a variety of sleep-related symptoms, and occurrence and severity of night sweats, day sweats, and hot flashes in the past month.  For women, information about menstrual status was also obtained. 

RESULTS:  Thirty-four percent of the 363 patients interviewed reported night sweats, half of whom reported saturating their bed clothes.  In the multivariate model, night sweats were associated with daytime tiredness (O.R.: 1.99; C.I._95%: 1.12 – 3.53), waking up with a bitter taste in the mouth (O.R.: 1.94; C.I._95%: 1.19 – 3.18), legs jerking during sleep (O.R.: 1.78; C.I._95%: 1.05 – 3.00), and awakening with pain in the night (O.R.: 1.87; C.I._95%: 1.16 – 2.99).  

CONCLUSIONS: Night sweats are associated with several sleep symptoms.  Both night sweats and sleep disturbances are commonly experienced by adult primary care patients.  Patients complaining of night sweats should be asked about sleep quality and sleep-related symptoms.

Mold JW, Vesely S, Schenk, J, Keyl B, and Roberts AM.  The prevalence, predictors, and consequences of peripheral sensory neuropathy in older patients.  JABFP September-October 2004, 17(5): 309-318. 

Methods: OKLAHOMA Studies pilot year data.  As above.  Two trained nurses performed standardized peripheral neurological examinations. 

Results: The prevalence of at least one bilateral peripheral neurological deficit rose from 26% in the 65-74 year old age group to 54% for those 85 and older.  Only 28% of those with a deficit had a history of a disease known to cause peripheral neuropathy.  In those who did, the prevalence was substantially higher overall (45% vs. 26%), and the prevalence did not increase with increasing age.  The most common deficit was loss of ankle reflex followed by loss of fine touch sensation.  After controlling for other relevant variables, the predictors of neurological deficits included: age (O.R.: 1.08/year), income less than $15,000 (O.R.: 1.94), a history of military service (O.R.: 1.77), body mass index (O.R.: 1.06/unit), a history of diabetes mellitus (O.R.: 2.50), Vitamin B12 deficiency (O.R.: 2.42), or rheumatoid arthritis (O.R.: 2.95), and the absence of hypertension (O.R.: 0.64).  The presence of neurological deficits was associated with numbness, pain, restless legs, trouble with walking and balance, and reduced quality of life but not with reported falls.  

Conclusions: Bilateral sensory deficits are exceedingly common in the elderly. In most cases, there is no history of a disease known to cause peripheral neuropathy. While their significance requires further elucidation, it appears that this problem is not as benign as generally supposed.

Mold JW, Fryer GE. When do older patients change primary care doctors?  JABFP January 2005 17: 453-460. 

Methods: Same as for the other OKLAHOMA Studies projects except that some data from years two and three were used. 

Results: The mean, median, and range of duration of relationship between participants and their primary care providers were 10.27, 8, and 1 – 40 years.  Just over 47% had seen the same PCP for 10 or more years.  After controlling for other relevant variables, duration of the relationship was positively associated with patient age (p<0.01), income (P<0.01), and education (p=0.03), and with the number of PCP office visits during the past year (p=0.03).  Patients with longer relationships rated their PCP higher on all eight subscales of the Components of Primary Care Index (CPCI).   Longer duration of current PCP relationship was associated with a greater likelihood that the participant last changed PCPs involuntarily (p=0.002).  Those who had changed PCPs more recently were much more likely to have changed because of change of insurance (p<0.001).  Lower CPCI scores in year one did not predict change of PCP between years one and two of the study.   

Conclusions: Older patients tend to stick with their PCP until they are forced to change because of change of insurance, doctor retirement, change of location, or death, patient change of location or death, or increased problems with transportation.

Nagykaldi Z, Mold JW, Aspy CB.  “Practice Facilitator: A Review of the Literature. Family Medicine 2005;37(8):581-8. 

Methods: We searched four electronic databases from 1966 through the present, reviewing all articles pertaining to PFs in an effort to understand the history, training, financing, roles, methods, and impact of PFs. 

Results:  Since the early 1980s, PFs have worked with individual practices on relationship building, education, and quality improvement (QI), particularly in the area of prevention.  A number of publications provide information on the roles of PFs in primary care and methods they use to enhance practices.  Many prospective, uncontrolled studies and a few randomized, controlled trials have documented the effectiveness of PFs but usually in combination with other interventions.  A number of primary care PBRNs in the United States have begun to use PFs as a way to bridge the gap between research and practice.  Limited information has been published about the training and funding of PFs. 

Conclusions: The PF concept seems to be a useful practice enhancement approach in primary care.

Mold JW and Peterson K.  “Primary Care Practice-Based Research Networks: Working at the Interface Between Research and Quality Improvement.” Annals of Family Medicine 2005;3(Suppl 1)S12-S15. 

Methods: We gathered information from the published literature discussions with PBRN leaders, case examples, and our own personal experience to describe a role for PBRNs  that comfortably bridges the gap between research and QI, discovery and application, academicians and practitioners - a role that may lead to the establishment of true learning communities.  We provide specific recommendations for network directors, network clinicians, and other potential stakeholders. 

Results: PBRNs function at the interface between research and QI, and interface called TRIP by some members of the research community.  In doing so, PBRNs are inappropriate disconnect between discovery and implementation, research and practice.  Participatory models are emerging in which stakeholders agree on their goals; apply their collective knowledge, skills, and resources to accomplish these goals; and use research and QI methods when appropriate. 

Conclusions: PBRNs appear to be evolving from clinical laboratories into learning communities, proving grounds for generalizable solutions to clinical problems, and engines for improvement of primary care delivery systems.

Nagykaldi Z, Mold JW.  Diabetes Patient Tracker, a Personal Digital Assistant-Based Diabetes Management System for Primary Care Practices in Oklahoma .  Diabetes Technology & Therapeutics 2003, 5(6): 997-1001. 

Methods:  The Diabetes Patient Tracker (DPT) was developed as a part of an OKPRN best practices research and development project aimed at improving documentation and delivery of medical services for diabetic patients.  Participants were introduced to the principles learned from exemplar physicians and supplied with a Diabetes Toolkit that contained findings and resources for implementation.  Following the chart audits, consultations were held with physicians and the office staff.  They were taught how to use the PDA and DPT handheld application. After and average of 4 months, patient charts in participating physician offices were audited by OFMQ to determine the post-intervention rates of delivering and documenting services. 

Results:  Eighty percent (20 of 25) of the physicians implemented the PDA-based electronic registry in their practices, and 76% (19 of 25) had regular Practice Enhancement Assistant visits to help them with the implementation of guidelines and the handheld system.  Statistical analysis, by patient, demonstrated a significant improvement (p<.05) in nine of the 10 measures included in the audit (HgbA1c measurement within 1 year, urine for protein within 1 year, lipid panel within 1 year, retinal examination within 1 year – both ordered and documented, foot examination within 1 year, use of angiotensin converting enzyme inhibitor for proteinuria, flu shot within 1 year, and Pneumovax ever).  These improvements correspond with previous reports on the effectiveness of electronic systems to improve disease management.