PRIMARY CARE PRACTICE-BASED RESEARCH NETWORKS (PBRNs) Release Date: January 21, 2000 RFA: HS-00-004 Agency for Healthcare Research and Quality (formerly AHCPR) Letter of Intent Receipt Date: March 10, 2000 Application Receipt Date: April 27, 2000 PURPOSE The Agency for Healthcare Research and Quality (AHRQ), formerly known as the Agency for Health Care Policy and Research (AHCPR), announces the availability of one-year exploratory grants to assist new or established practice-based research networks (PBRNs) in planning for activities that will enhance their capacity to conduct research in primary care settings and translate research findings into practice. Each grant will support the development of a PBRN- specific plan to: (1) establish or augment electronic collection and aggregation of practice-derived data, (2) increase network capacity to study the health care of racial and ethnic minority and/or underserved populations, (3) create systems to facilitate the implementation of research findings by network clinicians and practices, and, (4) identify potential sources of ongoing network support. It is anticipated that after completion of these exploratory grants, recipient organizations will be in a position to compete for subsequent funds AHRQ expects to award in 2001 (contingent upon funding availability) to assist PBRNs in carrying out individually developed plans. The long-term goal of the overall initiative is to improve the capacity of PBRNs to expand the primary care knowledge base and to establish mechanisms to assure that new knowledge is incorporated into actual practice and that its impact is assessed. For the purposes of this RFA, a PBRN is defined as a group of ambulatory practices devoted principally to the primary care of patients, affiliated with each other (and often with an academic or professional organization) in order to investigate questions related to community-based practice. This definition includes a sense of ongoing commitment to the research endeavor, and an organizational structure that transcends a single study (see further details Qualifications under SPECIAL REQUIREMENTS). HEALTHY PEOPLE 2010 The Public Health Service (PHS) is committed to achieving the health promotion and disease prevention objectives of Healthy People 2010, a PHS-led national activity for setting health improvement priorities for the United States. AHRQ encourages applicants to submit grant applications with relevance to the specific objectives of this initiative. Potential applicants may obtain a copy of Healthy People 2010" at ELIGIBILITY REQUIREMENTS Applications may be submitted by new or existing primary care practice-based research networks located in the U.S. or by institutions affiliated with a PBRN, which can be public or private non-profit organizations including universities, clinics, firms, or units of State and local governments. For the purpose of this RFA, AHRQ, by statute, can make grants only to non-profit organizations, however, for-profit organizations may participate in grant projects as members of a non-profit consortium or as subcontractors to a non- profit entity. Organizations described in section 501(c)4 of the Internal Revenue Code that engage in lobbying are not eligible. AHRQ encourages women, members of minority groups, and persons with disabilities to apply as Principal Investigators. MECHANISM OF SUPPORT This RFA will use the Exploratory Grant (P20) mechanism. Responsibility for the planning, direction, and execution of the proposed project will be solely that of the applicant. The Center for Primary Care Research (CPCR) within AHRQ will serve as a Coordinating Center to facilitate the sharing of ideas and encourage collaborations among recipient PBRNs. Representatives of recipient PBRNs will be expected to attend group meetings convened by CPCR during the funding period. This RFA is a one-time solicitation. The total project period for an application submitted in response to this RFA may not exceed one year. The anticipated award date is September 29, 2000. It is anticipated that after successful completion of these exploratory grants, recipient PBRNs will be in a position to compete for subsequent multi-year funds which AHRQ will offer, contingent upon funding availability, through a separate solicitation to be released in Fiscal Year 2001. FUNDS AVAILABLE AHRQ expects to award up to $1.5 million total costs in Fiscal Year 2000 to support up to 14 PBRNs under this RFA. The actual number of applications funded is dependent on the number of high quality applications received. Budget requests for applications submitted under this RFA should not exceed $75,000 in direct costs. Representatives of recipient PBRNs will meet with CPCR staff in Washington, D.C., as many as 3 times during the planning year. Budget requests should therefore include travel expenses for this purpose. Although the financial plan of AHRQ provides for this program, awards pursuant to this RFA are contingent upon the availability of funds for this purpose. RESEARCH OBJECTIVES Background Legislation passed by the one hundred sixth U.S. Congress and signed by the President in December, 1999, amended Title IX of the Public Health Service Act (42 U.S.C.299 et seq.) to mandate the establishment within the new AHRQ of a Center for Primary Care Research to serve as the principal source of funding for primary care practice research in the Department of Health and Human Services. In addition, the AHRQ was directed to: (1) support research and evaluations on the health care of priority populations, including low-income and minority groups, (2) develop and evaluate strategies for reducing medical errors and supporting clinical preventive services, (3) foster a range of innovative approaches to the management and communication of health information, (4) support efforts to speed the dissemination of research findings to community practice settings, and, (5) employ research strategies and mechanisms that link research directly with clinical practice in geographically diverse locations throughout the U.S., including provider- based research networks... especially (in) primary care. This RFA, supporting the development of primary care PBRNs, is part of AHRQ’s response to these Congressional mandates. Practice-Based Research Networks and Primary Care Building collaborative networks of office-based practices for the purpose of research is a promising approach to the study of almost any type of ambulatory health care, since findings from such research may be significantly influenced by the practice setting(s). This approach appears to be even more important, however, for the study of problems encountered in primary care, where the characteristics of the particular practice setting are often so influential that they become a constellation of factors that themselves must be considered in the research design (Starfield, 1992). Whereas studies conducted in inpatient settings or hospital outpatient departments may have limited applicability to community-based primary care, research conducted within primary care PBRNs can readily consider such factors as practice organization and finances, and the community within which the practice is located. These factors may be critical in the interpretation and generalizability of findings. The applicability of research findings to primary care practice is also significantly influenced by the nature of the study population. Primary care tends to deal with the management of unselected patients, many of whom present with undifferentiated clinical problems and/or have multiple problems at once. Findings from research that focuses on single diseases among highly selected or referred patients may therefore have little, if any, relevance to problems encountered in primary care. Moreover, such studies typically measure disease or condition-specific physiological outcomes while primary care clinicians are equally concerned about broader and more person-focused outcomes (AHCPR Task Force on Building Capacity in Primary Care Research, 1993). Research conducted within primary care PBRNs can potentially overcome these limitations since the PBRN study population is very likely to be representative of the general public, and primary care clinicians are typically involved as investigators or consultants in defining the research design and the outcomes to be measured. The first primary care PBRNs were initiated in the U.S. in the late 1970s, and a recent report indicates a total of 28 active primary care research networks in North America (Nutting, 1996). Although a few PBRNs are national in scope, the majority are local or regional in nature. Most exist within the organizational structure of professional associations, although a few exist within academic departments, and others are independent organizations. The number of PBRN practices participating in any study (ranging from 15 to more than 500) is usually sufficient to assure generalizability to average patient populations, providers, and practice settings. Much of the early work of PBRNs provided descriptions of the content and practice patterns of primary care, while more recent research from a few networks has included effectiveness studies and randomized clinical trials. The emerging body of research by PBRNs demonstrates the ability of networks to link relevant clinical questions with rigorous research methods in community settings to produce important scientific information that not only is externally valid but, in theory, is more easily assimilated into everyday practice (Nutting, 1999). Challenges to Primary Care PBRNs Whereas PBRNs have advantages for studying the common phenomena of primary care in primary care settings, they also face a number of challenges. Collecting, transferring and managing data generated from multiple sites is often problematic, but is particularly challenging in the setting of diverse primary care practices. Unlike the collection of data in most hospital settings, few if any standards currently exist for the coding of administrative/billing information routinely collected in primary care. Therefore, such data are often not compatible and cannot be easily aggregated for the purpose of analysis. Moreover, few existing primary care PBRNs have managed to develop electronic data systems dedicated to collecting primary research data, and the collection, transfer and aggregation of large volumes of hand-written information from network practices that often are widely dispersed geographically can be a major challenge. Of greater concern, however, is the integrity of such information, which is typically recorded by primary care clinicians or their staff in busy office settings. More efficient and reliable data systems are needed to address the issue of accuracy, reliability and validity of data generated within PBRNs (Wasson, 1997). Since most PBRNs are composed of practices that are located predominantly in suburban or rural sites, their ability to study the delivery of primary care services to urban minority and underserved patient populations is often limited. Very few published PBRN studies have specifically addressed the persistent, and often increasing, health disparities that have been correlated with race, ethnicity, poverty and insurance status, and the number of minority/underserved patients included in most PBRN research has been inadequate for meaningful subgroup analyses. One of the early promises of the organizers of primary care PBRNs was that research conceived and conducted in practice settings could follow a short feedback loop back into practice and thus shorten the usually laborious translation process of applying the research results to the practice of primary care (Green, 1990). In the absence of methods to measure baseline and subsequent rates of compliance with recommended evidence-based practices, however, it is difficult to know whether this promise has in fact been fulfilled. Information systems are needed to assist with prompt and appropriate dissemination of new research evidence and to measure subsequent changes in the processes of primary care practice. Such systems can inform future research needs and enhance collective understanding of strategies to accelerate continuous quality improvement in routine practice. In particular, improved computer-based information systems can contribute significantly to efforts aimed at reducing medical error rates and implementing clinical preventive recommendations in primary care settings. Finally, most if not all primary care PBRNs share the serious challenge of sustaining an infrastructure capable of recruiting and retaining participating practices, supporting the network, and generating fundable research projects. Although there is considerable variation in the status of current PBRN infrastructural support, few have significant, ongoing funding from any academic institution or other organization. All appear to rely heavily on volunteerism for central staff support and the cooperation of participating practices and investigators. Primary care PBRNs must begin to seek new avenues of funding from a variety of sources to provide support for PBRN infrastructural needs, especially in those periods between major funded research efforts. SPECIAL REQUIREMENTS Applications are encouraged from newly formed PBRNs as well as existing networks, including those that have received funds from AHRQ, other Governmental agencies, or private sources. Each PBRN funded by AHRQ will be expected to develop, within twelve months, a detailed plan for network growth specific to its current state of development as well as its size, patient population served, and the practice styles of the group’s clinicians. At the same time, AHRQ recognizes that the power of individual networks to study health care events of primary care can be multiplied through regular communication and research collaborations among PBRNs. To encourage such collaborations and to assure the sharing of ideas across PBRNs during this planning phase, CPCR intends to serve as a Coordinating Center for PBRN planning activities. In addition to hosting conference calls and list-serve discussions, CPCR will convene up to 3 meetings of representatives of recipient PBRNs during the year of funding. The meetings will include initial discussions of standard data elements, standard coding of primary care processes, and the feasibility of aggregating certain data elements collected from numerous PBRNs into a primary care database. Required Elements of Planning and Development Effort During the funding period, each PBRN will be required to develop a plan for network growth in four key areas: (a) computerized data management and practice evaluation, (b) research of special relevance to minority and/or underserved populations, (c) translation of research into practice, and (d) predictable network funding. The responsibility for directing the planning and development effort should be assigned to a senior level person familiar with PBRN research and competent in administration. This person should devote a significant proportion (30% or more) of his/her time to this endeavor. The PBRN may also choose to have an internal planning committee to assist the planning director. The director/planning committee should evaluate the current strengths and weaknesses of the network in the key identified areas and consider all available resources in the planning process. Appropriate consultants may be called upon to assist. Specific required planning activities to be accomplished with funding through the present RFA are listed below, by Area of Focus. I. Data Management o Evaluation of existing data collection capacities within all network- affiliated practices, including the ability to use current informatic systems to identify and follow eligible patients according to symptomatic or diagnostic criteria. o Development of options and specific methods to collect and aggregate electronically from affiliated practices both standard core clinical data and project-specific data. PBRN plans should consider all viable computer-based options, including Internet-based data collection and the use of electronic medical records. The final plan should include the projected cost of implementing each option. o Development of options and specific methods for ensuring data integrity and the confidentiality of identifiable personal health information. The plan should include a discussion of who will be permitted access to the information, both raw data and machine readable files, and how personal identifiers and other identifying or identifiable data will be safeguarded. The final plan should include the projected cost of each option. o Discussion of methods to coordinate appropriate review by institutional review boards of future network studies, especially those in which clinical data will be collected from multiple independent practices. II. Minority And/Or Underserved Population Research o Documentation that practices currently affiliated with the network serve sufficient numbers of minority and/or underserved patients to permit studies that have the statistical power to generate significant findings related to ethnic minority subgroups (Blacks/African-Americans, Hispanic Americans, American Indians, Alaskan Natives, Asian Americans and Pacific Islanders), OR o Development of formal network linkages with additional primary care practices that serve sufficient numbers of minority and/or underserved patients to permit such studies. III. Translation of Research Into Practice o Development of methods to use new or existing computer-based information systems to assess changes in clinical practice resulting from the dissemination of new research evidence into practices affiliated with the PBRN and to measure the impact of these changes on outcomes, cost and/or use of services. The plan should specifically consider methods of using computer- based information systems to assess strategies for reducing preventable health care errors. o Testing and implementation of appropriate tools developed by AHRQ and others (e.g., evidence reports, quality measures, etc.) for the purpose of translating research into practice. The plan should specifically include a discussion of potential methods for evaluating the extent to which practices implement clinical preventive recommendations. o Development of specific strategies, including the use of computer-based information systems, to accelerate the diffusion of new research knowledge into actual practice. The final plan should include a menu of strategies that the network has used successfully in the past or could be capable of using in the future. To the extent possible, the plan should also include the projected costs of each strategy. IV. Predictable Network Funding o Exploration of potential sources of ongoing funding for the PBRN research infrastructure, including professional organizations, academic institutions, governmental sources, foundations and other private sources such as pharmaceutical companies and clinical research organizations. o Development of a five year business plan demonstrating how core administrative functions of the network can be supported even in the absence of major funding for project-specific research. Qualifications PBRNs should document in their applications that they meet, at minimum, the following qualifications: o The PBRN organizational structure includes, or will include, a core of at least 15 ambulatory practices and/or 15 clinicians located in the U.S. and devoted principally to the primary care of patients. o The network has an accepted statement of its purpose and research mission that includes an ongoing commitment to the research endeavor. o A director has been identified who is, or will be, responsible for most administrative, financial and planning functions. o The director is, or will be, supported by a staff of at least one person. o A mechanism (such as a community advisory board) is planned or in place to solicit advice/feedback from the communities of patients served by the PBRN. o An organizational structure exists, or will exist, that transcends a single study, including multiple systems of communication with and among participating practices in the form of regularly produced newletters, e-mail or list-serves, conference calls, and/or face-to-face meetings of various combinations of network members. Data Privacy Application materials will include citations for federal data security standards and background materials on the AHRQ confidentiality statute [section 903(c) of the Public Health Service Act (42 USC 299a-1(c)] that protects and restricts disclosure of identifiable information about individuals or entities collected in the course of any AHRQ-funded study. Should planning activities or pilot projects undertaken as part of this initiative involve confidential, identifiable data, the grantee must ensure that computer systems containing these data have a level and scope of security that equals or exceeds those established by the Office of Management and Budget (OMB) in OMB Circular No. A-130, Appendix III - Security of Federal Automated Information Systems . The National Institute of Standards and Technology (NIST) has published several implementation guides for this circular. They are: An Introduction to Computer Security: The NIST Handbook, Generally Accepted Principals and Practices for Securing Information Technology Systems, and Guide for Developing Security Plans for Information Technology Systems. The circular and guides are available on the web at Rights in Data To encourage dissemination of AHRQ products by grantees, application materials will include information on copyrighting or seeking patents, as appropriate, for final and interim products and materials. Examples of such products and materials are methodological tools or measures or software with documentation, literature searches, and analyses, which are developed in whole or in part with AHRQ funds. Such copyrights and patents will be subject to a Federal government license to use and permit others to use these products and materials for AHRQ purposes. Important legal rights and requirements applicable to AHRQ grantees are set out or referenced in the AHRQ’s grants regulation at 42 CFR Part 67, Subpart A (Available in libraries and from the GPO’s website INCLUSION OF WOMEN, MINORITIES, AND CHILDREN IN RESEARCH STUDY POPULATIONS It is the policy of AHRQ that women and members of minority groups be included in all AHRQ-supported research projects involving human subjects, unless a clear and compelling rationale and justification are provided that inclusion is inappropriate with respect to the health of the subjects or the purpose of the research. AHRQ is also encouraging investigators to include children in study populations whenever appropriate. Planning and development projects should consider how to facilitate the collection of data pertaining to these populations. Further information about these inclusion policies is available through the AHRQ Website (Funding Opportunities) and InstantFAX (see instructions under INQUIRIES). LETTER OF INTENT Prospective applicants are asked to submit, by March 10, 2000, a letter of intent that includes a descriptive title of their proposed project, the name, address, and telephone number of the Principal Investigator, other key personnel and participating institutions, and the number and title of the RFA in response to which the application may be submitted. Although a letter of intent is not required, is not binding, and does not enter into the consideration of any subsequent application, the information allow AHRQ staff to estimate the potential review workload and avoid conflict of interest in the review. AHRQ will not provide responses to letters of intent. The letter of intent is to be sent to Kelly Morgan (see address under APPLICATION PROCEDURES). APPLICATION PROCEDURES The research grant application form PHS 398 (rev. 4/98) is to be used in applying for these planning and development grants. State and local government applicants may use PHS 5161-1, Application for Federal Assistance (rev. 5/96), and follow those requirements for copy submission. Application kits are available at most institutional offices of sponsored research. They may also be obtained from the Division of Extramural Outreach and Information Resources, National Institutes of Health, 6701 Rockledge Drive, MSC 7910, Bethesda, MD 20892-7910, telephone (301) 710-0267, email: AHRQ applicants are encouraged to obtain application materials from the AHRQ Publications Clearinghouse (see INQUIRIES). The RFA label available and line 2 in the PHS 398 (rev. 4/98) application form should both indicate RFA number. The RFA label must be affixed to the bottom of the face page of the original application. Failure to do so could result in delayed processing of the application such that it may not reach the review committee in time for review. In addition, the RFA title and number must be typed on line 2 of the face page and the Yes box must be marked. The sample RFA label available at has been modified to allow for this change. Applicants are encouraged to read all PHS Form 398 instructions carefully prior to preparing an application in response to this RFA. The PHS 398 type size requirements (p.6) will be enforced rigorously and non- compliant applications will be returned. Application Preparation Complete information about the proposed planning effort must be submitted with the application. The narrative portions of the PBRN application, described below under Research Plan, should be limited to twenty-five pages of text. The application should be a complete document that includes all essential information necessary for its evaluation. While additional explanatory material may be submitted as appendices, such appendices should not be used to bypass page limitations in the application because only selected reviewers will receive copies of the appendices. Since the form PHS 398 was developed for research grant applications, the following supplemental instructions should be used as a guide in the preparation of the application. 1) Under Performance Sites (page 2), list only the official name of the PBRN and the address of the PBRN office. A complete listing of the clinicians and practice sites involved in the network should be attached to the application as an appendix. 2) Detailed Budget. In general, allowable budget items for these planning and development grants are limited to a portion of the salaries of the planning director, consultation fees, key administrative and clerical support personnel, travel and per diem expenses for outside consultants/advisors, supplies, travel and per diem expenses for the planning director and/or other key personnel to be involved in 3 meetings in Washington, D.C. with CPCR staff, and other justifiable operating expenses of the planning effort. The level of effort of personnel should reflect the commitment of the individual to the planning process. The purchase of equipment is discouraged, and any request for equipment must be well justified. Budget requests submitted under this part of the RFA should not exceed $75,000 in direct costs. 3) Biographical Sketches. Include in this section a biographical sketch of the planning director (equivalent of Principal Investigator) and other key personnel to be involved in the planning effort. 4) Resources available to the PBRN should be described once, either in a separate section following the biographical sketches or included in the narrative text (see below). 5) Research Plan. This narrative part of the application should contain the following elements: Section I. The Practice-Based Research Network a) Description of the existing or planned PBRN. Describe the practices included in the current or developing network, including geographical distribution of practices, types of clinicians, and patient population served by the practices. As noted above, a complete up-to-date listing of network clinicians and practice addresses should be included as an appendix to the application. b) Current or proposed infrastructure supporting the PBRN. Describe and discuss the existing or planned infrastructure that supports the PBRN research effort. This discussion (which may alternatively be included in the Resources section of the application) should include details of any computer-based or other information systems currently in use (or planned) to collect and aggregate research data or communicate with clinicians. The current, or proposed, director and any network support staff should be identified, including a description of their qualifications and source of salary support (if any). If the network is affiliated with an academic department or other research unit, the relationship with that institution should be described, including a list of consultants and other resources available to the network as a result of the affiliation. Senior officials in any PBRN-affiliated organizations(s) should provide a letter documenting support for the proposed planning and development process. These and other letters of support should be included as an appendix and referenced in this section of the application. The discussion should also include references to the existing, or proposed, mechanism for obtaining advice/feedback from the communities of patients served by the network practices. c) Progress to date in conducting research. Include a summary of the research completed to date by the PBRN, including sources and amounts of funding received for the research. A complete list of publications (if any) resulting from PBRN research should be included as an appendix and referenced in this section of the application. Emerging PBRNs should describe their research goals and objectives and provide examples of specific projects their networks are interested in (and capable of) pursuing. d) Progress to date in translating research into practice. Describe any formal or informal systems or mechanisms within the PBRN, current or planned, to disseminate the results of research to network clinicians and evaluate the impact of this information on practices. Section II. The Proposed Planning Effort a) Description of the planning director and his/her responsibilities and authority to carry out the proposed planning process for the PBRN. Discuss the selection of this individual as planning director (equivalent of principal investigator) and his/her future role in the PBRN. This section should present an adequate description of his/her qualifications and administrative experience. b) Description of the planning committee. If an internal planning committee is being proposed, list and discuss the membership. List any external consultants to the planning committee. c) Description of other key personnel and their duties. Discuss the selection and duties of the key personnel supporting the planning director and planning committee. d) Description of issues that will need to be resolved through the planning and development process. Discuss the issues/obstacles that must be considered in the planning and development process. An example of such an issue is anticipated change in the practice environment (e.g., managed care penetration in the area) affecting the practices involved in the network. e) Detailed description of the planning proposed. Include discussions of the proposed approach to planning activities for each of the Areas of Focus. Submit a signed, typewritten original of the application, including the Checklist, and three signed photocopies, in one package to: Center for Scientific Review National Institutes of Health 6701 Rockledge Drive, Room 1040, MSC 7710 Bethesda, MD 20892-7710 Express/courier service zip code (20817) At the time of submissions, two additional copies of the application, labeled Advanced Copies must also be sent to: Kelly Morgan Center for Primary Care Research Agency for Healthcare Research and Quality 6010 Executive Boulevard, Suite 201 Rockville, MD 20852-4908 Telephone: (301) 594-1782 FAX: (301) 594-3721 E-mail address: Applications submitted under this RFA must be received by April 27, 2000. An application received after the deadline may be acceptable if it carries a legible proof-of-mailing date, assigned by the carrier, and the proof-of- mailing is not later than one week prior to the deadline date. If an application is received after that date, it will be returned to the applicant without review. REVIEW CONSIDERATIONS Upon receipt, applications will be reviewed for completeness and responsiveness. Incomplete applications will be returned to the applicant without further consideration. Applications that are complete and responsive to the RFA will be evaluated for scientific and technical merit by an appropriate peer review group convened by AHRQ in accordance with AHRQ peer review procedures. If the application is not responsive to the RFA, it will be returned to the applicant without review. As part of the merit review, all applications will receive a written critique, and also may undergo a process in which only those applications deemed to have the highest scientific merit will be discussed and assigned a priority score. General Review Criteria Applications will be assessed in two general areas: 1) technical merit of the proposed planning process, and 2) potential of the new or existing PBRN to enhance its capacity to conduct research and translate research findings into practice. Peer reviewers will be asked to specifically comment in these two areas. An unacceptable evaluation in either category can be grounds for disapproval of the application. The final priority scores will reflect the peer reviewer’s overall assessment based on their judgements of the two review areas. 1. The technical merit of the proposed planning process. a) Clarity and appropriateness of planning goals and objectives, b) Extent to which the application appropriately defines the problems that need to be resolved in the planning process, c) Extent to which the proposed detailed planning effort has clear and appropriate goals consistent with the stated goals of AHRQ and is of adequate scope with regard to the Areas of Focus, d) Qualifications of the proposed planning director to lead the planning and development effort and his/her leadership experience, administrative skills and research background, e) Qualifications and appropriateness of the key personnel designated to assist the planning director, and, f) Appropriateness of the membership and stated functions, as well as potential effectiveness, of the proposed internal planning committee (or advisors to the planning director). 2. The potential of the PBRN to enhance its capacity to conduct primary care research and translate research findings into practice. a) Adequacy of the commitment of network practices to primary care research, as evidenced by published findings from PBRN studies or letters of support from participating clinicians, b) Adequacy of the patient populations served by the PBRN practices to support primary care research, and the potential for research that includes minority and/or underserved populations, c) Adequacy and stability of the PBRN’s administrative, organizational and management capabilities, and, d) Extent to which the award of grant funds will enhance the ability of the PBRN to plan future activities for enhancing primary care research and translating research findings into practice. The initial review group will also examine the appropriateness of the proposed project budget. AWARD CRITERIA Applications will compete for available funds with all other applications under this RFA. The following will be considered in making funding decisions: (1) quality of the proposed project as determined by peer review, (2) program balance and the desire to fund a group of networks that capture the full scope of primary care practice, including providers from multiple disciplines and populations of all ages, and, (3) availability of funds. INQUIRIES Copies of this RFA and all currently active AHRQ grant announcements are available from: AHRQ Publications Clearinghouse P.O. Box 8547 Silver Spring, MD 20907-8547 Telephone: 800-358-9295 TDD service: 888-586-6340 E-mail: This RFA is also available on AHRQ’s Web site,, and through AHRQ InstantFAX at (301) 594-2800. To use InstantFAX, you must call from a facsimile (FAX) machine with a telephone handset. Follow the voice prompt to obtain a copy of the table of contents, which has the document order number (not the same as the RFA number). The RFA will be sent at the end of the ordering process. AHRQ InstantFAX operates 24 hours a day, 7 days a week. For comments or problems concerning AHRQ InstantFAX, please call (301) 594- 6344. AHRQ welcomes the opportunity to clarify any issues or questions from potential applicants who have obtained and read the RFA. Written and telephone inquiries concerning this RFA are encouraged. Direct inquiries regarding programmatic issues should be addressed to: David Lanier, M.D. Center for Primary Care Research Agency for Healthcare Research and Quality 6010 Executive Boulevard, Suite 201 Rockville, MD 20852-4908 Telephone (301) 594-1489 FAX (301) 594-3721 E-mail address: Direct inquiries regarding fiscal and eligibility matters to: George Skip Moyer Grants Management Specialist Agency for Healthcare Research and Quality 2101 East Jefferson Street, Suite 601 Rockville, MD 20852 Telephone: (301) 594-1842 FAX: (301) 594-3210 E-mail address: AUTHORITY AND REGULATIONS This program is described in the Catalog of Federal Domestic Assistance No. 93.226. Awards are made under authorization of Title IX of the Public Health Service Act (42 USC 299-299c-6). Awards are administered under the PHS Grants Policy Statement and Federal Regulations 42 CFR 67, Subpart A, and 45 CFR Parts 74 and 92. This program is not subject to the intergovernmental review requirements of Executive Order 12372 or Health Systems Agency review. The PHS strongly encourages all grant and contract recipients to provide a smoke-free workplace and promote the non-use of all tobacco products. In addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits smoking in certain facilities (or in some cases, any portion of a facility) in which regular or routine education, library, day care, health care or early childhood development services are provided to children. This is consistent with the PHS mission to protect and advance the physical and mental health of the American people. REFERENCES Starfield B. Primary Care: Concept, Evaluation, and Policy. New York: Oxford University Press, 1992. AHCPR Task Force. Putting Research into Practice. Report of the Task Force on Building Capacity for Research in Primary Care. AHCPR Publication No. 94- 0062. August, 1993. Nutting PA. Practice-Based Research Networks: Building the Infrastructure of Primary Care Research. Journal of Family Practice 42:199-203, 1996. Nutting PA, Beasley JW, Werner JJ. Practice-Based Research Networks Answer Primary Care Questions. Journal of the American Medical Association 281:686- 8, 1999. Wasson JH, Jette AM, Johnson DJ, et al. A Replicable and Customizable Approach to Improve Ambulatory Care and Research. Journal of Ambulatory Care Management 20(1):17-27, 1997. Green LA, Lutz LJ. Notions about Networks: Primary Care Practices in Pursuit of Improved Primary Care. Conference on Primary Care Research: An Agenda for the 1990s. J Mayfield and M Grady (eds), U.S. Department of Health & Human Services, September 1990.

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