Finding patient experts: How to conduct positive deviance research

By analyzing clinical data on complex type 2 diabetes patients in a rural New Hampshire community, Cole Zanetti, DO, and his primary care team were able to locate a small group of patients who’d made major progress toward controlling their conditions despite facing poverty and other obstacles. The project was inspired by the positive deviance movement, which looks for locals who’ve found creative, effective ways to tackle challenging problems.

In Dr. Zanetti’s project, these positive deviant patients, dubbed “bright spotters,” gave the primary care team detailed information about their habits and coping strategies. Using these insights, the bright spotters worked with Dr. Zanetti’s team to create an ongoing dinner and discussion series for other local patients who are still struggling. The dinner club is scheduled to debut by summer; the research team will have preliminary data on the project’s results next year. In the meantime, Dr. Zanetti offered these steps for researchers and physicians who’d like to undertake positive deviance research in their own communities.

1. Work with primary care teams to determine which patient population is struggling most.

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2. Identify recurring local barriers and consult clinical literature to pinpoint the risk factors that are related to your patient population. Your “bright spotter” patients will be those who have a severe medical condition and face the risk factors you’ve established, but have gotten their health under control and are doing well. For example, Dr. Zanetti’s team sought complex type 2 diabetes patients who had achieved sustained reductions in their hemoglobin A1C levels and reduced the amount of medication they needed to manage their diabetes.
3. Analyze clinical data to find a pool of patients who match the criteria.
4. Share your preliminary list of patients with the primary care team to understand the bigger picture. Has each patient made sustained improvements independently, or are other factors beyond the patient’s control impacting his or her health for the better? Whittle your list so it includes only patients who’ve made self-directed changes.
5. Conduct qualitative research with these patients to learn about the strategies and solutions they’ve developed for managing their health.
6. Distill your findings. What are the key patterns and takeaways from the bright spotters’ success stories?
7. Share the expertise. Partner with the bright spotters in designing an interactive outreach program for similar patients in the community. Engage them in brainstorming changes that could be made to the local health care delivery system.
8. Return to the clinic with what you’ve learned about local obstacles and resources. When a physician meets a patient who fits the population-based profile for risk, he or she will be able to ask about common pitfalls and suggest solutions.
9. Monitor your results. Dr. Zanetti and his team plan to evaluate the initiative using the clinical value compass framework, which includes clinical data, cost, patient satisfaction and functional criteria based on each patient’s goals.