Is there time for management of patients with chronic diseases in primary care?

PURPOSE

Despite the availability of national practice guidelines, many patients fail to receive recommended chronic disease care. Physician time constraints in primary care are likely one cause.

METHODS

We applied guideline recommendations for 10 common chronic diseases to a panel of 2,500 primary care patients with an age-sex distribution and chronic disease prevalences similar to those of the general population, and estimated the minimum physician time required to deliver high-quality care for these conditions. The result was compared with time available for patient care for the average primary care physician.

RESULTS

Eight hundred twenty-eight hours per year, or 3.5 hours a day, were required to provide care for the top 10 chronic diseases, provided the disease is stable and in good control. We recalculated this estimate based on increased time requirements for uncontrolled disease. Estimated time required increased by a factor of 3. Applying this factor to all 10 diseases, time demands increased to 2,484 hours, or 10.6 hours a day.

CONCLUSIONS

Current practice guidelines for only 10 chronic illnesses require more time than primary care physicians have available for patient care overall. Streamlined guidelines and alternative methods of service delivery are needed to meet recommended standards for quality health care.

Prevalence and predictors of multiple behavioral risk factors for colon cancer

OBJECTIVES

This paper examines the prevalence of behavioral risk factors for colorectal cancer (CRC) (e.g., red meat consumption, fruit and vegetable intake, multivitamin intake, alcohol, smoking, and physical inactivity), co-occurrence among these behaviors, and motivation for change among patients at increased risk.

METHODS

The study sample included 1,247 patients with recent diagnosis of adenomatous colorectal polyps. Within 4 weeks following the polypectomy, participants completed a baseline survey by telephone.

RESULTS

Sixty-six percent of participants had not been diagnosed with polyps before. Fifty-eight percent of the sample had red meat as a risk factor, 63% had fruit and vegetable consumption as a risk factor, 54% did not take a daily multivitamin, and 44% had physical activity as a risk factor. In contrast, only 9% of the sample had alcohol consumption as a risk factor and only 14% were current smokers. The prevalence of the six individual risk factors was combined into an overall multiple risk factor score (MRF). The average number of risk factors was 2.43. Men, those with a high school education or below, those reporting fair or poor health status, and those with less self-efficacy about risk factor change had more risk factors.

CONCLUSIONS

There is a need for multiple risk factor interventions that capitalize on natural intersections among intra- and interpersonal factors that maintain them.

Age-related vulnerabilities of older adults with colon adenomas: evidence from Project Prevent

BACKGROUND

This report addresses the interface between cancer and aging in the context of colorectal carcinoma (CRC), the second leading cause of cancer death in the U.S. overall and the first leading cause among individuals age > or = 75 years. Because polyp risk increases with age, interventions to prevent recurrent polyps among older adults likely would reduce CRC morbidity and mortality.

METHODS

Data for this study derive from Project Prevent, a multisite, randomized controlled trial designed to reduce behavioral risk factors for CRC among 1247 adults who underwent the removal of > or = 1 adenomatous colon polyps. Middle-aged and older patients were compared on key cognitive-behavioral mechanisms associated with CRC risk and established age-related factors associated with adverse health outcomes. Relations between cognitive-behavioral mechanisms and age-related vulnerability factors identified subgroups of older polyp patients that may have an enhanced risk for CRC.

RESULTS

Compared with middle-aged patients, older patients were less concerned about developing CRC, less motivated to reduce their risk, and less confident that their behavior change efforts would succeed. As expected, they also reported more age-related physical, social, and economic vulnerabilities, as expected. Evidence for enhanced CRC risk was found for older patients with multiple comorbid conditions, low social support for change, and perceptions of income inadequacy.

CONCLUSIONS

The presence of age-related vulnerability factors may enhance the risk of CRC among older cancer patients by creating barriers to behavioral change. Efforts to reduce the cancer burden in older populations will require attention beyond early detection and surveillance to interventions that account for the unique physical and psychosocial characteristics of older adults.

Interpretation of Genetic Risk Feedback Among African American Smokers With Low Socioeconomic Status

The authors report on factors related to interpretation of feedback on genetic susceptibility to lung cancer among 371 African American smokers receiving care in a community health clinic, with a focus on whether smokers were interpreting feedback consistent with a defensive processing or an accuracy orientation. Smokers were given feedback on the absence (indicating increased risk) or presence (indicating average risk) of the gene for the mu isoform of glutathione S-transferase. Smokers who were told they were at higher risk were more likely to inaccurately recall the result than those deemed at average risk. Smokers who inaccurately recalled the result, regardless of risk status, were most likely to misinterpret the meaning of the result. Perceived lung cancer risks and worries were not associated with comprehension of the test result. The authors suggest additional research is needed to develop more effective strategies for communicating genetic risk feedback to motivate smoking cessation.

A Randomized Trial Comparing the Effects of Self-Help Materials and Proactive Telephone Counseling on Teen Smoking Cessation

We conducted a 2-arm randomized trial to test the efficacy of self-help materials with or without proactive telephone counseling to increase cessation among teen smokers. Teen smokers (N = 402) recruited from 11 shopping malls and 1 amusement park in the southeastern United States were randomized to 1 of 2 groups: written self-help material plus video; or written self-help material, video, and telephone counseling. Cessation rates based on 7-day point-prevalent abstinence for the self-help and counseling arms were 11% and 16%, respectively (p = .25), at 4 months postbaseline and 19% and 21%, respectively (p = .80), at 8 months postbaseline. Sustained abstinence, reflecting 7-day abstinence at both time points, in the self-help and counseling arms was 7% and 9% (p = .59). Results suggest that minimal self-help cessation approaches that target youth have comparable success to that shown among adult smokers. However, refinements in telephone-counseling approaches may be needed to achieve the success observed in adult populations.

Weight and smoking cessation among low-income African Americans

BACKGROUND

Concerns about weight gain have been a commonly cited barrier to cessation among white, affluent, female populations, but less is known about this relationship among minority smokers and those with low incomes. Although smoking cessation is strongly encouraged for this population, it often leads to weight gain. Cultural differences in weight standards and the high prevalence of weight-related health conditions (e.g., hypertension and diabetes) may influence concerns about smoking cessation-related weight gain.

METHODS

A secondary analysis of low-income African-American smokers (n=367) from a randomized intervention trial was conducted to explore the association of weight concerns with comorbidities and smoking cessation.

RESULTS

Less than one quarter of participants were considered concerned about weight, defined as having high general concern about weight and high expectation of post-cessation weight gain. Those for whom weight gain could be riskiest--obese participants--were least concerned about gaining weight. Further, weight concerns were not associated with successful smoking cessation, quit attempts, confidence in quitting, or desire or readiness to quit.

CONCLUSIONS

Because post-cessation weight gain may be a serious health threat for this population, but weight gain was not a concern for these smokers, smoking-cessation interventions for low-income African-American smokers may need to incorporate weight-gain education and prevention.

Primary care residents' characteristics and motives for providing differential medical treatment of cervical cancer screening

BACKGROUND

Cervical cancer screening rates in the United States are sub-optimal. Physician factors likely contribute to these lower rates. Previous studies provide inconclusive evidence about the association between physician characteristics and the likelihood of addressing cervical cancer. This report assesses potential mechanisms that explain why certain providers do not address cervical cancer screening.

METHODS

One hundred primary care residents from various specialties were asked to indicate the preventive topics they would address with a hypothetical white female in her early 20s, who was portrayed as living a "high risk" lifestyle, and visiting her provider only for acute care reasons.

RESULTS

Among the provider characteristics assessed, only residents' ethnicity was associated with the likelihood of and time spent addressing cervical cancer screening. In particular, Asian-American residents were least likely to address cervical cancer, while African-American residents were most likely. A mediation analyses revealed that perceived barriers for addressing cervical cancer accounted for this difference.

CONCLUSIONS

Study results suggest that there may be cultural factors among health care providers that may account for differential referral and treatment practices. Findings from this study may help identify factors that explain why cervical cancer screening rates are not higher.

Primary care: is there enough time for prevention?

OBJECTIVES

We sought to determine the amount of time required for a primary care physician to provide recommended preventive services to an average patient panel.

METHODS

We used published and estimated times per service to determine the physician time required to provide all services recommended by the US Preventive Services Task Force (USPSTF), at the recommended frequency, to a patient panel of 2500 with an age and sex distribution similar to that of the US population.

RESULTS

To fully satisfy the USPSTF recommendations, 1773 hours of a physician's annual time, or 7.4 hours per working day, is needed for the provision of preventive services.

CONCLUSIONS

Time constraints limit the ability of physicians to comply with preventive services recommendations.

Influence of stereotyping in smoking cessation counseling by primary care residents

This study examined racial differences in primary care residents' rates of addressing smoking cessation. We expected residents to have higher rates of addressing cessation with White female patients as compared with African-American or Hispanic female patients, due, in part, to residents having higher outcome expectancies, self-efficacy, lower barriers, and less reliance on stereotypes. Residents (N = 90) were an average of 31 years old; two-thirds were White internal medicine residents. Residents viewed a video of a lower-middle class White, African-American, or Hispanic female interacting with her physician about stomach pain. Results indicate that residents were very likely to address smoking cessation, regardless of patients' race. Compared to residents assigned to an ethnic minority patient, residents assigned to the White patient were less likely to believe the patient would follow their advice (P < .03) and also perceived more barriers to address smoking cessation (P < .04). Reliance on the stereotype of Whites mediated the racial difference in outcome expectancies. Implications are that residents may be relying on stereotypes when they assess lower-middle class White female patients' receptivity to smoking cessation advice. Future research on the role of stereotyping in medical settings is warranted.

Distress and motivation for smoking cessation among lung cancer patients' relatives who smoke

BACKGROUND

Heightened distress at the time of a loved one's lung cancer diagnosis may motivate relatives to quit smoking or could undermine cessation.

METHODS

Relatives of new lung cancer patients at Duke were surveyed by telephone to assess diagnosis-related depression, distress, and motivation for smoking cessation.

RESULTS

Relatives who reported above average avoidant and intrusive thinking patterns, depressive symptoms or worry were more likely to report that the patient's diagnosis increased their intentions to quit than the less distressed.

CONCLUSIONS

Interventions are needed that encourage smoking cessation as a strategy for adaptively coping with a loved ones' lung cancer diagnosis.

Reported cessation advice given to African Americans by health care providers in a community health clinic

Physician smoking cessation advice has been shown to be effective in encouraging patients to attempt cessation. Few studies have examined factors associated with patient-reported physician advice in an inner city community health clinic. Smokers identified via chart review and provider referral met with a study "smoking specialist." Eligible participants self-identified as African American, smoked at least 1 cigarette per day in the prior 7 days, were 18 or older, had access to a telephone, and agreed to consider blood testing for genetic susceptibility to lung cancer. Of the 869 smokers identified, 487 were eligible and completed a brief in-person and a more extensive follow-up telephone survey within one week after their visit. Patient reports of smoking cessation advice by providers were regressed on patient demographic, smoking, health, and social support variables. Seventy percent of participants reported that they had been advised to quit smoking. Smokers who were older, did not smoke menthol cigarettes, were in poorer health, and who had a regular health care provider were most likely to report having received advice. Patients in this community health setting reported high rates of provider advice to quit smoking. Yet, even in this optimal condition, young healthy smokers did not report receiving advice, even when they were ready to quit smoking. Providers may need additional training and prompting to counsel young healthy smokers about the importance of cessation.

Women's reports of smoking cessation advice during reproductive health visits and subsequent smoking cessation

OBJECTIVE

To examine associations of women's characteristics with reports of provider advice to quit smoking and smoking cessation 1 year after a reproductive health visit.

STUDY DESIGN

Prospective survey.

METHODS

As part of a randomized smoking cessation trial, 432 women smokers completed telephone surveys 1 month and 1 year after their reproductive health visit. Most women were white (85%) with a mean age of 36 years.

RESULTS

Women more likely to report their provider advised them to quit smoking were white rather than another race (adjusted risk ratio, [RR] = 1.4, confidence interval [CI] = 1.14-1.64), employed versus unemployed (RR = 1.3, CI = 1.04-1.49), engaged in safer versus riskier sexual practices (RR = 1.3, CI = 1.09-1.54), were more rather than less ready to quit (RR = 1.3, Cl = 1.08-1.44), and saw family physicians versus gynecologists (RR = 1.3, CI = 1.12-1.41). Reported provider advice to quit smoking was not associated with subsequent cessation. Women were more likely to have quit smoking by the 1-year follow-up if at baseline they reported an annual Papanicolaou test in the prior 3 years (RR = 1.6, Cl = 1.02-2.26), were more rather than less ready to quit smoking (RR = 2.0, CI = 1.36-2.62), and were less rather than more dependent on nicotine (RR = 0.7, CI = 0.59-0.84).

CONCLUSIONS

Provider advice to quit is being directed to women who are most likely to quit and contributes little in explaining subsequent cessation. Providers may not be giving enough cessation advice to minority women, those not considering cessation, and those not prevention oriented. Interventions and system improvements are needed to increase providers' counseling of smokers who are unmotivated and from racial/ethnic minorities.

Relations between self-generated positive and negative expected smoking outcomes and smoking behavior: an exploratory study among adolescents

The expected outcomes of drug use figure prominently in models of drug motivation. This report presents the relations between self-generated expected outcomes of smoking and smoking behavior in 674 adolescents. Expected outcomes of smoking were related to current smoking, experimentation, and susceptibility among never-smokers, even after controlling for key correlates of smoking behavior, including gender, grade, ethnicity, and peer smoking. Although more negative than positive smoking outcomes were accessible from memory, more positive than negative expected outcomes were correlated with smoking behavior. Both the content and number of self-generated expected outcomes provided unique associative information. In sum, greater elaboration of smoking-related memory networks, as well as the specific content of those networks, appear to be associated with smoking behavior.

Factors associated with patient-recalled smoking cessation advice in a low-income clinic

It is recommended that providers advise cessation to their patients who smoke. However, patients' reports of cessation advice indicate disparities based on patients' race, gender, age, and smoking level. Providers' reports do not corroborate these disparities. We investigated whether smokers who receive their care in a community health center recalled their providers advising them to quit smoking when their providers documented such advice. We examined 219 patient-provider dyads to assess factors associated with lack of agreement between providers' documentation and patient recall. Patients were asked to recall any provider advice to quit smoking in the post 2 years. After every visit, providers completed a form to record the content of the visit. Most of the patients were African American, married, and uninsured. Sixty-eight percent of the dyads agreed in their documentation/recall. Patient race was the only factor associated with lack of agreement; African-American patients were more likely than white patients to provide discrepant reports. Although this study can not disentangle the racial difference in patient-provider recall/documentation, results may indicate an important area in which health disparities exist. Future studies should address the dynamics of patient-provider communication about smoking cessation, especially in populations that include ethnically diverse patients.

Exploring the association between perceived risks of smoking and benefits to quitting: who does not see the link?

This report explored associations between different measures of smokers' perceived risks of smoking and benefits to quitting and the extent to which these associations varied by demographic and other characteristics for 144 smokers. We hypothesized greater perceived risk of smoking would be associated with greater perceived benefits to quitting and would be strongest among smokers who were concerned about health effects of smoking and motivated to quit. Results indicated smokers' perceived themselves at risk for lung cancer regardless if they continued or quit smoking and was strongest for smokers who were older and minimized the importance of reducing lung cancer risk. There was a weak correlation between perceived risk for lung cancer when compared to nonsmokers and perception that quitting smoking would reduce lung cancer risk and was weakest for African Americans, lighters smokers, and smokers with higher intrinsic relative to extrinsic motivation for cessation. In conclusion, these subgroup differences in the relationship between perceptions of risks and benefits could be important to consider to increase the relevance and motivational potency of smoking cessation interventions.

Reasons for quitting smoking among low-income African American smokers

The psychometric characteristics of the Reasons For Quitting scale (RFQ) were assessed among a sample of African American smokers with low income (N=487). The intrinsic and extrinsic scales and their respective subscales were replicated. As hypothesized, higher levels of motivation were associated significantly, in patterns that supported the measure's construct validity, with advanced stage of readiness to quit smoking, greater perceived vulnerability to health effects of smoking, and greater social support for cessation. On the basis of the present study, the RFQ might best predict short-term cessation among older and female smokers. Refinement of the RFQ is needed to assess intrinsic motivators other than health concerns and to identify salient motivators for young and male smokers.

Women's perceived and partners' reported support for smoking cessation during pregnancy

Studies of the influence of social support on successful smoking cessation have been based on the smoker's perceptions only. In this pilot study of 58 couples, pregnant women who had smoked in the 30 days before pregnancy and their partners reported the positive and negative support for cessation they had received (women) or provided (partners). Mean levels of the women's and partners' perceptions of support were compared, and correlations of the two reports were analyzed while controlling for the effect of the couple's smoking status. Women's and partners' reports were similar except partners reported wanting the women to stop smoking more than women perceived. Women's and partners' perceived negative support were moderately correlated (r approximately equal to .48, p approximately equal to .001). Partner-reported positive support also was associated with women's perceived negative support (r approximately equal to .30, p approximately equal to .03). These relationships remained signif cant after controllingfor partners' and women's smoking status. Generally, partners reported giving more positive and less negative support than women perceived. Results suggest the need for further examination of couples' perceptions of support and the impact on smoking cessation during pregnancy.

How do residents prioritize smoking cessation for young "high-risk" women? Factors associated with addressing smoking cessation

BACKGROUND

Sixty-seven percent of physicians report advising their smoking patients to quit. Primary care residents' priorities for preventive health for a young "high-risk" female are unknown. Factors related to residents addressing smoking also need examining.

METHODS

One hundred residents completed a survey about preventive health issues for a woman in her 20s "who leads a high-risk lifestyle." Residents indicated which topics they would address, and the likelihood that they would address each of 12 relevant preventive health topics, their outcome expectancies that the patient would follow their advice on each topic, their confidence that they could address the topic, and perceived barriers for addressing the topic.

RESULTS

Residents listed STD prevention most frequently. Drug use and smoking cessation were second and third most frequently listed. Residents who believed that the patient would follow their advice were more likely to list smoking cessation than residents who had lower outcome expectancies for that patient. Higher barriers were negatively related to addressing smoking cessation.

CONCLUSIONS

When time is not a barrier, residents are likely to address smoking cessation. Teaching residents how to incorporate this subject into their clinical practice is needed. Raising residents' outcome expectancies may increase their likelihood of addressing smoking cessation.

Gender differences in the processes of change for condom use: patterns across stages of change in crack cocaine users

Interventions to increase condom use in crack users have had mixed results. For interventions to achieve greater success, the mechanisms of behavior change in this population need to be understood. One mechanism, the processes of change, was examined across stages of change for condom use. Results from the analysis of variance for males and females revealed that stage of change was associated with different levels of three experiential processes: consciousness raising, social liberation and self-reevaluation. However, these analyses found that male and females seem to have different patterns of behavioral process use. Specifically, females in the preparation stage were different from those in precontemplation, whereas this difference was not pronounced in males. In general, people had high levels of experimental processes in every stage of change. The patterns of behavior process use mimicked patterns found for other behaviors with a linear increase across the stages of change. This may indicate that for maintaining condom use, more emotional and behavioral activities are required throughout the process of acquisition and maintenance than are necessary for other health-related activities. Implications of this research are that interventions for increasing condom use in drug users may target behavioral steps differently for males and females.

Reasons for quitting smoking among low-income African American smokers

The psychometric characteristics of the Reasons For Quitting scale (RFQ) were assessed among a sample of African American smokers with low income (N=487). The intrinsic and extrinsic scales and their respective subscales were replicated. As hypothesized, higher levels of motivation were associated significantly, in patterns that supported the measure's construct validity, with advanced stage of readiness to quit smoking, greater perceived vulnerability to health effects of smoking, and greater social support for cessation. On the basis of the present study, the RFQ might best predict short-term cessation among older and female smokers. Refinement of the RFQ is needed to assess intrinsic motivators other than health concerns and to identify salient motivators for young and male smokers.

Relationships among breast cancer perceived absolute risk, comparative risk, and worries

When trying to predict breast cancer screening, it may be important to understand the relationships between perceived breast cancer risks and worries about getting breast cancer. This study examines the extent to which women's worries about breast cancer correlate with perceptions of both absolute (assessment of own) and comparative (self versus other) 10-year and lifetime risks. As part of a larger randomized intervention trial concerning hormone replacement therapy, 581 women participated in a telephone baseline survey to assess their perceptions of breast cancer risks and worries. Worries about getting breast cancer in the next 10 years and in one's lifetime were related positively to both absolute and comparative 10-year and lifetime risks. The magnitude of these relationships did not differ by time frame. Worry about breast cancer is a function of both how a woman views her own risk and how she compares her risk with that of other women. Some practitioners may encourage women to get screened for breast cancer by using emotional appeals, such as heightening women's worries about breast cancer by using risk information. Our data suggest that they should give careful consideration how best to combine, if at all, information about absolute and comparative risks. For example, if the motivation to screen is based on a sequential assessment of risk beginning with comparative and then absolute risk, creating communications that heighten perceived risk on both of these risk dimensions may be needed to evoke sufficient worry to initiate breast cancer screening.

Causal relationships of processes of change and decisional balance: stage-specific models for smoking

This study, a secondary analysis of prospective data of smokers, tested whether the causal relationships between the processes of change and decisional balance of the transtheoretical model of change (TTM) are stage-specific. It was expected that for smokers in the contemplation stage, higher levels of experiential processing cause the cons of smoking to become more important and the pros of smoking to become less important. In other words, the level of experiential process use was expected to causally influence decisional balance (pros minus cons) for people in the contemplation stage. For ex-smokers in the action stage, when the cons outweigh the pros (cons become more important while pros become less important), they should increase their behavioral process use: decisional balance was expected to causally influence use of behavioral processes. Cross-lagged panels were analyzed using structural equation modeling. Results indicate that experiential process use has causal predominance over decisional balance for smokers in the contemplation stage. For those in the action stage, however, neither decisional balance nor behavioral process had apparent causal predominance. Mean-level invariance indicates that the contemplation and action stages are different. Further analysis investigated smokers who progressed from contemplation to either preparation or action or from preparation to action. For these smokers who had progressed toward action, decisional balance did causally influence use of behavioral processes. This evidence provides support for the use of the TTM as the basis for planning interventions that target specific stage-dependent causal mechanisms.

Prenatal smoking cessation counseling by Texas obstetricians

BACKGROUND

Smoking during pregnancy causes 20 to 30 percent of low birthweight and 10 percent of infant mortality in the United States. Brief counseling can reduce rates of smoking. The study objectives were to describe Texas obstetricians' pregnancy smoking cessation counseling activity and to identify attributes associated with consistent, effective counseling.

METHODS

A survey was mailed to a random sample of Texas obstetricians.

RESULTS

A response rate of 44 percent (n = 204) was attained. A counseling coverage-effectiveness index was created based on the percentage of smokers counseled and use of specific techniques. Almost all respondents reported asking about smoking; fewer, however, reported counseling smokers. Physicians with low index scores, indicating inconsistent coverage, ineffective counseling, or both were dissatisfied with their current counseling, did not perceive counseling to decrease smoking, were not aware of the risks of smoking, and were unfamiliar with expert reports and recommendations for prenatal care.

CONCLUSIONS

Obstetricians who are not reached by expert reports and guidelines from groups outside their specialty or who do not perceive the seriousness of maternal smoking are less likely to counsel consistently and to use the most effective techniques. Continuing medical education at local, state, and national levels should be directed toward increasing knowledge and skills about smoking cessation counseling of pregnant women.