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.

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.

Understanding health behavior change among couples: An interdependence and communal coping approach

Marriage is a ubiquitous social status that consistently is linked to health. Despite this, there has been very little theory development or related research on the extent to which couple members are jointly motivated to and actively engage in health-enhancing behaviors. In this paper we propose an integrative model, based on interdependence theory and communal coping perspectives, that explicitly considers dyadic processes as determinants of couple behavior. Our integrated model applies these constructs to consider how couple dynamics might influence adoption of risk-reducing health habits. Accordingly, we suggest that the couple's interdependence can transform motivation from doing what is in the best interest of the self (person-centered), to doing even selfless actions that are best for the continuation of the relationship (relationship-centered). In turn, this transformation can lead to enhanced motivation for the couple to cope communally or act cooperatively in adopting health-enhancing behavior change. Implications for research related to couples and health behavior change are also highlighted.

Oncologist communication about emotion during visits with patients with advanced cancer

INTRODUCTION

Cancer care involves addressing patient emotion. When patients express negative emotions, empathic opportunities emerge. When oncologists respond with a continuer statement, which is one that offers empathy and allows patients to continue expressing emotions, rather than with a terminator statement, which is one that discourages disclosure, patients have less anxiety and depression and report greater satisfaction and adherence to therapy. We studied whether oncologist traits were associated with empathic opportunities and empathic responses.

PATIENTS AND METHODS

We audio-recorded 398 clinic conversations between 51 oncologists and 270 patients with advanced cancer; oncologists also completed surveys. Conversations were coded for the presence of empathic opportunities and oncologist responses. Analyses examined the relationship with oncologists' demographics, self-reported confidence, outcome expectancies, and comfort to address social versus technical aspects of care.

RESULTS

In 398 conversations, 37% contained at least one empathic opportunity; the range was 0 to 10, and the total empathic opportunities was 292. When they occurred, oncologists responded with continuers 22% of the time. Oncologist sex was related to the number of empathic opportunities; female patients seen by female oncologists had the most empathic opportunities (P = .03). Younger oncologists (P = .02) and those who rated their orientation as more socioemotional than technical (P = .03) were more likely to respond with empathic statements.

CONCLUSION

Oncologists encountered few empathic opportunities and responded with empathic statements infrequently. Empathic responses were more prevalent among younger oncologists and among those who were self-rated as socioemotional. To reduce patient anxiety and increase patient satisfaction and adherence, oncologists may need training to encourage patients to express emotions and to respond empathically to patients' emotions.

Enhancing communication between oncologists and patients with a computer-based training program: a randomized trial

BACKGROUND

Quality cancer care requires addressing patients' emotions, which oncologists infrequently do. Multiday courses can teach oncologists skills to handle emotion; however, such workshops are long and costly.

OBJECTIVE

To test whether a brief, computerized intervention improves oncologist responses to patient expressions of negative emotion.

DESIGN

Randomized, controlled, parallel-group trial stratified by site, sex, and oncologic specialty. Oncologists were randomly assigned to receive a communication lecture or the lecture plus a tailored CD-ROM. (ClinicalTrials.gov registration number: NCT00276627)

SETTING

Oncology clinics at a comprehensive cancer center and Veterans Affairs Medical Center in Durham, North Carolina, and a comprehensive cancer center in Pittsburgh, Pennsylvania.

PARTICIPANTS

48 medical, gynecologic, and radiation oncologists and 264 patients with advanced cancer.

INTERVENTION

Oncologists were randomly assigned in a 1:1 ratio to receive an interactive CD-ROM about responding to patients' negative emotions. The CD-ROM included tailored feedback on the oncologists' own recorded conversations.

MEASUREMENTS

Postintervention audio recordings were used to identify the number of empathic statements and responses to patients' expressions of negative emotion. Surveys evaluated patients' trust in their oncologists and perceptions of their oncologists' communication skills.

RESULTS

Oncologists in the intervention group used more empathic statements (relative risk, 1.9 [95% CI, 1.1 to 3.3]; P = 0.024) and were more likely to respond to negative emotions empathically (odds ratio, 2.1 [CI, 1.1 to 4.2]; P = 0.028) than control oncologists. Patients of intervention oncologists reported greater trust in their oncologists than did patients of control oncologists (estimated mean difference, 0.1 [CI, 0.0 to 0.2]; P = 0.036). There was no significant difference in perceptions of communication skills.

LIMITATIONS

Long-term effects were not examined. The findings may not be generalizable outside of academic medical centers.

CONCLUSION

A brief computerized intervention improves how oncologists respond to patients' expressions of negative emotions.

PRIMARY FUNDING SOURCE

National Cancer Institute.

A Research Agenda for Communication Between Health Care Professionals and Patients Living With Serious Illness

IMPORTANCE

Poor communication by health care professionals contributes to physical and psychological suffering in patients living with serious illness. Patients may not fully understand their illness, prognosis, and treatment options or may not receive medical care consistent with their goals. Despite considerable research exploring the role of communication in this setting, many questions remain, and a clear agenda for communication research is lacking.

OBSERVATIONS

Through a consensus conference and subsequent activities, we reviewed the state of the science, identified key evidence gaps in understanding the impact of communication on patient outcomes, and created an agenda for future research. We considered 7 broad topics: shared decision making, advance care planning, communication training, measuring communication, communication about prognosis, emotion and serious illness communication, and cultural issues. We identified 5 areas in which further research could substantially move the field forward and help enhance patient care: measurement and methodology, including how to determine communication quality; mechanisms of communication, such as identifying the specific clinician behaviors that patients experience as both honest and compassionate, or the role of bias in the clinical encounter; alternative approaches to advance care planning that focus on the quality of serious illness communication and not simply completion of forms; teaching and disseminating communication skills; and approaches, such as economic incentives and other clinician motivators, to change communication behavior.

CONCLUSIONS

Our findings highlight the urgent need to improve quality of communication between health care professionals and patients living with serious illness through a broad range of research that covers communication skills, tools, patient education, and models of care.

Sexuality talk during adolescent health maintenance visits

IMPORTANCE

Physicians may be important sources of sexuality information and preventive services, and one-on-one confidential time during health maintenance visits is recommended to allow discussions of sexual development, behavior, and risk reduction. However, little is known about the occurrence and characteristics of physician-adolescent discussions about sexuality.

OBJECTIVE

To examine predictors of time spent discussing sexuality, level of adolescent participation, and physician and patient characteristics associated with sexuality discussions during health maintenance visits by early and middle adolescents.

DESIGN, SETTING, AND PARTICIPANTS

Observational study of audio-recorded conversations between 253 adolescents (mean age, 14.3 years; 53% female; 40% white; 47% African American) and 49 physicians (82% pediatricians; 84% white; 65% female; mean age, 40.9 years; mean [SD] duration in practice, 11.8 [8.7] years) coded for sexuality content at 11 clinics (3 academic and 8 community-based practices) located throughout the Raleigh/Durham, North Carolina, area.

MAIN OUTCOMES AND MEASURES

Total time per visit during which sexuality issues were discussed. RESULTS One hundred sixty-five (65%) of all visits had some sexual content within it. The average time of sexuality talk was 36 seconds (35% 0 seconds; 30% 1-35 seconds; and 35% ≥ 36 seconds). Ordinal logistic regression (outcome of duration: 0, 1-35, or ≥ 36 seconds), adjusted for clustering of patients within physicians, found that female patients (odds ratio [OR] = 2.58; 95% CI, 1.53-4.36), older patients (OR = 1.37; 95% CI, 1.13-1.65), conversations with explicit confidentiality discussions (OR = 4.33; 95% CI, 2.58-7.28), African American adolescents (OR = 1.58; 95% CI, 1.01-2.48), and longer overall visit (OR = 1.07; 95% CI, 1.03-1.11) were associated with more sexuality talk, and Asian physicians were associated with less sexuality talk (OR = 0.13; 95% CI, 0.08-0.20). In addition, the same significant associations between adolescent, physician, and visit characteristics were significantly associated with greater adolescent participation.

CONCLUSIONS AND RELEVANCE

Our study may be the first to directly observe sexuality talk between physicians and adolescents. We found that one-third of all adolescents had annual visits without any mention of sexuality issues; when sexuality talk occurred, it was brief. Research is needed to identify successful strategies physicians can use to engage adolescents in discussions about sexuality to help promote healthy sexual development and decision making.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01040975.

Nicotine replacement and behavioral therapy for smoking cessation in pregnancy

BACKGROUND

This study examines whether adding nicotine replacement therapy (NRT) to cognitive-behavioral therapy (CBT) for pregnant smokers increases rates of smoking cessation.

METHODS

An open-label randomized trial (Baby Steps, n=181) of CBT-only versus CBT+NRT (choice of patch, gum, or lozenge; 1:2 randomization) was used. Data were collected from 2003 through 2005; analyses were conducted in 2006 and 2007. Outcomes were biochemically validated self-reported smoking status at 7 weeks post-randomization, 38 weeks gestation, and 3 months postpartum.

RESULTS

Women in the CBT+NRT arm were almost three times more likely than women in the CBT-only arm to have biochemically validated cessation at both pregnancy time points (after 7 weeks: 24% vs 8%, p=0.02; at 38 weeks gestation: 18% vs 7%, p=0.04), but not at 3 months postpartum (20% vs 14%, p=0.55). Recruitment was suspended early by an Independent Data and Safety Monitoring Board when an interim analysis found a higher rate of negative birth outcomes in the CBT+NRT arm than in the CBT-only arm. In the final analysis, the difference between the arms in rate of negative birth outcomes was 0.09 (p=0.26), when adjusted for previous history of preterm birth.

CONCLUSIONS

The addition of NRT to CBT promoted smoking cessation in pregnant women. This effect did not persist postpartum. More data are needed to determine safety parameters and to confirm the efficacy of NRT use during pregnancy.

Hypertension improvement project: randomized trial of quality improvement for physicians and lifestyle modification for patients

Despite widely publicized hypertension treatment guidelines for physicians and lifestyle recommendations for patients, blood pressure control rates remain low. In community-based primary care clinics, we performed a nested, 2 x 2 randomized, controlled trial of physician intervention versus control and/or patient intervention versus control. Physician intervention included internet-based training, self-monitoring, and quarterly feedback reports. Patient intervention included 20 weekly group sessions followed by 12 monthly telephone counseling contacts and focused on weight loss, Dietary Approaches to Stop Hypertension dietary pattern, exercise, and reduced sodium intake. The primary outcome was change in systolic blood pressure at 6 months. Eight primary care practices (32 physicians) were randomized to physician intervention or control groups. Within those practices, 574 patients were randomized to patient intervention or control groups. Patient mean age was 60 years, 61% were women, and 37% were black. Blood pressure data were available for 91% of patients at 6 months. The main effect of physician intervention on systolic blood pressure at 6 months, adjusted for baseline pressure, was 0.3 mm Hg (95% CI: 1.5 to 2.2; P=0.72). The main effect of the patient intervention was 2.6 mm Hg (95% CI: 4.4 to 0.7; P=0.01). The interaction of the 2 interventions was significant (P=0.03); the largest impact was observed with the combination of physician and patient intervention (9.7 +/- 12.7 mm Hg). Differences between treatment groups did not persist at 18 months. Combined physician and patient interventions lowers blood pressure; future research should focus on enhancing effectiveness and sustainability of these interventions.

Perceptions of patients' self-efficacy for managing pain and lung cancer symptoms: correspondence between patients and family caregivers

This study examined the degree of correspondence between lung cancer patients and their family caregivers in their perceptions of the patients' self-efficacy for managing pain and other symptoms of lung cancer, and the association of this correspondence to demographic, disease, and psychosocial variables. Thirty patients who were newly diagnosed with lung cancer and their primary family caregivers completed telephone interviews assessing the patient's symptoms, the patient's self-efficacy for managing symptoms, the quality of the relationship between the patient and caregiver, patient and caregiver psychological distress, and caregiver strain. Although patients and their caregivers showed a moderate degree of agreement in their perceptions of the patient's self-efficacy for managing pain and other symptoms, there was considerable variability in the degree of congruence. Factors that contributed to lower levels of congruence included low patient-rated self-efficacy, female gender of the patient, high patient psychological distress, and high caregiver strain. Caregivers were about evenly split in their tendency to overestimate versus underestimate the patient's self-efficacy. A poorer quality of relationship between the caregiver and the patient (as rated by the patient), high levels of patient-rated symptoms, and high levels of caregiver strain were associated with caregivers overestimating patient self-efficacy.

Understanding the role of cancer worry in creating a "teachable moment" for multiple risk factor reduction

The manuscript examines the influence of contextual factors on whether and for whom a colon polyp diagnosis might be a teachable moment, as indicated by engagement with a proactively delivered intervention. Baseline and 8-month follow-up data were analyzed from a two-site behavioral intervention trial with patients in Massachusetts and North Carolina, USA who had recently undergone polypectomy for pre-cancerous colon polyps and were randomized to a behavior change intervention condition (N=591). Intervention "buy-in" was used as an indicator of response consistent with the polyp identification serving as a teachable moment. Cancer worry, personal risk, health-related self-identity and other sociodemographic factors were tested to predict intervention buy-in. As predicted, those who were most worried about colon cancer were most likely to engage in the intervention. One indicator of personal risk, number of risk behaviors, was significantly and negatively associated with buy-in. Predictors of intervention buy-in and cancer worry were not consistent. We recommend that expanded measures of affect and health-related self-identity should be considered in future research to understand the motivational potential of health events for increasing engagement in effective behavior change interventions.

The impact of physician weight discussion on weight loss in US adults

PROBLEM

The increasing prevalence of overweight and obesity in the United States and worldwide is at epidemic levels. Physicians may play a vital role in addressing this epidemic. We aimed to examine the association of a physician's discussion of patients’ weight status with self-reported weight loss. We hypothesized that physician discussion of patients’ being overweight is associated with increased weight loss in patients with overweight and obesity.

METHODS

Data analysis of participants (n = 5054) in the National Health and Nutritional Examination Survey (NHANES) in 2005-2008. The main outcome was rates of self-reported weight loss and the association with physicians’ discussion of their patients’ weight status.

RESULTS

Overweight and obese participants were significantly more likely to report a 5% weight loss in the past year if their doctor had told them they were overweight (adjusted OR (AOR) 1.88; 95% CI 1.45-2.44; AOR 1.79; 95% CI 1.30-2.46, respectively).

CONCLUSIONS

Physicians’ direct discussion of their patients’ weight status is associated with clinically significant patient weight loss and may be a targetable intervention. Further studies are needed to determine if increasing physician discussion of patients’ weight status leads to significant weight loss.

Can metaphors and analogies improve communication with seriously ill patients?

OBJECTIVE

It is not known how often physicians use metaphors and analogies, or whether they improve patients' perceptions of their physicians' ability to communicate effectively. Therefore, the objective of this study was to determine whether the use of metaphors and analogies in difficult conversations is associated with better patient ratings of their physicians' communication skills.

DESIGN

Cross-sectional observational study of audio-recorded conversations between patients and physicians.

SETTING

Three outpatient oncology practices.

PATIENTS

Ninety-four patients with advanced cancer and 52 physicians.

INTERVENTION

None.

MAIN OUTCOME MEASURES

Conversations were reviewed and coded for the presence of metaphors and analogies. Patients also completed a 6-item rating of their physician's ability to communicate.

RESULTS

In a sample of 101 conversations, coders identified 193 metaphors and 75 analogies. Metaphors appeared in approximately twice as many conversations as analogies did (65/101, 64% versus 31/101, 31%; sign test p < 0.001). Conversations also contained more metaphors than analogies (mean 1.6, range 0-11 versus mean 0.6, range 0-5; sign rank test p < 0.001). Physicians who used more metaphors elicited better patient ratings of communication (rho = 0.27; p = 0.006), as did physicians who used more analogies (Spearman rho = 0.34; p < 0.001).

CONCLUSIONS

The use of metaphors and analogies may enhance physicians' ability to communicate.

Project PREVENT: A Randomized Trial to Reduce Multiple Behavioral Risk Factors for Colon Cancer

BACKGROUND

This report examines the outcome data for Project PREVENT, a two-site randomized control trial designed to reduce behavioral risk factors for colorectal cancer among individuals who have been diagnosed with adenomatous colon polyps.

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, and were randomized to either Usual Care (UC) or the PREVENT intervention, which was designed to target multiple risk factors. The intervention consisted of a telephone-delivered intervention plus tailored materials, and focused on the six primary behavioral risk factors for colorectal cancer, including red meat consumption, fruit and vegetable intake, multivitamin intake, alcohol, smoking, and physical inactivity.

RESULTS

Participation in the PREVENT intervention was associated with a significantly greater reduction in prevalence of multiple risk factors for colorectal cancer compared with UC. Only about one third of UC participants dropped any risk factors during the study period, compared with almost half of the PREVENT participants. PREVENT participants were also significantly more likely to change more than one behavior than UC participants.

CONCLUSIONS

The PREVENT intervention was effective in helping patients change multiple risk factors. These results provide further support that more comprehensive interventions that move beyond emphasis on a single risk factor are acceptable to patient populations, can result in improvements, and are cost effective.

Physicians' beliefs about discussing obesity: results from focus groups

PURPOSE

Physicians are expected to discuss weight loss with overweight and obese patients. Physicians' beliefs, outcome expectancies, and strategies for addressing weight with patients have not been examined.

DESIGN

Two focus groups of family physicians and internists included questions about obesity and how physicians discuss weight loss with patients.

SETTING/SUBJECTS

Family physicians (n = 11) and internists (n = 6) from Duke University Medical Center's Department of Community and Family Medicine and Department of Medicine.

ANALYSIS

Qualitative analysis approach using grounded theory methodology.

RESULTS

Physicians' responses centered on five key themes: (1) responsibility, (2) barriers, (3) target populations, (4) introducing topic, and (5) ways to talk about obesity.

CONCLUSION

Physicians have many barriers related to discussing weight loss with patients. Given the obesity epidemic, the need to understand how to have these discussions, when to have these discussions, and with whom to have these discussions becomes paramount to providing effective care for patients with obesity. Limited physician training in weight-loss counseling explains why physicians find it challenging to discuss obesity with patients.

Negative emotions in cancer care: do oncologists' responses depend on severity and type of emotion?

OBJECTIVE

To examine how type and severity of patients' negative emotions influence oncologists' responses and subsequent conversations.

METHODS

We analyzed 264 audio-recorded conversations between advanced cancer patients and their oncologists. Conversations were coded for patients' expressions of negative emotion, which were categorized by type of emotion and severity. Oncologists' responses were coded as using either empathic language or blocking and distancing approaches.

RESULTS

Patients presented fear more often than anger or sadness; severity of disclosures was most often moderate. Oncologists responded to 35% of these negative emotional disclosures with empathic language. They were most empathic when patients presented intense emotions. Responding empathically to patients' emotional disclosures lengthened discussions by an average of only 21s.

CONCLUSION

Greater response rates to severe emotions suggest oncologists may recognize negative emotions better when patients express them more intensely. Oncologists were least responsive to patient fear and responded with greatest empathy to sadness.

PRACTICE IMPLICATIONS

Oncologists may benefit from additional training to recognize negative emotions, even when displayed without intensity. Teaching cancer patients to better articulate their emotional concerns may also enhance patient-oncologist communication.

Effects of counseling techniques on patients' weight-related attitudes and behaviors in a primary care clinic

OBJECTIVE

Examine primary care physicians' use of counseling techniques when treating overweight and obese patients and the association with mediators of behavior change as well as change in nutrition, exercise, and weight loss attempts.

METHODS

We audio recorded office encounters between 40 physicians and 461 patients. Encounters were coded for physician use of selected counseling techniques using the Motivational Interviewing Treatment Integrity (MITI) scale. Patient motivation and confidence as well as Fat and Fiber Diet score (1-4), Framingham physical activity questionnaire (MET-minutes), and weight loss attempts (yes/no) were assessed by surveys. Generalized linear models were fit, including physician, patient, and visit level covariates.

RESULTS

Patients whose physicians were rated higher in empathy improved their Fat and Fiber intake 0.18 units (95% CI 0, 0.4). When physicians used "MI consistent" techniques, patients reported higher confidence to improve nutrition (OR 2.57, 95% CI 1.2, 5.7).

CONCLUSION

When physicians used counseling techniques consistent with MI principles, some of their patients' weight-related attitudes and behaviors improved.

PRACTICE IMPLICATIONS

Physicians may not be able to employ formal MI during a clinic visit. However, use of counseling techniques consistent with MI principles, such as expression of empathy, may improve patients' weight-related attitudes and behaviors.

Use of email in a family practice setting: opportunities and challenges in patient- and physician-initiated communication

BACKGROUND

Electronic mail (email) has the potential to improve communication between physicians and patients.

METHODS

We conducted two research studies in a family practice setting: 1) a brief, anonymous patient survey of a convenience sample to determine the number of clinic patients receptive to communicating with their physician via email, and 2) a randomized, controlled pilot study to assess the feasibility of providing health education via email to family practice patients.

RESULTS

Sixty-eight percent of patients used email, and the majority of those (80%) were interested in using email to communicate with the clinic. The majority also reported that their email address changed less frequently than their home address (65%, n = 173) or telephone number (68%, n = 181). Forty-two percent were willing to pay an out-of-pocket fee to have email access to their physicians. When evaluating email initiated by the clinic, 26% of otherwise eligible patients could not participate because they lacked email access; those people were more likely to be black and to be insured through Medicaid. Twenty-four subjects agreed to participate, but one-third failed to return the required consent form by mail. All participants who received the intervention emails said they would like to receive health education emails in the future.

CONCLUSION

Our survey results show that patients are interested in email communication with the family practice clinic. Our feasibility study also illustrates important challenges in physician-initiated electronic communication. The 'digital divide' - decreased access to electronic technologies in lower income groups - is an ethical concern in the use of email for patient-physician communication.

Estimated time spent on preventive services by primary care physicians

BACKGROUND

Delivery of preventive health services in primary care is lacking. One of the main barriers is lack of time. We estimated the amount of time primary care physicians spend on important preventive health services.

METHODS

We analyzed a large dataset of primary care (family and internal medicine) visits using the National Ambulatory Medical Care Survey (2001-4); analyses were conducted 2007-8. Multiple linear regression was used to estimate the amount of time spent delivering each preventive service, controlling for demographic covariates.

RESULTS

Preventive visits were longer than chronic care visits (M = 22.4, SD = 11.8, M = 18.9, SD = 9.2, respectively). New patients required more time from physicians. Services on which physicians spent relatively more time were prostate specific antigen (PSA), cholesterol, Papanicolaou (Pap) smear, mammography, exercise counseling, and blood pressure. Physicians spent less time than recommended on two "A" rated ("good evidence") services, tobacco cessation and Pap smear (in preventive visits), and one "B" rated ("at least fair evidence") service, nutrition counseling. Physicians spent substantial time on two services that have an "I" rating ("inconclusive evidence of effectiveness"), PSA and exercise counseling.

CONCLUSION

Even with limited time, physicians address many of the "A" rated services adequately. However, they may be spending less time than recommended for important services, especially smoking cessation, Pap smear, and nutrition counseling. Future research is needed to understand how physicians decide how to allocate their time to address preventive health.

Adherence to nicotine replacement therapy among pregnant smokers

INTRODUCTION

This secondary analysis examined the association between adherence to nicotine replacement therapy (NRT) and smoking cessation among pregnant smokers enrolled in Baby Steps, an open-label randomized controlled trial testing cognitive-behavioral therapy (CBT) versus CBT plus NRT.

METHOD

The analysis included only women who received NRT for whom we had complete data (N = 104). Data came from daily calendars created from recordings of counseling sessions and from telephone surveys at baseline and 38 weeks gestation.

RESULTS

Overall, 29% of the 104 women used NRT for the recommended 6 weeks and 41% used NRT as directed in the first 48 hr after a quit attempt. Ordinal logistic regression modeling indicated that using NRT as directed in the first 48 hr and having made a previous quit attempt were the strongest predictors of longer NRT use. Univariate analyses suggested that primigravid women and women who used NRT longer were more likely to report quitting at 38 weeks gestation.

DISCUSSION

Findings indicated that adherence to NRT is low among pregnant smokers, but adherence was a predictor of cessation. Future trials should emphasize adherence, particularly more days on NRT, to promote cessation during pregnancy.

Studying communication in oncologist-patient encounters: the SCOPE Trial

STUDY OBJECTIVE

Most oncologists have not received adequate training in physician-patient communication, and existing effective courses tend to be time and resource intensive. We are developing and testing a tailored CD-ROM educational intervention that includes feedback on oncologists' own audio-recorded conversations with their advanced cancer patients. In this report, we describe the study methods and identify challenges to implementation and how these were overcome.

STUDY DESIGN

A three-phase, randomized, controlled trial. In Phase 1, we audio-recorded oncologist-patient clinic encounters. In Phase 2, oncologists were randomly assigned to a communication CD-ROM intervention or control. Phase 3 consisted of audio-recording all participating oncologists conversing with a new sample of patients, two to 12 months after the intervention, to assess its effectiveness.

SETTING

Oncology clinics at Duke University Medical Center (DUMC) and the Durham Veterans Affairs Medical Center (DVAMC) in Durham, NC, and the University of Pittsburgh Medical Center (UPMC) in Pittsburgh, PA.

PARTICIPANTS

Medical, radiation and gynecological oncologists and their patients with advanced cancer.

INTERVENTION

A tailored CD-ROM that contains an interactive educational interface with reference materials and video-clips of model conversations, along with the oncologists' own Phase 1 audio-recorded conversations.

CONCLUSION

We present challenges and solutions to oncologist recruitment, identifying appropriate patients with advanced cancer, adapting to clinic flow, and developing a self-administered communications intervention.

How oncologists and their patients with advanced cancer communicate about health-related quality of life

OBJECTIVE

To describe the content and frequency of communication about health-related quality of life (HRQOL) during outpatient encounters between oncologists and their patients with advanced cancer.

METHODS

We coded for HRQOL talk in a subset of audio-recorded conversations (each previously found to contain prognostic talk by the oncologist) from the Study of Communication in Oncologist-Patient Encounters Trial, a randomized controlled trial conducted from 2003 to 2008 in two large US academic medical centers and one Veterans Affairs Medical Center.

RESULTS

Seventy-three encounters involved 70 patients and 37 oncologists. Patients were more likely to be female (53%), White (86%), married (78%), and possessing some college education (62%). Most oncologists were male (78%) and White (78%). Mean ages were 59 years for patients and 44 years for oncologists. Every encounter included some talk about HRQOL and HRQOL discussions made up, on average, 25% of the visit time. HRQOL segments described symptoms (50%), general HRQOL (27%), and the following concerns: physical (27%), functional (22%), psychological (9%), social (7%), spiritual (1%), and other (28%). Topics included treatment (56%), disease (14%), and testing (3%), and conversations focused on past (44%), present (68%), and future HRQOL (59%).

CONCLUSIONS

HRQOL discussions between oncologists and patients are common, but the emphasis is often on treatment (e.g. side effects) and symptoms (e.g. pain) even in patients with advanced disease. Given the often intense emotional experience of patients with advanced cancer, oncologists may need to pay more attention to psychological, social, and spiritual HRQOL concerns.

Weight-related SMS texts promoting appropriate pregnancy weight gain: a pilot study

OBJECTIVES

Excessive gestational weight gain (GWG) puts women and children at risk of obesity. We piloted an SMS-texting intervention to promote healthy GWG among overweight and obese women.

METHODS

We recruited 35 women and randomized them in a 2:1 fashion to: a tailored SMS-texting intervention (Preg CHAT) vs. a generic texting intervention (Txt4baby). Preg CHAT texts provided personalized feedback based on women's intake of sweetened beverages, fruits and vegetables, fast food, daily steps taken, and weight. We abstracted women's weights from charts and surveyed women at baseline and 32 weeks gestation.

RESULTS

Few women refused the study; many (30%) did not complete the study, however. Of those in the Preg CHAT arm, 86% responded to texts, and 80% said they would recommend this program to a friend. For women who completed the surveys (n=23), those in the Preg CHAT arm had a mean gain of 6 less pounds than women in the Txt4Baby arm (95% CI -15.9, 4.0; p=0.24).

CONCLUSIONS

This pilot study shows feasibility, acceptability, and potential efficacy of a low-intensity and disseminable intervention to help overweight and obese women reduce GWG.

PRACTICE IMPLICATIONS

An SMS texting program might help overweight women reduce excessive GWG.

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.