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The Impact of Team-Based Primary Care on Guideline-Recommended Disease Screening. Am J Prev Med 2020; 58:407-417. [PMID: 31952941 DOI: 10.1016/j.amepre.2019.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 10/20/2019] [Accepted: 10/21/2019] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Family Medicine Groups, implemented in Quebec in 2002, are interprofessional primary care teams designed to improve timely access to high-quality primary care. This study investigates whether Family Medicine Groups increased rates of guideline-recommended screenings for 3 chronic diseases: colorectal cancer (colonoscopy/sigmoidoscopy), breast cancer (mammography), and osteoporosis (bone mineral density testing). METHODS Using population-based administrative health data from the provincial insurer (2000-2010), the authors examined elderly and chronically ill patients who registered with a general practitioner in the first 15 months of the Family Medicine Group policy. Propensity score weighting and a difference-in-differences model estimated differential change in biennial screening rates among Family Medicine Group and non-Family Medicine Group patients over 5 years of follow-up (analysis, 2016-2018). RESULTS Rates of mammography, colonoscopy/sigmoidoscopy, and bone mineral density testing increased after patient registration with a general practitioner, similarly for both Family Medicine Group and non-Family Medicine Group patients. Colonoscopy/sigmoidoscopy rates increased by 9.7% and 10.4% for Family Medicine Group and non-Family Medicine Group patients, mammography rates by 5.3% and 3.4%, and bone mineral density testing by 4.2% and 7.1%. Difference-in-differences estimates showed no detectable effect of Family Medicine Groups on disease screening rates: -0.06 percentage points (95% CI= -0.32, 0.20) for colonoscopy/sigmoidoscopy, 1.01 percentage points (95% CI= -0.25, 2.27) for mammography, and -0.32 (95% CI= -0.71, -0.07) for bone mineral density testing. CONCLUSIONS This study found no evidence that Family Medicine Groups affected screening rates for these 3 chronic diseases. Limitations in the implementation of the Family Medicine Group policy in its early years may have contributed to this lack of impact. Interprofessional primary care teams may need to include elements other than organizational changes to increase disease prevention efforts.
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Krist AH, Tong ST, Aycock RA, Longo DR. Engaging Patients in Decision-Making and Behavior Change to Promote Prevention. Stud Health Technol Inform 2017; 240:284-302. [PMID: 28972524 PMCID: PMC6996004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Effectively engaging patients in their care is essential to improve health outcomes, improve satisfaction with the care experience, reduce costs, and even benefit the clinician experience. This chapter will address the topic of patient engagement directly and review the relationships between health literacy and patient engagement. While there are many ways to define patient and family engagement, this chapter will consider engagement as "patients, families, their representatives, and health professionals working in active partnership at various levels across the health care system - direct care, organizational design and governance, and policy making - to improve health and health care [1]." We will specifically focus on the patient engagement and health literacy needs for three scenarios (1) decision-making, (2) health behavior change, and (3) chronic disease management; we will include the theoretical underpinnings of engagement, the systems required to better support patient engagement, how social determinants of health influence patient engagement, and practical examples to demonstrate approaches to better engage patients in their health and wellbeing. We will close by describing the future of patient engagement, which extends beyond the traditional domains of decision-making and self-care to describe how patient engagement can influence the design of the healthcare delivery system; local, state, and national health policies; and future research relevant to the needs and experiences of patients.
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Affiliation(s)
- Alex H. Krist
- Corresponding author: Alex H. Krist, One Capital Square Room 631, 830 East Main Street, Richmond VA 23219.
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DiClemente RJ, Murray CC, Graham T, Still J. Overcoming barriers to HPV vaccination: A randomized clinical trial of a culturally-tailored, media intervention among African American girls. Hum Vaccin Immunother 2015; 11:2883-94. [PMID: 26378650 DOI: 10.1080/21645515.2015.1070996] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
Although genital HPV is the most prevalent STI in the US, rates of vaccination uptake among high-risk subgroups remain low. Investigations of vaccine compliance have mainly targeted mother-daughter dyads, which in some settings may prove difficult. This study examines an innovative culturally tailored, computer-delivered media-based strategy to promote HPV vaccine uptake. Data, inclusive of sociodemographics, sexual behaviors, knowledge, attitudes, and beliefs about HPV and vaccination were collected via ACASI from 216 African American adolescent females (ages 14-18 years) seeking services in family planning and STI public health clinics in metropolitan Atlanta. Data were obtained prior to randomization and participation in an interactive media-based intervention designed to increase HPV vaccination uptake. Medical record abstraction was conducted 7 month post-randomization to assess initial vaccine uptake and compliance. Participants in the intervention were more compliant to vaccination relative to a placebo comparison condition (26 doses vs. Seventeen doses; p=0.12). However, vaccination series initiation and completion were lower than the national average. Thorough evaluation is needed to better understand factors facilitating HPV vaccine uptake and compliance, particularly perceived susceptibility and the influence of the patient-provider encounter in a clinical setting.
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Affiliation(s)
- Ralph J DiClemente
- a Department of Behavioral Sciences and Health Education ; Emory University Rollins School of Public Health ; Atlanta , GA USA.,b Department of Pediatrics ; Division of Infectious Diseases, Epidemiology, and Immunology; Emory University School of Medicine ; Atlanta , GA USA
| | | | - Tracie Graham
- d Office of Academic Advancement; Emory University Nell Hodgson Woodruff School of Nursing ; Atlanta , GA USA
| | - Julia Still
- e Salud Para La Gente ; Watsonville , CA USA
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LaBresh KA, Ariza AJ, Lazorick S, Furberg RD, Whetstone L, Hobbs C, de Jesus J, Salinas IG, Bender RH, Binns HJ. Adoption of cardiovascular risk reduction guidelines: a cluster-randomized trial. Pediatrics 2014; 134:e732-8. [PMID: 25157013 PMCID: PMC4144001 DOI: 10.1542/peds.2014-0876] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/19/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Cardiovascular disease (CVD) and underlying atherosclerosis begin in childhood and are related to CVD risk factors. This study evaluates tools and strategies to enhance adoption of new CVD risk reduction guidelines for children. METHODS Thirty-two practices, recruited and supported by 2 primary care research networks, were cluster randomized to a multifaceted controlled intervention. Practices were compared with guideline-based individual and composite measures for BMI, blood pressure (BP), and tobacco. Composite measures were constructed by summing the numerators and denominators of individual measures. Preintervention and postintervention measures were assessed by medical record review of children ages 3 to 11 years. Changes in measures (pre-post and intervention versus control) were compared. RESULTS The intervention group BP composite improved by 29.5%, increasing from 49.7% to 79.2%, compared with the control group (49.5% to 49.6%; P < .001). Intervention group BP interpretation improved by 61.1% (from 0.2% to 61.3%), compared with the control group (0.4% to 0.6%; P < .001). The assessment of tobacco exposure or use for 5- to 11-year-olds in the intervention group improved by 30.3% (from 3.4% to 49.1%) versus the control group (0.6% to 21.4%) (P = .042). No significant change was seen in the BMI or tobacco composites measures. The overall composite of 9 measures improved by 13.4% (from 48.2% to 69.8%) for the intervention group versus the control group (47.4% to 55.2%) (P = .01). CONCLUSIONS Significant improvement was demonstrated in the overall composite measure, the composite measure of BP, and tobacco assessment and advice for children aged 5 to 11 years.
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Affiliation(s)
| | - Adolfo J Ariza
- Pediatric Practice Research Group, Mary Ann & J. Milburn Smith Child Health Research Program, Stanley Manne Children's Research Institute, Chicago, Illinois; Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Suzanne Lazorick
- Brody School of Medicine, Departments of Pediatrics and Public Health, East Carolina University, Greenville North Carolina
| | | | - Lauren Whetstone
- Brody School of Medicine, Departments of Pediatrics and Public Health, East Carolina University, Greenville North Carolina; Public Health Institute, Research and Evaluation Section Nutrition Education and Obesity Prevention Branch, California Department of Public Health, Sacramento, California; and
| | | | - Janet de Jesus
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Ilse G Salinas
- Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | | | - Helen J Binns
- Pediatric Practice Research Group, Mary Ann & J. Milburn Smith Child Health Research Program, Stanley Manne Children's Research Institute, Chicago, Illinois
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Noël PH, Parchman ML, Palmer RF, Romero RL, Leykum LK, Lanham HJ, Zeber JE, Bowers KW. Alignment of patient and primary care practice member perspectives of chronic illness care: a cross-sectional analysis. BMC FAMILY PRACTICE 2014; 15:57. [PMID: 24678983 PMCID: PMC3974922 DOI: 10.1186/1471-2296-15-57] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/21/2013] [Accepted: 03/20/2014] [Indexed: 11/17/2022]
Abstract
Background Little is known as to whether primary care teams’ perceptions of how well they have implemented the Chronic Care Model (CCM) corresponds with their patients’ own experience of chronic illness care. We examined the extent to which practice members’ perceptions of how well they organized to deliver care consistent with the CCM were associated with their patients’ perceptions of the chronic illness care they have received. Methods Analysis of baseline measures from a cluster randomized controlled trial testing a practice facilitation intervention to implement the CCM in small, community-based primary care practices. All practice “members” (i.e., physician providers, non-physician providers, and staff) completed the Assessment of Chronic Illness Care (ACIC) survey and adult patients with 1 or more chronic illnesses completed the Patient Assessment of Chronic Illness Care (PACIC) questionnaire. Results Two sets of hierarchical linear regression models accounting for nesting of practice members (N = 283) and patients (N = 1,769) within 39 practices assessed the association between practice member perspectives of CCM implementation (ACIC scores) and patients’ perspectives of CCM (PACIC). ACIC summary score was not significantly associated with PACIC summary score or most of PACIC subscale scores, but four of the ACIC subscales [Self-management Support (p < 0.05); Community Linkages (p < 0.02), Delivery System Design (p < 0.02), and Organizational Support (p < 0.02)] were consistently associated with PACIC summary score and the majority of PACIC subscale scores after controlling for patient characteristics. The magnitude of the coefficients, however, indicates that the level of association is weak. Conclusions The ACIC and PACIC scales appear to provide complementary and relatively unique assessments of how well clinical services are aligned with the CCM. Our findings underscore the importance of assessing both patient and practice member perspectives when evaluating quality of chronic illness care. Trial registration NCT00482768
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Affiliation(s)
- Polly H Noël
- South Texas Veterans Health Care System, 7400 Merton Minter Blvd, San Antonio, TX 78229, USA.
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Klabunde CN, Clauser SB, Liu B, Pronk NP, Ballard-Barbash R, Huang TTK, Smith AW. Organization of Primary Care Practice for Providing Energy Balance Care. Am J Health Promot 2014; 28:e67-80. [DOI: 10.4278/ajhp.121219-quan-626] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose. Primary care physicians (PCPs) may not adequately counsel or monitor patients regarding diet, physical activity, and weight control (i.e., provide energy balance care). We assessed the organization of PCPs' practices for providing this care. Design. The study design was a nationally representative survey conducted in 2008. Setting. The study setting was U.S. primary care practices. Subjects. A total of 1740 PCPs completed two sequential questionnaires (response rate, 55.5%). Measures. The study measured PCPs' reports of practice resources, and the frequency of body mass index assessment, counseling, referral for further evaluation/management, and monitoring of patients for energy balance care. Analysis. Descriptive statistics and logistic regression modeling were used. Results. More than 80% of PCPs reported having information resources on diet, physical activity, or weight control available in waiting/exam rooms, but fewer billed (45%), used reminder systems (< 30%), or received incentive payments (3%) for energy balance care. A total of 26% reported regularly assessing body mass index and always/often providing counseling as well as tracking patients for progress related to energy balance. In multivariate analyses, PCPs in practices with full electronic health records or those that bill for energy balance care provided this care more often and more comprehensively. There were strong specialty differences, with pediatricians more likely (odds ratio, 1.78; 95% confidence interval, 1.26–2.51) and obstetrician/gynecologists less likely (odds ratio, 0.28; 95% confidence interval, 0.17–0.44) than others to provide energy balance care. Conclusion. PCPs' practices are not well organized for providing energy balance care. Further research is needed to understand PCP care-related specialty differences.
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Meltzer DO, Chung JW. The Population Value Of Quality Indicator Reporting: A Framework For Prioritizing Health Care Performance Measures. Health Aff (Millwood) 2014; 33:132-9. [DOI: 10.1377/hlthaff.2011.1283] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- David O. Meltzer
- David O. Meltzer ( ) is an associate professor in the Department of General Internal Medicine, University of Chicago, in Illinois
| | - Jeanette W. Chung
- Jeanette W. Chung is a research assistant professor in surgical oncology at Northwestern University, in Chicago
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Jimbo M, Rana GK, Hawley S, Holmes-Rovner M, Kelly-Blake K, Nease DE, Ruffin MT. What is lacking in current decision aids on cancer screening? CA Cancer J Clin 2013; 63:193-214. [PMID: 23504675 PMCID: PMC3644368 DOI: 10.3322/caac.21180] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Recent guidelines on cancer screening have provided not only more screening options but also conflicting recommendations. Thus, patients, with their clinicians' support, must decide whether to get screened, which modality to use, and how often to undergo screening. Decision aids could potentially lead to better shared decision-making regarding screening between the patient and the clinician. A total of 73 decision aids concerning screening for breast, cervical, colorectal, and prostate cancers were reviewed. The goal of this review was to assess the effectiveness of such decision aids, examine areas in need of more research, and determine how the decision aids can be currently applied in the real-world setting. Most studies used sound study designs. Significant variation existed in the setting, theoretical framework, and measured outcomes. Just over one-third of the decision aids included an explicit values clarification. Other than knowledge, little consistency was noted with regard to which patient attributes were measured as outcomes. Few studies actually measured shared decision-making. Little information was available regarding the feasibility and outcomes of integrating decision aids into practice. In this review, the implications for future research, as well as what clinicians can do now to incorporate decision aids into their practice, are discussed.
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Affiliation(s)
- Masahito Jimbo
- Departments of Family Medicine and Urology, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48109-0708, Phone: (734) 998-7120 Ext 334, Fax: (734) 998-7335
| | - Gurpreet K. Rana
- Taubman Health Sciences Library, University of Michigan, 1135 E. Catherine, Ann Arbor, MI 48109-0726, Phone: (734) 936-1399, Fax: (734) 763-1473
| | - Sarah Hawley
- Departments of Internal Medicine and Health Management and Policy, University of Michigan, NCRC 2800 Plymouth Road Building, 16/406E, Ann Arbor, MI 48109-2800, Phone: (734) 936-8816
| | - Margaret Holmes-Rovner
- Health Services Research, Center for Ethics and Department of Medicine, Michigan State University College of Human Medicine, 965 Fee Road Rm C203, East Lansing, MI, 48824-1316, Phone: (517) 353-5197
| | - Karen Kelly-Blake
- Center for Ethics and Humanities in the Life Sciences, Michigan State University College of Human Medicine, East Fee Hall, 965 Fee Road Room C215, East Lansing, MI 48824, Phone: (517) 353-8582, Fax: (517) 353-3289
| | - Donald E. Nease
- Department of Family Medicine and Colorado Health Outcomes Program, University of Colorado – Denver, 13199 E. Montview Blvd, Suite 300, Mail Stop F443, Aurora, CO 80045, Phone: (303) 724-6270, Fax: (303) 724-1839
| | - Mack T. Ruffin
- Associate Chair for Research Programs, Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48109-0708, Phone: (734) 998-7120 Ext 310, Fax: (734) 998-7335
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Shires DA, Stange KC, Divine G, Ratliff S, Vashi R, Tai-Seale M, Lafata JE. Prioritization of evidence-based preventive health services during periodic health examinations. Am J Prev Med 2012; 42:164-73. [PMID: 22261213 PMCID: PMC3262983 DOI: 10.1016/j.amepre.2011.10.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 09/20/2011] [Accepted: 10/14/2011] [Indexed: 01/12/2023]
Abstract
BACKGROUND Delivery of preventive services sometimes falls short of guideline recommendations. PURPOSE To evaluate the multilevel factors associated with evidence-based preventive service delivery during periodic health examinations (PHEs). METHODS Primary care physicians were recruited from an integrated delivery system in southeast Michigan. Audio recordings of PHE office visits conducted from 2007 to 2009 were used to ascertain physician recommendation for or delivery of 19 guideline-recommended preventive services. Alternating logistic regression was used to evaluate factors associated with service delivery. Data analyses were completed in 2011. RESULTS Among 484 PHE visits to 64 general internal medicine and family physicians by insured patients aged 50-80 years, there were 2662 services for which patients were due; 54% were recommended or delivered. Regression analyses indicated that the likelihood of service delivery decreased with patient age and with each concern the patient raised, and it increased with increasing BMI and with each additional minute after the scheduled appointment time the physician first presented. The likelihood was greater with patient-physician gender concordance and less if the physician used the electronic medical record in the exam room or had seen the patient in the past 12 months. CONCLUSIONS A combination of patient, patient-physician relationship, and visit contextual factors are associated with preventive service delivery. Additional studies are warranted to understand the complex interplay of factors that support and compromise preventive service delivery.
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Affiliation(s)
- Deirdre A Shires
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan, USA
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Kirsh S, Hein M, Pogach L, Schectman G, Stevenson L, Watts S, Radhakrishnan A, Chardos J, Aron D. Improving Outpatient Diabetes Care. Am J Med Qual 2011; 27:233-40. [DOI: 10.1177/1062860611418491] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
More than 20% of patients in the Veterans Health Administration (VHA) have diabetes; therefore, disseminating “best practices” in outpatient diabetes care is paramount. The authors’ goal was to identify such practices and the factors associated with their development. First, a national VHA diabetes registry with 2008 data identified clinical performance based on the percentage of patients with an A1c >9%. Facilities (n = 140) and community-based outpatient clinics (n = 582) were included and stratified into high, mid, and low performers. Semistructured telephone interviews (31) and site visits (5) were conducted. Low performers cited lack of teamwork between physicians and nurses and inadequate time to prepare. Better performing sites reported supportive clinical teams sharing work, time for non-face-to-face care, and innovative practices to address local needs. A knowledge management model informed our process. Notable differences between performance levels exist. “Best practices” will be disseminated across the VHA as the VHA Patient-Centered Medical Home model is implemented.
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Affiliation(s)
- Susan Kirsh
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
- Case Western Reserve University, Cleveland, OH
| | - Michael Hein
- Veterans Affairs Nebraska-Western Iowa Health Care System, Grand Island, NE
| | - Leonard Pogach
- New Jersey Veterans Affairs Healthcare System, Trenton, NJ
- University of Medicine and Dentistry of New Jersey, Newark, NJ
| | - Gordon Schectman
- Clement J. Zablocki Milwaukee Veterans Affairs Medical Center and Medical College of Wisconsin, Milwaukee, WI
| | - Lauren Stevenson
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
| | - Sharon Watts
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
- Case Western Reserve University, Cleveland, OH
| | | | - John Chardos
- Palo Alto Veterans Affairs Medical Center, Palo Alto, CA
- Stanford University, Stanford, CA
| | - David Aron
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH
- Case Western Reserve University, Cleveland, OH
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Davis MA, Pavur RJ. The relationship between office system tools and evidence-based care in primary care physician practice. Health Serv Manage Res 2011; 24:107-13. [PMID: 21840895 DOI: 10.1258/hsmr.2010.010019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
A number of office system tools have been developed to improve the rates of preventive services and enhance the quality of medical care in practice settings. New approaches to measuring physician adherence to evidence-based standards of treatment, offer a unique opportunity to examine the link between the use of office system tools and evidence-based practices in primary care. Using episode-based profiling measures of adherence as the criterion, results from this investigation suggest that the application of simple physician reminders can be an effective technique for promoting evidence-based treatment. The data also reveal that the influence of health information technology (HIT) resources on adherence was not exclusively positive. Specifically, adherence to evidence-based standards was higher for primary care practices that employed HIT resources judiciously. In contrast, extensive use of personal digital assistants was negatively associated with adherence. Despite concerns directed towards the new generation of episode-based profiling measures, results from this research indicate that the measures behave similarly to traditional measures of quality.
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Affiliation(s)
- Mark A Davis
- Department of Management, College of Business, University of North Texas, Denton, USA.
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Ludt S, Campbell SM, van Lieshout J, Grol R, Szecsenyi J, Wensing M. Development and pilot of an internationally standardized measure of cardiovascular risk management in European primary care. BMC Health Serv Res 2011; 11:70. [PMID: 21473758 PMCID: PMC3080793 DOI: 10.1186/1472-6963-11-70] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Accepted: 04/07/2011] [Indexed: 11/18/2022] Open
Abstract
Background Primary care can play an important role in providing cardiovascular risk management in patients with established Cardiovascular Diseases (CVD), patients with a known high risk of developing CVD, and potentially for individuals with a low risk of developing CVD, but who have unhealthy lifestyles. To describe and compare cardiovascular risk management, internationally valid quality indicators and standardized measures are needed. As part of a large project in 9 European countries (EPA-Cardio), we have developed and tested a set of standardized measures, linked to previously developed quality indicators. Methods A structured stepwise procedure was followed to develop measures. First, the research team allocated 106 validated quality indicators to one of the three target populations (established CVD, at high risk, at low risk) and to different data-collection methods (data abstraction from the medical records, a patient survey, an interview with lead practice GP/a practice survey). Secondly, we selected a number of other validated measures to enrich the assessment. A pilot study was performed to test the feasibility. Finally, we revised the measures based on the findings. Results The EPA-Cardio measures consisted of abstraction forms from the medical-records data of established Coronary Heart Disease (CHD)-patients - and high-risk groups, a patient questionnaire for each of the 3 groups, an interview questionnaire for the lead GP and a questionnaire for practice teams. The measures were feasible and accepted by general practices from different countries. Conclusions An internationally standardized measure of cardiovascular risk management, linked to validated quality indicators and tested for feasibility in general practice, is now available. Careful development and pilot testing of the measures are crucial in international studies of quality of healthcare.
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Affiliation(s)
- Sabine Ludt
- Department of General Practice and Health Services Research, University of Heidelberg Hospital, Voßstrasse 2, D-69115 Heidelberg, Germany.
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Wilson DB, Johnson RE, Jones RM, Krist AH, Woolf SH, Flores SK. Patient weight counseling choices and outcomes following a primary care and community collaborative intervention. PATIENT EDUCATION AND COUNSELING 2010; 79:338-343. [PMID: 20338714 DOI: 10.1016/j.pec.2010.01.025] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Revised: 01/14/2010] [Accepted: 01/30/2010] [Indexed: 05/29/2023]
Abstract
OBJECTIVE Obesity has become a public health epidemic in adults and children. Clinician practices need new models to effectively address overweight in patients, yet, practices lack time and resources. We tested a clinician-delivered intervention that utilized community resources for in-depth counseling for unhealthy behaviors including overweight. METHODS Eligible patients in nine primary care practices were identified using an electronic linkage system (eLinkS) which also automated patient referrals to group (Weight Watcher's), telephone counseling (TC), or usual care. Pre/post-survey data were used to assess factors related to counseling choices as well as changes in BMI (kg/m(2)) and weight-related behaviors using descriptive statistics, unadjusted, and adjusted statistical analyses. RESULTS Study sample (n=146) was 70% female with a mean age of 57 years. More patients (57%) selected WW, followed by usual care (27%) or TC (16%). Age, gender, clinician recommendation, and counseling program characteristics were influential in counseling selections. Weight Watcher's participants and those in TC, reported statistically significant weight loss, WW participants also reported significant increases in fruit/vegetable intake; after 4 months compared with usual care. CONCLUSIONS This practice-based intervention utilizing community counseling referrals was associated with positive health behavior change. PRACTICE IMPLICATIONS Identifying influential factors related to patient weight counseling choices may help guide referrals to community programs.
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Affiliation(s)
- Diane B Wilson
- Department of Internal Medicine and Massey Cancer Center, Virginia Commonwealth University, Richmond, VA, USA.
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Rose GL, Plante DA, Thomas CS, Denton LJ, Helzer JE. Utility of prompting physicians for brief alcohol consumption intervention. Subst Use Misuse 2010; 45:936-50. [PMID: 20397878 PMCID: PMC3776315 DOI: 10.3109/10826080903534434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A comprehensive prompting strategy designed to maximize the rate of Brief Intervention (BI) for "heavy drinking" was implemented from 2001 to 2003 for a randomized controlled trial of a post-BI treatment enhancement. Thirty-one internists at four outpatient practices in a county of 150,000 in a rural US state documented their BI's using an intervention checklist. The prompting procedures implemented in this study yielded documented BI for 39% of identified cases, but participation rates varied by physician and clinic and over time. The overall rate was lower than expected. Implications and recommendations for future BI research and training are offered; the paper's limitations are discussed.
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Affiliation(s)
- Gail L Rose
- Department of Psychiatry, University of Vermont College of Medicine, Burlington, Vermont 05401, USA.
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Anhang Price R, Zapka J, Edwards H, Taplin SH. Organizational factors and the cancer screening process. J Natl Cancer Inst Monogr 2010; 2010:38-57. [PMID: 20386053 PMCID: PMC3731433 DOI: 10.1093/jncimonographs/lgq008] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Cancer screening is a process of care consisting of several steps and interfaces. This article reviews what is known about the association between organizational factors and cancer screening rates and examines how organizational strategies can address the steps and interfaces of cancer screening in the context of both intraorganizational and interorganizational processes. We reviewed 79 studies assessing the relationship between organizational factors and cancer screening. Screening rates are largely driven by strategies to 1) limit the number of interfaces across organizational boundaries; 2) recruit patients, promote referrals, and facilitate appointment scheduling; and 3) promote continuous patient care. Optimal screening rates can be achieved when health-care organizations tailor strategies to the steps and interfaces in the cancer screening process that are most critical for their organizations, the providers who work within them, and the patients they serve.
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Affiliation(s)
- Rebecca Anhang Price
- SAIC-Frederick, Inc., Applied Cancer Screening Research Branch, Division of Cancer Control and Population Sciences, National Cancer Institute, 6130 Executive Blvd, EPN 4103A, Rockville, MD 20852, USA.
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Seth P, Wingood GM, Robinson LS, DiClemente RJ. Exposure to high-risk genital human papillomavirus and its association with risky sexual practices and laboratory-confirmed chlamydia among African-American women. Womens Health Issues 2009; 19:344-51. [PMID: 19679492 PMCID: PMC2743976 DOI: 10.1016/j.whi.2009.06.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Revised: 06/08/2009] [Accepted: 06/09/2009] [Indexed: 11/25/2022]
Abstract
BACKGROUND Genital human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the United States and African-American women have the highest prevalence of high-risk HPV. This study examined exposure to high-risk HPV in African-American women and its relation to risky sexual practices and laboratory-confirmed chlamydia. METHODS A sample of 665 African-American women between 18 and 29 years old, recruited from October 2002 to March 2006 in Atlanta, Georgia, completed an Audio Computer-Assisted Survey Interview assessing sociodemographics, health practices, and risky sexual practices. Participants also provided vaginal swab specimens assayed for STIs and high-risk HPV. RESULTS The overall prevalence of high-risk HPV was 38.9%. Among women 18 to 24 years old, it was 42.4%; it was 31% among women 25 to 29 years old. Age-stratified logistic regression analyses indicated that women between the ages of 18 and 29 and 18 and 24 who had multiple male sexual partners did not use a condom during their last casual sexual encounter and tested positive for chlamydia were significantly more likely to test positive for high-risk HPV. Women 18 to 24 years old who reported having a casual or risky sexual partner were significantly more likely to test positive for high-risk HPV. No significant correlates were identified among women 25 to 29 years old. CONCLUSIONS Programs should aim to educate, decrease risky sexual practices, and increase screening and treatment for STIs among women with high-risk HPV infections. HPV vaccination recommendations for young adult African-American women warrant special consideration.
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Affiliation(s)
- Puja Seth
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University
- Emory Center for AIDS Research, Social and Behavioral Sciences Core
| | - Gina M. Wingood
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University
- Emory Center for AIDS Research, Social and Behavioral Sciences Core
- 1518 Clifton Road NE, Room 556, Atlanta, GA 30322; ; Telephone: (404) 727-0241; Fax: (404) 727-1369
| | - LaShun S. Robinson
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University
- 1520 Clifton Road NE, Room 274, Atlanta, GA 30322; ; Telephone: (404) 712-9189; Fax: (404) 712-9738
| | - Ralph J. DiClemente
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University
- Emory Center for AIDS Research, Social and Behavioral Sciences Core
- 1518 Clifton Road NE, Room 554, Atlanta, GA 30322; ; Telephone: (404) 727-0237; Fax: (404) 727-1369
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Hudson SV, Ohman-Strickland P, Ferrante JM, Lu-Yao G, Orzano AJ, Crabtree BF. Prostate-specific antigen testing among the elderly in community-based family medicine practices. J Am Board Fam Med 2009; 22:257-65. [PMID: 19429731 PMCID: PMC2756417 DOI: 10.3122/jabfm.2009.03.080136] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Controversy surrounds prostate-specific antigen (PSA) testing for prostate cancer screening, especially among elderly men aged 75 and older. This study examines whether patient age results in differential use of PSA testing and if organizational attributes such as communication, stress, decision making, and practice history of change predict PSA testing among men aged 75 and older. METHODS Data came from chart audits of 1149 men > or =50 years old who were patients of 46 family medicine practices participating in 2 northeastern practice-based research networks. Surveys administered to clinicians and staff in each practice provide practice-level data. A stratified Cochran-Mantel-Haenszel test was applied to examine whether PSA testing decreased with age. Hierarchical logistic regression analyses determined characteristics associated with PSA testing for men > or =75 years old. RESULTS Comparable rates for annual PSA testing of 77.2% for men aged 50 to 74 years and 74.6% for men > or =75 years old were reported. The Cochran-Mantel-Haenszel test indicated no significant change in trend. Hierarchical models suggest that practice communication is the only organizational attribute that influences PSA testing for men 75 years of age or older (odds ratio, 5.04; P = .022). Practices with higher communication scores (eg, promoted constructive work relationships and a team atmosphere between staff and clinicians) screened men aged 75 and older at lower rates than others. CONCLUSIONS Elderly men in community settings receive PSA testing at rates comparable to their younger counterparts even though major clinical practice guidelines discourage the practice for this population. Intraoffice practice interventions that target PSA testing to the most appropriate populations and focus on communication (both within the office and with patients) are needed.
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Affiliation(s)
- Shawna V Hudson
- The Cancer Institute of New Jersey, UMDNJ/Robert Wood Johnson Medical School, 195 Little Albany Street, New Brunswick, NJ 08903-2681, USA.
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Ariza AJ, Laslo KM, Thomson JS, Seshadri R, Binns HJ. Promoting growth interpretation and lifestyle counseling in primary care. J Pediatr 2009; 154:596-601.e1. [PMID: 19028389 DOI: 10.1016/j.jpeds.2008.10.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2008] [Revised: 08/27/2008] [Accepted: 10/02/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To pilot a practice-directed intervention to promote growth interpretation and lifestyle counseling during child health supervision visits. STUDY DESIGN The intervention at 4 diverse primary care practices included education, facilitation by a practice-change leadership team, tools, and guidance from the study team. Preintervention and postintervention evaluations used were clinician interviews, in-office surveys of parents, 1-month post-visit telephone survey, visit observations, and medical record reviews. Outcomes evaluated growth interpretation documentation, clinician recognition of overweight, topic discussed at health supervision visit, and parental visit content recall and health behavior changes. RESULTS The intervention was well accepted, and tools provided were deemed helpful. Documentation of growth interpretation was higher after intervention (pre versus post: 32% vs 87%; P< .001). Parent reports of topics discussed were similar between evaluation periods (pre versus post: growth 96% vs 99%; diet 90% vs 93%; physical activity 81% vs 85%). Observed topics at health supervision visits were similarly high and were unchanged between periods. Parental recall of topics at 1 month was also high and similar between periods. Parental report of adoption of a healthier behavior for themselves or their child at 1 month did not significantly change. CONCLUSIONS The Systematic Nutritional Assessment in Pediatric Practice intervention provides a promising model to increase interpretation and documentation of growth.
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Affiliation(s)
- Adolfo J Ariza
- Mary Ann and J. Milburn Smith Child Health Research Program, Children's Memorial Research Center, Chicago, IL, USA.
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Litaker D, Bobiak S, Latigo M, Carter C, Ruhe M, Stange KC. Correlates of baseline performance do not predict results of an intervention to improve preventive care. Prev Med 2008; 47:635-7. [PMID: 18848958 DOI: 10.1016/j.ypmed.2008.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2008] [Revised: 08/31/2008] [Accepted: 09/03/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cross-sectional analyses of baseline performance often inform the development of interventions to improve care. An implicit assumption in these studies is that factors associated with better performance at baseline may also be useful in predicting change in performance over time. METHODS We analyzed data collected from 1997-2002 at 77 practices in Northeast Ohio participating in an intervention to increase evidence-based preventive services delivery (PSD). Spearman's correlation coefficients and multivariable models assessed associations between practice-level characteristics (e.g., organizational structure, objectives, climate, and culture) and baseline PSD, and with final PSD controlling for baseline values. Patterns of associations for both outcomes were inspected for overlap. RESULTS The mean PSD rate was 36.8% (+/-8.8%) at baseline. This measure increased by an average of 4.9% (+/-6.3%) by the end of the intervention. Of eight practice characteristics correlated with either baseline performance or change from baseline in PSD, only two were common to both: characteristics associated with baseline PSD did not predict final PSD in multivariable models. CONCLUSIONS Correlates of baseline performance differ from those related to change in performance. Practice assessments that focus on factors associated with change may be more useful in developing and implementing interventions to improve care.
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Affiliation(s)
- David Litaker
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
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Margolis PA, McLearn KT, Earls MF, Duncan P, Rexroad A, Reuland CP, Fuller S, Paul K, Neelon B, Bristol TE, Schoettker PJ. Assisting Primary Care Practices in Using Office Systems to Promote Early Childhood Development. ACTA ACUST UNITED AC 2008; 8:383-7. [DOI: 10.1016/j.ambp.2008.06.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Revised: 05/11/2008] [Accepted: 06/06/2008] [Indexed: 10/21/2022]
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Martin LA, Ariza AJ, Thomson JS, Binns HJ. Seconds for care: evaluation of five health supervision visit topics using a new method. J Pediatr 2008; 153:706-11, 711.e1-2. [PMID: 18589443 DOI: 10.1016/j.jpeds.2008.05.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2007] [Revised: 03/24/2008] [Accepted: 05/01/2008] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To describe content and time devoted to 5 preventive health topics during health supervision visits (HSVs). STUDY DESIGN New software (Pediatric Health Supervision Timer Software, PHSTS) run in handheld computers was developed to record time and content while observing HSVs. 185 visits of children ages 2 to 10 years (58% Medicaid/self-pay) to 28 clinicians were observed at 6 practices. Parents were surveyed on demographics. Data on times and actions related to assessments and counseling of growth, diet, physical activity, safety, and tobacco were collected using PHSTS. RESULTS The PHSTS method was well accepted (89% participation rate). Most visits included assessment/counseling for diet (95%), growth (84%), and safety (71%) and less often physical activity (52%) and tobacco (43%). Discussions occurring were short (median time [25th to 75th percentiles]: diet, 42 seconds [21 to 85 seconds]; safety, 24 seconds [11 to 61 seconds]; growth, 15 seconds [7 to 31 seconds]; physical activity, 12 seconds [5 to 22 seconds]; and tobacco, 3 seconds [2 to 6 seconds]). Clinicians expressed concerns about child weight during 18 of 33 visits (55%) that included an obese child and provided tobacco-related counseling at 6 of 30 visits (20%) that included a child living with a smoker. CONCLUSIONS The PHSTS method was successfully used. Our observations found that limited time was devoted to assessment and counseling on key health topics during HSVs.
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Affiliation(s)
- Lisa A Martin
- Department of Pediatrics, Children's Memorial Hospital, Chicago, IL 60614, USA
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Impact of a generalizable reminder system on colorectal cancer screening in diverse primary care practices: a report from the prompting and reminding at encounters for prevention project. Med Care 2008; 46:S68-73. [PMID: 18725836 DOI: 10.1097/mlr.0b013e31817c60d7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Computerized reminder systems (CRS) show promise for increasing preventive services such as colorectal cancer (CRC) screening. However, prior research has not evaluated a generalizable CRS across diverse, community primary care practices. We evaluated whether a generalizable CRS, ClinfoTracker, could improve screening rates for CRC in diverse primary care practices. METHODS The study was a prospective trial to evaluate ClinfoTracker using historical control data in 12 Great Lakes Research In Practice Network community-based, primary care practices distributed from Southeast to Upper Peninsula Michigan. Our outcome measures were pre- and post-study practice-level CRC screening rates among patients seen during the 9-month study period. Ability to maintain the CRS was measured by days of reminder printing. Field notes were used to examine each practice's cohesion and technology capabilities. RESULTS All but one practice increased their CRC screening rates, ranging from 3.3% to 16.8% improvement. t tests adjusted for within practice correlation showed improvement in screening rates across all 12 practices, from 41.7% to 50.9%, P = 0.002. Technology capabilities impacted printing days (74% for high technology vs. 45% for low technology practices, P = 0.01), and cohesion demonstrated an impact trend for screening (15.3% rate change for high cohesion vs. 7.9% for low cohesion practices). CONCLUSIONS Implementing a generalizable CRS in diverse primary care practices yielded significant improvements in CRC screening rates. Technology capabilities are important in maintaining the system, but practice cohesion may have a greater influence on screening rates. This work has important implications for practices implementing reminder systems.
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El Fakiri F, Hoes AW, Uitewaal PJM, Frenken RAA, Bruijnzeels MA. Process evaluation of an intensified preventive intervention to reduce cardiovascular risk in general practices in deprived neighbourhoods. Eur J Cardiovasc Nurs 2008; 7:296-302. [PMID: 18296125 DOI: 10.1016/j.ejcnurse.2008.01.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2006] [Revised: 10/07/2007] [Accepted: 01/06/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND A RCT, conducted to examine the effectiveness of a structured collaboration in general practice to provide intensified preventive care in patients at high cardiovascular risk yielded no effect in the total group but differences across healthcare centres and ethnic groups become apparent. We conducted a process evaluation to explain these differences. METHODS We assessed the reach of the target group and whether key intervention components (individual educational sessions, structured team meetings, and risk assessments) were performed as planned (maximum score for protocol completion is 11). RESULTS The reach was initially 91%, but only a minority of patients completed the intervention activities as planned. The average score of the number of intervention components was low (5.66 out of 11 (sd 2.8)) and varied between centres (4.84 to 7.40) and ethnic groups (4.89 to 7.38), with team meetings as the least implemented activity conform plan. CONCLUSION This study indicates that adding a practice nurse and a peer health educator to the general practice did not seem to result in the desired collaboration between the healthcare personnel. Further research is needed to investigate the reasons behind the low participation rate of the patients in the intervention.
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Affiliation(s)
- Fatima El Fakiri
- Department of Health Policy and Management, Erasmus Medical Centre Rotterdam, Netherlands.
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Klabunde CN, Lanier D, Breslau ES, Zapka JG, Fletcher RH, Ransohoff DF, Winawer SJ. Improving colorectal cancer screening in primary care practice: innovative strategies and future directions. J Gen Intern Med 2007; 22:1195-205. [PMID: 17534688 PMCID: PMC2305744 DOI: 10.1007/s11606-007-0231-3] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2006] [Revised: 04/02/2007] [Accepted: 04/06/2007] [Indexed: 01/30/2023]
Abstract
Colorectal cancer (CRC) screening has been supported by strong research evidence and recommended in clinical practice guidelines for more than a decade. Yet screening rates in the United States remain low, especially relative to other preventable diseases such as breast and cervical cancer. To understand the reasons, the National Cancer Institute and Agency for Healthcare Research and Quality sponsored a review of CRC screening implementation in primary care and a program of research funded by these organizations. The evidence base for improving CRC screening supports the value of a New Model of Primary Care Delivery: 1. a team approach, in which responsibility for screening tasks is shared among other members of the practice, would help address physicians' lack of time for preventive care; 2. information systems can identify eligible patients and remind them when screening is due; 3. involving patients in decisions about their own care may enhance screening participation; 4. monitoring practice performance, supported by information systems, can help target patients at increased risk because of family history or social disadvantage; 5. reimbursement for services outside the traditional provider-patient encounter, such as telephone and e-mail contacts, may foster enhanced screening delivery; 6. training opportunities in communication, cultural competence, and use of information technologies would improve provider competence in core elements of screening programs. Improvement in CRC screening rates largely depends on the efforts of primary care practices to implement effective systems and procedures for screening delivery. Active engagement and support of practices are essential for the enormous potential of CRC screening to be realized.
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Affiliation(s)
- Carrie N Klabunde
- Health Services and Economics Branch, Applied Research Program, Division of Cancer Control and Population Sciences, National Cancer Institute, EPN 4005, 6130 Executive Boulevard, Bethesda, MD 20892-7344, USA.
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Yano EM, Soban LM, Parkerton PH, Etzioni DA. Primary care practice organization influences colorectal cancer screening performance. Health Serv Res 2007; 42:1130-49. [PMID: 17489907 PMCID: PMC1955248 DOI: 10.1111/j.1475-6773.2006.00643.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To identify primary care practice characteristics associated with colorectal cancer (CRC) screening performance, controlling for patient-level factors. DATA SOURCES/STUDY SETTING Primary care director survey (1999-2000) of 155 VA primary care clinics linked with 38,818 eligible patients' sociodemographics, utilization, and CRC screening experience using centralized administrative and chart-review data (2001). STUDY DESIGN Practices were characterized by degrees of centralization (e.g., authority over operations, staffing, outside-practice influence); resources (e.g., sufficiency of nonphysician staffing, space, clinical support arrangements); and complexity (e.g., facility size, academic status, managed care penetration), adjusting for patient-level covariates and contextual factors. DATA COLLECTION/EXTRACTION METHODS Chart-based evidence of CRC screening through direct colonoscopy, sigmoidoscopy, or consecutive fecal occult blood tests, eliminating cases with documented histories of CRC, polyps, or inflammatory bowel disease. PRINCIPAL FINDINGS After adjusting for sociodemographic characteristics and health care utilization, patients were significantly more likely to be screened for CRC if their primary care practices had greater autonomy over the internal structure of care delivery (p<.04), more clinical support arrangements (p<.03), and smaller size (p<.001). CONCLUSIONS Deficits in primary care clinical support arrangements and local autonomy over operational management and referral procedures are associated with significantly lower CRC screening performance. Competition with hospital resource demands may impinge on the degree of internal organization of their affiliated primary care practices.
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Affiliation(s)
- Elizabeth M Yano
- VA Greater Los Angeles HSR&D Center of Excellence, Sepulveda VA Ambulatory Care Center, Sepulveda, CA 91343, USA
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Litaker D, Watts B, Samaan R, Ober S, Lawrence RH. Are provider self-efficacy and attitudes related to cardiovascular prevention associated with better treatment outcomes? Transl Res 2007; 149:165-72. [PMID: 17383590 DOI: 10.1016/j.trsl.2006.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2006] [Revised: 11/29/2006] [Accepted: 12/01/2006] [Indexed: 10/23/2022]
Abstract
Cardiovascular risk factor control is inadequate in many high-risk patients. Although many provider-directed educational interventions attempt to address this issue by enhancing provider self-efficacy, a link between greater self-efficacy and better patient outcomes has not been established. Primary care providers (PCPs) in outpatient clinics of a large Veteran's Administration (VA) facility were asked to complete 4 subscales assessing self-efficacy and attitudes related to cardiovascular prevention (CVP). Using a cross-sectional study design, responses were linked with process and CVP outcomes related to blood pressure (BP) and low-density lipoprotein-cholesterol (LDL-C) control and the Framingham Risk Score (FRS), a summary measure of risk factor control, in diabetic patients observed by participating PCPs between December 1, 2004 and December 31, 2005. Multivariable, multilevel models assessed associations between these patient outcomes and provider self-efficacy and CVP-related attitudes, after accounting for patient characteristics, including baseline risk factor control, provider characteristics, and patient clustering within provider practices. Fifty-nine PCPs (86%) providing care to 1495 patients with diabetes completed the survey. Mean scores for provider efficacy and CVP-related attitudes were moderate to high. Higher self-efficacy scores were associated with initiation of medications in previously untreated individuals with inadequate BP or lipid control at baseline. Despite adequate power, however, multilevel models demonstrated neither consistent nor substantive associations between providers' self-efficacy and CVP-related attitudes and patient outcome measures. These findings underscore the need for interventions to enhance cardiovascular risk factor control that look beyond educational strategies to address a broader range of factors with potential influence on patient outcomes and the delivery of preventive care.
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Affiliation(s)
- David Litaker
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio, USA.
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Abstract
BACKGROUND Strategies to improve preventive services delivery (PSD) have yielded modest effects. A multidimensional approach that examines distinctive configurations of physician attributes, practice processes, and contextual factors may be informative in understanding delivery of this important form of care. OBJECTIVE We identified naturally occurring configurations of physician practice characteristics (PPCs) and assessed their association with PSD, including variation within configurations. DESIGN Cross-sectional study. PARTICIPANTS One hundred thirty-eight family physicians in 84 community practices and 4,046 outpatient visits. MEASUREMENTS Physician knowledge, attitudes, use of tools and staff, and practice patterns were assessed by ethnographic and survey methods. PSD was assessed using direct observation of the visit and medical record review. Cluster analysis identified unique configurations of PPCs. A priori hypotheses of the configurations likely to perform the best on PSD were tested using a multilevel random effects model. RESULTS Six distinct PPC configurations were identified. Although PSD significantly differed across configurations, mean differences between configurations with the lowest and highest PSD were small (i.e., 3.4, 7.7, and 10.8 points for health behavior counseling, screening, and immunizations, respectively, on a 100-point scale). Hypotheses were not confirmed. Considerable variation of PSD rates within configurations was observed. CONCLUSIONS Similar rates of PSD can be attained through diverse physician practice configurations. Significant within-configuration variation may reflect dynamic interactions between PPCs as well as between these characteristics and the contexts in which physicians function. Striving for a single ideal configuration may be less valuable for improving PSD than understanding and leveraging existing characteristics within primary care practices.
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Affiliation(s)
- Susan A Flocke
- Department of Family Medicine, Case Western Reserve University, Cleveland, OH, USA.
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Dubey V, Mathew R, Iglar K, Moineddin R, Glazier R. Improving preventive service delivery at adult complete health check-ups: the Preventive health Evidence-based Recommendation Form (PERFORM) cluster randomized controlled trial. BMC FAMILY PRACTICE 2006; 7:44. [PMID: 16836761 PMCID: PMC1543627 DOI: 10.1186/1471-2296-7-44] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2005] [Accepted: 07/12/2006] [Indexed: 11/25/2022]
Abstract
BACKGROUND To determine the effectiveness of a single checklist reminder form to improve the delivery of preventive health services at adult health check-ups in a family practice setting. METHODS A prospective cluster randomized controlled trial was conducted at four urban family practice clinics among 38 primary care physicians affiliated with the University of Toronto. Preventive Care Checklist Forms were created to be used by family physicians at adult health check-ups over a five-month period. The sex-specific forms incorporate evidence-based recommendations on preventive health services and documentation space for routine procedures such as physical examination. The forms were used in two intervention clinics and two control clinics. Rates and relative risks (RR) of the performance of 13 preventive health maneuvers at baseline and post-intervention and the percentage of up-to-date preventive health services delivered per patient were compared between the two groups. RESULTS Randomly-selected charts were reviewed at baseline (n = 509) and post-intervention (n = 608). Baseline rates for provision of preventive health services ranged from 3% (fecal occult blood testing) to 93% (blood pressure measurement), similar to other settings. The percentage of up-to-date preventive health services delivered per patient at the end of the intervention was 48.9% in the control group and 71.7% in the intervention group. This is an overall 22.8% absolute increase (p = 0.0001), and 46.6% relative increase in the delivery of preventive health services per patient in the intervention group compared to controls. Eight of thirteen preventive health services showed a statistically significant change (p < 0.05) in favor of the intervention (adjusted RR (95% C.I.)): counseling on brushing/flossing teeth (9.2 (4.3-19.6)), folic acid counseling (7.5 (2.7-20.8)), fecal occult blood testing (6.7 (1.9-24.1)), smoking cessation counseling (3.9 (2.2-7.2)), tetanus immunization (3.0 (1.7-5.2)), history of alcohol intake (1.33 (1.2-1.5)), history of smoking habits (1.28 (1.2-1.4)) and blood pressure measurement (1.05 (1.00-1.10)). CONCLUSION This simple, low cost, clinically relevant intervention improves the delivery of preventive health services by prompting physicians of evidence-based recommendations in a checklist format that incorporates existing practice patterns. Periodic updates of the Preventive Care Checklist Forms will allow a feasible and easy-to-use tool for primary care physicians to provide evidence-based preventive health services to adults at routine health check-ups. The forms can also be incorporated into an electronic health record. The Preventive Care Checklist Forms are accessible in English and French at the College of Family Physicians of Canada web site.
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Affiliation(s)
- Vinita Dubey
- Dept of Public Health Sciences, University of Toronto; 1 Bluenose Cres, Toronto ON M1C 4R7, Canada
| | - Roy Mathew
- Dept of Family and Community Medicine, St. Michael's Hospital, 30 Bond St, Toronto ON M5B 1W8, Canada
| | - Karl Iglar
- Dept of Family and Community Medicine, St. Michael's Hospital, 30 Bond St, Toronto ON M5B 1W8, Canada
| | - Rahim Moineddin
- Inner City Health Research Unit, University of Toronto and St. Michael's Hospital, 30 Bond St, Toronto ON M5B 1W8, Canada
| | - Richard Glazier
- Inner City Health Research Unit, University of Toronto and St. Michael's Hospital, 30 Bond St, Toronto ON M5B 1W8, Canada
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Woolf SH, Krist AH, Johnson RE, Wilson DB, Rothemich SF, Norman GJ, Devers KJ. A practice-sponsored Web site to help patients pursue healthy behaviors: an ACORN study. Ann Fam Med 2006; 4:148-52. [PMID: 16569718 PMCID: PMC1467008 DOI: 10.1370/afm.522] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We tested whether patients are more likely to pursue healthy behaviors (eg, physical activity, smoking cessation) if referred to a tailored Web site that provides valuable information for behavior change. METHODS In a 9-month pre-post comparison with nonrandomized control practices, 6 family practices (4 intervention, 2 control) encouraged adults with unhealthy behaviors to visit the Web site. For patients from intervention practices, the Web site offered tailored health advice, a library of national and local resources, and printouts for clinicians. For patients from control practices, the Web site offered static information pages. Patient surveys assessed stage of change and health behaviors at baseline and follow-up (at 1 and 4 months), Web site use, and satisfaction. RESULTS During the 9 months, 932 patients (4% of adults attending the practice) visited the Web site, and 273 completed the questionnaires. More than 50% wanted physician assistance with health behaviors. Stage of change advanced and health behaviors improved in both intervention and control groups. Intervention patients reported greater net improvements at 1 month, although the differences approached significance only for physical activity and readiness to change dietary fat intake. Patients expressed satisfaction with the Web site but wished it provided more detailed information and greater interactivity with clinicians. CONCLUSIONS Clinicians face growing pressure to offer patients good information on health promotion and other health care topics. Referring patients to a well-designed Web site that offers access to the world's best information is an appealing alternative to offering handouts or impromptu advice. Interactive Web sites can facilitate behavior change and can interface with electronic health records. Determining whether referral to an informative Web site improves health outcomes is a methodological challenge, but the larger question is whether information alone is sufficient to promote behavior change. Web sites are more likely to be effective as part of a suite of tools that incorporate personal assistance.
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Affiliation(s)
- Steven H Woolf
- Departments of Family Medicine, Epidemiology, and Community Health, Virginia Commonwealth University, Richmond, Va, USA. [corrected]
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Affiliation(s)
- Masahito Jimbo
- Department of Family Medicine, University of Michigan, 1018 Fuller Street, Ann Arbor, MI 48109, USA.
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Abstract
The provision of heart disease prevention services in primary care is currently inadequate, but can be improved with the establishment of a practice system. The system process involves all members of the practice in a clearly defined, well-organized approach to patient care. An initial review of patient care services will help practices identify prevention areas that they would like to improve by defining protocols, roles, and routines within the practice. Once established, the prevention system can improve patient care and satisfaction of practice staff and physicians, but requires on-going assessment, modification, and commitment.
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Affiliation(s)
- Gail Underbakke
- Preventive Cardiology Program, University of Wisconsin Hospital and Clinics, Madison, WI 53792, USA.
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Crosson JC, Stroebel C, Scott JG, Stello B, Crabtree BF. Implementing an electronic medical record in a family medicine practice: communication, decision making, and conflict. Ann Fam Med 2005; 3:307-11. [PMID: 16046562 PMCID: PMC1466907 DOI: 10.1370/afm.326] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Electronic medical record (EMR) systems offer substantial opportunities to organize and manage clinical data in ways that can potentially improve preventive health care, the management of chronic illness, and the financial health of primary care practices. The functionality of EMRs as implemented, however, can vary substantially from that envisaged by their designers and even from those who purchase the programs. The purpose of this study was to explore how unique aspects of a family medicine office culture affect the initial implementation of an EMR. METHODS As part of a larger study, we conducted a qualitative case study of a private family medicine practice that had recently purchased and implemented an EMR. We collected data using participant observation, in-depth interviews, and key informant interviews. After the initial data collection, we shared our observations with practice members and returned 1 year later to collect additional data. RESULTS Dysfunctional communication patterns, the distribution of formal and informal decision-making power, and internal conflicts limited the effective implementation and use of the EMR. The implementation and use of the EMR made tracking and monitoring of preventive health and chronic illness unwieldy and offered little or no improvement when compared with paper charts. CONCLUSIONS Implementing an EMR without an understanding of the systemic effects and communication and the decision-making processes within an office practice and without methods for bringing to the surface and addressing conflicts limits the opportunities for improved care offered by EMRs. Understanding how these common issues manifest within unique practice settings can enhance the effective implementation and use of EMRs.
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Affiliation(s)
- Jesse C Crosson
- Department of Family Medicine, University of Medicine and Dentistry, New Jersey Medical School, Newark, NJ 07107, USA.
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Litaker D, Flocke SA, Frolkis JP, Stange KC. Physicians' attitudes and preventive care delivery: insights from the DOPC study. Prev Med 2005; 40:556-63. [PMID: 15749138 DOI: 10.1016/j.ypmed.2004.07.015] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Interventions that modify physician attitudes to enhance preventive service delivery are common, yet other factors may be relatively more important in determining whether these services are provided. We assessed associations between physicians' attitudes and delivery of preventive care, compared with factors related to the patient, visit, or practice. METHODS One hundred twenty-eight primary care physicians rated the importance of five preventive services and their effectiveness at delivering them. We assessed whether their patients had received cervical smears, prostate-specific antigen (PSA) testing, smoking cessation advice, recommendation to use aspirin to prevent myocardial infarction, or weight-maintenance counseling, when appropriate. Multilevel models assessed associations between physician attitudinal characteristics and a patient's likelihood of being up to date for each service. RESULTS Importance of PSA screening and tobacco cessation counseling were weakly associated with patients' receipt of preventive care; no association between attitudes and other services was observed. Factors such as having a visit for well care and use of prevention flowcharts were associated with delivery of preventive services to a greater extent. CONCLUSIONS Physicians' attitudes toward prevention are necessary, but not sufficient in ensuring the delivery of preventive services. Future interventions should address visit- and practice-specific factors more closely associated with preventive care.
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Affiliation(s)
- David Litaker
- Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Case Western Reserve University, Cleveland, OH 44106, USA.
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Hogg W, Baskerville N, Lemelin J. Cost savings associated with improving appropriate and reducing inappropriate preventive care: cost-consequences analysis. BMC Health Serv Res 2005; 5:20. [PMID: 15755330 PMCID: PMC1079830 DOI: 10.1186/1472-6963-5-20] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2004] [Accepted: 03/09/2005] [Indexed: 11/23/2022] Open
Abstract
Background Outreach facilitation has been proven successful in improving the adoption of clinical preventive care guidelines in primary care practice. The net costs and savings of delivering such an intensive intervention need to be understood. We wanted to estimate the proportion of a facilitation intervention cost that is offset and the potential for savings by reducing inappropriate screening tests and increasing appropriate screening tests in 22 intervention primary care practices affecting a population of 90,283 patients. Methods A cost-consequences analysis of one successful outreach facilitation intervention was done, taking into account the estimated cost savings to the health system of reducing five inappropriate tests and increasing seven appropriate tests. Multiple data sources were used to calculate costs and cost savings to the government. The cost of the intervention and costs of performing appropriate testing were calculated. Costs averted were calculated by multiplying the number of tests not performed as a result of the intervention. Further downstream cost savings were determined by calculating the direct costs associated with the number of false positive test follow-ups avoided. Treatment costs averted as a result of increasing appropriate testing were similarly calculated. Results The total cost of the intervention over 12 months was $238,388 and the cost of increasing the delivery of appropriate care was $192,912 for a total cost of $431,300. The savings from reduction in inappropriate testing were $148,568 and from avoiding treatment costs as a result of appropriate testing were $455,464 for a total savings of $604,032. On a yearly basis the net cost saving to the government is $191,733 per year (2003 $Can) equating to $3,687 per physician or $63,911 per facilitator, an estimated return on intervention investment and delivery of appropriate preventive care of 40%. Conclusion Outreach facilitation is more expensive but more effective than other attempts to modify primary care practice and all of its costs can be offset through the reduction of inappropriate testing and increasing appropriate testing. Our calculations are based on conservative assumptions. The potential for savings is likely considerably higher.
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Affiliation(s)
- William Hogg
- Department of Family Medicine, University of Ottawa, Canada
| | - Neill Baskerville
- Department of Health Studies and Gerontology, University of Waterloo, Canada
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Abstract
BACKGROUND Cancer screening in primary care offices is reaching only a modest percentage of adults 50 years and older. The objectives of this study were to determine if screening rates for breast, cervical, and colorectal cancer could be significantly increased by two simple office interventions in community-based primary care offices and then maintained over 3 years. METHODS Twenty-two community-based primary care practices were divided randomly into four arms: control, practice-based intervention, patient-based intervention, and both interventions combined. At baseline and annually for 3 years, medical records from approximately 100 male and 100 female patients 50 years and older were randomly selected. The outcome measures were screening rates for mammogram, Pap smear, fecal occult blood test, and flexible sigmoidoscopy or other colonic imaging. RESULTS Generally each study arm evidenced a significant 1-year increase in screening rates, followed by an overall decline to approximate baseline levels. The first year increases in screening were not related to either invention, alone or in combination. CONCLUSIONS These interventions do not have a significant impact on cancer screening rates in adults over several years. A variety of possible variables may have affected the long-term outcomes.
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Affiliation(s)
- Mack T Ruffin
- Department of Family Medicine, University of Michigan, Ann Arbor, MI 48109-0708, USA.
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