One minute for prevention: the power of leveraging to fulfill the promise of health behavior counseling

A health-social service partnership programme for improving the health self-management of community-dwelling older adults: a hybrid effectiveness-implementation pilot study protocol

BACKGROUND

The ageing population requires seamless, integrated health and social care services in the community to promote the health of older adults. However, inadequate financial resources, a lack of clear operational guidelines, and various organisational work cultures may affect the implementation quality and sustainability of these services. As a unique approach, this study seeks to examine the preliminary effects of a health-social partnership programme on the health self-management of community-dwelling older adults in Hong Kong. Additionally, the study seeks to ascertain key insights into the mechanisms and processes required to implement and sustain a self-care management programme in broader practice in community settings.

METHODS

This study will use a hybrid effectiveness-implementation design. During the 3-month programme, subjects in the intervention group will receive four Zoom video conference sessions and four telephone calls conducted by a health-social service team that will include a nurse case manager, community workers, general practitioners, a Chinese medicine practitioner, and social workers. Subjects in the control group will receive a monthly social telephone call from a trained research assistant to rule out the possible social effect of the intervention. The reach, effectiveness, adoption, implementation, and maintenance framework (i.e. RE-AIM framework) will be used to evaluate the implementation and effectiveness outcomes. Of the five dimensions included in the RE-AIM framework, only effectiveness and maintenance outcomes will be collected from both the intervention and control groups. The outcomes of the other three dimensions-reach, adoption, and implementation-will only be collected from subjects in the intervention group. Data will be collected pre-intervention, immediately post-intervention, and 3 months after the intervention is completed to evaluate the maintenance effect of the programme.

DISCUSSION

This programme will aim to enhance health-promoting self-care management behaviours in older adults dwelling in the community. This will be the first study in Hong Kong to use the hybrid effectiveness-implementation design and involve key stakeholders in the evaluation and implementation of a health self-management programme using a health-social service partnership approach. The programme, which will be rooted in the community, may be used as a model, if proven successful, for similar types of services.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04442867. Submitted 19 June 2020.

Use of the behaviour change wheel to improve everyday person-centred conversations on physical activity across healthcare

Background

An implementation gap exists between the evidence supporting physical activity in the prevention and management of long-term medical conditions and clinical practice. Person-centred conversations, i.e. focussing on the values, preferences and aspirations of each individual, are required from healthcare professionals. However, many currently lack the capability, opportunity, and motivation to have these conversations. This study uses the Behaviour Change Wheel (BCW) to inform the development of practical and educational resources to help bridge this gap.

Methods

The BCW provides a theoretical approach to enable the systematic development of behaviour change interventions. Authors followed the described eight-step process, considered results from a scoping review, consulted clinical working groups, tested and developed ideas across clinical pathways, and agreed on solutions to each stage by consensus.

Results

The behavioural diagnosis identified healthcare professionals’ initiation of person-centred conversations on physical activity at all appropriate opportunities in routine medical care as a suitable primary target for interventions. Six intervention functions and five policy categories met the APEASE criteria. We mapped 17 Behavioural Change Techniques onto BCW intervention functions to define intervention strategies.

Conclusions

This study uses the BCW to outline a coherent approach for intervention development to improve healthcare professionals’ frequency and quality of conversations on physical activity across clinical practice. Time-sensitive and role-specific resources might help healthcare professionals understand the focus of their intervention. Educational resources aimed at healthcare professionals and patients could have mutual benefit, should fit into existing care pathways and support professional development. A trusted information source with single-point access via the internet is likely to improve accessibility. Future evaluation of resources built and coded using this framework is required to establish the effectiveness of this approach and help improve understanding of what works to change conversations around physical activity in clinical practice.

A cross-sectional analysis of associations between lifestyle advice and behavior changes in patients with hypertension or diabetes: NHANES 2015-2018

Clinicians supporting patients in lifestyle behavior change is an important strategy to help reduce chronic disease burden. Using National Health and Nutrition Examination Survey (NHANES) data from 2015 to 2018, this study assessed rates of and associations between patient-reported receipt of lifestyle behavior change advice and corresponding self-reported behavior change for four different lifestyle behaviors: 1) weight loss, 2) increase physical activity, 3) reduce sodium, and 4) reduce fat and calories. Adult survey respondents with hypertension and/or diabetes (n = 4716) who received lifestyle advice ranged from 43% to 58%, with the most common recommendation being to increase physical activity. Between 61% and 73% of respondents reported currently modifying health behaviors, with the greatest number reporting weight loss. Multiple logistic regression models were used to test associations for each lifestyle behavior advice-behavior change pair, adjusting for demographic characteristics. Compared to those who received no advice, respondents who received advice had significantly higher odds of reporting losing weight (aOR: 1.93; 95% CI: 1.51, 2.48); increasing physical activity (aOR 2.02; 95% CI: 1.73, 2.37); reducing dietary sodium (aOR 4.95; 95% CI: 3.93, 6.25); and reducing intake of fat/cal (aOR 3.57; 95% CI: 2.86, 4.45). This study utilized population level data to lend further evidence that provider advice about lifestyle behaviors for patients who have hypertension or diabetes may influence patient behavior. However, prevalence of advice is low, and differences in rates of behavior change exist across socioeconomic status and race/ethnicity, indicating a need to further research how providers might better support patients with varying social needs.

An overview of general practitioner consultations in China: a direct observational study

BACKGROUND

General practitioner (GP) consultation has long been considered an important component of general practice, but few studies have focused on its characteristics in China.

OBJECTIVE

This study aimed to explore the content and elucidate the characteristics of GP consultations in general practice in China.

METHODS

A multimethod investigation of GP consultations in eight community health centres in Guangzhou and Shenzhen, China was conducted between July 2018 and January 2019. Data from 445 GP consultations were collected by direct observation and audio tape and analysed by a modified Davis Observation Code with indicators for frequencies and detailed time durations. GP and patient characteristics were collected by post-visit surveys.

RESULTS

The mean visit duration was approximately 5.4 minutes. GPs spent the most time on treatment planning, history taking, negotiating, notetaking and physical examination and less time on health promotion, family information collecting, discussing substance use, procedures and counselling. The time spent on procedures ranked first (66 seconds), followed by history taking (65 seconds) and treatment planning (63 seconds). Besides, patients were very active in the consultation, specifically for topics related to medicine ordering and drug costs.

CONCLUSIONS

This study described the profile of GP consultations and illustrated the complexity of care provided by GPs in China. As patient activation in GP consultations becomes increasingly important, future studies need to explore how to promote the engagement of patients in the whole consultation process other than just requesting for medicine.

The Elusive Search for Success: Defining and Measuring Implementation Outcomes in a Real-World Hospital Trial

Objective and Study Setting: Research efforts to identify factors that influence successful implementation are growing. This paper describes methods of defining and measuring outcomes of implementation success, using a cluster randomized controlled trial with 12 cancer services in Australia comparing the effectiveness of implementation strategies to support adherence to the Australian Clinical Pathway for the Screening, Assessment and Management of Anxiety and Depression in Adult Cancer Patients (ADAPT CP). Study Design and Methods: Using the StaRI guidelines, a process evaluation was planned to explore participant experience of the ADAPT CP, resources and implementation strategies according to the Implementation Outcomes Framework. This study focused on identifying measurable outcome criteria, prior to data collection for the trial, which is currently in progress. Principal Findings: We translated each implementation outcome into clearly defined and measurable criteria, noting whether each addressed the ADAPT CP, resources or implementation strategies, or a combination of the three. A consensus process defined measures for the primary outcome (adherence) and secondary (implementation) outcomes; this process included literature review, discussion and clear measurement parameters. Based on our experience, we present an approach that could be used as a guide for other researchers and clinicians seeking to define success in their work. Conclusions: Defining and operationalizing success in real-world implementation yields a range of methodological challenges and complexities that may be overcome by iterative review and engagement with end users. A clear understanding of how outcomes are defined and measured, based on a strong theoretical framework, is crucial to meaningful measurement and outcomes. The conceptual approach described in this article could be generalized for use in other studies. Trial Registration: The ADAPT Program to support the management of anxiety and depression in adult cancer patients: a cluster randomized trial to evaluate different implementation strategies of the Clinical Pathway for Screening, Assessment and Management of Anxiety and Depression in Adult Cancer Patients was prospectively registered with the Australian New Zealand Clinical Trials Registry Registration Number: ACTRN12617000411347.

Behavioral and mental health risk factor profiles among diverse primary care patients

Behavioral and mental health risk factors are prevalent among primary care patients and contribute substantially to premature morbidity and mortality and increased health care utilization and costs. Although prior studies have found most adults screen positive for multiple risk factors, limited research has attempted to identify factors that most commonly co-occur, which may guide future interventions. The purpose of this study was to identify subgroups of primary care patients with co-occurring risk factors and to examine sociodemographic characteristics associated with these subgroups. We assessed 12 behavioral health risk factors in a sample of adults (n=1628) receiving care from nine primary care practices across six U.S. states in 2013. Using latent class analysis, we identified four distinct patient subgroups: a 'Mental Health Risk' class (prevalence=14%; low physical activity, high stress, depressive symptoms, anxiety, and sleepiness), a 'Substance Use Risk' class (29%; highest tobacco, drug, alcohol use), a 'Dietary Risk' class (29%; high BMI, poor diet), and a 'Lower Risk' class (27%). Compared to the Lower Risk class, patients in the Mental Health Risk class were younger and less likely to be Latino/Hispanic, married, college educated, or employed. Patients in the Substance Use class tended to be younger, male, African American, unmarried, and less educated. African Americans were over 7 times more likely to be in the Dietary Risk versus Lower Risk class (OR 7.7, 95% CI 4.0-14.8). Given the heavy burden of behavioral health issues in primary care, efficiently addressing co-occurring risk factors in this setting is critical.

"Are you eating healthy?" Nutrition discourse in Midwestern clinics for the underserved

OBJECTIVE

To investigate nutrition information provided and exchanged between patients and health providers in Midwestern clinics for underserved populations.

METHODS

Forty-six clinic visits were observed to determine content and direction of nutrition information. In-depth data were collected with clinicians and clinic administrators regarding nutrition education provided to patients.

RESULTS

All patients were diagnosed with multiple obesity-related morbidities. Although women more often posed nutrition questions, few patients asked about dietary intake. Two-thirds of healthcare professionals initiated discussion about dietary intake; however, nutrition education was not provided regardless of clinician's profession.

CONCLUSIONS

Patients did not appear to link morbidity with diet. Providers did not share comprehensive nutrition knowledge during clinic visits. Dietitians, who specialize in nutrition education, rarely had access to patients.

IMPLICATIONS

Nutrition education during clinic visits is essential for reducing obesity rates. Nutrition students need clinic experience and could provide important patient education at low cost.

Brief Intervention for Heavy Drinking in Primary Care: Role of Patient Initiation

BACKGROUND

Alcohol brief intervention (BI) in primary care (PC) is effective, but remains underutilized despite multiple efforts to increase provider-initiated BI. An alternative approach to promote BI is to prompt patients to initiate alcohol-related discussions. Little is known about the role of patients in BI delivery.

OBJECTIVES

To determine the characteristics of PC patients who reported initiating BI with their providers, and to evaluate the association between the initiator (patient vs provider) and drinking after a BI.

METHODS

In the context of clinical trial, patients (n = 267) who received BI during a PC visit reported on the manner in which the BI was initiated, readiness to change, demographics, and recent history of alcohol consumption. Drinking was assessed again at 6-months after the BI.

RESULTS

Fifty percent of patients receiving a BI reported initiating the discussion of drinking themselves. Compared with those who reported a provider-initiated discussion, self-initiators were significantly younger (43.7 years vs 47.1 years; P = 0.03), more likely to meet Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for current major depression (24% vs 14%; P = 0.04), and more likely to report a history of alcohol withdrawal symptoms (68% vs 52%; P < 0.01). Baseline readiness to change, baseline consumption rates, and current DSM-IV alcohol dependence were not different between groups. In the 2 to 3 weeks after BI, self-initiators reported greater decreases in drinks per week (5.7 vs 2.4; P = 0.02), and drinking days per week (1.0 vs 0.3; P = 0.002). At 6-month follow-up, self-initiators showed significantly greater reductions in weekly drinking compared to those whose provider initiated the BI (P = 0.002).

CONCLUSIONS

Patient- and provider-initiated BI occurred with equal frequency, and patient-initiated BIs were associated with greater reductions in alcohol use. Future efforts to increase the BI rate in PC should include a focus on prompting patients to initiate alcohol-related discussions.

Perceptions of clinicians and staff about the use of digital technology in primary care: qualitative interviews prior to implementation of a computer-facilitated 5As intervention

BACKGROUND

Digital health interventions using hybrid delivery models may offer efficient alternatives to traditional behavioral counseling by addressing obstacles of time, resources, and knowledge. Using a computer-facilitated 5As (ask, advise, assess, assist, arrange) model as an example (CF5As), we aimed to identify factors from the perspectives of primary care providers and clinical staff that were likely to influence introduction of digital technology and a CF5As smoking cessation counseling intervention. In the CF5As model, patients self-administer a tablet intervention that provides 5As smoking cessation counseling, produces patient and provider handouts recommending next steps, and is followed by a patient-provider encounter to reinforce key cessation messages, provide assistance, and arrange follow-up.

METHODS

Semi-structured in-person interviews of administrative and clinical staff and primary care providers from three primary care clinics.

RESULTS

Thirty-five interviews were completed (12 administrative staff, ten clinical staff, and 13 primary care providers). Twelve were from an academic internal medicine practice, 12 from a public hospital academic general medicine clinic, and 11 from a public hospital HIV clinic. Most were women (91 %); mean age (SD) was 42 years (11.1). Perceived usefulness of the CF5As focused on its relevance for various health behavior counseling purposes, potential gains in counseling efficiency, confidentiality of data collection, occupying patients while waiting, and serving as a cue to action. Perceived ease of use was viewed to depend on the ability to accommodate: clinic workflow; heavy patient volumes; and patient characterisitics, e.g., low literacy. Social norms potentially affecting implementation included beliefs in the promise/burden of technology, priority of smoking cessation counseling relative to other patient needs, and perception of CF5As as just "one more thing to do" in an overburdened system. The most frequently cited facilitating conditions were staffing levels and smoking cessation resources and training; the most cited hindering factors were visit time constraints and patients' complex health care needs.

CONCLUSIONS

Integrating CF5As and other technology-enhanced behavioral counseling interventions in primary care requires flexibility to accommodate work flow and perceptions of overload in dynamic environments. Identifying factors that promote and hinder CF5As adoption could inform implementation of other CF behavioral health interventions in primary care.

Feasibility of automated pre-screening for lifestyle and behavioral health risk factors in primary care

BACKGROUND

Screening of primary care patients for unhealthy behaviors and mental health issues is recommended by numerous governing bodies internationally, yet evidence suggests that provider-initiated screening is not routine practice. The objective of this study was to implement systematic pre-screening of primary care patients for common preventive health issues on a large scale.

METHODS

Patients registered for non-acute visits to one of 40 primary care providers from eight clinics in an Academic Medical Center health care network in the United States from May, 2012 to May, 2014 were contacted one- to three-days prior to their visit. Patients were invited to complete a questionnaire using an Interactive Voice Response (IVR) system. Six items assessed pain, smoking, alcohol use, physical activity, concern about weight, and mood.

RESULTS

The acceptance rate among eligible patients reached by phone was 65.6 %, of which 95.5 % completed the IVR-Screen (N = 8,490; mean age 57; 57 % female). Sample demographics were representative of the overall primary care population from which participants were drawn on gender, race, and insurance status, but participants were slightly older and more likely to be married. Eighty-seven percent of patients screened positive on at least one item, and 59 % endorsed multiple problems. The majority of respondents (64.2 %) reported being never or only somewhat physically active. Weight concern was reported by 43.9 % of respondents, 36.4 % met criteria for unhealthy alcohol use, 23.4 % reported current pain, 19.6 % reported low mood, and 9.4 % reported smoking.

CONCLUSIONS

The percent endorsement for each behavioral health concern was generally consistent with studies of screening using other methods, and contrasts starkly with the reported low rates of screening and intervention for such concerns in typical PC practice. Results support the feasibility of IVR-based, large-scale pre-appointment behavioral health/ lifestyle risk factor screening of primary care patients. Pre-screening in this population facilitated participation in a controlled trial of brief treatment for unhealthy drinking, and also could be valuable clinically because it allows for case identification and management during routine care.

Association between organizational climate and perceptions and use of an innovation in Swedish primary health care: a prospective study of an implementation

BACKGROUND

There is a need for new knowledge regarding determinants of a successful implementation of new methods in health care. The role of a receptive context for change to support effective diffusion has been underlined, and could be studied by assessing the organizational climate. The aim of this study was to assess the association between organizational climate when a computer-based lifestyle intervention tool (CLT) was introduced in primary health care (PHC) and the implementation outcome in terms of how the tool was perceived and used after 2 years.

METHODS

The CLT was offered to 32 PHC units in Sweden, of which 22 units agreed to participate in the study. Before the introduction of the CLT, the creative climate at each participating unit was assessed. After 24 months, a follow-up questionnaire was distributed to the staff to assess how the CLT was perceived and how it was used. A question on the perceived need for the CLT was also included.

RESULTS

The units were divided into three groups according to the creative climate: high, medium and low. The main finding was that the units identified as having a positive creative climate demonstrated more frequent use and more positive perceptions regarding the new tool than those with the least positive creative climate. More positive perceptions were seen at both individual and unit levels.

CONCLUSIONS

According to the results from this study there is an association between organizational climate at baseline and implementation outcome after 2 years when a tool for lifestyle intervention is introduced in PHC in Sweden. Further studies are needed before measurement of organizational climate at baseline can be recommended in order to predict implementation outcome.

Documented lifestyle education among young adults with incident hypertension

BACKGROUND

Only 38% of young adults with hypertension have controlled blood pressure. Lifestyle education is a critical initial step for hypertension control. Previous studies have not assessed the type and frequency of lifestyle education in young adults with incident hypertension.

OBJECTIVE

The purpose of this study was to determine patient, provider, and visit predictors of documented lifestyle education among young adults with incident hypertension.

DESIGN

We conducted a retrospective analysis of manually abstracted electronic health record data.

PARTICIPANTS

A random selection of adults 18-39 years old (n = 500), managed by a large academic practice from 2008 to 2011 and who met JNC 7 clinical criteria for incident hypertension, participated in the study.

MAIN MEASURES

The primary outcome was the presence of any documented lifestyle education during one year after meeting criteria for incident hypertension. Abstracted topics included documented patient education for exercise, tobacco cessation, alcohol use, stress management/stress reduction, Dietary Approaches to Stop Hypertension (DASH) diet, and weight loss. Clinic visits were categorized based upon a modified established taxonomy to characterize patients' patterns of outpatient service. We excluded patients with previous hypertension diagnoses, previous antihypertensive medications, or pregnancy. Logistic regression was used to identify predictors of documented education.

KEY RESULTS

Overall, 55% (n = 275) of patients had documented lifestyle education within one year of incident hypertension. Exercise was the most frequent topic (64%). Young adult males had significantly decreased odds of receiving documented education. Patients with a previous diagnosis of hyperlipidemia or a family history of hypertension or coronary artery disease had increased odds of documented education. Among visit types, chronic disease visits predicted documented lifestyle education, but not acute or other/preventive visits.

CONCLUSIONS

Among young adults with incident hypertension, only 55% had documented lifestyle education within one year. Knowledge of patient, provider, and visit predictors of education can help better target the development of interventions to improve young adult health education and hypertension control.

Long-term impact of a real-world coordinated lifestyle promotion initiative in primary care: a quasi-experimental cross-sectional study

BACKGROUND

Integration of lifestyle promotion in routine primary care has been suboptimal. Coordinated care models (e.g. screening, brief advice and referral to in-house specialized staff) could facilitate lifestyle promotion practice; they have been shown to increase the quality of services and reduce costs in other areas of care. This study evaluates the long-term impact of a coordinated lifestyle promotion intervention with a multidisciplinary team approach in a primary care setting.

METHODS

A quasi-experimental, cross-sectional design was used to compare three intervention centres using a coordinated care model and three control centres using a traditional model of lifestyle promotion care. Outcomes were inspired by using the RE-AIM framework: reach, the proportion of patients receiving lifestyle promotion; effectiveness, self-reported attitudes and competency among staff; adoption, proportion of staff reporting daily practice of lifestyle promotion and referral; and implementation, of the coordinated care model. The impact was investigated after 3 and 5 years. Data collection involved a patient questionnaire (intervention, n = 433-497; control, n = 455-497), a staff questionnaire (intervention, n = 77-76; control, n = 43-56) and structured interviews with managers (n = 8). The χ(2) test or Fisher exact test with adjustment for clustering by centre was used for the analysis. Problem-driven content analysis was used to analyse the interview data.

RESULTS

The findings were consistent over time. Intervention centres did not show higher rates for reach of patients or adoption among staff at the 3- or 5-year follow-up. Some conceptual differences between intervention and control staff remained over time in that the intervention staff were more positive on two of eight effectiveness outcomes (one attitude and one competency item) compared with control staff. The Lifestyle team protocol, which included structural opportunities for coordinated care, was implemented at all intervention centres. Lifestyle teams were perceived to have an important role at the centres in driving the lifestyle promotion work forward and being a forum for knowledge exchange. However, resources to refer patients to specialized staff were used inconsistently.

CONCLUSIONS

The Lifestyle teams may have offered opportunities for lifestyle promotion practice and contributed to enabling conditions at centre level but had limited impact on lifestyle promotion practices.

'I wouldn't push that further because I don't want to lose her': a multiperspective qualitative study of behaviour change for long-term conditions in primary care

Background

Health outcomes for long‐term conditions (LTCs) can be improved by lifestyle, dietary and condition management‐related behaviour change. Primary care is an important setting for behaviour change work. Practitioners have identified barriers to this work, but there is little evidence examining practices of behaviour change in primary care consultations and how patients and practitioners perceive these practices.

Objective

To examine how behaviour change is engaged with in primary care consultations for LTCs and investigate how behaviour change is perceived by patients and practitioners.

Design

Multiperspective, longitudinal qualitative research involving six primary health‐care practices in England. Consultations between patients with LTCs and health‐care practitioners were audio‐recorded. Semi‐structured interviews were completed with patients and practitioners, using stimulated recall. Patients were re‐interviewed 3 months later. Framework analysis was applied to all data.

Participants

Thirty‐two people with at least one LTC (chronic obstructive pulmonary disease, diabetes, asthma and coronary heart disease) and 10 practitioners.

Results

Behaviour change talk in consultations was rare and, when it occurred, was characterized by deflection and diffidence on the part of practitioners. Patient motivation tended to be unaddressed. While practitioners positioned behaviour change work as outside their remit, patients felt uncertain about, yet responsible for, this work. Practitioners raised concerns that this work could damage other aspects of care, particularly the patient–practitioner relationship.

Conclusion

Behaviour change work is often deflected or deferred by practitioners in consultations, who nevertheless vocalize support for its importance in interviews. This discrepancy between practitioners’ accounts and behaviours needs to be addressed within primary health‐care organizations.

Frequency and prioritization of patient health risks from a structured health risk assessment

PURPOSE

To describe the frequency and patient-reported readiness to change, desire to discuss, and perceived importance of 13 health risk factors in a diverse range of primary care practices.

METHODS

Patients (n = 1,707) in 9 primary care practices in the My Own Health Report (MOHR) trial reported general, behavioral, and psychosocial risk factors (body mass index [BMI], health status, diet, physical activity, sleep, drug use, stress, anxiety or worry, and depression). We classified responses as "at risk" or "healthy" for each factor, and patients indicated their readiness to change and/or desire to discuss identified risk factors with providers. Patients also selected 1 of the factors they were ready to change as most important. We then calculated frequencies within and across these factors and examined variation by patient characteristics and across practices.

RESULTS

On average, patients had 5.8 (SD = 2.12; range, 0-13) unhealthy behaviors and mental health risk factors. About 55% of patients had more than 6 risk factors. On average, patients wanted to change 1.2 and discuss 0.7 risks. The most common risks were inadequate fruit/vegetable consumption (84.5%) and overweight/obesity (79.6%). Patients were most ready to change BMI (33.3%) and depression (30.7%), and most wanted to discuss depression (41.9%) and anxiety or worry (35.2%). Overall, patients rated health status as most important.

CONCLUSIONS

Implementing routine comprehensive health risk assessments in primary care will likely identify a high number of behavioral and psychosocial health risks. By soliciting patient priorities, providers and patients can better manage counseling and behavior change.

Teachable moments for health behavior change and intermediate patient outcomes

OBJECTIVE

Teachable moments (TM) are opportunities created through physician-patient interaction and used to encourage patients to change unhealthy behaviors. We examine the effectiveness of TMs to increase patients' recall of advice, motivation to modify behavior, and behavior change.

METHODS

A mixed-method observational study of 811 patient visits to 28 primary care clinicians used audio-recordings of visits to identify TMs and other types of advice in health behavior change talk. Patient surveys assessed smoking, exercise, fruit/vegetable consumption, height, weight, and readiness for change prior to the observed visit and 6-weeks post-visit.

RESULTS

Compared to other identified categories of advice (i.e. missed opportunities or teachable moment attempts), recall was greatest after TMs occurred (83% vs. 49-74%). TMs had the greatest proportion of patients change in importance and confidence and increase readiness to change; however differences were small. TMs had greater positive behavior change scores than other categories of advice; however, this pattern was statistically non-significant and was not observed for BMI change.

CONCLUSION

TMs have a greater positive influence on several intermediate markers of patient behavior change compared to other categories of advice.

PRACTICE IMPLICATIONS

TMs show promise as an approach for clinicians to discuss behavior change with patients efficiently and effectively.

Implementing health information technology in a patient-centered manner: patient experiences with an online evidence-based lifestyle intervention

The patient-centered care (PCC) model and the use of health information technology (HIT) are major initiatives for improving U.S. healthcare quality and delivery. A lack of published data on patient perceptions of Internet-based care makes patient-centered implementation of HIT challenging. To help ascertain patients' perceptions of an online intervention, patients completing a 1-year web-based lifestyle intervention were asked to complete a semistructured interview. We used qualitative methodology to determine frequency and types of interview responses. Overall satisfaction with program features was coded on a Likert-type scale. High levels of satisfaction were seen with the online lifestyle coaching (80%), self-monitoring tools (57%), and structured lesson features (54%). Moderated chat sessions and online resources were rarely used. Frequently identified helpful aspects were those that allowed for customized care and shared decision-making consistent with the tenets of PCC. Unhelpful program aspects were reported less often. Findings suggest that despite challenges for communicating effectively in an online forum, the personalized support, high-tech data management capabilities, and easily followed evidence-based curricula afforded by HIT may be a means of providing PCC and improving healthcare delivery and quality.

The content of diet and physical activity consultations with older adults in primary care

OBJECTIVE

Despite numerous benefits of consuming a healthy diet and receiving regular physical activity, engagement in these behaviors is suboptimal. Since primary care visits are influential in promoting healthy behaviors, we sought to describe whether and how diet and physical activity are discussed during older adults' primary care visits.

METHODS

115 adults aged 65 and older consented to have their routine primary care visits recorded. Audio-recorded visits were transcribed and diet and physical activity content was coded and analyzed.

RESULTS

Diet and physical activity were discussed in the majority of visits. When these discussions occurred, they lasted an average of a minute and a half. Encouragement and broad discussion of benefits of improved diet and physical activity levels were the common type of exchange. Discussions rarely involved patient behavioral self-assessments, patient questions, or providers' recommendations.

CONCLUSIONS

The majority of patient visits include discussion of diet and physical activity, but these discussions are often brief and rarely include recommendations.

PRACTICE IMPLICATIONS

Providers may want to consider ways to expand their lifestyle behavior discussions to increase patient involvement and provide more detailed, actionable recommendations for behavior change. Additionally, given time constraints, a wider array of approaches to lifestyle counseling may be necessary.

Development of a Mapped Diabetes Community Program Guide for a Safety Net Population

PURPOSE

Enhancing linkages between patients and community programs is increasingly recognized as a method for improving physical activity, nutrition, and weight management. Although interactive mapped community program guides may be beneficial, there remains a dearth of articles that describe the processes and practicalities of creating such guides. This article describes the development of an interactive web-based mapped community program guide at a safety net institution and the lessons learned from that process.

CONCLUSIONS

This project demonstrated the feasibility of creating 2 maps: a program guide and a population health map. It also revealed some key challenges and lessons for future work in this area, particularly within safety net institutions. Our work underscores the need for developing partnerships outside the health care system and the importance of employing community-based participatory methods. In addition to facilitating improvements in individual wellness, mapping community programs has the potential to improve population health management by health care delivery systems such as hospitals, health centers, or public health systems, including city and state departments of health.

What does it mean to be pragmatic? Pragmatic methods, measures, and models to facilitate research translation

BACKGROUND

One of the reasons for the slow and uncertain translation of research into practice is likely due to the emphasis in science on explanatory models and efficacy designs rather than more pragmatic approaches.

METHODS

Following a brief definition of what constitutes a pragmatic approach, I provide examples of pragmatic methods, measures, and models and how they have been applied.

RESULTS

Descriptions are provided of pragmatic trials and related designs, practical measures including patient-reported items for the electronic health record, and the Evidence Integration Triangle and RE-AIM practical models, each of which can help increase the relevance of research to policy makers, practitioners, and patients/consumers.

CONCLUSIONS

By focusing on the perspective of stakeholders and the context for application of scientific findings, pragmatic approaches can accelerate the integration of research, policy, and practice. Progress has been made, especially in pragmatic trials but even more opportunities remain.

Inadequacies of current approaches to prediabetes and diabetes prevention

In view of the global shift from communicable to chronic, non-communicable diseases including obesity, prediabetes, and type 2 diabetes mellitus, the increasing prevalence of the latter creates a considerable challenge to the clinician and public health infrastructure. Despite the substantial research efforts in the last 10-15 years highlighting the considerable benefit of lifestyle modification in thwarting the insidious progression to diabetes and its complications, many individuals will ineluctably progress even when initially responsive. Furthermore, the vast majority of individuals with prediabetes remain undiagnosed and untreated. Therefore, the responsibilities of the medical and public health communities involve identifying new methods for screening and identifying those at risk as well as refining therapeutic approaches availing as many high-risk individuals as possible to novel treatment modalities.

Live well: a practical and effective low-intensity dietary counseling intervention for use in primary care patients with dyslipidemia--a randomized controlled pilot trial

Background

Diet is the first line of treatment for elevated cholesterol. High-intensity dietary counseling (≥360 minutes/year of contact with providers) improves blood lipids, but is expensive and unsustainable in the current healthcare settings. Low-intensity counseling trials (≤ 30 minutes/year) have demonstrated modest diet changes, but no improvement in lipids. This pilot study evaluated the feasibility and the effects on lipids and diet of a low-intensity dietary counseling intervention provided by the primary care physician (PCP), in patients at risk for cardiovascular diseases.

Methods

Six month study with a three month randomized-controlled phase (group A received the intervention, group B served as controls) followed by three months of intervention in both groups.

Sixty-one adults age 21 to 75 years, with LDL-cholesterol ≥ 3.37 mmol/L, possessing Internet access and active email accounts were enrolled. Diet was evaluated using the Rate-Your-Plate questionnaire. Dietary counseling was provided by the PCP during routine office visits, three months apart, using printed educational materials and a minimally interactive counseling website. Weekly emails were sent reminding participants to use the dietary counseling resources. The outcomes were changes in LDL-cholesterol, other lipid subclasses, and diet quality.

Results

At month 3, group A (counseling started at month 1) decreased their LDL-cholesterol by −0.23 mmol/L, (−0.04 to −0.42 mmol/L, P = 0.007) and total cholesterol by −0.26 mmol/L, (−0.05 to −0.47 mmol/L, P = 0.001). At month 6, total and LDL-cholesterol in group A remained better than in group B (counseling started at month 3). Diet score in group A improved by 50.3 points (38.4 to 62.2, P < 0.001) at month 3; and increased further by 11.8 (3.5 to 20.0, P = 0.007) at month 6. Group B made the largest improvement in diet at month 6, 55 points (40.0 to 70.1, P < 0.001), after having a small but significant improvement at month 3, 22.3 points (12.9 to 31.7, P < 0.001). No significant changes occurred in HDL-cholesterol in either group.

Conclusions

A low-intensity dietary counseling provided by the PCP in patients at risk for cardiovascular diseases produced clinically meaningful improvements in both diet and lipids of magnitude similar to changes reported with high intensity interventions.

Trial registration

ClinicalTrials.gov: NCT01695837

Electronic tools to assist with identification and counseling for overweight patients: a randomized controlled trial

BACKGROUND

Physicians often do not recognize when their patients are overweight and infrequently counsel them about weight loss.

OBJECTIVE

To evaluate a set of electronic health record (EHR)-embedded tools to assist with identification and counseling of overweight patients.

DESIGN

Randomized controlled trial.

PARTICIPANTS

Physicians at an academic general internal medicine clinic were randomized to activation of the EHR tools (n = 15) or to usual care (n = 15). Patients of these physicians were included in analyses if they had a body mass index (BMI) between 27 and 29.9 kg/m(2).

INTERVENTION

The EHR tool set included: a physician point-of-care alert for overweight (BMI 27-29. 9 kg/m(2)); a counseling template to help physicians counsel patients on action plans; and an order set to facilitate entry of overweight as a diagnosis and to order relevant patient handouts.

MAIN MEASURES

Physician documentation of overweight as a problem; documentation of weight-specific counseling; physician perceptions of the EHR tools; patient self-reported progress toward their goals and perspectives about counseling received.

KEY RESULTS

Patients of physicians receiving the intervention were more likely than those of usual care physicians to receive a diagnosis of overweight (22% vs. 7%; p = 0.02) and weight-specific counseling (27% vs. 15%; p = 0.02). Most patients receiving counseling in the intervention group reported increased motivation to lose weight (90%) and taking steps toward their goal (93%). Most intervention physicians agreed that the tool alerted them to patients they did not realize were overweight (91%) and improved the effectiveness of their counseling (82%); more than half (55%) reported counseling overweight patients more frequently (55%). However, most physicians used the tool infrequently because of time barriers.

CONCLUSIONS

EHR-based alerts and management tools increased documentation of overweight and counseling frequency; the majority of patients for whom the tools were used reported short-term behavior change.

An evolving perspective on physical activity counselling by medical professionals

BACKGROUND

Physical inactivity is a modifiable risk factor for many chronic conditions and a leading cause of premature mortality. An increasing proportion of adults worldwide are not engaging in a level of physical activity sufficient to prevent or alleviate these adverse effects. Medical professionals have been identified as potentially powerful sources of influence for those who do not meet minimum physical activity guidelines. Health professionals are respected and expected sources of advice and they reach a large and relevant proportion of the population. Despite this potential, health professionals are not routinely practicing physical activity promotion.

DISCUSSION

Medical professionals experience several known barriers to physical activity promotion including lack of time and lack of perceived efficacy in changing physical activity behaviour in patients. Furthermore, evidence for effective physical activity promotion by medical professionals is inconclusive. To address these problems, new approaches to physical activity promotion are being proposed. These include collaborating with community based physical activity behaviour change interventions, preparing patients for effective brief counselling during a consultation with the medical professional, and use of interactive behaviour change technology.

SUMMARY

It is important that we recognise the latent risk of physical inactivity among patients presenting in clinical settings. Preparation for improving patient physical activity behaviours should commence before the consultation and may include physical activity screening. Medical professionals should also identify suitable community interventions to which they can refer physically inactive patients. Outsourcing the majority of a comprehensive physical activity intervention to community based interventions will reduce the required clinical consultation time for addressing the issue with each patient. Priorities for future research include investigating ways to promote successful referrals and subsequent engagement in comprehensive community support programs to increase physical activity levels of inactive patients. Additionally, future clinical trials of physical activity interventions should be evaluated in the context of a broader framework of outcomes to inform a systematic consideration of broad strengths and weaknesses regarding not only efficacy but cost-effectiveness and likelihood of successful translation of interventions to clinical contexts.

Twelve-month outcomes of an Internet-based diabetes self-management support program

OBJECTIVE

Internet-based programs offer potential for practical, cost-effective chronic illness self-management programs.

METHODS

We report 12-month results of an Internet-based diabetes self-management program, with and without additional support, compared to enhanced usual care in a 3-arm practical randomized trial. Patients (n=463) were randomized: 77.3% completed 12-month follow-up. Primary outcomes were changes in health behaviors of healthy eating, physical activity, and medication taking. Secondary outcomes were hemoglobin A1c, body mass index, lipids, blood pressure, and psychosocial factors.

RESULTS

Internet conditions improved health behaviors significantly vs. usual care over the 12-month period (d for effect size=.09-.16). All conditions improved moderately on biological and psychosocial outcomes. Latinos, lower literacy, and higher cardiovascular disease risk patients improved as much as other participants.

CONCLUSIONS

The Internet intervention meets the reach and feasibility criteria for a potentially broad public health impact. However, 12-month magnitude of effects was small, suggesting that different or more intensive approaches are necessary to support long-term outcomes. Research is needed to understand the linkages between intervention and maintenance processes and downstream outcomes.

PRACTICE IMPLICATIONS

Automated self-management interventions should be tailored and integrated into primary care; maintenance of patient self-management can be enhanced through links to community resources.

Findings and Recommendations From the Interim Evaluation of the Bright Futures for Women’s Health and Wellness Physical Activity and Healthy Eating Tools

The Bright Futures for Women’s Health and Wellness Initiative (BFWHW) Physical Activity and Healthy Eating tools encourage patient–provider discussion in the primary care setting, and promote patient self-management, goal setting, and behavior change. An interim evaluation of the BFWHW tools with 274 female adult patients, 18 providers, and 4 site administrators was conducted at 4 health care sites in the United States. Results suggest that patients, particularly overweight women, were interested in discussing healthy eating and physical activity with their provider during the health care visit and that the tools were helpful for goal setting. Nearly three quarters of providers reported that the materials strengthened their discussion of healthy eating with patients; 67% reported an enhanced conversation about physical activity. Site administrators reported several common themes, including the need for flexibility to adopt new routines and using a patient self-management approach. Barriers to implementation included lack of time in the clinical visit and lack of reimbursement. Recommendations for new approaches to address multiple structural, financial, and literacy barriers in order to facilitate the integration of gender-specific health promotion materials into primary care settings are discussed.

Identifying teachable moments for health behavior counseling in primary care

OBJECTIVE

Situations with potential to motivate positive change in unhealthy behavior have been called 'teachable moments'. Little is known about how they occur in the primary care setting.

METHODS

Cross-sectional observational design. Audio-recordings collected during 811 physician-patient interactions for 28 physicians and their adult patients were analyzed using conversation analysis.

RESULTS

Teachable moments were observed in 9.8% of the cases, and share three features: (1) the presence of a concern that is salient to the patient that is either obviously relevant to an unhealthy behavior, or through conversation comes to be seen as relevant; (2) a link that is made between the patient's salient concern and a health behavior that attempts to motivate the patient toward change; and (3) a patient response indicating a willingness to discuss and commit to behavior change. Additionally, we describe phenomena related to, but not teachable moments, including teachable moment attempts, missed opportunities, and health behavior advice.

CONCLUSIONS

Success of the teachable moment rests on the physician's ability to identify and explore the salience of patient concerns and recognize opportunities to link them with unhealthy behaviors.

PRACTICE IMPLICATIONS

The skills necessary for accomplishing teachable moments are well within the grasp of primary care physicians.

Use of RE-AIM to develop a multi-media facilitation tool for the patient-centered medical home

Background

Much has been written about how the medical home model can enhance patient-centeredness, care continuity, and follow-up, but few comprehensive aids or resources exist to help practices accomplish these aims. The complexity of primary care can overwhelm those concerned with quality improvement.

Methods

The RE-AIM planning and evaluation model was used to develop a multimedia, multiple-health behavior tool with psychosocial assessment and feedback features to facilitate and guide patient-centered communication, care, and follow-up related to prevention and self-management of the most common adult chronic illnesses seen in primary care.

Results

The Connection to Health Patient Self-Management System, a web-based patient assessment and support resource, was developed using the RE-AIM factors of reach (e.g., allowing input and output via choice of different modalities), effectiveness (e.g., using evidence-based intervention strategies), adoption (e.g., assistance in integrating the system into practice workflows and permitting customization of the website and feedback materials by practice teams), implementation (e.g., identifying and targeting actionable priority behavioral and psychosocial issues for patients and teams), and maintenance/sustainability (e.g., integration with current National Committee for Quality Assurance recommendations and clinical pathways of care). Connection to Health can work on a variety of input and output platforms, and assesses and provides feedback on multiple health behaviors and multiple chronic conditions frequently managed in adult primary care. As such, it should help to make patient-healthcare team encounters more informed and patient-centered. Formative research with clinicians indicated that the program addressed a number of practical concerns and they appreciated the flexibility and how the Connection to Health program could be customized to their office.

Conclusions

This primary care practice tool based on an implementation science model has the potential to guide patients to more healthful behaviors and improved self-management of chronic conditions, while fostering effective and efficient communication between patients and their healthcare team. RE-AIM and similar models can help clinicians and media developers create practical products more likely to be widely adopted, feasible in busy medical practices, and able to produce public health impact.

Coordination of health behavior counseling in primary care

PURPOSE

We wanted to examine how coordinated care is implemented in primary care practices to address patients' health behavior change needs.

METHODS

Site visit notes, documents, interviews, and online implementation diaries were collected from July 2005 to September 2007 from practice-based research networks (PBRNs) participating in Prescription for Health: Promoting Healthy Behaviors in Primary Care Research Networks (P4H). An iterative group process was used to conduct a cross-case comparative analysis of 9 interventions. Published patient outcomes reports from P4H interventions were referenced to provide information on intervention effectiveness.

RESULTS

In-practice health risk assessment (HRA) and brief counseling, coupled with referral and outreach to a valued and known counseling resource, emerged as the best way to consistently coordinate and encourage follow-through for health behavior counseling. Findings from published P4H outcomes suggest that this approach led to improvement in health behaviors. Automated prompts and decision support tools for HRA, brief counseling and referral, training in brief counseling strategies, and co-location of referral with outreach facilitated implementation. Interventions that attempted to minimize practice or clinician burden through telephone and Web-based counseling systems or by expanding the medical assistant role in coordination of health behavior counseling experienced difficulties in implementation and require more study to determine how to optimize integration in practices.

CONCLUSIONS

Easy-to-use system-level solutions that have point-of-delivery reminders and decision support facilitate coordination of health behavior counseling for primary care patients. Infrastructure is needed if broader integration of health behavior counseling is to be achieved in primary care.

Experiences of the implementation of a tool for lifestyle intervention in primary health care: a qualitative study among managers and professional groups

BACKGROUND

In recent years there has been increasing interest in transferring new knowledge into health care practices, a process often referred to as implementation. The various subcultures that exist among health care workers may be an obstacle in this process. The aim of this study was to explore how professional groups and managers experienced the implementation of a new tool for lifestyle intervention in primary health care (PHC). The computer-based tool was introduced with the intention of facilitating the delivery of preventive services.

METHODS

Focus group interviews with staff and individual interviews with managers at six PHC units in the southeast of Sweden were performed 9 months after the introduction of the new working tool. Staff interviews were conducted in groups according to profession, and were analysed using manifest content analysis. Experiences and opinions from the different staff groups and from managers were analysed.

RESULTS

Implementation preconditions, opinions about the lifestyle test, and opinions about usage were the main areas identified. In each of the groups, managers and professionals, factors related to the existing subcultures seemed to influence their experiences of the implementation. Managers were visionary, GPs were reluctant, nurses were open, and nurse assistants were indifferent.

CONCLUSION

This study indicates that the existing subcultures in PHC influence how the implementation of an innovation is perceived by managers and the different professionals. In PHC, an organization with several subcultures and an established hierarchical structure, an implementation strategy aimed at all groups did not seem to result in a successful uptake of the new method.

Standardized Patient Instructor (SPI) interactions are a viable way to teach medical students about health behavior counseling

OBJECTIVES

We explored comfort levels of third-year medical (M3) students through two health behavior counseling (HBC) interactions with Standardized Patient Instructors (SPIs) in tobacco cessation (TCC) and nutrition and physical activity (NPA).

METHODS

Nearly 200 M3s participated in two SPI HBC interactions; including a role-play interview and subsequent feedback session on performance. Students completed a 5-point Likert scale evaluation measuring pre- and post-comfort level on two HBC sessions.

RESULTS

Both interactions resulted in statistically significant increases in student's pre- and post-interaction comfort levels. A paired-sample t-test revealed a mean increase of 0.91 for TCC (t = 14.01, df = 197, p<0.001), and a mean increase of 0.69 for NPA (t = 12.65, df = 198, p<0.001).

CONCLUSION

The use of SPIs is a viable approach to exposing medical students and future doctors to health behavior counseling, and increasing comfort level with such skills. The SPI experience ensures that HBC opportunities are available and contain meaningful feedback on performance.

PRACTICE IMPLICATIONS

Encouraging patient behavior modification is a skill that can be developed during undergraduate medical training. Combining HBC with SPI sessions and traditional learning approaches could prove effective in a curriculum intended to teach students strategies that improve patient health behavior.

The "ins" and "outs" of provider-parent communication: perspectives from adolescent primary care providers on challenges to forging alliances to reduce adolescent risk

PURPOSE

For several decades, the goal to protect adolescents' confidentiality in addition to state and professional mandates to provide confidential health services have sometimes outweighed the interest of involving parents in risk reduction efforts. More recently, experts acknowledge that a balance must be found between maintaining adolescent confidentiality and involving parents in preventing poor adolescent outcomes resulting from risky behaviors. The purpose of this research was to elucidate the challenges in and identify solutions to realizing this newer vision in the primary care setting.

METHODS

We conducted a qualitative study featuring in-depth interviews with 37 primary care providers among whom a significant component of their practice involved adolescent patients. Purposeful sampling was aimed at a diversity of gender, practice specialty, practice venues, and geographic areas.

RESULTS

We identified individual and structural barriers and facilitators to involving parents in their adolescents' primary care. Barriers included parents' lack of knowledge and awareness of their children's risk behaviors; providers time constraints and competing clinical demands, concerns for confidentiality and developing a trusting relationship with the child; and legal and system requirements that limit engagement with parents. Facilitators included interest and for some, planned approaches by the provider to engage the parent; encouragement by the provider to the adolescent to communicate with a trusted adult about their risky behavior; and opportunities to educate the parent about risk reduction in general.

CONCLUSION

Opportunities for further research on strategies to improve communication and develop a partnership between providers and parents are described.

Development and evaluation of an instrument for assessing brief behavioral change interventions

OBJECTIVE

To develop an observational coding instrument for evaluating the fidelity and quality of brief behavioral change interventions based on the behavioral theories of the 5 A's, Stages of Change and Motivational Interviewing.

METHODS

Content and face validity were assessed prior to an intervention where psychometric properties were evaluated with a prospective cohort of 116 medical students. Properties assessed included the inter-rater reliability of the instrument, internal consistency of the full scale and sub-scales and descriptive statistics of the instrument. Construct validity was assessed based on student's scores.

RESULTS

Inter-rater reliability for the instrument was 0.82 (intraclass correlation). Internal consistency for the full scale was 0.70 (KR20). Internal consistencies for the sub-scales were as follows: MI intervention component (KR20=.7); stage-appropriate MI-based intervention (KR20=.55); MI spirit (KR20=.5); appropriate assessment (KR20=.45) and appropriate assisting (KR20=.56).

CONCLUSIONS

The instrument demonstrated good inter-rater reliability and moderate overall internal consistency when used to assess performing brief behavioral change interventions by medical students.

PRACTICE IMPLICATIONS

This practical instrument can be used with minimal training and demonstrates promising psychometric properties when evaluated with medical students counseling standardized patients. Further testing is required to evaluate its usefulness in clinical settings.

The adoption of mobile health management services: an empirical study

As their populations age, many countries are facing the increasing economic pressure of providing healthcare to their people. In Taiwan, this problem is exacerbated by an increasing rate of obesity and obesity-related conditions. Encouraging the adoption of personal health management services is one way to maintain current levels of personal health and to efficiently manage the distribution of healthcare resources. This study introduces Mobile Health Management Services (MHMS) and employs the Technology Acceptance Model (TAM) to explore the intention of students in Executive Master of Business Management programs to adopt mobile health management technology. Partial least squares (PLS) was used to analyze the collected data, and the results revealed that "perceived usefulness" and "attitude" significantly affected the behavioral intention of adopting MHMS. Both "perceived ease of use" and "perceived usefulness," significantly affected "attitude," and "perceived ease of use" significantly affected "perceived usefulness" as well. The results also show that the determinants of intention toward MHMS differed with age; young adults had higher intention to adopt MHMS to manage their personal health. Therefore, relevant governmental agencies may profitably promote the management of personal health among this population. Successful promotion of personal health management will contribute to increases in both the level of general health and the efficient management of healthcare resources.

Rural Residents' Perspectives on Multiple Morbidity Management and Disease Prevention

Middle-aged and older adults often experience several simultaneously occurring chronic conditions or "multiple morbidity" (MM). The task of both managing MM and preventing chronic conditions can be overwhelming, particularly in populations with high disease burdens, low socioeconomic status, and health care provider shortages. This article sought to understand Appalachian residents' perspectives on MM management and prevention. Forty-one rural Appalachian residents aged 50 and above with MM were interviewed about disease management and colorectal cancer (CRC) prevention. Transcripts were examined for overall analytic categories and coded using techniques to enhance transferability and rigor. Participants indicate facing various challenges to prevention due, in part, to conditions within their rural environment. Patients and providers spend significant time and energy on MM management, often precluding prevention activities. This article discusses implications of MM management for CRC prevention and strategies to increase disease prevention among this rural, vulnerable population burdened by MM.

Defining and measuring the patient-centered medical home

The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices' internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare. The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care. The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change. Measuring the PCMH involves the following: Giving primacy to the core tenets of primary care. Assessing practice and system changes that are hypothesized to provide added value Assessing development of practices' core processes and adaptive reserve. Assessing integration with more functional healthcare system and community resources. Evaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspects. Recognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings. Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.

Structure and measurement properties of the Patient Assessment of Chronic Illness Care instrument

OBJECTIVE

In this study, the authors investigated the psychometric properties of a modified version of the Patient Assessment of Chronic Illness Care (PACIC) - a self-report instrument designed to measure the extent to which patients with chronic illness receive care congruent with the chronic care model.

RESEARCH DESIGN AND METHOD

Five hundred and twenty-nine (529) type 2 diabetics were surveyed with a modified-PACIC.

RESULTS

An exploratory and confirmatory factor analysis was conducted that accounted for the ordinal nature of the PACIC items. Ordinal alpha (0.972) and omega (0.973) reliability coefficients were calculated on the latent factor underlying the modified-PACIC. Correlation analyses were used to investigate the relationship between the modified-PACIC and numerous clinical labs related to diabetes. Validity for the original five-factor structure proposed by developers of the PACIC could not be confirmed.

CONCLUSIONS

More research focusing on the instrument's psychometric properties is necessary before researchers use it to investigate the chronic care model and patient health. Researchers will need to ensure that the composite scores underlying the instrument are normally distributed and correlated with behavioural and health indexes.

Screening, referral, and participation in a weight management program implemented in five CHCs

Community health centers have the potential to lessen obesity. We conducted a retrospective evaluation of a quality improvement program that included electronic body mass index (BMI) screening with provider referral to an in-clinic lifestyle behavior change counselor with weekly nutrition and exercise classes. There were 26,661 adult patients seen across five community health centers operating the weight management program. There were 23,593 (88%) adult patients screened, and 12,487 (53%) of these patients were overweight or obese (BMI >or=25). Forty percent received a provider referral, 15.6% had program contact, and 2.1% had more than 10 program contacts. A mean weight loss of seven pounds was observed among those patients with more than 10 program contacts. No significant weight change was observed in patients with less contact. Achieving public health impact from guideline recommended approaches to CHC-based weight management will require considerable improvement in patient and provider participation.

Diabetes risk reduction behaviors among U.S. adults with prediabetes

BACKGROUND

Diabetes can be prevented or delayed in high-risk adults through lifestyle modifications, including dietary changes, moderate-intensity exercise, and modest weight loss. However, the extent to which U.S. adults with prediabetes are making lifestyle changes consistent with reducing risk is unknown.

PURPOSE

This study aimed to study lifestyle changes consistent with reducing diabetes risk and factors associated with their adoption among adults with prediabetes.

METHODS

In 2009, data were analyzed from 1402 adults aged > or =20 years without diabetes who participated in the 2005-2006 National Health and Nutrition Examination Survey and had valid fasting plasma glucose and oral glucose tolerance tests. The extent to which adults with prediabetes report that in the past year they tried to control or lose weight, reduced the amount of fat or calories in their diet, or increased physical activity or exercise was estimated and factors associated with the adoption of these behaviors were examined.

RESULTS

Almost 30% of the U.S. adult population had prediabetes in 2005-2006, but only 7.3% (95% CI=5.5%, 9.2%) were aware they had it. About half of adults with prediabetes reported performing diabetes risk reduction behaviors in the past year, but only about one third of adults with prediabetes had received healthcare provider advice about these behaviors in the past year. In multivariate analyses, provider advice, female gender, and being overweight or obese were positively associated with all three risk reduction behaviors.

CONCLUSIONS

Adoption of risk reduction behaviors among U.S. adults with prediabetes is suboptimal. Efforts to improve awareness of prediabetes, increase promotion of healthy behaviors, and improve availability of evidence-based lifestyle programs are needed to slow the growth in new cases of diabetes.

The effect of linking community health centers to a state-level smoker's quitline on rates of cessation assistance

Background

Smoking cessation quitlines are an effective yet largely untapped resource for clinician referrals. The aim of this study was to assess the effect of a fax referral system that links community health centers (CHCs) with the New York State Quitline on rates of provider cessation assistance.

Methods

This study was conducted in four CHCs using a quasi experimental study design. Two comparison sites offered usual care (expanded vital sign chart stamp that prompted providers to ask about tobacco use, advice smokers to quit, assess readiness, and offer assistance (4As)) and two intervention sites received the chart stamp plus an office-based fax referral link to the New York State Quitline. The fax referral system links patients to a free proactive telephone counseling service. Provider adherence to the 4 As was assessed with 263 pre and 165 post cross sectional patient exit interviews at all four sites.

Results

Adherence to the 4As increased significantly over time in the intervention sites with no change from baseline in the comparison sites. Intervention sites were 2.4 (p < .008) times more likely to provide referrals to the state Quitline over time than the comparison sites and 1.8 (p < .001) times more likely to offer medication counseling and/or a prescription.

Conclusions

Referral links between CHCs and state level telephone quitlines may facilitate the provision of cessation assistance by offering clinicians a practical method for referring smokers to this effective service. Further studies are needed to confirm the efficacy of fax referral systems and to identify implementation strategies that work to facilitate the utilization of these systems across a wide range of clinical settings.

Using the internet to translate an evidence-based lifestyle intervention into practice

Despite evidence-based recommendations for addressing obesity in the clinical setting, lifestyle interventions are lacking in practice. The objective of this study was to translate an evidence-based lifestyle program into the clinical setting by adapting it for delivery via the Internet. We adapted the Diabetes Prevention Program's lifestyle curriculum to an online format, comprising 16 weekly and 8 monthly lessons, and conducted a before-and-after pilot study of program implementation and feasibility. The program incorporates behavioral tools such as e-mail prompts for online self-monitoring of diet, physical activity, and weight, and automated weekly progress reports. Electronic counseling provides further support. Physician referral, automated progress reports, and as-needed communication with lifestyle coaches integrate the intervention with clinical care. We enrolled 50 patients from a large academic general internal practice into a pilot program between November 16, 2006 and February 11, 2007. Patients with a body mass index (BMI) =25 kg/m2, at least one weight-related cardiovascular risk factor, and Internet access were eligible if referring physicians felt the lifestyle goals were safe and medically appropriate. Participants were primarily female (76%), with an average age of 51.94 (standard deviation [SD] 10.82), and BMI of 36.43 (SD 6.78). At 12 months of enrollment, 50% of participants had logged in within 30 days. On average, completers (n = 45) lost 4.79 (SD 8.55) kg. Systolic blood pressure dropped 7.33 (SD 11.36) mm Hg, and diastolic blood pressure changed minimally (+0.44 mm Hg; SD 9.27). An Internet-based lifestyle intervention may overcome significant barriers to preventive counseling and facilitate the incorporation of evidence-based lifestyle interventions into primary care.

Implementing a fax referral program for quitline smoking cessation services in urban health centers: a qualitative study

Background

Fax referral services that connect smokers to state quitlines have been implemented in 49 U.S. states and territories and promoted as a simple solution to improving smoker assistance in medical practice. This study is an in-depth examination of the systems-level changes needed to implement and sustain a fax referral program in primary care.

Methods

The study involved implementation of a fax referral system paired with a chart stamp prompting providers to identify smoking patients, provide advice to quit and refer interested smokers to a state-based fax quitline. Three focus groups (n = 26) and eight key informant interviews were conducted with staff and physicians at two clinics after the intervention. We used the Chronic Care Model as a framework to analyze the data, examining how well the systems changes were implemented and the impact of these changes on care processes, and to develop recommendations for improvement.

Results

Physicians and staff described numerous benefits of the fax referral program for providers and patients but pointed out significant barriers to full implementation, including the time-consuming process of referring patients to the Quitline, substantial patient resistance, and limitations in information and care delivery systems for referring and tracking smokers. Respondents identified several strategies for improving integration, including simplification of the referral form, enhanced teamwork, formal assignment of responsibility for referrals, ongoing staff training and patient education. Improvements in Quitline feedback were needed to compensate for clinics' limited internal information systems for tracking smokers.

Conclusions

Establishing sustainable linkages to quitline services in clinical sites requires knowledge of existing patterns of care and tailored organizational changes to ensure new systems are prioritized, easily integrated into current office routines, formally assigned to specific staff members, and supported by internal systems that ensure adequate tracking and follow up of smokers. Ongoing staff training and patient self-management techniques are also needed to ease the introduction of new programs and increase their acceptability to smokers.

A medical assistant-based program to promote healthy behaviors in primary care

PURPOSE

Most primary care patients have at least 1 major behavioral risk: smoking, risky drinking, low physical activity, or unhealthy diet. We studied the effectiveness of a medical assistant-based program to identify and refer patients with risk behaviors to appropriate interventions.

METHODS

We undertook a randomized control trial in a practice-based research network. The trial included 864 adult patients from 6 primary care practices. Medical assistants screened patients for 4 risk behaviors and applied behavior-specific algorithms to link patients with interventions. Primary outcomes were improved risk behaviors on standardized assessments. Secondary outcomes included participation in a behavioral intervention and the program's effect on the medical assistants' workflow and job satisfaction.

RESULTS

Follow-up data were available for 55% of participants at a mean of 12 months. The medical assistant referral arm referred a greater proportion of patients than did usual care (67.4 vs 21.8%; P <.001) but did not achieve a higher success rate for improved behavioral outcomes (21.7 vs 16.9%; P=0.19). Qualitative interviews found both individual medical assistant and organizational effects on program adoption.

CONCLUSION

Engaging more primary care team members to address risk behaviors improved referral rates. More extensive medical assistant training, changes in practice culture, and sustained behavioral interventions will be necessary to improve risk behavior outcomes.

Efficient assessment of social problem-solving abilities in medical and rehabilitation settings: a Rasch analysis of the Social Problem-Solving Inventory-Revised

The Social Problem Solving Inventory-Revised Scale (SPSI-R) has been shown to be a reliable and valid self-report measure of social problem-solving abilities. In busy medical and rehabilitation settings, a brief and efficient screening version with psychometric properties similar to the SPSI-R would have numerous benefits including decreased patient and caregiver assessment burden and administration/scoring time. Thus, the aim of the current study was to identify items from the SPSI-R that would provide for a more efficient assessment of global social problem-solving abilities. This study consisted of three independent samples: 121 persons in low-vision rehabilitation (M age=71 years old, SD=15.53), 301 persons living with diabetes mellitus (M age=58, and SD=14.85), and 131 family caregivers of persons with severe disabilities (M age=56 years old, SD=12.15). All persons completed a version of the SPSI-R, Center for Epidemiological Studies Depression Scale (CES-D), and the Satisfaction with Life Scale (SWLS). Using Rasch scaling of the SPSI-R short-form, we identified a subset of 10 items that reflected the five-component model of social problem solving. The 10 items were separately validated on the sample of persons living with diabetes mellitus and the sample of family caregivers of persons with severe disabilities. Results indicate that the efficient 10-item version, analyzed separately for all three samples, demonstrated good reliability and validity characteristics similar to the established SPSI-R short form. The 10-item version of the SPSI-R represents a brief, effective way in which clinicians and researchers in busy health care settings can quickly assess global problem-solving abilities and identify those persons at-risk for complicated adjustment. Implications for the assessment of social problem-solving abilities are discussed.