Applying Machine Learning Techniques to Implementation Science

Machine learning (ML) approaches could expand the usefulness and application of implementation science methods in clinical medicine and public health settings. The aim of this viewpoint is to introduce a roadmap for applying ML techniques to address implementation science questions, such as predicting what will work best, for whom, under what circumstances, and with what predicted level of support, and what and when adaptation or deimplementation are needed. We describe how ML approaches could be used and discuss challenges that implementation scientists and methodologists will need to consider when using ML throughout the stages of implementation.

Impact of COVID-19 Pandemic on Assessing Tobacco Status in Community Health Centers

Few have studied the COVID-19 pandemic's impact on tobacco use status assessment and cessation counseling. Electronic health record data from 217 primary care clinics were examined from January 1, 2019 to July 31, 2021. Data included telehealth and in-person visits for 759,138 adult patients (aged ≥18 years). Monthly rates of tobacco assessment per 1,000 patients were calculated. From March 2020 to May 2020, tobacco assessment monthly rates declined by 50% and increased from June 2020 to May 2021 but remained 33.5% lower than pre-pandemic levels. Rates of tobacco cessation assistance changed less, but remain low. These findings are significant given the relevance of tobacco use to increased severity of COVID-19.

Measuring nicotine dependence among adolescent and young adult cigarillo users

INTRODUCTION

Current measures of nicotine dependence (ND) were developed and validated for cigarette smokers only, limiting their utility for other combustible tobacco users. This study evaluates the psychometric properties of a pool of new and adapted items to measure ND among cigarillo and multiple tobacco product users.

METHODS

Items were drawn from the PROMIS Nicotine Dependence Item Bank which were adapted to be product neutral and new items were developed from a qualitative study of 60 adolescent and young adult cigarillo smokers. A total of 42 ND items were included in a web-based survey. Eligible participants were 14 to 28 year olds who smoked a minimum of 2 cigarillos per week. Analyses included confirmatory factor analysis, item response theory analysis, analysis of differential item functioning (DIF) and reliability. Ordinary least square regression was used to test the association of ND score with deciles of nicotine consumption.

RESULTS

Among the 1089 participants, the median number of cigarillos smoked per week was 20; 54% of participants also smoked cigarettes. All PROMIS items and 8 of 10 new items met the IRT fit criteria. Two PROMIS items had non-ignorable DIF. The pool of 40 items had good score reliability for a range of 2 standard deviations. Twenty-, eight-, and four-item short forms showed similarly good measurement properties; each was positively associated with decile of nicotine consumption, p<.001; R 2 = 0.33.

CONCLUSIONS

This adapted bank of ND items is psychometrically sound and includes items that are product neutral, making it suitable for assessing ND among cigarillo and polytobacco users.

IMPLICATIONS

This study rigorously evaluates adapted items to measure ND among cigarillo and polytobacco users and reports the reliability initial evidence of validity of short form scores.

Characteristics of Patients Engaging in Quitline Counseling After an Electronic Referral

INTRODUCTION

Proactive, electronic referral of primary care patients to quitlines has great potential to provide evidence-based tobacco-cessation assistance to tobacco users. However, the quitline contact rates and engagement of individuals beyond 1 counseling call are poor. This study examines the characteristics of electronically referred patients who engage with the quitline.

METHODS

This cross-sectional study included 2,407 primary care patients who reported using tobacco and accepted an electronic referral to the quitline. Outcomes included contact, enrollment, and receipt of ≥2 counseling sessions from the quitline. All measures were assessed from the electronic health record. The association of patient characteristics and outcomes was evaluated using logistic regression modeling with generalized estimating equation methods. Data were collected in 2016‒2018 and were analyzed in 2020.

RESULTS

Among 2,407 referred patients, 794 (33.0%) were contacted; of those, 571 enrolled (71.9%); and of those, 240 (42.0%) engaged in ≥2 quitline counseling sessions. In multivariable analyses, older adults (aged 50-64 and ≥65 years) were significantly more likely to be contacted (OR=2.32, 95% CI=1.6, 3.4) and to receive ≥2 counseling sessions (OR=2.34, 95% CI=1.2, 4.7) than those aged 18-34 years. Those with both Medicare and Medicaid insurance coverage were more likely than those with Medicaid only to be contacted (OR=1.71, 95% CI=1.4, 2.2), to enroll (OR=1.84, 95% CI=1.2, 2.9), and to receive ≥2 counseling sessions (OR=1.83, 95% CI=1.2, 2.9).

CONCLUSIONS

The current quitline phone-based approach is less likely to engage younger adults and those with Medicaid coverage; however, there is a need to improve quitline engagement across all patients. Identification and testing of alternative engagement approaches are needed.

A cluster randomized trial evaluating a teachable moment communication process for tobacco cessation support

Introduction

This study examines the uptake of a clinician-focused teachable moment communication process (TMCP) and its impact on patient receipt of tobacco cessation support. The TMCP is a counseling method that uses patient concerns to help clinicians guide behavior change discussions about tobacco. We evaluate the added value of the TMCP training in a health system that implemented an Ask-Advise-Connect (AAC) systems-based approach.

Methods

A stepped wedge cluster randomized trial included eight community health centers. Training involved a web module and onsite skill development with standardized patients and coaching. Main outcome measures included contact and enrollment in cessation services among patients referred for counseling, prescription of cessation medications and quit attempts.

Results

Forty-four of 60 eligible clinicians received the TMCP training. Among TMCP-trained clinicians 68% used a TMCP approach (documented by flowsheet use) one or more times, with the median number of uses being 15 (IQR 2–33). Overall, the TMCP was used in 661 out of 8198 visits by smokers (8%). There was no improvement in any of the tobacco cessation assistance outcomes for the AAC + TMCP vs. the AAC only period. Visits where clinicians used the TMCP approach were associated with increased ordering of tobacco cessation medications, (OR = 2.6; 95% CI = 1.9, 3.5) and providing advice to quit OR 3.2 (95% CI 2.2, 4.7).

Conclusions

Despite high fidelity to the training, uptake of the TMCP approach in routine practice was poor, making it difficult to evaluate the impact on patient outcomes. When the TMCP approach was used, ordering tobacco cessation medications increased.

Implications

Tobacco cessation strategies in primary care have the potential to reach a large portion of the population and deliver advice tailored to the patient. The poor uptake of the approach despite high training fidelity suggests that additional implementation support strategies, are needed to increase sustainable adoption of the TMCP approach.

Trial Registration

clinicaltrials.gov #NCT02764385, registration date 06/05/2016.

Challenges and opportunities using online portals to recruit diverse patients to behavioral trials

We describe the use of an online patient portal to recruit and enroll primary care patients in a randomized trial testing the effectiveness of a colorectal cancer (CRC) screening decision support program. We use multiple logistic regression to identify patient characteristics associated with trial recruitment, enrollment, and engagement. We found that compared to Whites, Blacks had lower odds of viewing the portal message (OR = 0.46, 95% CI = 0.37-0.57), opening the attached link containing the study material (OR = 0.75, 95% CI = 0.62-0.92), and consenting to participate in the trial (OR = 0.85, 95% CI = 0.67-0.93). We also found that compared to Whites, Asians had lower odds of viewing the portal message (OR = 0.53, 95% CI = 0.33-0.64), opening the attached link containing the study material (OR = 0.76, 95% CI = 0.54-0.97), consenting to participate in the trial (OR = 0.68, 95% CI = 0.53-0.95), and completing the trial's baseline questionnaire (OR = 0.59, 95% CI = 0.36-0.90). While portals offer an opportunity to mitigate human bias in trial invitations, because of racial disparities-not only in who has a portal account, but in how they interact with trial recruitment and enrollment material within the portal-using portals alone for trial recruitment may generate study samples that are not racially diverse.

Cigarillo and multiple tobacco product use and nicotine dependence in adolescents and young adults

INTRODUCTION

Multiple tobacco product (MTP) use is a growing public health concern, particularly among adolescents and young adults. This study identifies subgroups of MTP use among cigarillo users and examines associations with nicotine dependence (ND).

METHODS

1089 youth (ages 14-28) who currently smoke cigarillos completed a web-based survey regarding their current use of cigarillos, little cigars, traditional cigars, cigarettes, e-cigarettes, and waterpipe/hookah. Latent class analysis (LCA) was used to identify patterns of product use by type and amount. The LCA also assessed the relationship between the latent classes and a 38-item measure of ND, controlling for relevant demographics.

RESULTS

Most participants (88.2%) reported using two or more tobacco products in the past 30 days. The best-fitting LCA solution revealed 7 classes: (1) Mixed-Light tipped cigarillo and light cigarette users, 28.9%; (2) Light tipped cigarillo users, 15.8%; (3) Light untipped cigarillo users, 14.3%; (4) Heavy tipped cigarillo users, 13.4%; (5) E-cigarette and waterpipe users, 11.9%; (6) Heavy users of tipped and untipped cigarillos and light users of cigarettes, 9.8%; and (7) Dabblers who primarily used traditional cigars, but were also likely to use a variety of other products, 6.1%. Classes comprised of those using multiple products-particularly those that included cigarettes-had significantly higher levels of ND than other classes (Tukey's HSD P < .05).

CONCLUSIONS

Distinct patterns of MTP use are evident among young cigarillo smokers. Smoking multiple products, particularly smoking cigarillos in combination with cigarettes, is associated with higher ND compared to other product use patterns.

12-Month Evaluation of an EHR-Supported Staff Role Change for Provision of Tobacco Cessation Care in 8 Primary Care Safety-Net Clinics

SIGNIFICANCE

Guidelines urge primary care practices to routinely provide tobacco cessation care (i.e., assess tobacco use, provide brief cessation advice, and refer to cessation support). This study evaluates the impact of a systems-based strategy to provide tobacco cessation care in eight primary care clinics serving low-income patients.

METHODS

A non-randomized stepped wedge study design was used to implement an intervention consisting of (1) changes to the electronic health record (EHR) referral functionality and (2) expansion of staff roles to provide brief advice to quit; assess readiness to quit; offer a referral to tobacco cessation counseling; and sign the referral order. Outcomes assessed from the EHR include performance of tobacco cessation care tasks, referral contact, and enrollment rates for the quitline (QL) and in-house Freedom from Smoking (FFS) program. Generalized estimating equations (GEE) methods were used to compute odds ratios contrasting the pre-implementation vs. 1-, 3-, 6-, and 12-month post-implementation periods.

RESULTS

Of the 176,061 visits, 26.1% were by identified tobacco users. All indicators significantly increased at each time period evaluated post-implementation. In comparison with the pre-intervention period, assessing smoking status (26.6% vs. 55.7%; OR = 3.7, CI = 3.6-3.9), providing advice (44.8% vs. 88.7%; OR = 7.8, CI = 6.6-9.1), assessing readiness to quit (15.8% vs. 55.0%; OR = 6.2, CI = 5.4-7.0), and acceptance of a referral to tobacco cessation counseling (0.5% vs. 30.9%; OR = 81.0, CI = 11.4-575.8) remained significantly higher 12 months post-intervention. For the QL and FFS, respectively, there were 1223 and 532 referrals; 324 (31.1%) and 103 (24.7%) were contacted; 241 (74.4%) and 72 (69.6%) enrolled; and 195 (80.9%) and 14 (19.4%) received at least one counseling session.

CONCLUSIONS

This system change intervention that includes an EHR-supported role expansion substantially increased the provision of tobacco cessation care and improvements were sustained beyond 1 year. This approach has the potential to greatly increase the number of individuals referred for tobacco cessation counseling.

Assessing the Longitudinal Impact of Physician-Patient Relationship on Functional Health

PURPOSE

Access to a usual source of care is associated with improved health outcomes, but research on how the physician-patient relationship affects a patient's health, particularly long-term, is limited. The aim of this study was to investigate the longitudinal effect of changes in the physician-patient relationship on functional health.

METHODS

We conducted a prospective cohort study using the Medical Expenditure Panel Survey (MEPS, 2015-2016). The outcome was 1-year change in functional health (12-Item Short-Form Survey). The predictors were quality of physician-patient relationship, and changes in this relationship, operationalized with the MEPS Primary Care (MEPS-PC) Relationship subscale, a composite measure with preliminary evidence of reliability and validity. Confounders included age, sex, race/ethnicity, educational attainment, insurance status, US region, and multimorbidity. We conducted analyses with survey-weighted, covariate-adjusted, predicted marginal means, used to calculate Cohen effect estimates. We tested differences in trajectories with multiple pairwise comparisons with Tukey contrasts.

RESULTS

Improved physician-patient relationships were associated with improved functional health, whereas worsened physician-patient relationships were associated with worsened functional health, with 1-year effect estimates ranging from 0.05 (95% CI, 0-0.10) to 0.08 (95% CI, 0.02-0.13) compared with -0.16 (95% CI, -0.35 to -0.03) to -0.33 (95% CI, -0.47 to -0.02), respectively.

CONCLUSION

The quality of the physician-patient relationship is positively associated with functional health. These findings could inform health care strategies and health policy aimed at improving patient-centered health outcomes.

Quitting the quitline: a qualitative study of patient experience of electronic referrals to quitlines

BACKGROUND

The use of electronic referrals (eReferrals) to state quitlines (QLs) for tobacco-using patients is a promising approach for addressing smoking cessation on a large scale. However, QL contact, enrollment, and completion rates are low. The purpose of this study was to examine the eReferral to QL process from the patient's perspective in order to inform strategies for improving QL engagement.

METHODS

We conducted interviews with 55 patients who agreed to an eReferral at a primary care visit to 1 of 8 safety-net community health centers in Cuyahoga County, Ohio (September 2017-August 2018). Interviews were designed to explore the experiences of three subgroups of patients who subsequently: 1) declined participation in the QL; 2) were unreachable by the QL; or 3) were enrolled in or had completed the QL program. Analysis was guided by a phenomenological approach designed to identify emergent themes.

RESULTS

Reasons for QL program non-completion included changing life circumstances and events making cessation unviable; misunderstandings about the QL; discomfort with telephonic counseling; perceived lack of time for counseling; cell phone barriers; and having already quit smoking. We found that some individuals who were no longer engaged with the QL still desired continued support from the QL.

CONCLUSIONS

Participants intentionally and unintentionally disengage from the QL for a wide variety of reasons, several of which are mediated by low socioeconomic status. Integrating QL care with community-based resources that address these mediators could be a promising strategy.

A comparison of methods to measure daily cigarillo consumption among adolescents and young adults

OBJECTIVE

Cigarillo use is widespread among young people. Accurate assessment of cigarillo consumption is necessary to inform and evaluate tobacco research, but is complicated by product sharing and irregular use. This study compares a conventional approach with a detailed approach for measuring cigarillo consumption.

METHODS

Data are drawn from a cross-sectional, web-based survey of 1089 young (aged 15-28 years) cigarillo smokers. The conventional measure of cigarillo consumption employs two common tobacco use items-the number of days a product was smoked in the past month and the average number of products smoked per day. The detailed measure uses a time line follow-back procedure to assess product use on each of the past 7 days, both in a group and alone. Paired t-tests compare daily cigarillo use estimates from the two methods overall, and are stratified by sample characteristics and behaviours; associations with multiple factors are examined simultaneously using linear regression.

RESULTS

Compared with the conventional measure, the detailed measure yields significantly higher daily consumption estimates for moderate and high-level users and for non-daily tobacco users, and significantly lower estimates for those who always share products and daily tobacco users. Differences remain after controlling for demographics and product use behaviours. There are no differences by gender, age, race or multiple product use.

CONCLUSIONS

The two measurement methods yield significantly different consumption estimates based on sharing behaviour, regularity of use and use level. Improving accuracy in the measurement of tobacco product consumption is important and timely for tobacco control research and policy.

Logic model framework for considering the inputs, processes and outcomes of a healthcare organisation-research partnership

BACKGROUND

The published literature provides few insights regarding how to develop or consider the effects of knowledge co-production partnerships in the context of delivery system science.

OBJECTIVE

To describe how a healthcare organisation-university-based research partnership was developed and used to design, develop and implement a practice-integrated decision support tool for patients with a physician recommendation for colorectal cancer screening.

DESIGN

Instrumental case study.

PARTICIPANTS

Data were ascertained from project documentation records and semistructured questionnaires sent to 16 healthcare organisation leaders and staff, research investigators and research staff members.

RESULTS

Using a logic model framework, we organised the key inputs, processes and outcomes of a healthcare organisation-university-based research partnership. In addition to pragmatic researchers, partnership inputs included a healthcare organisation with a supportive practice environment and an executive-level project sponsor, a mid-level manager to serve as the organisational champion and continual access to organisational employees with relevant technical, policy and system/process knowledge. During programme design and implementation, partnership processes included using project team meetings, standing organisational meetings and one-on-one consultancies to provide platforms for shared learning and problem solving. Decision-making responsibility was shared between the healthcare organisation and research team. We discuss the short-term outcomes of the partnership, including how the partnership affected the current research team's knowledge and health system initiatives.

CONCLUSION

Using a logic model framework, we have described how a healthcare organisation-university-based research team partnership was developed. Others interested in developing, implementing and evaluating knowledge co-production partnerships in the context of delivery system science projects can use the experiences to consider ways to develop, implement and evaluate similar co-production partnerships.

Use of Evidence-Based Interventions and Implementation Strategies to Increase Colorectal Cancer Screening in Federally Qualified Health Centers

While colorectal cancer (CRC) screening rates have been increasing in the general population, rates are considerably lower in Federally Qualified Health Centers (FQHCs), which serve a large proportion of uninsured and medically vulnerable patients. Efforts to screen eligible patients must be accelerated if we are to reach the national screening goal of 80% by 2018 and beyond. To inform this work, we conducted a survey of key informants at FQHCs in eight states to determine which evidence-based interventions (EBIs) to promote CRC screening are currently being used, and which implementation strategies are being employed to ensure that the interventions are executed as intended. One hundred and forty-eight FQHCs were invited to participate in the study, and 56 completed surveys were received for a response rate of 38%. Results demonstrated that provider reminder and recall systems were the most commonly used EBIs (44.6%) while the most commonly used implementation strategy was the identification of barriers (84.0%). The mean number of EBIs that were fully implemented at the centers was 2.4 (range 0-7) out of seven. Almost one-quarter of respondents indicated that their FQHCs were not using any EBIs to increase CRC screening. Full implementation of EBIs was correlated with higher CRC screening rates. These findings identify gaps as well as the preferences and needs of FQHCs in selecting and implementing EBIs for CRC screening.

Electronic medical record documentation of tobacco cessation support at eight community safety-net clinics with a high prevalence of tobacco use

OBJECTIVES

The high prevalence of tobacco use at primary care safety-net clinics represents an opportunity to offer assistance with cessation. Documentation of smoking status, offering advice and medications, and referral to cessation services are important steps in supporting cessation attempts and are required elements by payors and accrediting agencies to demonstrate care quality. This study examines tobacco cessation support rates and patient characteristics using electronic medical record (EMR) data.

METHODS

This cross-sectional study engaged eight community health centers affiliated with a county hospital system in NE Ohio where adult tobacco use rates exceed 30%. EMR data from June 2014 through May 2016 were analysed to assess rates of tobacco cessation counselling, order of cessation medications, or both. The association of tobacco cessation support with patient characteristics and quit attempts was assessed using multivariable logistic regression models.

RESULTS

Among 21 702 current tobacco users, 74% had no intervention documented; 15.4% had counselling documented, 6.4% were prescribed tobacco cessation medication, and 4.2% had both documented. Males, those aged 18 to 34, and African Americans were more likely to have no documented intervention. Of current tobacco users with at least two visits, 5.6% had a quit attempt. Medication alone was associated with a greater likelihood of a quit attempt (AOR: 1.72 [95% CI: 1.36-2.17]) as well as counselling and medication combined (AOR: 1.95 [95% CI: 1.48-2.56]).

CONCLUSIONS

Tobacco cessation support was lacking for 74% of current smokers and was less likely in subgroups including males, younger adults, and African Americans. Ordering tobacco cessation medication combined with counselling nearly doubled the likelihood of a quit attempt.

A National Study of Oncology Nurses Discussing Cancer Clinical Trials With Patients

In the United States less than 10% of cancer patients engage in clinical trials. Although most oncology nurses have multiple opportunities to discuss clinical trials with patients, barriers including attitudes and social norms may impede these discussions. Guided by the Theory of Planned Behavior, we developed and evaluated measures for attitudes, subjective norms, and perceived behavioral control of nurses for discussing clinical trials with cancer patients. Of the 18,000 Oncology Nurse Society members invited, 1,964 completed the survey. Structural equation modeling and internal consistency reliability were used to evaluate items and constructs. We found that overall model fit and reliability was good: Confirmatory Fit Index (CFI) = 0.91, Root Mean Square Error of Approximation (RMSEA) = 0.05; attitudes, 21 items, alpha = 0.84; perceived behavioral control, 10 items, alpha = 0.85; and subjective norms, 9 items, alpha = 0.89. These measures of attitudes, subjective norms, and perceived behavioral control show good reliability and initial evidence of validity.

Patient-Reported Needs Following a Referral for Colorectal Cancer Screening

INTRODUCTION

Patient-physician communication about colorectal cancer screening can affect screening use, but discussions often lack information that patients need for informed decision making and seldom address personal preferences or barriers. To address this gap, a series of patient focus groups was conducted to guide the development of an online, interactive decision support program. This article presents findings on patient information needs and barriers to colorectal cancer screening after receiving a screening recommendation from a physician, and their perspectives on using electronic patient portals as platforms for health-related decision support.

METHODS

Primary care patients with recent colonoscopy or stool testing orders were identified via the centralized data repository of a large Midwestern health system. Seven gender-stratified focus groups (N=45 participants) were convened between April and July 2016. Sessions were audio recorded, transcribed, coded, and analyzed for commonly expressed themes beginning in August 2016.

RESULTS

Findings reveal a consistent need for simple and clear information on colorectal cancer screening. Participants desired step-by-step explanations of the colonoscopy procedure and information about bowel preparation options/alternatives. The desired level of additional information varied: some patients wanted to know about and act on test options, whereas others preferred following their physician-recommended testing path. Fears and concerns were prevalent, particularly about colonoscopy, and patients reported challenges getting these concerns and their informational needs addressed. Finally, they expressed consistent support for using the patient portal to gather additional information from their physician.

CONCLUSIONS

Patient portals may offer an opportunity to build sustainable programs for decision support and assistance that are integrated with clinic workflows and processes.

Randomised trial to evaluate the effectiveness and impact of offering postvisit decision support and assistance in obtaining physician-recommended colorectal cancer screening: the e-assist: Colon Health study-a protocol study

INTRODUCTION

How to provide practice-integrated decision support to patients remains a challenge. We are testing the effectiveness of a practice-integrated programme targeting patients with a physician recommendation for colorectal cancer (CRC) screening.

METHODS AND ANALYSIS

In partnership with healthcare teams, we developed 'e-assist: Colon Health', a patient-targeted, postvisit CRC screening decision support programme. The programme is housed within an electronic health record (EHR)-embedded patient portal. It leverages a physician screening recommendation as the cue to action and uses the portal to enrol and intervene with patients. Programme content complements patient-physician discussions by encouraging screening, addressing common questions and assisting with barrier removal. For evaluation, we are using a randomised trial in which patients are randomised to receive e-assist: Colon Health or one of two controls (usual care plus or usual care). Trial participants are average-risk, aged 50-75 years, due for CRC screening and received a physician order for stool testing or colonoscopy. Effectiveness will be evaluated by comparing screening use, as documented in the EHR, between trial enrollees in the e-assist: Colon Health and usual care plus (CRC screening information receipt) groups. Secondary outcomes include patient-perceived benefits of, barriers to and support for CRC screening and patient-reported CRC screening intent. The usual care group will be used to estimate screening use without intervention and programme impact at the population level. Differences in outcomes by study arm will be estimated with hierarchical logit models where patients are nested within physicians.

ETHICS AND DISSEMINATION

All trial aspects have been approved by the Institutional Review Board of the health system in which the trial is being conducted. We will disseminate findings in diverse scientific venues and will target clinical and quality improvement audiences via other venues. The intervention could serve as a model for filling the gap between physician recommendations and patient action.

TRIAL REGISTRATION NUMBER

NCT02798224; Pre-results.

Addressing Tobacco Cessation at Federally Qualified Health Centers: Current Practices & Resources

This study assesses the current practices of Federally Qualified Health Centers (FQHCs) to address tobacco cessation with patients. A national sample of 112 FQHC medical directors completed the web-based survey. Frequently endorsed barriers to providing tobacco cessation services were: patients lacking insurance coverage (35%), limited transportation (27%), and variance in coverage of cessation services by insurance type (26%). Nearly 50% indicated that two or more tobacco cessation resources met the needs of their patients; 25% had one resource, and the remaining 25% had no resources. There were no differences among resource groups in the use of electronic health record (EHR) best-practice-alerts for tobacco use or in the perceived barriers to providing tobacco cessation assistance. Systems changes to harmonize coverage of tobacco assistance, such as broader accessibility to evidence-based cessation services could have a positive impact on the efforts of FQHCs to provide tobacco cessation assistance to their patients.

People and places shaping food procurement among recipients of Supplemental Nutrition Assistance Program (SNAP)

A key gap in existing food environment research is a more complex understanding of the interplay between physical and social contexts, including the influence of social networks on food habits. This mixed methods research examined the nature of social connections at food procurement places among a sample of 30 people receiving Supplemental Nutrition Assistance Program (SNAP) benefits in an urban setting. Results highlight the significance of social connections as motivators to use food places, the value of access to information and other resources at food places, and the role of weak ties with actors within food places to facilitate utilization and interaction. Social connections at the varied places individuals procure food may be leveraged to disseminate information and resources to further healthy food access.

The Role of Oncology Nurses in Discussing Clinical Trials

PURPOSE/OBJECTIVES

To describe oncology nurses' experiences discussing clinical trials with their patients, and to assess barriers to these discussions.
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RESEARCH APPROACH

A qualitative study designed to elicit narratives from oncology nurses. 
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SETTING

Community- and academic-based oncology clinics throughout the United States.
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PARTICIPANTS

33 oncology nurses involved in direct patient care in community-based and large hospital-based settings. The sample was drawn from members of the Oncology Nursing Society. 
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METHODOLOGIC APPROACH

In-depth interviews were conducted and analyzed using a 
immersion/crystallization approach to identify themes and patterns. The analyses highlight specific issues, examples, and contexts that present challenges to clinical trial discussions with patients.
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FINDINGS

Oncology nurses view their roles as patient educators and advocates to be inclusive of discussion of clinical trials. Barriers to such discussions include lack of knowledge and strategies for addressing patients' common misconceptions and uncertainty about the timing of discussions.
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INTERPRETATION

These data indicate that enabling nurses to actively engage patients in discussions of clinical trials requires educational interventions to build self-efficacy and close knowledge gaps. 
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IMPLICATIONS FOR NURSING

Oncology nurses can play a critical role in advancing cancer care by supporting patients in decision making about clinical trial participation. This will require training and education to build their knowledge, reduce barriers, and increase their self-efficacy to fulfill this responsibility in various clinical settings.

Challenges Implementing Lung Cancer Screening in Federally Qualified Health Centers

INTRODUCTION

The purpose of this study is to identify issues faced by Federally Qualified Health Centers (FQHCs) in implementing lung cancer screening in low-resource settings.

METHODS

Medical directors of 258 FQHCs serving communities with tobacco use prevalence above the median of all 1,202 FQHCs nationally were sampled to participate in a web-based survey. Data were collected between August and October 2016. Data analysis was completed in June 2017.

RESULTS

There were 112 (43%) FQHC medical directors or surrogates who responded to the 2016 survey. Overall, 41% of respondents were aware of a lung cancer screening program within 30 miles of their system's largest clinic. Although 43% reported that some providers in their system offer screening, it was typically at a very low volume (less than ten/month). Although FQHCs are required to collect tobacco use data, only 13% indicated that these data can identify patients eligible for screening. Many FQHCs reported important patient financial barriers for screening, including lack of insurance (72%), preauthorization requirements (58%), and out-of-pocket cost burdens for follow-up procedures (73%). Only 51% indicated having adequate access to specialty providers to manage abnormal findings, and few reported that leadership had either committed resources to lung cancer screening (12%) or prioritized lung cancer screening (12%).

CONCLUSIONS

FQHCs and other safety-net clinics, which predominantly serve low-socioeconomic populations with high proportions of smokers eligible for lung cancer screening, face significant economic and resource challenges to implementing lung cancer screening. Although these vulnerable patients are at increased risk for lung cancer, reducing patient financial burdens and appropriately managing abnormal findings are critical to ensure that offering screening does not inadvertently lead to harm and increase disparities.

Development of a Measure of Incremental Behavior Change Toward Smoking Cessation

INTRODUCTION

A reliable measure capable of detecting progression towards smoking cessation would be valuable for evaluating and optimizing the effectiveness of low- to moderate-intensity cessation interventions, such as brief advice in the primary care setting. This article presents the development and evaluation of a brief self-report measure of Incremental Behavior Change toward Smoking cessation (IBC-S).

METHODS

Sequential samples of 411 and 399 adult smokers completed items representing a spectrum of behavioral and cognitive changes antecedent to smoking cessation. The dimensionality, fit, range of difficulty, and reliability of items were evaluated using factor analysis and Rasch modeling.

RESULTS

The final 15-item IBC-S measure met fit criteria and demonstrated acceptable reliability. Participants with a significant change in IBC-S score were over four times more likely to report cessation at 6-week follow-up (OR 4.37, 95% CI 1.83-10.42).

CONCLUSION

The IBC-S is brief, reliable and associated with self-report of smoking reduction and cessation.

IMPLICATIONS

This article presents the psychometric evaluation of a measure to assess a spectrum of behaviors and cognitions antecedent to smoking cessation. The findings indicate that the items show good measurement properties and good potential as a sensitive measure to evaluate interventions. This measure provides an alternative outcome for interventions that are designed to move individuals towards cessation attempts.

The Hawthorne effect in direct observation research with physicians and patients

RATIONALE, AIMS, AND OBJECTIVES

This study examines the degree to which a "Hawthorne effect" alters outpatient-visit content.

METHODS

Trained research nurses directly observed 4454 visits to 138 family physicians. Multiple data sources were used to examine the Hawthorne effect including differences in medical record documentation for observed visits and the prior visit by the same patient, time use during visits on the first versus the second observation day of each physician, and report by the patient, physician, and observer of the effect of observation.

RESULTS

Visits on the first versus the second observation day were longer by an average of 1 minute (P < .001); there were time-use differences for 4 of 20 behaviour categories evaluated. No effect of the observer on the interaction was reported by 74% of patients and 55% of physicians. Most of those that reported an affect indicated it was slight. Patients with non-White race, lower-educational level, and poorer health were more likely to report being affected by the observer.

CONCLUSIONS

In a study that was designed to minimize the Hawthorne effect, the presence of an observer had little effect on most patient-physician visits but appeared to at least slightly effect a subgroup of vulnerable patients.

Food Melt in Consumer Food Environments in Low-income Urban Neighborhoods

OBJECTIVES

We systematically evaluated changes in availability, price, and quality of perishable food items from the beginning to the end of the month in lowincome, urban neighborhoods.

METHODS

The sample included grocery stores or supermarkets in Cleveland, Ohio, within neighborhoods with >30% of population receiving food assistance. We collected data for 2 sequential months during the first and fourth weeks of each month. Two coders evaluated stores, collecting measures of availability, price, and quality for 50 items. We examined difference in number and proportion of items available at the beginning of the month (BOM) to items remaining available at the end of the month (EOM), as well as quality and price of those items.

RESULTS

Across 48 stores, availability at EOM was lower than BOM; as store size increased, reduction in availability (ie, food melt) was significantly (p < .01) less pronounced. Overall, items became less expensive at the EOM whereas quality remained consistent; we noted no statistically significant differences by store type for price or quality.

CONCLUSIONS

Food melt differentially affects individuals in neighborhoods without grocery stores. Findings reveal composition of food environments is dynamic rather than static, influencing food-purchasing choices among lowincome consumers.

The Breast and Cervical Cancer Early Detection Program, Medicaid, and breast cancer outcomes among Ohio's underserved women

BACKGROUND

As an organized screening program, the national Breast and Cervical Cancer Early Detection Program (BCCEDP) was launched in the early 1990s to improve breast cancer outcomes among underserved women. To analyze the impact of the BCCEDP on breast cancer outcomes in Ohio, this study compared cancer stages and mortality across BCCEDP participants, Medicaid beneficiaries, and "all others."

METHODS

This study linked data across the Ohio Cancer Incidence Surveillance System, Medicaid, the BCCEDP database, death certificates, and the US Census and identified 26,426 women aged 40 to 64 years who had been diagnosed with incident invasive breast cancer during the years 2002-2008 (deaths through 2010). The study groups were as follows: BCCEDP participants (1-time or repeat users), Medicaid beneficiaries (women enrolled in Medicaid before their cancer diagnosis [Medicaid/prediagnosis] or around the time of their cancer diagnosis [Medicaid/peridiagnosis]), and all others (women identified as neither BCCEDP participants nor Medicaid beneficiaries). The outcomes included advanced-stage cancer at diagnosis and mortality. A multivariable logistic and survival analysis was conducted to examine the independent association between the BCCEDP and Medicaid status and the outcomes.

RESULTS

The percentage of women presenting with advanced-stage disease was highest among women in the Medicaid/peridiagnosis group (63.4%) and lowest among BCCEDP repeat users (38.6%). With adjustments for potential confounders and even in comparison with Medicaid/prediagnosis beneficiaries, those in the Medicaid/peridiagnosis group were twice as likely to be diagnosed with advanced-stage disease (adjusted odds ratio, 2.20; 95% confidence interval, 1.83-2.66).

CONCLUSIONS

Medicaid/peridiagnosis women are at particularly high risk to be diagnosed with advanced-stage disease. Efforts to reduce breast cancer disparities must target this group of women before they present to Medicaid. Cancer 2017;123:3097-106. © 2017 American Cancer Society.

The Prevalence of Tobacco Use at Federally Qualified Health Centers in the United States, 2013

We explored tobacco use across federally qualified health centers (FQHCs) and compared data on state-level tobacco use between FQHC patients and the general population. We used data from the Uniform Data System (UDS) and the Behavioral Risk Factor Surveillance System (BRFSS) to generate estimates of 2013 prevalence of tobacco use among adults aged 18 years or older. According to UDS data, the overall prevalence of tobacco use was 25.8% in FQHCs compared with 20.6% in the general population represented by BRFSS data, an average of 5.2 percentage points (range, −4.9 to 20.9) higher among FQHCs. Among FQHCs, the burden of tobacco use and the opportunity for offering cessation assistance is substantial.

Effectiveness of a clinician intervention to improve physical activity discussions in underserved adults

BACKGROUND

Physical activity (PA) counselling is challenging in primary care. It is unknown whether clinician training on the 5As (Ask, Advise, Agree, Assist, Arrange) improves PA counselling skills.

OBJECTIVE

To evaluate the effect of a clinician training intervention on PA counselling for underserved adults using the 5As framework.

METHODS

Pragmatic pilot clinical trial was used in the study. Clinicians (n = 13) were randomly assigned to two groups. Each group received the intervention consisting of four 1-hour training sessions to teach the 5As for PA counselling. Patient-clinician visits (n = 325) were audio recorded at baseline, immediately post-intervention, and at 6 months. Outcomes were the frequency and quality of PA discussions using the 5As, assessed by blinded coders.

RESULTS

Patients' mean age was 44 years; 75% were African American. PA was discussed in 37% (n = 119) of visits overall and did not change from baseline to follow-up. When PA discussions occurred, the frequency of 5As increased from baseline to follow-up for Advise (51-54%), Agree (11-26%), and Assist (11-17%); however, none of the 5As had a statistically significant increase. For Agree, exploration of patient willingness to engage in PA increased from 23% at baseline to 50% at follow-up.

CONCLUSION

A clinician-directed intervention to improve PA counselling increased the frequency of Advise, Agree and Assist, and the quality of Ask and Agree statements, though the absolute numbers were small and only Agree reached statistical significance. Future research is needed to understand the factors that affect the optimal uptake and approach to 5As counselling.

Understanding and measuring health care insecurity

PURPOSE

To define the concept of "health care insecurity,” validate a new self-report measure, and examine the impact of beginning care at a free clinic on uninsured patients' health care insecurity.

METHODS

Consecutive new patients presenting at a free clinic completed 15 items assessing domains of health care insecurity (HCI) at their first visit and again four to eight weeks later. Psychometrics and change of the HCI measure were examined.

RESULTS

The HCI measure was found to have high internal consistency (α=0.94). Evidence of concurrent validity was indicated by negative correlation with VR-12 health-related quality of life physical and mental health components and positive correlation with the Perceived Stress Scale. Predictive validity was shown among the 83% of participants completing follow-up: HCI decreased after beginning care at a free clinic (p<.001).

CONCLUSION

Reliably assessing patient experience of health care insecurity is feasible and has potential to inform efforts to improve quality and access to care among underserved populations.

Primary Care Resident Training for Obesity, Nutrition, and Physical Activity Counseling: A Mixed-Methods Study

National guidelines have been established to support the role of primary care physicians in addressing obesity. Preparing primary care residents to recognize and treat overweight/obesity has been identified as an essential component of postgraduate medical training that is currently lacking. This study aims to identify how primary care residency programs are preparing physicians to counsel about obesity, nutrition, and physical activity (ONPA) and to examine program members' perspectives regarding the place of ONPA counseling in the curriculum, and its relevance in primary care training. Using mixed methods, we collected and analyzed data on 25 family medicine, internal medicine, and obstetrics/gynecology residency programs across Ohio. Programs averaged 2.8 hours of ONPA-related didactics per year. Ten programs (42%) taught techniques for health behavior counseling. Having any ONPA-related didactics was associated with greater counseling knowledge (p = .01) among residents but poorer attitudes (p < .001) and poorer perceived professional norms (p = .004) toward ONPA counseling. Findings from interview data highlighted similar perceived barriers to ONPA counseling across all three specialties but variation in perception of responsibility to provide ONPA counseling. While widespread expectations that primary care physicians counsel their overweight and obese patients prevail, few residency programs provide training to support such counseling.

User and Content Characteristics of Public Tweets Referencing Little Cigars

OBJECTIVES

Compared to cigarettes, little cigars and cigarillos (LCC) are minimally regulated, affordable, and widely available to young people. Because Twitter is a preferred mode of communication among younger people, product portrayals may be useful for informing both interventions and public health or tobacco policy.

METHODS

A mixed-methods study was implemented to analyze the content of public tweets (N = 288) and profile photos sampled from a search of 2 LCC brands (Black & Mild and Swisher Sweets). Metadata and manifest attributes of profile photo demographic features and tweet message features were coded and analyzed. Thematic analysis of the tweets was conducted using an iterative immersion/ crystallization method.

RESULTS

Tweeters were most often boys or men (63%) and appeared young (76%). Prevalent content themes included expressing affiliation for the LCC product and reporting smoking activity. Although men and women tweeted affiliation for LCC products and reported smoking activity in similar numbers, women were significantly less likely to tweet about blunting than men.

CONCLUSIONS

Twitter provides a potentially potent source of nuanced information about how young people are using little cigars. These observed characteristics may be useful to inform counter-messaging strategies and interventions.

Comparing Breast Cancer Outcomes Between Medicaid and the Ohio Breast and Cervical Cancer Early Detection Program

PURPOSE

To compare outcomes between women enrolling in Medicaid after being diagnosed with breast cancer and those referred to Medicaid through the Ohio Breast and Cervical Cancer Early Detection Program (BCCEDP).

METHODS

Using linked data from the 2002 to 2008 Ohio Cancer Incidence Surveillance System, Medicaid, the BCCEDP database, and Ohio death certificates (through 2010), we identified women 40 to 64 years of age diagnosed with incident invasive breast cancer during the study years and enrolled in Medicaid 3 months before or after cancer diagnosis. We compared the following outcomes across BCCEDP one-time and repeat participants and nonparticipants: (1) cancer stage at diagnosis, (2) treatment delays, (3) receipt of standard treatment, and (4) survival. We conducted multivariable logistic regression and survival analysis to examine the association between BCCEDP participation and the outcomes of interest, controlling for potential confounders.

RESULTS

We identified 427 and 654 BCCEDP participants and nonparticipants, respectively; 28.5% of BCCEDP women were repeat participants. Compared with nonparticipants, BCCEDP one-time and repeat participants were significantly less likely to be diagnosed with advanced-stage cancer (one-time: adjusted odds ratio [AOR], 0.64; 95% CI, 0.49 to 0.85; repeat: AOR, 0.34; 95% CI, 0.23 to 0.52), or experience delays in treatment initiation (one-time: adjusted hazard ratio [AHR], 1.29; 95% CI, 1.09 to 1.51; repeat: AHR, 1.38; 95% CI, 1.11 to 1.72). In addition, although we observed no difference in receipt of standard cancer treatment, BCCEDP participants experienced cancer-specific and overall survival benefits.

CONCLUSION

Compared with nonparticipants, BCCEDP participants experienced earlier breast cancer stage at diagnosis, shorter time to treatment initiation, and survival benefits.

Primary Care Residents' Knowledge, Attitudes, Self-Efficacy, and Perceived Professional Norms Regarding Obesity, Nutrition, and Physical Activity Counseling

BACKGROUND

Obesity and being overweight are both significant risk factors for multiple chronic conditions. Primary care physicians are in a position to provide health behavior counseling to the majority of US adults, yet most report insufficient training to deliver effective counseling for obesity.

OBJECTIVE

To assess the degree to which residents training in adult primary care programs are prepared to provide obesity, nutrition, and physical activity (ONPA) counseling.

METHODS

Senior residents (postgraduate year [PGY]-3 and PGY-4) from 25 Ohio family medicine, internal medicine, and obstetrics and gynecology programs were surveyed regarding their knowledge about obesity risks and effective counseling, as well as their attitudes, self-efficacy, and perceived professional norms toward ONPA counseling. We examined summary scores, and used regression analyses to assess associations with resident demographics and training program characteristics.

RESULTS

A total of 219 residents participated (62% response rate). Mean ONPA counseling knowledge score was 50.8 (± 15.6) on a 0 to 100 scale. Specialty was associated with counseling self-efficacy (P < .001) and perceived norms (P = .002). Residents who reported having engaged in an elective rotation emphasizing ONPA counseling had significantly higher self-efficacy and more positive attitudes and professional norms scores.

CONCLUSIONS

Our findings suggest that primary care residents' knowledge of ONPA assessment and management strategies has room for improvement. Attitudes, self-efficacy, and perceived norms also are low and vary by training program characteristics. A deeper understanding of curricula associated with improved performance in these domains could inform interventions to enhance residents' ONPA counseling skills and prevent chronic disease.

Lasting Effects of the Breast and Cervical Cancer Early Detection Program on Breast Cancer Detection and Outcomes, Ohio, 2000-2009

Introduction

The National Breast and Cervical Cancer Early Detection Program (BCCP) in Ohio provides screening and treatment services for uninsured low-income women aged 40 to 64. Because participation in the BCCP might engender greater self-efficacy for cancer screening, we hypothesized that breast cancer and survival outcomes would be better in BCCP participants who become age-eligible to transition to Medicare than in their low-income non-BCCP counterparts.

Methods

Linking data from the 2000 through 2009 Ohio Cancer Incidence Surveillance System with the BCCP database, Medicare files, Ohio death certificates (through 2010), and the US Census, we identified Medicare beneficiaries who were aged 66 to 74 and diagnosed with incident invasive breast cancer. We compared the following outcomes between BCCP women (n = 93) and low-income non-BCCP women (n = 420): receipt of screening mammography in previous year, advanced-stage disease at diagnosis, timely and standard care, all-cause survival, and cancer survival. We conducted multivariable logistic regression and survival analysis to examine the association between BCCP status and each of the outcomes, adjusting for patient covariates.

Results

Women who participated in the BCCP were nearly twice as likely as low-income non-BCCP women to have undergone screening mammography in the previous year (adjusted odds ratio, 1.77; 95% confidence interval, 1.01–3.09). No significant differences were detected in any other outcomes.

Conclusion

With the exception of screening mammography, the differences in outcomes were not significant, possibly because of the small size of the study population. Future analysis should be directed toward identifying the factors that explain these findings.

Physician use of persuasion and colorectal cancer screening

The impact of patient-physician communication on subsequent patient behavior has rarely been evaluated in the context of colorectal cancer (CRC) screening discussions. We describe physicians' use of persuasive techniques when recommending CRC screening and evaluate its association with patients' subsequent adherence to screening. Audio recordings of N = 414 periodic health examinations were joined with screening use data from electronic medical records and pre-/post-visit patient surveys. The association between persuasion and screening was assessed using generalized estimating equations. According to observer ratings, primary care physicians frequently use persuasive techniques (63 %) when recommending CRC screening, most commonly argument or refutation. However, physician persuasion was not associated with subsequent screening adherence. Physician use of persuasion may be a common vehicle for information provision during CRC screening discussions; however, our results do not support the sole reliance on persuasive techniques if the goal is to improve adherence to recommended screening.

Health behaviors in family members of patients completing cancer treatment

PURPOSE/OBJECTIVES

To describe the impact of the cancer experience on the health behaviors of survivors' family members and to determine factors associated with family members' intentions for health behavior change.

DESIGN

Descriptive, cross-sectional, correlational.

SETTING

A National Cancer Institute-designated comprehensive cancer center in the midwestern United States.

SAMPLE

39 family members and 50 patients with diagnoses of breast, colorectal, head and neck, lung, or prostate cancer who were completing definitive cancer treatment.

METHODS

Patients and family members were approached in the clinic at three weeks or fewer before the completion of their course of treatment. Family members completed surveys and a structured interview in person or via telephone.

MAIN RESEARCH VARIABLES

Intention, perceived benefit, and confidence about eating a healthful diet, physical activity, and smoking cessation; emotional distress; and family cohesion, conflict, and expressiveness.

FINDINGS

Family members had high ratings for intention, perceived benefit, and confidence related to the behaviors of eating a healthful diet and performing 30 minutes of daily moderate-intensity physical activity. They also had high ratings for the extent to which the cancer experience had raised awareness of their cancer risk and made them consider undergoing screening tests for cancer; ratings were lower for making changes in their health behaviors.

CONCLUSIONS

Family members expressed strong intentions to engage in health-promoting behaviors related to physical activity and nutrition at the post-treatment transition.

IMPLICATIONS FOR NURSING

Oncology nurses are in a key position to engage family members and patients in behavior change. Nurses should assess family members at the completion of treatment for distress and provide interventions to influence the trajectory of distress in survivorship.

Health behaviors in family members of patients completing cancer treatment

PURPOSE/OBJECTIVES

To describe the impact of the cancer experience on the health behaviors of survivors' family members and to determine factors associated with family members' intentions for health behavior change.

DESIGN

Descriptive, cross-sectional, correlational.

SETTING

A National Cancer Institute-designated comprehensive cancer center in the midwestern United States.

SAMPLE

39 family members and 50 patients with diagnoses of breast, colorectal, head and neck, lung, or prostate cancer who were completing definitive cancer treatment.

METHODS

Patients and family members were approached in the clinic at three weeks or fewer before the completion of their course of treatment. Family members completed surveys and a structured interview in person or via telephone.

MAIN RESEARCH VARIABLES

Intention, perceived benefit, and confidence about eating a healthful diet, physical activity, and smoking cessation; emotional distress; and family cohesion, conflict, and expressiveness.

FINDINGS

Family members had high ratings for intention, perceived benefit, and confidence related to the behaviors of eating a healthful diet and performing 30 minutes of daily moderate-intensity physical activity. They also had high ratings for the extent to which the cancer experience had raised awareness of their cancer risk and made them consider undergoing screening tests for cancer; ratings were lower for making changes in their health behaviors.

CONCLUSIONS

Family members expressed strong intentions to engage in health-promoting behaviors related to physical activity and nutrition at the post-treatment transition.

IMPLICATIONS FOR NURSING

Oncology nurses are in a key position to engage family members and patients in behavior change. Nurses should assess family members at the completion of treatment for distress and provide interventions to influence the trajectory of distress in survivorship.

A randomized trial to evaluate primary care clinician training to use the Teachable Moment Communication Process for smoking cessation counseling

OBJECTIVE

To implement and evaluate the impact of a Teachable Moment Communication Process (TMCP) training intervention on clinicians' smoking cessation counseling behaviors in practice.

METHOD

Using a group randomized trial, 31 community-based, primary care clinicians in Northeast Ohio received either TMCP training or an attention control (2010-2012). TMCP training consisted of two, three-hour sessions involving didactic instruction, skill practice with standardized patients, and coaching. Clinician performance of TMCP elements was assessed by coding audio-recordings of routine visits with smokers at baseline and post-intervention (n=806).

RESULTS

Baseline performance of all TMCP elements was similar in the two groups. After the intervention, TMCP-trained clinicians were more often observed advising patients to quit while linking smoking to the patient's concern (58% vs. 44%, p=0.01), expressing optimism (36% vs. 3%, p<0.001), expressing partnership (40% vs. 12%, p=0.003) and eliciting the patient's readiness to quit (84% vs. 65%, p=0.006) than clinicians in the comparison group. TMCP-trained clinician responses were also better aligned with patients' expressed readiness to quit smoking than comparison group clinicians (p<0.001).

CONCLUSION

The intervention significantly changed the content of clinicians' smoking cessation communication in ways consistent with the TMCP model for health behavior change.

How well do physician and patient visit priorities align?

This study found that there is alignment between a patient's reason for a visit and the physician's main concern 69% of the time. Less than fully aligned priorities were associated with insurance status and the number of problems addressed.

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.

Creating a culture of inquiry in family medicine

BACKGROUND AND OBJECTIVES

Strengthening the contribution of reflective practice and new knowledge generation to the learning relationships forged during graduate and undergraduate medical training offers a possibility to create a climate more conducive to the recruitment and retention of family physicians. The Culture of Inquiry (CI) fellowship, an immersive, experientially based training program, combines didactic instruction, workshops, and mentoring to develop the capacity of family medicine's teachers to imagine, implement, and disseminate clinically relevant research and stimulate collaborations with those whom they train. This article outlines the CI fellowship program, summarizes its outcomes, and offers insights about programmatic features contributing to its success.

METHODS

The Department of Family Medicine and Community Health at Case Western Reserve University selected CI fellows from interested local family physicians who train residents and medical students. Over 10 months, with 10% effort expected from fellows, the CI fellowship exposed each fellow to the entire research process and provided technical and logistical support for the design and completion of two research projects. Quantitative and qualitative program evaluation were used to assess outcomes.

RESULTS

Scholarly productivity of fellows exceeded expectations. Collaborations with students and residents produced a ripple effect that amplified the fellowship's impact by strengthening those relationships crucial to the creation of a culture of inquiry among family medicine's teachers, learners, and practitioners.

CONCLUSIONS

The CI fellowship represents a highly replicable program to connect committed and interested clinicians to research mentors with the goal of increasing scholarship and creating a growing culture of inquiry in family medicine.

Direct observation of weight counselling in primary care: alignment with clinical guidelines

Primary care physicians provide care to a disproportionate number of overweight and obese patients and are uniquely positioned to help patients manage their weight in the context of a continuity relationship. The US National Heart, Lung and Blood Institute (NHLBI) developed evidence-based guidelines for the effective and efficient care of overweight/obese patients, but little is known about the use of these guidelines in practice. To determine the content of weight discussions and assess the elements of the NHLBI guidelines that were accomplished, office visits of 544 adult, overweight/obese patients to 28 primary care physicians were observed and audio recorded. Associations between type of weight management discussion and patient, physician and visit characteristics were examined. Fifty per cent (n = 270) of visits included weight discussions; 47% and 38% included use of at least one NHLBI assessment or treatment element during discussions about weight, respectively. Only 35% (n = 193) of discussions included an assessment and treatment strategy; none included all NHLBI-recommended elements. Overall, adherence to guidelines was poor, particularly with regard to reporting body mass index to the patient, measuring waist circumference and setting realistic weight loss goals. Weight discussions did not clearly vary by the patient, physician or visit characteristics examined. These findings suggest opportunities to develop and further tailor resources for improved physician training in patient weight management communication and treatment techniques that are both consistent with current standards for effective, evidence-based care and efficient enough for routine use during busy primary care visits.

Patient-physician colorectal cancer screening discussion content and patients' use of colorectal cancer screening

OBJECTIVE

The US Preventive Services Task Force recommends using the 5As (i.e., Assess, Advise, Agree, Assist and Arrange) when discussing preventive services. We evaluate the association of the 5As discussion during primary care office visits with patients' subsequent colorectal cancer (CRC) screening use.

METHODS

Audio-recordings of n=443 periodic health exams among insured patients aged 50-80 years and due for CRC screening were joined with pre-visit patient surveys and screening use data from an electronic medical record. Association of the 5As with CRC screening was assessed using generalized estimating equations.

RESULTS

93% of patients received a recommendation for screening (Advise) and 53% were screened in the following year. The likelihood of screening increased as the number of 5A steps increased: compared to patients whose visit contained no 5A step, those whose visit contained 1-2 steps (OR=2.96 [95% CI 1.16, 7.53]) and 3 or more steps (4.98 [95% CI 1.84, 13.44]) were significantly more likely to use screening.

CONCLUSIONS

Physician CRC screening recommendations that include recommended 5A steps are associated with increased patient adherence.

PRACTICE IMPLICATIONS

A CRC screening recommendation (Advise) that also describes patient eligibility (Assess) and provides help to obtain screening (Assist) may lead to improved adherence to CRC screening.

Factors associated with patient reports of positive physician relational communication

OBJECTIVE

To evaluate the patient, physician, and visit-related factors associated with patient ratings of positive physician relational communication.

METHODS

Pre- and post-visit surveys were conducted with 485 patients attending a routine periodic health exam with one of 64 participating physicians. The audio-recorded visits were coded for elements of patient-physician communication including assertive responses, partnership building, question asking, supportive talk, and expressions of concern.

RESULTS

Patient reports of positive physician relational communication were associated with patient perceptions of how well the physician understood the patient's health care preferences and values, a patient-physician interaction outside of the exam room, and physician-prompted patient expressions of concern.

CONCLUSION

In addition to a patient's perception of their relationship with their physician going into the visit, relatively simple acts like extending the interaction beyond the exam room and ensuring that patients feel invited to express concerns they may have during the visit may influence patient perceptions of physician relational communication.

PRACTICE IMPLICATIONS

This study offers preliminary support for the idea that relational communication and its associated benefits may be fostered through simple physician-driven acts such as interacting with patients outside of the exam room and encouraging patients to express concerns within the visit.

The effect of insurance-driven medication changes on patient care

PURPOSE

Insurance plans periodically change their formularies to enhance medical efficacy and cost savings. Patients face challenges when formulary changes affect their treatment. This study assessed the impact of insurance-driven medication changes on primary care patients and examined implications for patient care.

METHODS

We mailed questionnaires to a cross-sectional random sample of 1200 adult patients who had visited one of 3 family medicine practices within the past 6 months, asking them to describe problems they had encountered in filling medication prescriptions. We performed descriptive analyses of the frequency and distribution of demographic variables and conditions being treated. Using logistic regression analysis, we identified demographic and health-related variables independently associated with patient-reported problems caused by formulary changes.

RESULTS

Three variables-a greater number of prescription medications taken, younger patient age, and reliance on government insurance-were independently associated with an increased likelihood of encountering a problem filling a medication. Patients who reported an insurance-related issue filling a new or existing prescription over the past year (23%) encountered an average of 3 distinct problems. Patients experienced adverse medical outcomes (41%), decreased satisfaction with the health care system (68%), and problems that burdened the physician practice (83%). Formulary changes involving cardiac/hypertension/lipid and neurologic/psychiatric medications caused the most problems.

CONCLUSIONS

Insurance-driven medication changes adversely affect patient care and access to treatment, particularly for patients with government insurance. A better understanding of the negative impact of formulary changes on patient care and indirect health care expenditures should inform formulary change practices in order to minimize cost-shifting and maximize continuity of care.

A Teachable Moment Communication Process for smoking cessation talk: description of a group randomized clinician-focused intervention

BACKGROUND

Effective clinician-patient communication about health behavior change is one of the most important and most overlooked strategies to promote health and prevent disease. Existing guidelines for specific health behavior counseling have been created and promulgated, but not successfully adopted in primary care practice. Building on work focused on creating effective clinician strategies for prompting health behavior change in the primary care setting, we developed an intervention intended to enhance clinician communication skills to create and act on teachable moments for smoking cessation. In this manuscript, we describe the development and implementation of the Teachable Moment Communication Process (TMCP) intervention and the baseline characteristics of a group randomized trial designed to evaluate its effectiveness.

METHODS/DESIGN

This group randomized trial includes thirty-one community-based primary care clinicians practicing in Northeast Ohio and 840 of their adult patients. Clinicians were randomly assigned to receive either the Teachable Moments Communication Process (TMCP) intervention for smoking cessation, or the delayed intervention. The TMCP intervention consisted of two, 3-hour educational training sessions including didactic presentation, skill demonstration through video examples, skills practices with standardized patients, and feedback from peers and the trainers. For each clinician enrolled, 12 patients were recruited for two time points. Pre- and post-intervention data from the clinicians, patients and audio-recorded clinician‒patient interactions were collected. At baseline, the two groups of clinicians and their patients were similar with regard to all demographic and practice characteristics examined. Both physician and patient recruitment goals were met, and retention was 96% and 94% respectively.

DISCUSSION

Findings support the feasibility of training clinicians to use the Teachable Moments Communication Process. The next steps are to assess how well clinicians employ these skills within their practices and to assess the effect on patient outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01575886.

Integrating routine lactation consultant support into a pediatric practice

BACKGROUND

Although research shows that healthcare professionals' support improves breastfeeding duration, many physicians do not believe they have adequate time to address breastfeeding concerns during office visits. This study evaluated the impact of a pediatric practice's postnatal lactation consultant intervention. To improve breastfeeding support, the study practice changed policy and began using a lactation consultant overseen by a physician, to conduct the initial postpartum office visit for all breastfeeding infants.

METHODS

A retrospective chart review was performed on consecutive newborns before (n = 166) and after (n = 184) implementation of the program. Feeding method was assessed at each well child visit during the infant's first 9 months. χ² and logistic growth curve analyses were used to test the association between implementation status and non-formula feeding (NFF).

RESULTS

Mothers and infants in 2007 and 2009 were similar with regard to type of insurance, parity, gestational age, multiple births, and cesarean sections. Overall, NFF improved after program implementation (odds ratio = 1.12, 95% confidence interval 1.02-1.23). In 2009, NFF rates at 2 months, 4 months, 6 months, and 9 months were greater than 2007 rates by 10%, 15%, 11%, and 9%, respectively. Logistic growth curve analysis indicated the difference across these time points was significant between 2007 and 2009.

CONCLUSION

A routine post-discharge outpatient lactation visit coordinated within a primary care practice improved breastfeeding initiation and intensity. This effect was sustained for 9 months.

Patient-physician colorectal cancer screening discussions: delivery of the 5A's in practice

BACKGROUND

The U.S. Preventive Services Task Force advocates use of a 5A's framework (assess, advise, agree, assist, and arrange) for preventive health recommendations.

PURPOSE

To describe 5A content of patient-physician colorectal cancer (CRC) screening discussions and physician-recommended screening modality and to test if these vary by whether patient previously received screening recommendation.

METHODS

Direct observation of periodic health examinations in 2007-2009 among average-risk primary care patients aged 50-80 years due for screening. Qualitative content analyses conducted 2008-2010 used to code office visit audio-recordings for 5A and other discussion content.

RESULTS

Among study-eligible visits (N=415), 59% contained assistance (i.e., help scheduling colonoscopy or delivery of stool cards), but the assess, advise, and agree steps were rarely comprehensively provided (1%-21%), and only 3% included the last step, arrange follow-up. Almost all physicians endorsed screening via colonoscopy (99%), either alone (69%) or in combination with other tests (30%). Patients nonadherent to a prior physician screening recommendation (31%) were less likely to have the reason(s) for screening discussed (37% vs 65%) or be told the endoscopy clinic would call them for scheduling (19% vs 27%), and more likely to have fecal occult blood testing (FOBT) alone (34% vs 25%) or FOBT and colonoscopy recommended (24% vs 14%), and a screening plan negotiated (21% vs 14%). Significance level is p<0.05 for all contrasts.

CONCLUSIONS

Most patients due for CRC screening discuss screening with their physician, but with limited application of the 5A's approach. Opportunities to improve CRC screening decision-making are great, particularly among patients who are nonadherent to a prior recommendation from a physician.

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.