Happy cats: stress in cats and their carers associated with outpatient visits to the clinic

OBJECTIVES

The importance of the effects of stress on cats is well recognised, with visits to the veterinary clinic a common cause of stress. The aim of this study was to explore owners' experiences of stress, both for themselves and their cat, during veterinary visits, and to gather data on owners' perception of resources within the clinic to reduce stress in their cats.

METHODS

A questionnaire aimed at cat owners with recent experience of an outpatient visit to the veterinary clinic was developed and distributed. Questions covered demographics; their most recent veterinary visit; their general experience of visits over the past 3 years; measures taken by the clinic to reduce stress; and awareness of the Cat Friendly Clinic programme. There were various question types, with owners often asked to rate stress from 1 (least stressful) to 10 (most stressful).

RESULTS

A total of 277 respondents gave details about their experience of consultations over the past 3 years. Owners rated the stress of travelling to the clinic, other animals in the waiting room and the consultation itself (all median 6, interquartile range 4-8) as the most stressful elements. Most owners reported gentle methods of removing the cat from their carrier; however, almost a third (n = 81/263; 30.8%) had seen their cat scruffed during a consultation. Cat-only waiting rooms were viewed as the most effective measure to reduce stress in the clinic.

CONCLUSIONS AND RELEVANCE

Veterinary clinics are already taking steps to address stress in cats, and owners have a good awareness of stress in their cats. Future work should focus on trialling specific interventions to determine their effectiveness in reducing stress in feline patients, and measures currently perceived by owners to be highly effective, such as cat-only waiting rooms, should be used where feasible.

Veterinary services during the COVID-19 pandemic: less stressful for cats and their carers?

OBJECTIVES

The COVID-19 pandemic saw major changes to small animal veterinary practice, many of which may have had an impact on stress in cats presented to the clinic. The aim of this study was to examine the nature of feline outpatient visits before and during the pandemic, and examine signs of stress noted in cats before, during and after these visits.

METHODS

A questionnaire was used to gather data on cat owner experiences of visits to the veterinary clinic. Data were gathered on the owner's most recent experience of a consultation, with consultations occurring in February 2020 or earlier coded as a standard consultation, and consultations occurring in March 2020 or later coded as COVID-19 consultations.

RESULTS

A total of 371 responses were received, with 210 coded as standard consultations and 161 coded as COVID-19 consultations. Consultation type varied significantly between standard and COVID-19 consultations (P <0.001), with emergency consultations more frequent and preventive healthcare consultations less frequent during the COVID-19 pandemic. The area in which the owner and their cat waited also varied significantly between standard and COVID-19 consultations (P <0.001), with standard consultations more likely to involve time in a waiting room while COVID-19 consultations were often called straight in or waited outside the practice. Most owners notedbehaviours associated with stress in their cats, regardless of consultation type, although trying to hide or escape were noted more frequently for cats seen prior to the COVID-19 pandemic.

CONCLUSIONS AND RELEVANCE

The findings suggest that outpatient visits to the veterinary clinic were stressful for cats both prior to and during the COVID-19 pandemic, but some measures taken during the pandemic, for example less use of waiting rooms, could be used alongside existing cat friendly measures to help to reduce stress in feline patients.

Usage Intensity of a Relapse Prevention Program and Its Relation to Symptom Severity in Remitted Patients With Anxiety and Depression: Pre-Post Study

BACKGROUND

Given that relapse is common in patients in remission from anxiety and depressive disorders, relapse prevention is needed in the maintenance phase. Although existing psychological relapse prevention interventions have proven to be effective, they are not explicitly based on patients' preferences. Hence, we developed a blended relapse prevention program based on patients' preferences, which was delivered in primary care practices by mental health professionals (MHPs). This program comprises contact with MHPs, completion of core and optional online modules (including a relapse prevention plan), and keeping a mood and anxiety diary in which patients can monitor their symptoms.

OBJECTIVE

The aims of this study were to provide insight into (1) usage intensity of the program (over time), (2) the course of symptoms during the 9 months of the study, and (3) the association between usage intensity and the course of symptoms.

METHODS

The Guided E-healTh for RElapse prevention in Anxiety and Depression (GET READY) program was guided by 54 MHPs working in primary care practices. Patients in remission from anxiety and depressive disorders were included. Demographic and clinical characteristics, including anxiety and depressive symptoms, were collected via questionnaires at baseline and after 3, 6, and 9 months. Log data were collected to assess the usage intensity of the program.

RESULTS

A total of 113 patients participated in the study. Twenty-seven patients (23.9%) met the criteria for the minimal usage intensity measure. The core modules were used by ≥70% of the patients, while the optional modules were used by <40% of the patients. Usage decreased quickly over time. Anxiety and depressive symptoms remained stable across the total sample; a minority of 15% (12/79) of patients experienced a relapse in their anxiety symptoms, while 10% (8/79) experienced a relapse in their depressive symptoms. Generalized estimating equations analysis indicated a significant association between more frequent face-to-face contact with the MHPs and an increase in both anxiety symptoms (β=.84, 95% CI .39-1.29) and depressive symptoms (β=1.12, 95% CI 0.45-1.79). Diary entries and the number of completed modules were not significantly associated with the course of symptoms.

CONCLUSIONS

Although the core modules of the GET READY program were used by most of the patients and all patients saw an MHP at least once, usage decreased quickly over time. Most patients remained stable while participating in the study. The significant association between the frequency of contact and the course of symptoms most likely indicates that those who received more support had more symptoms, and thus, it is questionable whether the support offered by the program was sufficient to prevent these patients from relapsing.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12888-019-2034-6.

Exploring system features of primary care practices that promote better providers' clinical work satisfaction: A qualitative comparative analysis

BACKGROUND

Health care delivery system features can have a profound effect on how frontline physicians and other clinical personnel in primary care practices (primary care providers [PCPs]) view the quality and safety of what they deliver and, ultimately, their clinical work satisfaction.

PURPOSE

The aim of this study was to investigate the combinations of system features (i.e., team dynamics, provider-perceived safety culture, and patient care coordination between PCPs) that are most conducive to positively enhancing PCPs' clinical work satisfaction.

APPROACH

Nineteen Harvard-affiliated primary care practice sites participated in the Academic Innovations Collaborative 2012-2016, which aimed to establish team-based care and improve patient safety. An All-Staff Survey was administered to 854 PCPs in 2015. The survey measured provider experience of team dynamics, provider-perceived safety culture, patient care coordination between PCPs, and providers' clinical work satisfaction. We performed a qualitative comparative analysis to identify "recipes," that is, combinations of conditions necessary and sufficient for enhancing PCPs' clinical work satisfaction.

RESULTS

Strong provider-perceived safety culture and effective team dynamics constitute sufficient conditions that, when present in practices, could best support PCPs to achieve greater clinical work satisfaction.

CONCLUSIONS

Our findings suggest the importance of creating and sustaining a strong safety culture and of establishing and implementing highly functioning teams in primary care practices for enhancing PCPs' clinical work satisfaction.

PRACTICE IMPLICATIONS

Conducting the qualitative comparative analysis provides a new perspective for informing primary care and encouraging primary care practices to pursue strategic priorities for enhancing PCPs' clinical work satisfaction and providing safe, high-quality care.

The Experience of Working With a Faith Community Nurse Liaison of Care in a Primary Care Practice Among Older Adult Clients and Their Informal Caregiver

Informal caregivers of older adults aging in place are at risk for adverse health and financial consequences. This descriptive qualitative study explored the experience of working with a faith community nurse (FCN) liaison of care in a Catholic health care system affiliated primary care practice among older adult clients and their informal caregiver. Semistructured face-to-face interviews were conducted with nine older adult client-informal caregiver dyads, three clients, and one caregiver (n = 22). Interviews were audio recorded, transcribed, and analyzed using Braun and Clarke's reflexive thematic analysis method. The analysis generated one overarching theme, I'm Sorry the Study and FCN Visits Are Coming to an End, and two key themes, The FCN Was Always There to Help Us (older adult clients) and The FCN Took the Pressure Off of Caregiving for Awhile (informal caregivers). Participants viewed the FCN as an instrumental member of their health care team and considered prayer and spiritual support offered by the FCN an essential element of care.

Parents and GPs' understandings and beliefs about food allergy testing in children with eczema: qualitative interview study within the Trial of Eczema allergy Screening Tests (TEST) feasibility trial

AIM

To explore parent and general practitioner (GP) understanding and beliefs about food allergy testing for children with eczema.

DESIGN AND SETTING

Qualitative interview study in UK primary care within the Trial of Eczema allergy Screening Tests feasibility trial.

PARTICIPANTS

Semi-structured interviews with parents of children with eczema taking part in the feasibility study and GPs at practices hosting the study.

RESULTS

21 parents and 11 GPs were interviewed. Parents discussed a range of potential causes for eczema, including a role for food allergy. They believed allergy testing to be beneficial as it could potentially identify a cure or help reduce symptoms and they found negative tests reassuring, suggesting to them that no dietary changes were needed. GPs reported limited experience and uncertainty regarding food allergy in children with eczema. While some GPs believed referral for allergy testing could be appropriate, most were unclear about its utility. They thought it should be reserved for children with severe eczema or complex problems but wanted more information to advise parents and help guide decision making.

CONCLUSIONS

Parents' motivations for allergy testing are driven by the desire to improve their child's condition and exclude food allergy as a possible cause of symptoms. GPs are uncertain about the role of allergy testing and want more information about its usefulness to support parents and help inform decision making.

TRIAL REGISTRATION NUMBER

ISRCTN15397185.

Beta-cell failure in type 2 diabetes: mechanisms, markers, and clinical implications

It is well known that type 2 diabetes mellitus (T2D) is a globally increasing health burden. Despite recent therapeutic advances and the availability of many different classes of antihyperglycemic therapy, a large proportion of people do not achieve glycemic control. A decline in pancreatic beta-cell function has been defined as a key contributing factor to progression of T2D. In fact, a significant proportion of beta-cell secretory capacity is thought to be lost well before the diagnosis of T2D is made. Several models have been proposed to explain the reduction in beta-cell function, including reduced beta-cell number, beta-cell exhaustion, and dedifferentiation or transdifferentiation into other cell types. However, there have been reports that suggest remission of T2D is possible, and it is believed that beta-cell dysfunction may be, in part, reversible. As such, the question of whether beta cells are committed to failure in people with T2D is complex. It is now widely accepted that early restoration of normoglycemia may protect beta-cell function. Key to the successful implementation of this approach in clinical practice is the appropriate assessment of individuals at risk of beta-cell failure, and the early implementation of appropriate treatment options. In this review, we discuss the progression of T2D in the context of beta-cell failure and describe how C-peptide testing can be used to assess beta-cell function in primary care practice. In conclusion, significant beta-cell dysfunction is likely in individuals with certain clinical characteristics of T2D, such as long duration of disease, high glycated hemoglobin (≥9%), and/or long-term use of therapies that continuously stimulate the beta cell. In these people, measurement of beta-cell status could assist with choice of appropriate therapy to delay or potentially reverse beta-cell dysfunction and the progression of T2D.

Four maternal characteristics determine the 12-month course of chronic severe postpartum depressive symptoms

BACKGROUND

Postpartum depression is a heterogeneous disorder in phenotype and etiology. Characterizing the longitudinal course of depressive symptoms over the first year after birth and identifying variables that predict distinct symptom trajectories will expedite efficient mental health treatment planning. The purpose was to determine 12-month trajectories of postpartum depressive symptoms, identify characteristics that predict the trajectories, and provide a computational algorithm that predicts trajectory membership.

METHODS

A prospective cohort of women delivering at an academic medical center (2006-2011) was recruited from an urban women's hospital in Pittsburgh, PA. Women with a postpartum depressive disorder (n = 507) participated and completed symptom severity assessments at 4-8 weeks (intake), 3 months, 6 months, and 12 months. Women were predominantly Caucasian (71.8%), married (53.3%), and college educated (38.7%). Clinician interviews of depressive symptom severity, medical and psychiatric history, assessment of function, obstetric experience, and infant status were conducted.

RESULTS

Analyses resulted in identification of three distinct trajectories of depressive symptoms: (1) gradual remission (50.4%), (2) partial improvement (41.8%), and (3) chronic severe (7.8%). Key predictive characteristics of the chronic severe versus gradual remission and partial improvement trajectories included parity, education, and baseline global functioning and depression severity. We were able to predict trajectory membership with 72.8% accuracy from these characteristics.

CONCLUSIONS

Four maternal characteristics predicted membership in the chronic severe versus gradual remission and partial improvement trajectories with 72.8% accuracy. The trajectory groups comprise clinically relevant subgroups with the potential for tailored treatments to reduce the disease burden of postpartum depression.

[Functional dyspepsia in primary care: therapeutic variety or helplessness?]

BACKGROUND

About 5% of all GP consultations are made for symptoms of functional dyspepsia. The definition of functional dyspepsia is in a state of flux, pathophysiology is poorly understood, and current diagnostic and therapeutic algorithms are not available.

AIM

Evaluation of the frequency and the practical procedure in the diagnosis and therapy of functional dyspepsia in German GP surgeries.

METHOD

Family physicians working in Germany (general practitioners, primary care internists) were contacted via postal survey. The frequency of patients with functional dyspepsia per week, the symptom spectrum complained of and the therapy strategy were inquired.

RESULTS

Data from 322 doctors from all over Germany could be evaluated. The majority of physicians cared for 6-10 RMS patients per week (44.1%). The most common symptoms reported by patients were postprandial fullness (81.7%), epigastric pain or burning (77.3%) and regurgitation (75.0%). Heartburn (50.0%), nausea/vomiting (42.5%) and premature satiety (15.8%) were reported less frequently. The most commonly prescribed drugs were phytotherapeutics (88.2%), proton-pump inhibitors (PPI, 73.6%) and prokinetics (61.5%). The frequency of prescribing antacids, digestive enzymes of the stomach and pancreas was 10-20%. There was a trend towards symptom-dependent differential therapy: phytotherapeutics and prokinetics in postprandial fullness and premature satiety, PPI in epigastric pain/burning. The treatment failure rate was estimated at 21-40%. For further diagnostics patients are often referred to gastroenterologists and psychotherapists.

CONCLUSION

Functional dyspepsia is common in primary care practice. Current recommendations for diagnosis and differential therapy are often not implemented. The rate of treatment failure is considerable.

Adoption of Serogroup B Meningococcal Vaccine Recommendations

: media-1vid110.1542/5799875076001PEDS-VA_2018-0344Video Abstract BACKGROUND AND OBJECTIVES: In 2015, the Advisory Committee on Immunization Practices recommended that 16- to 23-year-olds may be vaccinated with the serogroup B meningococcal (MenB) vaccine on the basis of individual clinical decision-making (Category B). We assessed the following among US pediatricians and family physicians (FPs): (1) practices regarding MenB vaccine delivery, (2) factors influencing a decision to recommend the MenB vaccine, and (3) factors associated with discussing the MenB vaccine.

METHODS

We surveyed a nationally representative sample of pediatricians and FPs via e-mail and Internet from October 2016 to December 2016.

RESULTS

The response rate was 72% (660 of 916). During routine visits, 51% of pediatricians and 31% of FPs reported always or often discussing MenB vaccine. Among those who discussed often or always, 91% recommended vaccination; among those who never or rarely discussed, 11% recommended. We found that 73% of pediatricians and 41% of FPs currently administered the MenB vaccine. Although many providers reported not knowing about factors influencing recommendation decisions, MenB disease outbreaks (89%), disease incidence (62%), and effectiveness (52%), safety (48%), and duration of protection of MenB vaccine (39%) increased the likelihood of recommendation, whereas the Category B recommendation (45%) decreased likelihood. Those somewhat or not at all aware of the MenB vaccine (risk ratio 0.32 [95% confidence interval 0.25-0.41]) and those practicing in a health maintenance organization (0.39 [0.18-0.87]) were less likely, whereas those aware of disease outbreaks in their state (1.25 [1.08-1.45]) were more likely to discuss MenB vaccine.

CONCLUSIONS

Primary care physicians have significant gaps in knowledge about MenB disease and the MenB vaccine, and this appears to be a major driver of the decision not to discuss the vaccines.

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.

Identification, Prevention, and Management of Childhood Overweight and Obesity in a Pediatric Primary Care Center

Background In the United States, overweight/obesity among youth has reached epidemic proportions. The purpose of this project was to (1) examine primary care provider adherence to American Academy of Pediatrics guidelines; (2) compare adherence based on patients' weight classification, age, race, and gender; and (3) identify areas for improvement in health care delivery. Methods A retrospective chart audit and feedback quality improvement project was conducted with a stratified random sample of 175 charts of 6- to 19-year-olds seen for well-child visits. Frequencies of provider adherence were reported. χ(2) Analyses of weight classification, age, race, or gender influence on adherence was calculated. Results After discussion with the primary care providers, 5 areas were identified as priorities for change (diagnosis based on BMI, parental history of obesity, sleep assessment, endocrine assessment, and attendance of patients at the follow-up visit). Conclusion Cost-efficient, feasible strategies to improve provider adherence to recommendations for identification, prevention and management of childhood overweight and obesity were identified.

Developing a framework of service convenience in health care: An exploratory study for a primary care provider

From retail health clinics and online appointment scheduling to (mobile) kiosks that enable patient check-in and automate the collection of copays and open balances, convenience has become an important topic in the health care sector over the last few years. While service convenience has also gained much interest in academia, one common limitation is that authors have adopted a "goods-centered" perspective focusing primarily on retail settings. Results of this exploratory study reveal that health care service convenience encompasses seven different dimensions: decision, access, scheduling, registration and check-in, transaction, care delivery, and postconsultation convenience. Implications and future research suggestions are discussed.

Multivitamin/multimineral supplements for cancer prevention: implications for primary care practice

There is a popular belief that multivitamin and mineral (MVM) supplements can help prevent cancer and other chronic diseases. Studies evaluating the effects of MVM supplements on cancer risk have largely been observational, with considerable methodologic limitations, and with conflicting results. We review evidence from the few available randomized, controlled trials that assessed the effects of supplements containing individual vitamins, a combination of a few select vitamins, or complete MVM supplements, with a focus on the recent Physicians' Health Study II (PHS II). PHS II is a landmark trial that followed generally healthy middle-aged and older men (mean age 64 years) who were randomized to daily MVM supplementation for a mean duration of 11 years. Men taking MVMs experienced a statistically significant 8% reduction in incidence of total cancer (hazard ratio [HR]: 0.92; 95% confidence interval [CI]: 0.86-0.998; p = 0.04). Men with a history of cancer derived an even greater benefit: cancer incidence was 27% lower with MVM supplementation versus placebo in this subgroup (HR: 0.73; 95% CI: 0.56-0.96; p = 0.02). Positive results of PHS II contrast with randomized studies of individual vitamins or small combinations of vitamins, which have largely shown a neutral effect, and in some cases, an adverse effect, on cancer risk. The results of PHS II may have a considerable public health impact, potentially translating to prevention of approximately 68 000 cancers per year if all men were to use similar supplements, and to an even greater benefit with regard to secondary prevention of cancer.

Measurement of eNO with portable analyser might improve the management of persistent cough at primary care practice in Japan

BACKGROUND AND AIMS

There are some controversial reports that investigated the usefulness of exhaled nitric oxide (eNO) to predict the efficacy of inhaled corticosteroids (ICS) in chronic cough patients. Therefore, we retrospectively analysed the usefulness of eNO measurement with portable analyser to predict the requirement of ICS therapy in persistent cough (defined as lasting for 3 weeks or more) patients in Japan and investigated whether it might improve the management of persistent cough at primary care practice.

METHODS

We retrospectively reviewed the clinical records of adult patients who had been referred to our hospital for persistent cough from 1 June 2009 to 30 April 2011.

RESULTS

Forty-two patients had the requirement of ICS (group S) and 35 patients had no requirement of ICS (group N). Forty-three per cent of the patients who required ICS had not received ICS, and 29% of the patients who did not required ICS had received ICS. In the steroid-naive patients without current smoking, mean eNO level was significantly higher in group S [60.6 ± 14.1 parts per billion (ppb) vs 22.2 ± 2.3 ppb, P = 0.001] and the sensitivity and the specificity of eNO for predicting the requirement of ICS were 78.6% and 80.0%, respectively. The rate of the patients who received inappropriate treatment about ICS tended to be reduced from 41% to 21% if the eNO was used to predict the requirement of ICS with cut-off value of eNO 26.5 ppb (P = 0.118).

CONCLUSION

Measurement of eNO could be one of the management tools for persistent cough at primary care practice.

Improving care coordination between nephrology and primary care: a quality improvement initiative using the renal physicians association toolkit

BACKGROUND

Individuals at risk for chronic kidney disease (CKD), including those with diabetes mellitus and hypertension, are prevalent in primary care physician (PCP) practices. A major systemic barrier to mitigating risk of progression to kidney failure and to optimal care is failure of communication and coordination among PCPs and nephrologists.

STUDY DESIGN

Quality improvement. Longitudinal practice-level study of tool-based intervention in nephrology practices and their referring PCP practices.

SETTING & PARTICIPANTS

9 PCP and 5 nephrology practices in Philadelphia and Chicago.

QUALITY IMPROVEMENT PLAN

Tools from Renal Physicians Association toolkit were modified and provided for use by PCPs and nephrologists to improve identification of CKD, communication, and comanagement.

OUTCOMES

CKD identification, referral to nephrologists, communication among PCPs and nephrologists, comanagement processes.

MEASUREMENTS

Pre- and postimplementation interviews, questionnaires, site visits, and monthly teleconferences were used to ascertain practice patterns, perceptions, and tool use. Interview transcripts were reviewed for themes using qualitative analysis based on grounded theory. Chart audits assessed CKD identification and referral (PCPs).

RESULTS

PCPs improved processes for CKD identification, referral to nephrologists, communication, and execution of comanagement plans. Documentation of glomerular filtration rate was increased significantly (P=0.01). Nephrologists improved referral and comanagement processes. PCP postintervention interviews documented increased awareness of risk factors, the need to track high-risk patients, and the importance of early referral. Final nephrologist interviews revealed heightened attention to communication and comanagement with PCPs and increased levels of satisfaction among all parties.

LIMITATIONS

Nephrology practices volunteered to participate and recruit their referring PCP practices. Audit tools were developed for quality improvement assessment, but were not designed to provide statistically significant estimates.

CONCLUSIONS

The use of specifically tailored tools led to enhanced awareness and identification of CKD among PCPs, increased communication between practices, and improvement in comanagement and cooperation between PCPs and nephrologists.

End-of-life care from the perspective of primary care providers

PURPOSE

To explore the factors influencing primary care providers' ability to care for their dying patients in Michigan.

METHODS

We conducted 16 focus groups to explore the provision of end-of-life care by 7 diverse primary care practices in southeast Michigan. Twenty-eight primary care providers and 22 clinical support staff participated in the study. Interviews were analyzed using thematic analysis.

RESULTS

Primary care providers (PCPs) wanted to care for their dying patients and felt largely competent to provide end-of-life care. They and their staff reported the presence of five structural factors that influenced their ability to do so: (1) continuity of care to help patients make treatment decisions and plan for the end of life; (2) scheduling flexibility and time with patients to address emergent needs, provide emotional support, and conduct meaningful end-of-life discussions; (3) information-sharing with outside providers and within the primary care practice; (4) coordination of care to address patients' needs quickly; and (5) authority to act on behalf of their patients.

CONCLUSIONS

In order to provide end-of-life care, PCPs need structural supports within primary care for continuity of care, flexible scheduling, information-sharing, coordination of primary care, and protection of their authority.

Implementing quality improvement in small, autonomous primary care practices: implications for the patient-centred medical home

BACKGROUND

Implementing improvement programmes to enhance quality of care in primary care clinics is complex. Understanding how improvement strategies can be implemented in primary care is timely given the recent national movement towards transforming primary care into patient centred medical homes (PCMH). This study examined practice members' perceptions of the opportunities and challenges associated with implementing changes in their practice.

METHODS

Semi-structured interviews were conducted with a sample of 56 individuals working in 16 small, community based primary care practices. The interviews consisted of open-ended questions focused on participants' perceptions of: (1) practice vision, (2) perceived need for practice improvement and (3) barriers that hinder practice improvement. The interviews were conducted at the participating clinics and were tape-recorded, transcribed, and content analysed.

RESULTS

Content analysis identified two main domains for practice improvement related to: (1) the process of care, and (2) patients' involvement in their disease management. Examples of desired process of care changes included improvement in patient tracking and follow-up, standardisation of processes of care and overall clinic documentation. Changes related to patients' involvement in their care included improving (a) health education, and (b) self-care management. Among the internal barriers were: staff readiness for change, poor communication and relationship difficulties among team members. External barriers were insurance regulations, finances and patient health literacy.

CONCLUSIONS

Transforming practices to more patient-centred models of care will be a priority for primary care providers. Identifying opportunities and challenges associated with implementing change is critical for successful improvement programmes. Successful strategies for enhancing the adoption and uptake of PCMH elements should leverage areas of concordance between practice members' perceived needs and planned improvement efforts.

Familial risk of cancer and knowledge and use of genetic testing

BACKGROUND

Identification of genetic risk factors for common diseases, including cancer, highlights the importance of familial risk assessment. Little is known about patterns of familial cancer risk in the general population, or whether this risk is associated with knowledge and use of genetic testing.

OBJECTIVE

To examine the distribution of familial cancer risk and its associations with genetic testing in the United States.

DESIGN

Cross-sectional analysis of the 2005 National Health Interview Survey (NHIS).

PARTICIPANTS

31,428 adults who completed the NHIS Cancer Control Supplement.

MAIN MEASURES

Familial cancer risk was estimated based on the number of first-degree relatives with a breast and ovarian cancer syndrome (BRCA)- or a Lynch-associated cancer, age of onset (<50 or > or = 50 years), and personal history of any cancer. Outcomes included having heard of genetic testing, discussed genetic testing with a physician, been advised by a physician to have testing, and received genetic testing.

KEY RESULTS

Most adults (84.5%) had no family history of BRCA- or Lynch syndrome-associated cancer; 12.9% had a single first-degree relative (5.3% with early onset); and 2.7% had > or = 2 first-degree relatives. Although 40.2% of adults had heard of genetic testing for cancer risk, only 5.6% of these individuals had discussed testing with a physician, and of these 36.9% were advised to be tested. Overall, only 1.4% of adults who had heard of genetic testing received a test. Familial risk was associated with higher rates of testing; 49.5% of participants in the highest risk group had heard of testing, of those 14.8% had discussed it with their physician, and 4.5% had received genetic testing.

CONCLUSIONS

These nationally representative data provide estimates of the prevalence of familial cancer risk in the US and suggest that information about genetic testing is not reaching many at higher risk of inherited cancer.

Clinician reflections on promotion of healthy behaviors in primary care practice

OBJECTIVE

Recommendations to use integrated models for health behavior change abound, however, the translation to practice has been poor. We used stimulated reflections of primary care physicians and nurse practitioners to generate insights about current practices and opportunities for changing how health behavior advice is addressed.

METHOD

Twenty-one community practicing primary care clinicians invited to a nationally sponsored practice-based research network conference on promotion of healthy behaviors were asked to record aspects of health behaviors they addressed during a day of outpatient visits. In response to eight questions, clinicians reflected insights which were then analyzed by a multidisciplinary team to identify over-arching themes.

RESULTS

Health behavior discussions are initiated and carried out predominantly by the clinician. These discussions occur primarily during health care maintenance visits or visits in which presenting complaints or chronic illnesses can be linked to health behaviors. Clinicians' reflections on viable opportunities for change include different modes of patient education materials such as web-based materials. Suprisingly infrequent were solutions outside of the clinical encounter or strategies that engage other staff or other community partners.

CONCLUSION

Implementation of the integrated care model as an opportunity to enhance health promotion seems far from the current realities and future vision of even motivated network-based clinicians.