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1.  A Novel Protocol for Streamlined IRB Review of PBRN Card Studies 
Purpose
The “card study,” in which clinicians record brief information about patient visits during usual clinical care, has long been a rapid method for conducting descriptive studies in practice-based research networks (PBRNs). Since an increasingly stringent regulatory environment has made conducting card studies difficult, we developed a streamlined method for obtaining card study Institutional Review Board (IRB) approval.
Methods
We developed a protocol for a study of the card study method, allowing new card study proposals of specific research questions to be submitted as addenda to the approved Card Study Protocol.
Results
Seven card studies were proposed and approved under the Card Study Protocol during the first year post implementation, contrasted with one card study proposed in the previous year. New card study ideas submitted as addenda to an approved protocol appeared to increase IRB comfort with the card study as a minimal risk method while reducing the hurdles to developing new study ideas.
Conclusions
A Card Study Protocol allowing new study questions to be submitted as addenda decreases time between idea generation and IRB approval. Shortened turn-around times may be useful for translating ideas into action while reducing regulatory burden.
doi:10.3122/jabfm.2011.05.110034
PMCID: PMC4331110  PMID: 21900445
practice-based research network; practice-based research; card study; weekly return; HIPAA; primary care research; institutional review board
2.  Guidance for Researchers Developing and Conducting Clinical Trials in Practice-based Research Networks (PBRNs) 
Background
There is increased interest nationally in multicenter clinical trials to answer questions about clinical effectiveness, comparative effectiveness, and safety in real-world community settings. Primary care practice-based research networks (PBRNs), comprising community- and/or academically affiliated practices committed to improving medical care for a range of health problems, offer ideal settings for these trials, especially pragmatic clinical trials. However, many researchers are not familiar with working with PBRNs.
Methods
Experts in practice-based research identified solutions to challenges that researchers and PBRN personnel experience when collaborating on clinical trials in PBRNs. These were organized as frequently asked questions in a draft document presented at a 2013 Agency for Health care Research and Quality PBRN conference workshop, revised based on participant feedback, then shared with additional experts from the DARTNet Institute, Clinical Translational Science Award PBRN, and North American Primary Care Research Group PBRN workgroups for further input and modification.
Results
The “Toolkit for Developing and Conducting Multi-site Clinical Trials in Practice-Based Research Networks” offers guidance in the areas of recruiting and engaging practices, budgeting, project management, and communication, as well as templates and examples of tools important in developing and conducting clinical trials.
Conclusion
Ensuring the successful development and conduct of clinical trials in PBRNs requires a highly collaborative approach between academic research and PBRN teams.
doi:10.3122/jabfm.2014.06.140166
PMCID: PMC4297606  PMID: 25381071
Clinical Trials as Topic; Practice-based Research
3.  Use of Mobile Health (mHealth) Tools by Primary Care Patients in the WWAMI Region Practice and Research Network (WPRN) 
Purpose
The purpose of this study was to determine the prevalence of mobile health (mHealth) use among primary care patients and examine demographic and clinical correlates.
Methods
Adult patients who presented to 1 of 6 primary care clinics in a practice-based research network in the northwest United States during a 2-week period received a survey that assessed smart-phone ownership; mHealth use; sociodemographic characteristics (age, sex, race/ethnicity, health literacy); chronic conditions; and depressive symptoms (2-item Patient Health Questionnaire). Data analysis used descriptive statistics and mixed logistic regression.
Results
Of 918 respondents (estimated response rate, 67.4%), 55% owned a smartphone, among whom 70% were mHealth users. In multivariate analyses, smartphone ownership and mHealth use were not associated with health literacy, chronic conditions, or depression but were less common among adults >45 years old (adjusted odds ratio, 0.07– 0.39; P < .001). Only 10% of patients learned about mHealth tools from their physician, and few (31%) prioritized their provider’s involvement.
Conclusions
Use of mHealth technologies is lower among older adults but otherwise is common among primary care patients, including those with limited health literacy and those with chronic conditions. Findings support the potential role of mHealth in improving disease management among certain groups in need; however, greater involvement of health care providers may be important for realizing this potential.
doi:10.3122/jabfm.2014.06.140108
PMCID: PMC4297607  PMID: 25381075
Chronic Disease; Mobile Health; Practice-based Research; Primary Health Care
4.  [No title available] 
PMCID: PMC4294578  PMID: 24204057
5.  The Relationship between Maternal Depressive Symptoms, Employment, and Social Support 
Journal of the American Board of Family Medicine : JABFM  2014;27(1):10.3122/jabfm.2014.01.130126.
Purpose
To characterize the relationship between maternal depressive symptoms and employment and whether it is mediated by social support.
Methods
We used data from a nationally-representative sample of 700 U.S. women who gave birth in 2005 and completed two surveys in the Listening to Mothers series, the first in early 2006, at an average of 7.3 months postpartum, and the second at an average of 13.4 months postpartum. A dichotomous measure of depressive symptoms was calculated from the 2-item Patient Health Questionnaire, and women reported their employment status and levels of social support from partners and others. We modeled the association between maternal employment and depressive symptoms using multivariate logistic regression, including social support and other control variables.
Results
Maternal employment and high support from a non-partner source were both independently associated with significantly lower odds of depressive symptoms (Adjusted Odds Ratio (AOR)=0.35, p=0.011; AOR=0.40, p=0.011, respectively). These relationships remained significant after controlling for mothers' baseline mental and physical health, baby's health, and demographic characteristics (AOR=0.326, p=0.015; AOR=0.267, p=0.025, respectively).
Conclusions
Maternal employment and strong social support, particularly non-partner support, were independently associated with fewer depressive symptoms. Clinicians should encourage mothers of young children who are at risk for depression to consider ways to optimize their employment circumstances and “other” social support.
doi:10.3122/jabfm.2014.01.130126
PMCID: PMC3882899  PMID: 24390890
mothers; depression; employment; social support
6.  Intrauterine devices at six months: does patient age matter? Results from an urban family medicine Federally Qualified Health Center (FQHC) network 
Background
Federally Qualified Health Centers (FQHCs) can address high unintended adolescent pregnancy rates in the United States by increasing access to intrauterine devices (IUDs) in underserved settings. Despite national guidelines endorsing IUDs in adolescents, some physicians remain concerned about IUD tolerance and safety in adolescents. Thus, we compared adolescents and adults in a family physician staffed FQHC network with regard to: (1) IUD post-insertion experience, (2) device discontinuation and (3) sexually transmitted infection (STI) rates.
Methods
We conducted a retrospective cohort study among women less than 36 years of age who had a 2011 IUD insertion at a New York City family physician staffed FQHC network.
Results
684 women (27 % adolescents, 73% adults) were included. During the six month post-insertion period, 59% of adolescent and 43% of adults initiated IUD related post-insertion clinical contact, most commonly for bleeding changes and pelvic or abdominal pain. There were no significant differences between groups in IUD expulsion, removal or STI rates.
Conclusions
Urban FQHC providers may anticipate that, as compared to their adult IUD utilizers, adolescents will initiate more clinical follow-up visits post-insertion. However both groups will have similar clinical concerns, reasons for and rate of device discontinuation and low STI rates.
doi:10.3122/jabfm.2014.06.140091
PMCID: PMC4280233  PMID: 25381080
7.  Results of Nurse Navigator follow-up after positive colorectal cancer screening test: a randomized trial 
Background
Follow-up after a positive colorectal cancer (CRC) screening test is necessary for screening to be effective. We hypothesized that nurse navigation would increase colonoscopy completion after a positive screening test.
Methods
This study was conducted between 2008 and 2012 at 21 primary care medical centers in Western Washington. Participants in the Systems of Support to Increase CRC Screening (SOS) study who had a positive fecal occult blood test (FOBT) or flexible sigmoidoscopy were randomized to usual care (UC) or nurse navigator (Navigation). UC included an electronic health record (EHR)-based positive FOBT registry and physician reminder system. Navigation included UC plus care coordination and patient self-management support from a registered nurse who tracked and assisted patients until they completed or refused colonoscopy. The primary outcome was colonoscopy completion within 6 months. After 6 months, both groups received navigation.
Results
147 participants with a positive FOBT or sigmoidoscopy were randomized. Colonoscopy completion was higher in the intervention group at 6 months, but differences were not statistically significant (Navigation 91.0% vs. UC 80.8%, adjusted difference 10.1%; P=.0.10). Reasons for no or late colonoscopies included refusal, failure to schedule or missed appointments, concerns about risks or costs, and competing health concerns.
Conclusions
Navigation did not lead to a statistically significant incremental benefit at 6 months.
Impact
Follow-up rates after a positive CRC screening test are high in a health care system where UC included a registry and physician reminders. Because of small sample size we cannot rule out incremental benefits of nurse navigation.
doi:10.3122/jabfm.2014.06.140125
PMCID: PMC4278960  PMID: 25381076
colorectal cancer screening; colonoscopy; complete diagnostic evaluation; navigation
8.  The Association of Type and Number of Chronic Diseases with Breast, Cervical and Colorectal Cancer Screening in Rural Primary Care Practices 
Purpose
To examine associations between the number and types of patients’ chronic diseases and being up-to-date for breast, cervical and colorectal cancer screening.
Methods
Data were abstracted from medical charts at four primary care clinics located in two rural Oregon communities. Eligibility criteria included being at least 55 years of age, having had at least one clinic visit in the last two years.
Results
Of 3,433 included patients, 503 (15%) had no chronic illness, 646 (19%) had one, 786 (23%) had two, and 1,498 (44%) had three or more chronic conditions. Women with asthma/chronic lung disease and with cardiovascular disease were less likely to be up-to-date for mammography screening (OR 0.59, 95%CI 0.43–0.80), and those with chronic digestive disorders were more likely to be up-to-date for mammography (OR 1.31, 95%CI 1.03–1.66) compared to those without chronic conditions. Women with arthritis, diabetes mellitus, and hypertension were less likely to be up-to-date for cervical cancer screening (OR 0.38, 95%CI 0.21–0.68) compared to those without chronic conditions. Men with cardiovascular disease were less likely to be up-to-date for colorectal cancer screening (adjusted OR 0.59, 95%CI 0.44–0.80), and women with depression were less likely to be up-to-date (OR 0.71, 95%CI 0.56–0.91) compared to men and women without chronic conditions.
Conclusion
Specific chronic conditions were found to be associated with up-to-date status for cancer screening. This finding may help practices to identify patients who need to receive cancer screening.
doi:10.3122/jabfm.2014.05.140005
PMCID: PMC4273642  PMID: 25201936
9.  Tobacco use treatment in primary care patients with psychiatric illness 
The prevalence of smoking is higher in patients with psychiatric illness compared to the general population. Smoking causes chronic illnesses which lead to premature mortality in those with psychiatric illness, is associated with greater burden of psychiatric symptoms, and contributes to the social isolation experienced by individuals with psychiatric disorders. Most patients with psychiatric illness present initially to primary care rather than specialty care settings, and some patients receive care exclusively in the primary care setting. Therefore, family physicians and other primary care clinicians have an important role in the recognition and treatment of tobacco use disorders in patients with psychiatric illnesses. In this article we review common myths associated with smoking and psychiatric illness, techniques in implementing evidence-based tobacco use treatments, the evidence base for tobacco use treatment for patients with specific psychiatric diagnoses, and factors to consider in treating tobacco use disorders in patients with psychiatric illness.
doi:10.3122/jabfm.2014.03.130252
PMCID: PMC4269522  PMID: 24808119
10.  Real world implementation and outcomes of health behavior and mental health assessment 
Background
Assessing patient-reported health behaviors is a critical first step to prioritizing prevention in primary care. We assessed the feasibility of point-of-care behavioral health assessment in nine diverse primary care practices, including four federally-qualified health centers (FQHCs), four Practice-based Research Network (PBRN) practices, and a Department of Veterans Affairs (VA) practice.
Methods
In this prospective mixed-methods study, practices were asked to integrate a standardized paper-based health behavior and mental health assessment into their workflow for 50 or more patients. We used three data sources to examine the implementation process: 1) patient responses to the health assessment, 2) patient feedback surveys about how assessments were used during encounters, and 3) post-implementation interviews.
Results
Most (71%) non-urgent patients visiting the participating practices during the implementation period completed the health assessment, but reach varied by practice (range: 59-88%). Unhealthy diet, sedentary lifestyle, and stress were the most common patient problems with similar frequencies observed across practices. The median number of “positive screens” per patient was similar across FQHCs (3.7-positives, SD=1.8), PBRN practices (3.8-positives, SD=1.9), and the VA clinic (4.1-positives, SD=2.0). Primary care clinicians discussed assessment results with patients about half of the time (54%), with considerable between practice variation (range: 13%-66% with lowest use among FQHC clinicians). Although clinicians were interested in routinely implementing assessments, many reported not feeling confident of having resources or support to address all patients’ behavioral health needs.
Conclusions
Primary care practices will need to revamp their patient-reported data collection processes in order to integrate routine health behavior assessments. Implementation support will be required if health assessments are to be actively used as part of routine primary care.
doi:10.3122/jabfm.2014.03.130264
PMCID: PMC4237013  PMID: 24808114
11.  Using Patient Monetary Incentives and Electronically Derived Patient Lists to Recruit Patients to a Clinical Trial 
Purpose:
To report using electronic medical record (EMR) data to identify patients eligible for a clinical trial and the impact of providing an honorarium and deadline on accrual.
Methods:
Six practices using a common EMR participated in a cluster-randomized trial testing a self-administered, web-based familial risk assessment tool. EMR-derived lists of eligible patients were made available for provider review. An honorarium and deadline for responding in the patient recruitment letter were implemented in the last half of the recruitment process.
Results:
We identified 22,376 potentially eligible patients. Lists not returned by providers accounted for 9840 (44%) patients. We mailed invitations to 11,956 patients; 2398 (20%) requested more information and a consent document, 1489 (12.5%) consented to participate, and 1305 (11%) completed the baseline data collection. Patients receiving the additional $2 and a deadline compared with those receiving the personal invitation alone had significantly higher interest in participating (25% vs. 17%, P = .0001) but were less likely to complete baseline data collection (57% vs. 65% P = .01). Once consented, 85% completed the study with no significant difference by recruitment approach.
Conclusions:
Using EMR data reduces the burden to identify potentially eligible patients. However, some providers still did not review and return the lists. Adding a $2 incentive and deadline for responding did not improve the rate of eligible patients consenting and completing the study. Other patient recruitment methods to get better response by providers and population from primary care offices must be explored.
doi:10.3122/jabfm.2011.05.100169
PMCID: PMC4224283  PMID: 21900440
Electronic Medical Records; Research Methods
12.  ColoRectal Cancer Predicted Risk Online (CRC-PRO) Calculator Using Data from the Multi-Ethnic Cohort Study 
Background
Better risk predictions for colorectal cancer (CRC) could improve prevention strategies by allowing clinicians to more accurately identify high-risk individuals. The National Cancer Institute's CRC risk calculator was created by Freedman et al using case control data.
Methods
An online risk calculator was created using data from the Multi-Ethnic Cohort Study, which followed >180,000 patients for the development of CRC for up to 11.5 years through linkage with cancer registries. Forward stepwise regression tuned to the c statistic was used to select the most important variables for use in separate Cox survival models for men and women. Model accuracy was assessed using 10-fold cross-validation.
Results
Patients in the cohort experienced 2762 incident cases of CRC. The final model for men contained age, ethnicity, pack-years of smoking, alcoholic drinks per day, body mass index, years of education, regular use of aspirin, family history of colon cancer, regular use of multivitamins, ounces of red meat intake per day, history of diabetes, and hours of moderate physical activity per day. The final model for women included age, ethnicity, years of education, use of estrogen, history of diabetes, pack-years of smoking, family history of colon cancer, regular use of multivitamins, body mass index, regular use of nonsteroidal anti-inflammatory drugs, and alcoholic drinks per day. The calculator demonstrated good accuracy with a cross-validated c statistic of 0.681 in men and 0.679 in women, and it seems to be well calibrated graphically. An electronic version of the calculator is available at http://rcalc.ccf.org.
Conclusion
This calculator seems to be accurate, is user friendly, and has been internally validated in a diverse population.
doi:10.3122/jabfm.2014.01.130040
PMCID: PMC4219857  PMID: 24390885
Colorectal Cancer; Medical Decision Making; Prevention and Control; Risk
13.  Patient Perspective on Watchful Waiting/Active Surveillance for Localized Prostate Cancer 
Objective
To describe prostate cancer treatment decision making, focusing on knowledge and attitudes toward observation, known as watchful waiting (WW) or active surveillance (AS), and reasons for not choosing WW/AS.
Methods
Semistructured in-person interviews were conducted with 21 men (14 black; 7 white) with recently diagnosed localized prostate cancer.
Results
All cancers were detected by prostate-specific antigen screening; 14 men had low-risk disease. Nineteen chose surgery or radiation treatment. The majority wanted to “get rid of” or “cure” the cancer by undergoing aggressive therapy, even with awareness of the potential for significant side effects. Most men seemed unaware of the uncertainty/controversies that aggressive treatment may not cure their cancer or improve their survival. Limited knowledge about WW/AS was common, and few remembered WW/AS being presented as a viable option. Rather, many men perceived it as “doing nothing.” Some men, who initially were inclined toward WW/AS, yielded to pressure from family, physicians, or both to choose aggressive treatment. Lack of physician support was a significant barrier to WW/AS.
Conclusions
The observational strategy (WW/AS) was not viewed as a reasonable approach, even for those with low-risk cancer. The desire for aggressive therapy may reflect the complex psychology associated with receiving a diagnosis of cancer and the limited supportive counseling received. Further efforts to better understand and educate patients and physicians may help men make informed and appropriate treatment decisions to maximize quality of life without compromising survival.
doi:10.3122/jabfm.2012.06.120128
PMCID: PMC4212643  PMID: 23136314
Active Surveillance; Decision Making; Medical Oncology; Prostate Cancer; Watchful Waiting
14.  Patient Opinions and Concerns Regarding a Pilot Academic Retainer Program for Uninsured Patients 
Background
Access Assured, an experimental program to deliver primary care to uninsured patients using a monthly retainer payment system, has been shown to provide a financially viable method of delivering primary care services to people without health insurance. This qualitative study was designed to assess patient attitudes and concerns about this program and to identify ways to improve it.
Methods
We conducted telephone interviews with 40 purposefully selected Access Assured members between May and June of 2009. This population was stratified to include a sample of 20 patients from those who had elected to renew enrollment in the program after their first six-month enrollment period. The other 20 patients were selected from those enrollees who had not re-enrolled in the program after this initial period. The semi-structured interviews were based on an original list of 19 standardized questions, which were asked of each participant. All interviews were audio taped. The interview tapes were transcribed verbatim and content analysis was carried out using immersion-crystallization methods.
Results
Content analysis identified nine themes related to patient attitudes and concerns about this program. (1) Patients could not understand why they needed to remain enrolled if they were healthy; (2) Patients had variable levels of personal agency or responsibility for their own care; (3) Patients reported they had no choice and needed to enroll in the program to have access to care; (4) Patients liked that the program allowed them to choose their provider and see that provider with continuity from visit to visit; (5) Patients felt they were respected and treated the same as other patients; (6) Patients expressed appreciation for the program; (7) Patients had a range of comments about the quality of care and service they received; (8) Patients reported confusion about the rules of the program and often did not understand its terms and benefits; and (9) Patients were under personal and family economic stress. Twenty of the subjects in our study had re-enrolled in Access Assured and eleven of the 20 patients who had not re-enrolled expressed an intention to do so.
Conclusions
Our study population expressed gratitude and other positive opinions about the retainer-based program for uninsured patients in two academic family medicine clinics. Conversely, some were concerned about the perceived lack of choice related to enrollment. Significant gaps in patient understanding about the program were identified. Based on these results, we have made improvements to the program and plan to continue to offer this care model to uninsured patients in our practices.
doi:10.3122/jabfm.2011.03.100228
PMCID: PMC4151114  PMID: 21551403
Retainer practice; primary care
15.  Measuring the Impact of Practice-based Research Networks (PBRNs) 
doi:10.3122/jabfm.2012.05.120176
PMCID: PMC4120825  PMID: 22956689
16.  Incidental Computer Tomography Radiologic Findings through Research Participation in the North Texas Healthy Heart Study 
Background
Although variation exists in the classification and practice of managing clinical findings in research, emerging views suggest that researchers bear some responsibility in the management of incidental findings. This study contributes to the documentation of the population characteristics and prevalence of medical findings incidental to research participation, specifically findings related to coronary calcium scores and computed tomography (CT) scans that investigated cardiovascular disparities in an asymptomatic population.
Methods
A total of 571 asymptomatic adult participants were recruited in the North Texas Healthy Heart Study. Participants completed a 16-slice CT scan of the heart and abdomen. Findings of radiology reports and 3 years of follow-up documentation were reviewed.
Results
A total of 246 clinically apparent findings were identified in 169 asymptomatic participants (32.9% of participants who completed a CT scan). Another 245 participants (48%) had findings of unknown significance, a total of 307 findings. At least 4 cases in this study led to a clinically significant intervention.
Conclusion
Although CT scans were completed for research purposes, study procedures resulted in the diagnosis and treatment of individuals who were previously asymptomatic. Potential clinical benefits in imaging research are moderated by considerations regarding possible harm and costs resulting from uncertain findings and the use of CT scans for nonclinical purposes. The continued development of protocols for the handling of incidental findings in research and the establishment of guidelines are needed to ensure that research procedures mirror the best interests of participants.
doi:10.3122/jabfm.2014.03.130250
PMCID: PMC4113722  PMID: 24808109
Computed Tomography; Incidental Findings; Medical Ethics; Practice-based Research Networks; Research Subjects
17.  More Extensive Implementation of the Chronic Care Model is Associated with Better Lipid Control in Diabetes 
Objective
Chronic disease collaboratives help practices redesign care delivery. The North Carolina Improving Performance in Practice program provides coaches to guide implementation of 4 key practice changes: registries, planned care templates, protocols, and self-management support. Coaches rate progress using the Key Drivers Implementation Scales (KDIS). This study examines whether higher KDIS scores are associated with improved diabetes outcomes.
Methods
We analyzed clinical and KDIS data from 42 practices. We modeled whether higher implementation scores at year 1 of participation were associated with improved diabetes measures during year 2. Improvement was defined as an increase in the proportion of patients with hemoglobin A1C values <9%, blood pressure values <130/80 mmHg, and low-density lipoprotein (LDL) levels <100 mg/dL.
Results
Statistically significant improvements in the proportion of patients who met the LDL threshold were noted with higher “registry” and “protocol” KDIS scores. For hemoglobin A1C and blood pressure values, none of the odds ratios were statistically significant.
Conclusions
Practices that implement key changes may achieve improved patient outcomes in LDL control among their patients with diabetes. Our data confirm the importance of registry implementation and protocol use as key elements of improving patient care. The KDIS tool is a pragmatic option for measuring practice changes that are rooted in the Chronic Care Model.
doi:10.3122/jabfm.2014.01.130070
PMCID: PMC4096824  PMID: 24390884
Chronic Disease; Diabetes Mellitus; Primary Health Care; Quality Improvement
18.  Organizational culture associated with provider satisfaction 
Objectives
Assess 1) provider satisfaction with specific elements of PCMH; 2) clinic organizational cultures; 3) associations between provider satisfaction and clinic culture.
Methods
Cross sectional study with surveys conducted in 2011 with providers and staff in 10 primary care clinics implementing their version of a PCMH: Care by Design™. Measures included the Organizational Culture Assessment Instrument (OCAI) and the American Medical Group Association provider satisfaction survey.
Results
Providers were most satisfied with quality of care (M=4.14; scale=1–5) and interactions with patients (M=4.12) and least satisfied with time spent working (M=3.47), paper work (M =3.45) and compensation (M=3.35). Culture profiles differed across clinics with family/clan and hierarchical the most common. Significant correlations (p ≤ 0.05) between provider satisfaction and clinic culture archetypes included: family/clan negatively correlated with administrative work; entrepreneurial positively correlated with the Time Spent Working dimension; market/rational positively correlated with how practices were facing economic and strategic challenges; and hierarchical negatively correlated with Relationships with Staff and Resource dimensions.
Discussion
Provider satisfaction is an important metric for assessing experiences with features of a PCMH model.
Conclusions
Identification of clinic-specific culture archetypes and archetype associations with provider satisfaction can help inform practice redesign. Attention to effective methods for changing organizational culture is recommended.
doi:10.3122/jabfm.2014.02.120338
PMCID: PMC4097883  PMID: 24610184
19.  Evidence-Based Selection of Candidates for the Levonorgestrel Intrauterine Device (IUD) 
Background
Recent evidence-based guidelines expanded the definition of appropriate candidates for the levonorgestrel-releasing intrauterine system (LNG-IUS). We investigated correlates of evidence-based selection of candidates for the LNG-IUS by physicians who offer insertion.
Methods
We conducted a mixed-mode (online and mail) survey of practicing family physicians and obstetrician-gynecologists in Seattle.
Results
A total of 269 physicians responded to the survey (44% response rate). Of the 217 respondents who inserted intrauterine devices, half or fewer routinely recommended the LNG-IUS to women who are nulliparous, younger than 20 years old, or have a history of sexually transmitted infections (STIs). In multivariable analyses, training/resident status was positively associated with recommending the LNG-IUS to women <20 years old (adjusted odds ratio [aOR], 3.6; 95% confidence interval [CI], 1.6–8.0) and women with history of STI (aOR, 3.7; 95% CI, 1.6–8.4). Perceived risk of infection or infertility was negatively associated with recommending the LNG-IUS to nulliparous women (aOR, 0.2; 95% CI, 0.1–0.5) and women with a history of STI (aOR, 0.3; 95% CI, 0.1–0.8).
Conclusions
Many family physicians and obstetrician-gynecologists who insert the LNG-IUS are overly restrictive in selecting candidates, although those who train residents are more likely to follow evidence-based guidelines. Interventions that address negative bias and perceptions of risks, in addition to improving knowledge, are needed to promote wider use of the LNG-IUS.
doi:10.3122/jabfm.2014.01.130142
PMCID: PMC4049525  PMID: 24390883
Contraception; Evidence-based Medicine; Graduate Education; Intrauterine Devices
20.  Intervention in Overweight Children Improves BMI and Physical Activity 
Background
Childhood obesity is a growing epidemic in family medicine with few clinical treatment options. We implemented and evaluated a group office-visit intervention by family physicians emphasizing nutrition and physical activity within a resiliency psychosocial model, for overweight children and their parents.
Methods
The intervention lasted for 3 months, with half of the children crossing over to intervention after 6 months on study. Participants included 35 children who met eligibility criteria of being in third through fifth grades and having a body mass index above the 85th percentile. The 3-month twelve-session intervention, “Choices”, included topics on nutrition, physical activity, and resiliency. The sessions were developed for delivery by a family physician, and a nutritionist, who all received training in positive psychology and resilience skills. Main outcome measures were body mass index (BMI) z-scores for age-and-gender, and weight-for-age-and-gender z-scores, as well as qualitative interviews to understand individual and family processes.
Results
The intervention resulted in a significant effect on one primary outcome, BMI z-score (-0.138 per 9 months (p =0.017) and a trend toward significance on the other, weight for age z-score (-0.87 per 9 months (p=0.09). The net shift of activity from the low METS to the high METS had an intervention effect of 2.84 METS (p = 0.037). Families reported lasting changes in behaviors and attitudes.
Discussion
The innovative approach used in this study demonstrated modest efficacy in reducing BMI z-score, changing physical activity levels, and possibly shifting family dynamics.
doi:10.3122/jabfm.2013.02.120118
PMCID: PMC4010584  PMID: 23471926
intervention for overweight children; sedentary behavior in children; resiliency
21.  Delivery of Confidential Care to Adolescent Males 
Purpose
Primary care providers’ (PCPs’) provision of time alone with an adolescent without the parents present (henceforth referred to as “confidential care”) has a significant impact on adolescents’ disclosure of risk behavior. To inform the development of interventions to improve PCPs’ delivery of confidential care, we obtained the perspectives of adolescent males and their mothers about the health care concerns of adolescent males and the provision of confidential care.
Methods
This focus-group study (5 groups: 2 with adolescent males and 2 with mothers) used standard qualitative methods for analysis. We recruited mother/son dyads who had been seen at urban primary care practices.
Results
Adolescents’ health concerns focused on pregnancy and sexually transmitted infections; mothers took a broader view. Many adolescents felt that PCPs often delivered safe sex counseling in a superficial, impersonal manner that did not add much value to what they already knew, and that their PCP’s principal role was limited to performing sexually transmitted infection testing. Though adolescents cited a number of advantages of confidential care and disclosure, they expressed some general mistrust in PCPs and concerns about limits of confidentiality. Rapport and relationship building with their PCP are key elements to adolescents’ comfort and increased disclosure. Overall, mothers viewed confidential care positively, especially in the context of continuity of care, but many felt excluded.
Conclusions
To increase adolescents’ perception of the relevance of primary care and to foster disclosure during health encounters, our participants described the critical nature of a strong doctor–patient relationship and positive physician demeanor and personalized messages, especially in the context of a continuity relationship. Regular, routine inclusion of confidential care time starting early in adolescence, as well as discussion of the purpose and limitations of confidentiality with parents and adolescents, could lead to greater parental comfort with confidential care and increased disclosure by the adolescent.
doi:10.3122/jabfm.2010.06.100072
PMCID: PMC3986269  PMID: 21057068
Confidentiality; Adolescents; Focus Groups; Primary Care
22.  Outcomes of Acupuncture for Chronic Pain in Urban Primary Care 
Purpose
To describe outcomes of the Acupuncture to Decrease Disparities in Outcomes of Pain Treatment (ADDOPT) trial, testing acupuncture as an adjunct to usual treatment for chronic pain in urban health centers.
Method
We conducted quasi-experimental trial. Primary care patients (>21 yrs) with chronic pain due to osteoarthritis, neck or back pain at four hospital owned safety net health centers in the Bronx, NY received weekly acupuncture treatments provided by supervised acupuncture students for up to 14 weeks. Pain and functional status were assessed during a 6-week run-in period before acupuncture, during treatment and post treatment.
Results
Of 495 referred patients, 226 (47%) initiated acupuncture. Back pain was the most common referring diagnosis (59.5%) followed by OA (16.3%). Patients were older (mean age 54.3), mostly Medicaid insured (60.4%), often on disability (38.3%), often (46.7%) in poor or fair overall health, and had high baseline levels of pain (mean BPI pain severity 6.8; mean days with pain, 12.3 of 14 days). The mean number of treatments was 9.7 (SD = 7.3). Pain severity improved from baseline (6.8 vs 5.6 at 12 wks and 5.5 at 24 wks) as did physical well-being (31.8 vs 35.7 at 12 wks and 35.3 at 24 wks). Using HLM methods, reduction in pain severity between baseline and treatment phase was significant (p <.001). Improvements in physical well-being were significant at 12 and 24 weeks post-baseline (p <.001).
Conclusions
Referred primary care patients experienced high levels of pain and pain-related disability. Weekly acupuncture was associated with short-term improvements in pain and quality of life.
doi:10.3122/jabfm.2013.06.130003
PMCID: PMC3979293  PMID: 24204065
23.  Documentation and management of overweight and obesity in primary care 
Purpose
We examine overweight/obesity management in primary care in relation to body mass index (BMI), documentation of weight status, and comorbidities.
Methods
This analysis of baseline data from the Cholesterol Education and Research Trial included 2,330 overweight and obese adult primary care patients from southeastern New England. Data were obtained via a telephone interview and abstraction of subjects’ medical record. BMI (kg/m2) was calculated from measured height and weight. Management of overweight/obesity included advice to lose weight, physical activity recommendations, dietary recommendations, and referral for nutrition counseling.
Results
Documentation of weight status was more common with increasing BMI (13% of overweight patients, 39% of mildly obese, and 77% of moderately/severely obese). Documentation of overweight/obesity was associated with increased behavioral treatment; the biggest increase was seen for advice to lose weight (ORs were 7.2 for overweight patients, 3.3 for patients with mild obesity, and 4.0 for moderate/severe obesity). While weight-related comorbidities were associated with increased overweight/obesity management at all BMIs, the biggest increase in odds was for patients with moderate/severe obesity.
Conclusions
Documentation of weight management was more common among patients with documented overweight/obesity and with weight-related comorbidities. These insights may help in designing new interventions in primary care setting for overweight and obese patients.
doi:10.3122/jabfm.2009.05.080173
PMCID: PMC3967526  PMID: 19734401
24.  Accuracy and congruence of patient and physician weight-related discussions: from Project CHAT (Communicating Health: Analyzing Talk) 
Objective
Primary care providers should counsel overweight patients to lose weight. Rates of self-reported weight-related counseling vary, perhaps due to self-report bias. We assessed accuracy and congruence of weight-related discussions among patients, physicians, and audio-recorded encounters.
Methods
We audio recorded encounters between physicians (n=40) and their overweight/obese patients (n=461) at five community-based practices. We coded weight-related content and surveyed patients and physicians immediately after the visit. Generalized linear mixed models assessed factors associated with accuracy.
Results
Overall, accuracy was moderate: patient (67%), physician (70%), and congruence (62%). When encounters contained weight-related content were analyzed, patients (98%) and physicians (97%) were highly accurate and congruent (95%) but when weight was not discussed patients and physicians were more inaccurate and incongruent (patient 36%; physician 44%; 28% congruence). Physicians less comfortable discussing weight were more likely to misreport that weight was discussed [OR = 4.5 (95% CI=1.88–10.75, p<0.001)]. White physicians with African-American patients were more likely to report accurately no discussion about weight than White physicians with White patients OR=0.30 (95% CI=0.13–0.69, p<0.01).
Conclusion
Physician and patient self-report of weight-related discussions were highly accurate and congruent when audio-recordings indicated weight was discussed, but not when recordings indicated no weight discussions. Physician overestimation of weight discussions when weight is not discussed constitutes missed opportunities for health interventions.
doi:10.3122/jabfm.2014.01.130110
PMCID: PMC3965664  PMID: 24390888
25.  Puzzling Dyspnea Caused by Respiratory Muscle Weakness 
Dyspnea is common in advanced stages of neuromuscular disorders, but it is infrequently the presenting symptom. However, dyspnea is a frequent complaint in a primary care setting but is rarely caused by a respiratory muscle weakness. Consequently, the diagnosis of respiratory muscle weakness often is delayed. First symptoms may occur when respiratory muscles are under increased load, such as when standing in the water higher than the chest, swimming, or in the supine position. We describe a patient in whom dyspnea was the first symptom of amyotrophic lateral sclerosis to remind clinicians of clinical features of respiratory muscle weakness and to help avoid the delay in diagnosis.
doi:10.3122/jabfm.2012.03.110220
PMCID: PMC3931301  PMID: 22570404
ALS (Amyotrophic Lateral Sclerosis); Dyspnea; Neuromuscular Disorders; Respiratory Muscles

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