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1.  Regional Supply of Chiropractic Care and Visits to Primary Care Physicians for Back and Neck Pain 
Whether availability of chiropractic care affects use of primary care physician (PCP) services is unknown.
We performed a cross-sectional study of 17.7 million older adults who were enrolled in Medicare from 2010 to 2011. We examined the relationship between regional supply of chiropractic care and PCP services using Spearman correlation. Generalized linear models were used to examine the association between regional supply of chiropractic care and number of annual visits to PCPs for back and/or neck pain.
We found a positive association between regional supply of chiropractic care and PCP services (rs = 0.52; P <.001). An inverse association between supply of chiropractic care and the number of annual visits to PCPs for back and/or neck pain was apparent. The number of PCP visits for back and/or neck pain was 8% lower (rate ratio, 0.92; 95% confidence interval, 0.91–0.92) in the quintile with the highest supply of chiropractic care compared to the lowest quintile. We estimate chiropractic care is associated with a reduction of 0.37 million visits to PCPs nationally, at a cost of $83.5 million.
Greater availability of chiropractic care in some areas may be offsetting PCP services for back and/or neck pain among older adults. (J Am Board Fam Med 2015;28:000–000.)
PMCID: PMC4512163  PMID: 26152439
Back Pain; Complementary Medicine; Primary Health Care
2.  Shared Decision Making in Prostate-Specific Antigen Testing With Men Older Than 70 Years 
Little is known about how shared decision making (SDM) is being carried out between older men and their health care providers. Our study aimed to describe the use of SDM key elements and assess their associations with prostate-specific antigen (PSA) testing among older men.
We conducted descriptive and logistic regression modeling analyses using the 2005 and 2010 National Health Interview Survey data.
Age-specific prevalence of PSA testing was similar in 2005 and 2010. In 2010, 44.1% of men aged ≥70 years had PSA testing. Only 27.2% (95% confidence interval, 22.2–32.9) of them reported having discussions about both advantages and disadvantages of testing. Multiple regression analyses showed that PSA-based screening was positively associated with discussions of advantages only (P < .001) and with discussions of both advantages and disadvantages (P < .001) compared with no discussion. Discussion of scientific uncertainties was not associated with PSA testing.
Efforts are needed to increase physicians’ awareness of and adherence to PSA-based screening recommendations. Given that discussions of both advantages and disadvantages increased the uptake of PSA testing and discussion of scientific uncertainties has no effect, additional research about the nature, context, and extent of SDM and about patients’ knowledge, values, and preferences regarding PSA-based screening is warranted.
PMCID: PMC4480614  PMID: 23833155
Aged; Prostate Cancer; Prostate-specific Antigen; Screening; Shared Decision Making
3.  Comparable sustained virologic suppression between community and academic-based HIV care settings 
The HIV/AIDS epidemic in the United States is evolving due to factors including aging and geographical diffusion. Provider shortages are also driving the restructuring of HIV care delivery away from specialized settings, and family medicine providers may play a larger role in the future. We attempted to compare the effectiveness of HIV treatment delivered at community versus hospital care settings.
The outcome of interest was sustained virologic suppression defined as two consecutive HIV-1 RNA measurements ≤ 400 copies/mL within one year after antiretroviral initiation. We used data from the multi-state HIV Research Network cohort to compare sustained virologic suppression outcomes among 15,047 HIV-infected adults followed from 2000–2008 at five community- and eight academic hospital-based ambulatory care sites. Community-based sites were mostly staffed by family medicine and general internal medicine physicians with HIV expertise whereas hospital sites were primarily staffed by infectious disease subspecialists. Multivariate mixed-effects logistic regression controlling for potential confounding variables was applied to account for clustering effects of study sites.
In an unadjusted analysis, the rate of sustained virologic suppression was significantly higher among subjects treated in the community-based care settings: 1,646/2,314 (71.1%) vs. 8,416/12,733 (66.1%) (p < 0.01). In the adjusted multivariate model with potential confounding variables, the rate was higher, although not statistically significant, in the community-based settings (AOR = 1.26, 95% CI 0.73–2.16).
Antiretroviral therapy can be delivered effectively through community-based treatment settings. This finding is potentially important for new program development to shift HIV care into community-based settings as the landscape of accountable care, health reform, and HIV funding and resources evolves.
PMCID: PMC4456020  PMID: 25567825
HIV primary care; community-based HIV care; virologic suppression
4.  Electronic Health Record Innovations for Healthier Patients and Happier Doctors 
This special issue explores a range of health information technology (HIT) issues that can help primary care practices and patients. Findings address the design of HIT systems, primarily electronic health records (EHRs), the utility of various functionalities, and implementation strategies that ensure the greatest value. The articles also remind us that, while HIT can support the delivery of care, it is not a panacea. To be effective, functionality needs to be relevant and timely for both the clinician and patient. Prompts and better documentation can improve care, and “prompt fatigue” is not inevitable. Information presented within EHRs needs to be actionable. There is an ongoing tension between information overload and the right—and helpful—information. Even the order of presentation of information can make a difference in the outcome. Whether supported by HIT or not, basic tenants of care, such as including the whole care team in trainings, communicating with other providers, and engaging patients, remain essential. The studies in this issue will prove useful for informatics developers, practices and health systems making HIT decisions, and care teams refining HIT to support the needs of their patients.
PMCID: PMC4450099  PMID: 25957359
5.  Health Information Technology Needs Help from Primary Care Researchers 
While health information technology (HIT) efforts are beginning to yield measurable clinical benefits, more is needed to meet the needs of patients and clinicians. Primary care researchers are uniquely positioned to inform the evidence-based design and use of technology. Research strategies to ensure success include engaging patient and clinician stakeholders, working with existing practice-based research networks, and using established methods from other fields such as human factors engineering and implementation science. Policies are needed to help support primary care researchers in evaluating and implementing HIT into everyday practice, including expanded research funding, strengthened partnerships with vendors, open access to information systems, and support for the Primary Care Extension Program. Through these efforts, the goal of improved outcomes through HIT can be achieved.
PMCID: PMC4450103  PMID: 25957361
6.  Comparing Chronic Pain Treatment Seekers in Primary Care versus Tertiary Care Settings 
Patients frequently seek treatment for chronic nonmalignant pain in primary care settings. Compared with physicians who have completed extensive specialization (eg, fellowships) in pain management, primary care physicians receive much less formal training in managing chronic pain. While chronic pain represents a complicated condition in its own right, the recent increase in opioid prescriptions further muddles treatment. It is unknown whether patients with chronic pain seeking treatment in primary care differ from those seeking treatment in tertiary care settings. This study sought to determine whether patients with chronic pain in primary care reported less pain, fewer psychological variables related to pain, and lower risk of medication misuse/abuse compared with those in tertiary care.
Data collected from patients with chronic pain in primary care settings and tertiary care settings were analyzed for significant differences using Wilcoxon rank sum tests, Fisher exact tests, and linear regression. A host of variables among populations, including demographics, self-reported pain severity, psychological variables related to pain, and risk for opioid misuse and abuse, were compared.
Findings suggest that primary care patients with chronic pain were similar to those in tertiary care on a host of indices and reported more severe pain. There were no significant group differences for risk of medication misuse or abuse.
It seems that primary care physicians care for a complicated group of patients with chronic pain that rivals the complexity of those seen in specialized tertiary care pain management facilities.
PMCID: PMC4410385  PMID: 25201929
Chronic Pain; Opioids; Primary Health Care
7.  Unconscious Biases: Racial Microaggressions in American Indian Health Care 
This paper reports on the prevalence and correlates of microaggressive experiences in healthcare settings reported by American Indian (AI) adults with type 2 diabetes.
This community-based participatory research project includes two AI reservation communities. Data were collected via in-person paper-and-pencil survey interviews with 218 AI adults diagnosed with type 2 diabetes.
Over 1/3 of the sample reported experiencing a microaggression in interactions with their health providers. Reports of microaggressions were correlated with self-reported history of heart attack, worse depressive symptoms, and prior year hospitalization. Depressive symptom ratings appeared to account for some of the association between microaggressions and hospitalization (but not history of heart attack) in multivariate models.
Microaggressive experiences undermine the ideals of patient-centered care and in this study were correlated with worse mental and physical health reports for American Indians living with a chronic disease. Providers should be cognizant of these subtle, often unconscious forms of discrimination.
PMCID: PMC4386281  PMID: 25748764
8.  Feasibility of Portable Sleep Monitors to Detect Obstructive Sleep Apnea (OSA) in a Vulnerable Urban Population 
Portable sleep monitors may offer a convenient method to expand detection of obstructive sleep apnea (OSA), yet few studies have evaluated this technology in vulnerable populations. We therefore aimed to assess the feasibility and acceptability of portable sleep monitors for detection of OSA in a prediabetic, urban minority population.
We recruited a convenience sample of participants at their 12-month follow-up for a community-partnered, peer-led lifestyle intervention aimed to prevent diabetes in prediabetic and overweight patients in this prospective mixed-methods pilot study. All participants wore portable sleep monitors overnight at home. We qualitatively explored perceptions about OSA and portable monitors in a subset of participants.
We tested 72 people, predominantly non-White, female, Spanish speaking, uninsured, and of low income. Use of portable sleep monitors was feasible: 100% of the monitors were returned and all participants received results. We detected OSA in 49% (defined as an Apnea-Hypopnea Index [AHI] >5) and moderate-severe OSA in 14% (AHI >15) requiring treatment in 14%. In 21 qualitative interviews, participants supported increased use of portable sleep monitors in their community, were appropriately concerned that OSA could cause progression to diabetes, and thought weight loss could prevent or improve OSA.
Portable sleep monitors may represent a feasible method for detecting OSA in high-risk urban minority populations.
PMCID: PMC4377645  PMID: 25748767
Community-Based Participatory Research; Diabetes Mellitus; Monitoring; Sleep; Obesity; Sleep Disorders
9.  Intrapartum Antibiotics and Childhood Atopic Dermatitis 
Atopic dermatitis (AD) in children significantly impacts families due to medical costs, “lost” hours, and secondary characteristics like asthma and ancillary infections. We investigate whether children delivered vaginally to women receiving intrapartum antibiotics have a greater risk of AD under the age of 2 years than their counterparts.
We conducted a retrospective analysis of women who delivered child(ren) vaginally between 1996 and 2008. Women were identified as those who received intrapartum antibiotics and those who did not. Pediatric records were used to determine incidence of AD.
We collected data for 492 mother-child pairs. Intrapartum antibiotics were administered during 128 births; 28.9% of those children were diagnosed with AD by 2 years (RR 1.03 [0.75-1.41], p=0.854). Factors with greatest risks of diagnosis with AD by 2 years were intrapartum antibiotic exposure for >24hrs (RR 1.99 [1.13-3.49], p=0.0173), first born (RR 1.78 [1.33-2.38], p<0.0001) and higher maternal education (RR 1.43[0.99-2.06], p=0.039). No statistical difference in prevalence of AD related to parental eczema, maternal Group B Streptococcus status, or gestational age existed.
Exposure to antibiotics for <24hrs during a vaginal delivery does not increase the risk of AD. Studies are needed to understand if exposures >24hrs during the intrapartum period increase the risk of AD.
PMCID: PMC4350816  PMID: 25567826
intrapartum antibiotics; eczema; atopic dermatitis; childbirth
10.  A Novel Protocol for Streamlined IRB Review of PBRN Card Studies 
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.
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.
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.
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.
PMCID: PMC4331110  PMID: 21900445
practice-based research network; practice-based research; card study; weekly return; HIPAA; primary care research; institutional review board
11.  Guidance for Researchers Developing and Conducting Clinical Trials in Practice-based Research Networks (PBRNs) 
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.
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.
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.
Ensuring the successful development and conduct of clinical trials in PBRNs requires a highly collaborative approach between academic research and PBRN teams.
PMCID: PMC4297606  PMID: 25381071
Clinical Trials as Topic; Practice-based Research
12.  Use of Mobile Health (mHealth) Tools by Primary Care Patients in the WWAMI Region Practice and Research Network (WPRN) 
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.
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.
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.
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.
PMCID: PMC4297607  PMID: 25381075
Chronic Disease; Mobile Health; Practice-based Research; Primary Health Care
13.  [No title available] 
PMCID: PMC4294578  PMID: 24204057
14.  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.
To characterize the relationship between maternal depressive symptoms and employment and whether it is mediated by social support.
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.
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).
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.
PMCID: PMC3882899  PMID: 24390890
mothers; depression; employment; social support
15.  Intrauterine devices at six months: does patient age matter? Results from an urban family medicine Federally Qualified Health Center (FQHC) network 
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.
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.
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.
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.
PMCID: PMC4280233  PMID: 25381080
16.  Results of Nurse Navigator follow-up after positive colorectal cancer screening test: a randomized trial 
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.
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.
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.
Navigation did not lead to a statistically significant incremental benefit at 6 months.
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.
PMCID: PMC4278960  PMID: 25381076
colorectal cancer screening; colonoscopy; complete diagnostic evaluation; navigation
17.  The Association of Type and Number of Chronic Diseases with Breast, Cervical and Colorectal Cancer Screening in Rural Primary Care Practices 
To examine associations between the number and types of patients’ chronic diseases and being up-to-date for breast, cervical and colorectal cancer screening.
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.
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.
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.
PMCID: PMC4273642  PMID: 25201936
18.  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.
PMCID: PMC4269522  PMID: 24808119
19.  Real world implementation and outcomes of health behavior and mental health assessment 
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.
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.
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.
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.
PMCID: PMC4237013  PMID: 24808114
20.  Using Patient Monetary Incentives and Electronically Derived Patient Lists to Recruit Patients to a Clinical Trial 
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.
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.
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.
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.
PMCID: PMC4224283  PMID: 21900440
Electronic Medical Records; Research Methods
21.  ColoRectal Cancer Predicted Risk Online (CRC-PRO) Calculator Using Data from the Multi-Ethnic Cohort Study 
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.
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.
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
This calculator seems to be accurate, is user friendly, and has been internally validated in a diverse population.
PMCID: PMC4219857  PMID: 24390885
Colorectal Cancer; Medical Decision Making; Prevention and Control; Risk
22.  Patient Perspective on Watchful Waiting/Active Surveillance for Localized Prostate Cancer 
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.
Semistructured in-person interviews were conducted with 21 men (14 black; 7 white) with recently diagnosed localized prostate cancer.
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.
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.
PMCID: PMC4212643  PMID: 23136314
Active Surveillance; Decision Making; Medical Oncology; Prostate Cancer; Watchful Waiting
23.  Patient Opinions and Concerns Regarding a Pilot Academic Retainer Program for Uninsured Patients 
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.
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.
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.
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.
PMCID: PMC4151114  PMID: 21551403
Retainer practice; primary care
24.  Measuring the Impact of Practice-based Research Networks (PBRNs) 
PMCID: PMC4120825  PMID: 22956689
25.  Incidental Computer Tomography Radiologic Findings through Research Participation in the North Texas Healthy Heart Study 
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.
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.
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.
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.
PMCID: PMC4113722  PMID: 24808109
Computed Tomography; Incidental Findings; Medical Ethics; Practice-based Research Networks; Research Subjects

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