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1.  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
2.  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
3.  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
4.  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
5.  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
6.  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
7.  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
8.  The impact of primary care physicians on follow-up care of underserved breast cancer survivors 
Purpose
To investigate the impact of primary care physicians’ (PCP) involvement in the receipt of follow-up cancer preventive care after a breast cancer (BC) diagnosis among a low-income population.
Methods
Multiple logistic regression analyses were performed to identify potential factors associated with receipt of cancer preventive care among 579 low-income women with breast cancer. The main outcome variables were receipt of annual mammography, Pap smear in the past 2 years, and ever had colonoscopy for those who were at least 50 years old, at 36 months after BC diagnosis. The main independent variable was provider visit type in the past 12 months.
Results
Women with a PCP visit only or both PCP and surgeon/cancer specialist visits in the past 12 months were more likely to have had annual mammography (AOR=2.67, P=0.109; AOR=2.20, P=0.0008, respectively), a Pap smear in the past 2 years (AOR=2.90, P=0.04; AOR=2.24, P=0.009, respectively) and colonoscopy (AOR=2.99, P=0.041; AOR=2.17, P=0.026, respectively) than those who only visited surgeons/cancer specialists. Indeed, women who only saw a PCP for their follow-up care had the highest odds ratio to receive each clinical care service.
Conclusions
PCP’s involvement in the medical care of low-income BC survivors results in better follow-up cancer preventive care. Getting PCPs involved in cancer survivor care might be particularly pertinent for low-income populations because of lower costs and ease of access compared to cancer specialist-provided care.
doi:10.3122/jabfm.2013.06.120345
PMCID: PMC3925245  PMID: 24204059
9.  Diabetes care quality is highly correlated with patient panel characteristics 
Introduction
Health care reimbursement is increasingly based on quality. Little is known about how clinic-level patient characteristics affect quality performance, particularly in community health centers (CHCs).
Methods
Using electronic health record data for 4,019 diabetic patients from 23 CHC primary care clinics in the OCHIN practice-based research network, we calculated correlations between a clinic’s patient panel characteristics and delivery rates of diabetes preventive services in 2007. Using regression models, we estimated the proportion of clinic variability in clinics’ preventive services rates associated with the variability in the clinics’ patient panel characteristics. We also explored whether clinics’ performance rates were affected by how patient panel denominators were defined.
Results
Clinic rates of glycosylated hemoglobin testing, influenza immunizations, and lipid screening were positively associated with the percentage of patients with continuous health insurance coverage, and negatively associated with the percentage uninsured. Microalbumin screening rates were positively associated with the percentage of racial minorities in a clinic’s panel. Associations remained consistent with different panel denominators.
Conclusions
Clinic variability in delivery rates of preventive services correlates with differences in clinics’ patient panel characteristics, particularly the percentage of patients with continuous insurance coverage. Quality scores that do not account for these differences could create disincentives to diabetes care for vulnerable patients.
doi:10.3122/jabfm.2013.06.130018
PMCID: PMC3922763  PMID: 24204063
10.  Do Primary Care Physicians Lose Contact with Their Colorectal Cancer Patients? 
Background
Primary care physicians and patients perceive that they lose contact with each other after a cancer diagnosis. The objective of this study was to determine whether colorectal cancer (CRC) patients are less likely to see their primary care physicians after cancer diagnosis.
Methods
This was a longitudinal cohort study using 1993 to 2001 Surveillance Epidemiology and End Results (SEER)-Medicare claims data. Eligible patients were those with stage 0 to 1 and 2 to 3 CRC aged 67 to 89 years at diagnosis. Main measures included the proportion of individuals with a face-to-face primary care visit and mean annual primary care visits per patient at baseline and during 5 years after treatment.
Results
Fewer than half of the cancer patients visited with a primary care physician at baseline. In the first year after treatment, patients with stage 0 to 1 CRC (48.9% vs 53.3%; P ≤ .001) and stage 2 to 3 CRC (43.6% vs 53.4%; P ≤ .001) significantly increased their likelihood of visiting a primary care physician from baseline. The proportion of patients with stage 0 to 1 CRC with a primary care visit remained relatively stable, and the proportion of patients with stage 2 to 3 CRC decreased somewhat between the first and fifth year after treatment. The findings for mean annual primary care visits per patient roughly paralleled those for the proportion of individuals with a primary care visit.
Conclusions
Elderly patients with CRC, especially stage 2 to 3 CRC, increase rather than decrease contact with primary care providers after diagnosis. More work is needed to understand the care that different physician specialties provide cancer patients and to support their collaboration.
doi:10.3122/jabfm.2011.06.100192
PMCID: PMC3918900  PMID: 22086813
Cancer; Medicare; Primary Health Care; Survivors
11.  Comparative Effectiveness of Antihypertensive Therapeutic Classes and Treatment Strategies In Initiation of Therapy In Primary Care Patients: A Distributed Ambulatory Research in Therapeutics Network (DARTNet) Study 
Background
Few comparative effectiveness studies of treatment strategies of the use of antihypertensive therapeutic classes in hypertension control have been assessed in a primary care environment.
Objectives
1) To compare the effectiveness of common antihypertensive therapeutic classes initiated as monotherapy in control of hypertension; and 2) To compare the effectiveness of fixed-dose combinations (FDC), free-equivalent combinations (FEC) and monotherapy on hypertension control.
Design
Observational comparative effectiveness analyses of data electronically extracted from the electronic health records.
Participants
The study population consisted of 8,676 patients with an incident prescription for an antihypertensive agent out of 79,176 patients receiving antihypertensive therapy under care in 33 geographically diverse primary care clinics.
Main Measures
Reductions in systolic (SBP) and diastolic (DBP) blood pressure and rates of JNC7 goal attainment.
Key Results
There were small, clinically insignificant differences in BP reductions between the monotherapy classes. Higher rates of BP control were obtained when patients were initiated on an angiotensin-converting-enzyme inhibitor than a thiazide or thiazide-like diuretic (47.8% vs. 39.9%) or a beta-blocker versus a thiazide (45.9% vs. 39.9%). Patients initiated on FDCs had significantly larger reductions in BP than patients initiated on FECs (−17.3 vs. −12.0 mm Hg SBP; −10.1 vs. −6.0 mm Hg DBP) or monotherapy (−17.3 vs. −13.6 mm Hg SBP; −10.1 vs. −7.9 mm Hg DBP). Rates of JNC7 goal attainment also were better for FDCs than FECs (57.2% vs. 42.5%) and for FDCs versus monotherapy (57.2% vs. 44.9%).
Conclusions
Patients initiated on ACEIs and Beta-blockers had slightly higher rates of BP control. The use of FDCs as initial therapy is more effective in the control of hypertension than monotherapy or FECs.
doi:10.3122/jabfm.2013.05.130048
PMCID: PMC3918237  PMID: 24004705
12.  Treatment failure and costs in patients with methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections: A South Texas Ambulatory Research Network (STARNet) study 
Objective
To measure the incidence of treatment failure and associated costs in patients with methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infections (SSTIs).
Methods
This was a prospective, observational study in 13 primary care clinics. Primary care providers collected clinical data, wound swabs, and 90-day follow-up information. Patients were considered to have “moderate or complicated” SSTIs if they had a lesion ≥ 5 cm in diameter or diabetes mellitus. Treatment failure was evaluated within 90 days of the initial visit. Cost estimates were obtained from federal sources.
Results
Overall, treatment failure occurred in 21% of patients (n=21/98) at a mean additional cost of $1,933.71 per patient. Treatment failure occurred in 27% of patients in the moderate or complicated group and 11% of patients in the mild or uncomplicated group (p = 0.08). In a subgroup analysis of patients who received I&D, patients with moderate or complicated SSTIs had higher rates of treatment failure than patients with mild or uncomplicated SSTIs (36% vs. 10%; p = 0.04).
Conclusions
One in five patients presenting to a primary care clinic for a MRSA SSTI will likely require additional interventions as a result of treatment failure at an associated cost of almost $2,000 per patient. Baseline risk stratification and new treatment approaches are needed to reduce treatment failures and costs in the primary care setting.
doi:10.3122/jabfm.2013.05.120247
PMCID: PMC3890434  PMID: 24004702
13.  Contraceptive Methods and Informed Consent among Women Receiving Medications with Potential for Adverse Fetal Effects: A Washington, Wyoming, Alaska, Montana, Idaho (WWAMI) Region Study 
Background
Increasing diabetes, hypertension, and hypercholesterolemia rates expose some young women to medications with potential adverse fetal effects, such as angiotensin-converting enzyme inhibitors (ACE-Is), angiotensin receptor blockers (ARBs), and statins. This study examined whether quality improvement (QI) interventions promote informed consent and contraception to minimize risks with use of ACE-I/ARB/statins.
Methods
This longitudinal cohort study at 7 clinics abstracted medical records of 328 women aged 18 to 44 with ≥1 prescription for ACE-I/ARB/statins and ≥1 visit for hypertension, diabetes, or hypercholesterolemia during the previous year. We measured informed consent documentation and contraceptive methods before and after QI interventions in which providers contacted their patients to discuss medication risks and benefits.
Results
Of 179 women who were not surgically sterilized, only 11.7% had documented informed consent related to the risks of ACE-I/ARB/statin use. One hundred fifty-eight women were eligible for the QI intervention (not surgically sterilized, no documented informed consent); only 76 (48.1%) received the intervention. Before the intervention, 23.7% of these 76 were “at risk” of an adverse fetal effect. After the intervention, only 7.9% (P ≤ .001) were “at risk” because some women started contraception, discontinued ACE-I/ARB/statins, or changed drug class.
Conclusions
Women prescribed ACE-I/ARB/statins were not consistently using contraception or were not consistently informed of the risks. Provider-implemented QI interventions improved care but were difficult to accomplish, suggesting that new interventions are needed.
doi:10.3122/jabfm.2012.05.120056
PMCID: PMC3888553  PMID: 22956701
Contraception; Drugs; Informed Consent; Pharmacology; Physician Behavior; Practice-based Research; Practice-based Research Networks; Preconception Care; Teratogens
14.  Barriers and Facilitators to Evidence-based Blood Pressure Control in Community Practice 
Journal of the American Board of Family Medicine : JABFM  2013;26(5):10.3122/jabfm.2013.05.130060.
Introduction
The Electronic Communications and Home Blood Pressure Monitoring trial (e-BP) demonstrated that team care incorporating a pharmacist to manage hypertension using secure E-mail with patients resulted in almost twice the rate of blood pressure (BP) control compared with usual care. To translate e-BP into community practices, we sought to identify contextual barriers and facilitators to implementation.
Methods
Interviews were conducted with medical providers, staff, pharmacists, and patients associated with community-based primary care clinics whose physician leaders had expressed interest in implementing e-BP. Transcripts were analyzed using qualitative template analysis, incorporating codes derived from the Consolidated Framework for Implementation Research (CFIR).
Results
Barriers included incorporating an unfamiliar pharmacist into the health care team, lack of information technology resources, and provider resistance to using a single BP management protocol. Facilitators included the intervention’s perceived potential to improve quality of care, empower patients, and save staff time. Sustainability of the intervention emerged as an overarching theme.
Conclusion
A qualitative approach to planning for translation is recommended to gain an understanding of contexts and to collaborate to adapt interventions through iterative, bidirectional information gathering. Interviewees affirmed that web pharmacist care offers small primary care practices a means to expand their workforce and provide patient-centered care. Reproducing e-BP in these practices will be challenging, but our interviewees expressed eagerness to try and were optimistic that a tailored intervention could succeed.
doi:10.3122/jabfm.2013.05.130060
PMCID: PMC3882900  PMID: 24004706
Evidence-based Medicine; Community Medicine; Home Blood Pressure Monitoring; Primary Health Care; Qualitative Research
15.  Bringing Together Community Health Centers, Information Technology and Data to Support a Patient-Centered Medical Village from the OCHIN community of solutions 
Journal of the American Board of Family Medicine : JABFM  2013;26(3):10.3122/jabfm.2013.03.120234.
Creating integrated, comprehensive care practices requires access to data and informatics expertise. Information technology (IT) resources are not readily available to individual practices. One model of shared IT resources and learning is a “patient-centered medical village.” We describe the OCHIN Community Health Information Network as an example of this model where community practices have come together collectively to form an organization which leverages shared IT expertise, resources, and data, providing members with the means to fully capitalize on new technologies that support improved care. This collaborative facilitates the identification of “problem-sheds” through surveillance of network-wide data, enables shared learning regarding best practices, and provides a “community laboratory” for practice-based research. As an example of a Community of Solution, OCHIN utilizes health IT and data-sharing innovations to enhance partnerships between public health leaders, community health center clinicians, informatics experts, and policy makers. OCHIN community partners benefit from the shared IT resource (e.g. a linked electronic health record (EHR), centralized data warehouse, informatics and improvement expertise). This patient-centered medical village provides (1) the collective mechanism to build community tailored IT solutions, (2) “neighbors” to share data and improvement strategies, and (3) infrastructure to support EHR-based innovations across communities, using experimental approaches.
doi:10.3122/jabfm.2013.03.120234
PMCID: PMC3883432  PMID: 23657695
community health; electronic health records; health information technology; practice-based research; community learning collaborative; quality improvement
16.  Practice-based Research Networks (PBRNs): Meeting the Challenges of the Future 
Journal of the American Board of Family Medicine : JABFM  2012;25(5):10.3122/jabfm.2012.05.120064.
Practice-based research networks (PBRNs) are useful tools for conducting studies in the busy primary care setting, but their continued existence is threatened by a range of challenges. PBRNs must position themselves now to be prepared to face the challenges ahead. For example, experience with the Clinical Translational Science Awards has placed PBRNs at the center of university efforts toward greater community engagement. Networks must use this opportunity to solicit infrastructure support and partner with experienced principal investigators from other disciplines. Successful networks must make greater use of health information technology to solicit clinician involvement, identify and recruit potential subjects, and disseminate key findings. To maintain the active participation of busy clinicians in the clinical research enterprise, networks must find new ways to engage their members and simplify study participation. Networks should pursue clinically relevant projects that create meaning and connect busy practitioners to the larger agenda of primary care research. Finally, collaborating with other networks in a structured and ongoing manner is one way for PBRNs to extend their reach while making maximal use of their unique resources and local expertise.
doi:10.3122/jabfm.2012.05.120064
PMCID: PMC3880656  PMID: 22956692
Health Information Technology; Practice-based Research; Practice-based Research Networks; Primary Health Care
17.  Opioids for Back Pain Patients: Primary Care Prescribing Patterns and Use of Services 
Journal of the American Board of Family Medicine : JABFM  2011;24(6):10.3122/jabfm.2011.06.100232.
Background
Opioid prescribing for non-cancer pain has increased dramatically. We examined whether the prevalence of unhealthy lifestyles, psychological distress, healthcare utilization, and co-prescribing of sedative-hypnotics increased with increasing duration of prescription opioid use.
Methods
We analyzed electronic data for 6 months before and after an index visit for back pain in a large managed care plan. Use of opioids was characterized as “none”, “acute” (≤ 90 days), “episodic”, or “long-term.” Associations with lifestyle factors, psychological distress, and utilization were adjusted for demographics and comorbidity.
Results
There were 26,014 eligible patients. Among these, 61% received a course of opioid therapy, and 19% were long-term users. Psychological distress, unhealthy lifestyles, and utilization were associated in stepwise fashion with duration of opioid prescribing, not just with chronic use. Among long-term opioid users, 59% received only short-acting drugs; 39% received both long and short acting drugs; 44% received a sedative-hypnotic. Of those with any opioid use, 36% had an emergency visit.
Conclusions
Opioid prescribing was common among patients with back pain. The prevalence of psychological distress, unhealthy lifestyles, and healthcare utilization increased incrementally with duration of opioid use. Despite safety concerns, co-prescribing of sedative-hypnotics was common. These data may help in predicting long-term opioid use and improving the safety of opioid prescribing.
doi:10.3122/jabfm.2011.06.100232
PMCID: PMC3855548  PMID: 22086815
18.  Boot Camp Translation: A Method For Building a Community of Solution 
Journal of the American Board of Family Medicine : JABFM  2013;26(3):10.3122/jabfm.2013.03.120253.
Objective
The National Institutes of Health (NIH) spend billions of dollars annually on biomedical research. A crucial, yet currently insufficient step is the translation of scientific evidence-based guidelines and recommendations into constructs and language accessible to every-day patients and community members. By building a community of solution that integrates primary care with public health and community-based organizations, evidence-based medical care can be translated into language and constructs accessible to community members and readily implemented to improve health.
Methods
Using a community-based participatory research approach, the High Plains Research Network (HPRN) and its Community Advisory Council developed a multi-component process to translate evidence into messages and dissemination methods to improve health in rural Colorado. This process, called Boot Camp Translation has brought together various community members, organizations, and primary care to build a community of solution to address local health problems.
Results
The HPRN has conducted 4 Boot Camp Translations on topics including colon cancer prevention, asthma diagnosis and management, hypertension treatment and management, and the patient-centered medical home. Each Boot Camp follows a standard agenda that requires flexibility and creativity. Thus far, the HPRN has used Boot Camp Translation to engage over a thousand rural community members and providers. Dissemination of Boot Camp messaging through the community of solution has led to increased colon cancer screening, improved care for asthma, and increased rates of controlled blood pressure.
Conclusions
Boot Camp translation successfully engages community members in a process to translate evidence-based medical care into locally relevant, culturally appropriate language and constructs. Boot Camp Translation is an appropriate method for engaging community members in patient-centered outcomes research. Boot Camp Translation may be an appropriate first step in building a local or regional community of solution aimed at improving health of the community.
doi:10.3122/jabfm.2013.03.120253
PMCID: PMC3828080  PMID: 23657693
community-based participatory research; translational research; rural practice-based research; rural; colon cancer prevention; asthma
19.  Do Clinicians Tell Patients They Have Prehypertension? 
Journal of the American Board of Family Medicine : JABFM  2011;24(1):10.3122/jabfm.2011.01.100206.
doi:10.3122/jabfm.2011.01.100206
PMCID: PMC3814021  PMID: 21209353
20.  Engagement of Groups in Family Medicine Board Maintenance of Certification 
Journal of the American Board of Family Medicine : JABFM  2013;26(2):10.3122/jabfm.2013.02.120262.
Purpose
The American Board of Medical Specialties’ performance in practice, ‘Part IV’, portion of Maintenance of Certification (MOC) requirement provides an opportunity for practicing physicians to demonstrate quality improvement (QI) competence. However, specialty boards’ certification of one physician at a time does not tap into the potential of collective effort. This paper shares learning from a project to help family physicians work in groups to meet their Part IV MOC requirement.
Methods
A year-long implementation and evaluation project was conducted. Initially, 348 members of a regional family physician organization were invited to participate. A second path for enrollment was established through three healthcare systems and a county-wide learning collaborative. The participants were offered: a) a basic and straightforward introduction to quality improvement (QI) methods, b) the option of an alternative Part IV MOC module using a patient experience survey to guide QI efforts, c) practice-level improvement coaching, d) support for intra- and inter-practice collaboration and co-learning, and e) provision of QI resources.
Results
More physicians participated through group (66) than individual (12) recruitment, for a total of 78 physicians in 20 practices. Participation occurred at three levels: individual, intra-practice, and inter-practice. Within the one-year time frame, intra-practice collaboration occurred most frequently. Inter-practice and system-level collaboration has begun and continues to evolve. Physicians felt that they benefited from access to a practice coach, group process, and a subset of participants also reported that their QI competency had improved with participation.
Conclusions
Practice-level collaboration, access to a practice coach, flexibility in choosing and focusing improvement projects, tailored support, and involvement with professional affiliations, can enhance the Part IV MOC process. Specialty boards are likely to discover productive opportunities from working with practices, professional organizations, and healthcare systems to support intra- and inter-practice collaborative QI work that uses Part IV MOC requirements to motivate practice improvement.
doi:10.3122/jabfm.2013.02.120262
PMCID: PMC3814031  PMID: 23471928
21.  Women Weigh In: Obese African-American and White Women’s Perspectives on Physicians’ Roles in Weight Management 
Background
There is little qualitative research on the type of weight loss counseling patients prefer from their physicians and whether preferences differ by race.
Methods
This qualitative study used semi-structured in-depth interviews of 33 moderately to severely obese white and African-American (AA) women to elucidate and compare their perceptions regarding their primary care physician’s approach to weight loss counseling. Data were analyzed using a grounded theory approach and a series of immersion/crystallization cycles.
Results
White and AA women appeared to internalize weight stigma differently. AA participants spoke about their pride and positive body image, while white women more frequently expressed self-deprecation and feelings of depression. Despite these differences, both groups of women desired similar physician interactions and weight management counseling, including: (1) giving specific weight loss advice and individualized plans for weight management; (2) addressing weight in an empathetic, compassionate, nonjudgmental, and respectful manner; and (3) providing encouragement to foster self-motivation for weight loss.
Conclusion
While both AA and white women desired specific strategies from physicians in weight management, some white women may first need assistance in overcoming their stigma, depression and low self-esteem before attempting weight loss.
doi:10.3122/jabfm.2013.04.120350
PMCID: PMC3791510  PMID: 23833157
obesity; stigmatization; physician-patient relations; cross-cultural comparison
22.  Comorbid Chronic Illness and the Diagnosis and Treatment of Depression in Safety Net Primary Care Settings 
Objective
To estimate the impact of chronic medical conditions on depression diagnosis, treatment, and follow-up care in primary care settings.
Design
This was a cross-sectional study that used interviewer-administered surveys and medical record reviews. Three hundred fifteen participants were recruited from 3 public primary care clinics. Depression diagnosis, guideline-concordant treatment, and follow-up care were the primary outcomes examined in individuals with depression alone compared with individuals with depression and chronic medical conditions measured using the Charlson Comorbidity Index (CCI).
Results
Physician diagnosis of depression (32.6%), guideline-concordant depression treatment (32.7%), and guideline-concordant follow-up care (16.3%) were all low. Logistic regression analysis showed no significant difference in the likelihood of depression diagnosis, guideline-concordant treatment, or follow-up care in individuals with depression alone compared with those with both depression and chronic medical conditions. Participants with severe depression were, however, twice as likely to receive a diagnosis of depression as participants with moderate depression. In addition, participants with moderately severe and severe depression received much less appropriate follow-up care than participants with moderate depression. Among participants receiving a depression diagnosis, 74% received guideline-concordant treatment.
Conclusion
Physician depression care in primary care settings is not influenced by competing demands for care for other comorbid medical conditions.
doi:10.3122/jabfm.2009.02.080035
PMCID: PMC3782997  PMID: 19264935
23.  The Medical Home: Locus of Physician Formation 
Family medicine is currently undergoing a transformation and, amid such change, the medical home has emerged as the new polestar. This article examines the medical home through the lens of philosopher Alasdair MacIntyre and offers a perspective, informed by Hubert Dreyfus and Peter Senge, about medical homes as practical sites of formation for family physicians. The intellectual past of family medicine points to contextually sensitive patient care as a practice that is particular to the discipline, with the virtue of “placing patients within contexts over time” as a commonly held virtue. Dreyfus provides a model of knowledge and skill acquisition that is relevant to the training of family physicians in practical wisdom. In this model, there is a continuum from novice to more advanced stages of professional formation that is aided by rules that not only must be learned, but must be applied in greater contextually informed situations. Senge’s emphasis on learning organizations— organizations where people are continually learning how to learn together—presents a framework for evaluating the extent to which future medical homes facilitate or retard the formation of family physicians.
doi:10.3122/jabfm.2008.05.080083
PMCID: PMC3776409  PMID: 18772299
24.  Brand-Name Prescription Drug Use Among Veterans Affairs and Medicare Part D Patients With Diabetes 
Background:
Medicare Part D and the U.S. Department of Veterans Affairs (VA) use different approaches to manage prescription drug benefits, with implications for spending. Medicare relies on private plans with distinct formularies, whereas the VA administers its own benefit using a national formulary.
Objective:
To compare overall and regional rates of brand-name drug use among older adults with diabetes in Medicare and the VA.
Design:
Retrospective cohort.
Setting:
Medicare and the VA, 2008.
Patients:
1 061 095 Medicare Part D beneficiaries and 510 485 veterans aged 65 years or older with diabetes.
Measurements:
Percentage of patients taking oral hypoglycemics, statins, and angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) who filled brand-name drug prescriptions and percentage of patients taking long-acting insulins who filled analogue prescriptions. Sociodemographic- and health status–adjusted hospital referral region (HRR) brand-name drug use was compared, and changes in spending were calculated if use of brand-name drugs in 1 system mirrored the other.
Results:
Brand-name drug use in Medicare was 2 to 3 times that in the VA: 35.3% versus 12.7% for oral hypoglycemics, 50.7% versus 18.2% for statins, 42.5% versus 20.8% for ACE inhibitors or ARBs, and 75.1% versus 27.0% for insulin analogues. Adjusted HRR-level brand-name statin use ranged (from the 5th to 95th percentiles) from 41.0% to 58.3% in Medicare and 6.2% to 38.2% in the VA. For each drug group, the 95th-percentile HRR in the VA had lower brand-name drug use than the 5th-percentile HRR in Medicare. Medicare spending in this population would have been $1.4 billion less if brand-name drug use matched that of the VA.
Limitation:
This analysis cannot fully describe the factors underlying differences in brand-name drug use.
Conclusion:
Medicare beneficiaries with diabetes use 2 to 3 times more brand-name drugs than a comparable group within the VA, at substantial excess cost.
Primary Funding Source:
U.S. Department of Veterans Affairs, National Institutes of Health, and Robert Wood Johnson Foundation.
doi:10.3122/jabfm.2009.02.080059
PMCID: PMC3766978  PMID: 19264942
25.  Screening Tests for Adults with Intellectual Disabilities 
Adults with intellectual disabilities need thoughtful, well-coordinated primary care from family physicians. However, evidence-based screening recommendations are lacking. We examined screening recommendations for common preventable conditions using the US Preventative Service Task Force guidelines. We also reviewed the literature about the prevalence of these conditions in adults with intellectual disabilities. Obesity, osteoporosis, and smoking are more prevalent in adults with intellectual disabilities, and enhanced screening for these conditions is recommended. Abnormal Papanicolaou smears and cervical cancer are less common in adults with intellectual disabilities and screening recommendations should be individualized. We also discussed strategies to make screening procedures less stressful for these patients.
doi:10.3122/jabfm.2007.04.060210
PMCID: PMC3708482  PMID: 17615421

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