There is little qualitative research on the type of weight loss counseling patients prefer from their physicians and whether preferences differ by race.
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.
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.
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.
obesity; stigmatization; physician-patient relations; cross-cultural comparison
To estimate the impact of chronic medical conditions on depression diagnosis, treatment, and follow-up care in primary care settings.
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).
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.
Physician depression care in primary care settings is not influenced by competing demands for care for other comorbid medical conditions.
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.
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.
To compare overall and regional rates of brand-name drug use among older adults with diabetes in Medicare and the VA.
Medicare and the VA, 2008.
1 061 095 Medicare Part D beneficiaries and 510 485 veterans aged 65 years or older with diabetes.
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.
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.
This analysis cannot fully describe the factors underlying differences in brand-name drug use.
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.
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.
Although 64% of cancer survivors are expected to live at least five years beyond diagnosis, the receipt of cancer screening by this population is unclear. The study objective is to assess the relation between a cancer diagnosis and future cancer screening, exploring provider, patient, and cancer-specific factors that explain observed relationships.
The Wisconsin Longitudinal Study (WLS) and Wisconsin Tumor Registry were used to identify two participant groups: 415 diagnosed with non-metastatic cancer between 1992-1993 (pre-cancer) and 2003-2004 (post-cancer) and 4,680 no-cancer controls. Adjusted average predicted probabilities of cancer screening were estimated with models that first did not include and then included, provider (provider relationship length), participant (depressive symptoms (CES-D)) and cancer-specific (time since diagnosis) factors. Participants with a history of the cancer associated with a given screening test were then excluded to assess whether relationships are explained by screening for recurrence versus second cancers.
Female cancer survivors were more likely than no-cancer controls to undergo pelvic/pap (70%, 95% confidence interval (CI)=63-76% and 61%,CI=59-63%) and mammography screening (86%,CI=78-90% and 76%,CI=74-77%), though male cancer survivors were not more likely to receive prostate exams (76%,CI=70-82% and 69%,CI=67-71%). After excluding people with a history of the cancer being screened for, there were few significant differences in cancer screening between short or long-term survivors (>5 years) and no-cancer controls. Relationships were not sensitive to adjustment for provider or participant factors.
The significant positive differences in cancer screening between people with and without cancer can be explained by screening for recurrence. Long-term cancer survivors are not more likely to receive follow-up screening for second cancers. This information should be used by providers to ensure patients receive recommended follow-up preventive care.
Cancer Screening; Cancer Survivorship; Primary Care; Preventive Care
The Institute of Medicine (IOM) proposed that cancer survivors and their primary care providers (PCPs) should receive survivorship care plans to inform ongoing care. We aimed to determine PCPs’ preferences for the content of survivorship care plans for colorectal cancer (CRC) survivors.
PCPs in three practice-based research networks completed a survey regarding 45 topics of CRC information based on the IOM‘s survivorship care plan framework.
156 PCPscompleted the survey. For 35 topics (78%), at least half of respondents felt the topic was very important. Most PCPs reported receiving too little information about problems with chemotherapy (68%) or radiation (60%), and whether the oncologist intended to monitor for other cancers (71%). PCPs widely agreed that they do not have enough information about increased risk of second CRCs, other cancers, and other diseases (78%); long-term effects of chemotherapy (73%) and radiation (67%); and genetic counseling (83%).
PCPs endorse the IOM's survivorship care plan framework as relevant and often report needing more information. Survivorship care plans may provide important information to PCPs by communicating patients’ cancer histories and making recommendations regarding which aspects of care should be provided by the oncologist or the PCP.
Colorectal neoplasms; Colorectal cancer; Colon cancer; Rectal cancer; Survivors; Practice-based research networks; Primary Health Care
Women with intellectual disabilities (ID) need thoughtful, well-coordinated care from primary care physicians. They are particularly susceptible to experiencing disparities in care because of varied participation in shared decision making. This review of the current literature comments on the quantity and quality of existing studies regarding several key women's health issues: menstrual disorders, cervical and breast cancer screening, contraception, and osteoporosis. A review of the current thinking regarding ethical and legal issues in medical decision making for these women is also provided. We found that there are several high-quality studies recommending early and frequent screening for osteoporosis, which is more common in women with ID. Smaller and fewer studies comment specifically on techniques for accomplishing the gynecological examination in women with ID, although the cervical cancer screening recommendation should be individualized for these patients. Consensus data on the management of menstrual problems and contraception in women with ID is provided. There are some data on breast cancer incidence but few articles on methods to improve screening rates in women with ID.
The aim of the Rural Older Adult Memory pilot study (ROAM) was to evaluate the feasibility of screening and diagnosing dementia in patients aged 75 years or older in six rural primary care practices in a practice—based research network.
Clinicians and medical assistants were trained in dementia screening using the ROAM protocol, via distance learning methods. Medical assistants screened patients aged 75 and older. For patients who screened positive, the clinician was alerted to the need for a dementia work-up. Outcomes included change in the proportion of patients screened and diagnosed with dementia or mild cognitive impairment and clinician confidence in diagnosing and managing dementia. Patient, medical assistant, and clinician response to the intervention were also evaluated.
Results included a substantial increase in screening for dementia, a modest increase in the proportion of cases diagnosed with dementia or mild cognitive impairment, and improved clinician confidence in diagnosing dementia. Although clinicians and medical assistants found the ROAM protocol easy to implement, there was substantial variability in adherence to the protocol in the six practices.
This study demonstrated the complex issues that must be addressed in implementing a dementia screening process in rural primary care. Further study is needed to develop effective strategies for overcoming the factors that impeded the full uptake of the protocol, including the logistical challenges in implementing practice change and clinician attitudes towards dementia screening and diagnosis.
Alzheimer's disease; dementia screening; primary care; clinical practice change; rural healthcare
Early awareness, recognition, and treatment of angina can help prevent or delay an acute myocardial infarction and potentially delay death. A patient’s educational level may affect a physician’s diagnosis of angina and/or a patient’s symptom recognition.
To determine whether low education is a risk factor for undiagnosed angina.
Cross-sectional observational study (National Health and Nutrition Examination Survey 2001–2008).
Nationally representative sample of adults ≥40 years with angina based on: physician diagnosis; and/or presence of angina symptoms based on the Rose Questionnaire.
Educational attainment (high school and less vs. >high school) was the independent variable of interest. Undiagnosed angina (angina symptoms in the absence of angina diagnosis) was the dependent variable.
We used logistic regression to control for age, sex, race/ethnicity, income, and health care visit in past year.
Low education was associated with undiagnosed angina (OR 1.43; 95% CI 1.01–2.03). Other undiagnosed angina predictors included being female, Black, and no health care visit in the past year.
Low education is associated with undiagnosed angina. These results underscore the need for providers to ask about angina symptoms and confirm patients’ understanding of their angina diagnosis among those with low education.
Angina; Rose Questionnaire; Educational Attainment; Awareness
Systems for efficient case finding of women with major depression during pregnancy and postpartum are needed. Here we assess the diagnostic accuracy of a modified 2-item patient health questionnaire (PHQ-2) as a pre-screen in assessing depression.
Cross-sectional assessments at 15 weeks’ gestation (n = 414), 30 weeks’ gestation (n = 334), and 6 to 16 weeks postpartum (n = 193) among women from a diverse set of races/ethnicities, participating in the IMPLICIT maternal care quality improvement network. The Edinburgh Postnatal Depression Scale score (≥13) was used as the criterion measure for the PHQ-2.
A positive 2-item screen had sensitivity of 93%, 82%, and 80% and specificity of 75%, 80%, and 86% for Edinburgh Postnatal Depression Scale score of ≥13 for assessment at 15 and 30 weeks gestational age and postpartum, respectively. The positive/negative predictive values for the PHQ-2 were 44/98, 24/91, and 30/98 for each time point, respectively. Areas under the receiver operating characteristic curve analysis suggested that 2-item assessments at each time point had approximately equal diagnostic validity.
Two questions were efficient to rule out depression and reduced the need for further screening of approximately 60% to 80% of women, depending on the point in pregnancy or postpartum. A diagnostic interview follow-up of women screening positive is still required.
Physician recommendation is one of the strongest, most consistent predictors of colorectal cancer (CRC) screening. Little is known regarding characteristics associated with patient adherence to physician recommendations in community and academic based primary care settings.
Data were analyzed from 975 patients, aged 50 and over, recruited from 25 primary care practices in New Jersey. Chi-square and generalized estimate equation (GEE) analyses determined independent correlates of receipt of and adherence to physician recommendation for CRC.
Patients reported high screening rates for CRC (59%). More than three-quarters of patients reported either screening or having received a screening recommendation (82%). Men (P=.0425), non-smokers (P=.0029), and patients who were highly educated (P=.0311) were more likely to receive a CRC screening recommendation. Patients more likely to adhere to CRC screening recommendations were older adults (P<.0001), non-smokers (P=.0005), those who were more highly educated (P=.0365), Hispanics (P=.0325), and those who were married (P<.0001).
Community and academic primary care clinicians appropriately recommended screening to high risk patients with familial risk factors. However, they less frequently recommended screening to others (i.e., women and smokers) also likely to benefit. To further increase CRC screening, clinicians must systematically recommend screening to all patients who may benefit.
We recently completed a strategic planning process to better understand the development of our five-year-old PBRN and to identify gaps between our original vision and current progress. While many of our experiences are not new to the PBRN community, our reflections may be valuable for those developing or re-shaping PBRNs in a changing health care environment.
We learned about the importance of: (1) Shared vision and commitment to a unique patient population; (2) Strong leadership, mentorship, and collaboration; (3) Creative approaches to engaging busy clinicians and bridging the worlds of academia and community practice; (4) Harnessing data from electronic health records and navigating processes related to data protection, sharing, and ownership.
We must emphasize research that is timely, relevant, and integrated into practice. One model supporting this goal involves a broader partnership than was initially envisioned for our PBRN, one which includes clinicians, researchers, information architects and quality improvement experts partnering to develop an Innovation Center. This Center could facilitate development of relevant research questions while also addressing ‘quick-turnaround’ needs.
Gaps remain between our PBRN’s initial vision and current reality. Closing these gaps may require future creativity in partnership building and nontraditional funding sources.
practice-based research; community health; primary care; electronic health records; health care safety net
We aimed (1) to demonstrate the application of national pediatric quality measures derived from claims-based data, for use with Electronic Medical Record (EMR) data, and (2) to determine the extent to which rates differ if specifications were modified to allow for flexibility in measuring receipt of care.
We reviewed EMR data for all patients up to 15 years with≥1 office visit to a safety net family medicine clinic in 2010 (n=1,544). We assessed rates of appropriate well-child visits (WCVs), immunizations, and body mass index (BMI) documentation, defined strictly by national guidelines versus by guidelines with clinically relevant modifications.
Among children <3 years, 52.4% attended ≥6 WCVs by 15 months; 60.8% had ≥6 visits by 2 years. Less than 10% completed 10 vaccination series before their 2nd birthday; with modifications, 36% were up-to-date. Among children aged 3-15 years, 63% had a BMI percentile recorded; 91% had BMI recorded within 36 months of the measurement year.
Applying relevant modifications to national quality measure definitions captured a substantial number of additional services. Strict adherence to measure definitions might miss the true quality of care provided, especially in populations who may have sporadic patterns of care utilization.
quality of health care; child health; Electronic Medical Record; low-income population
Change champions are important for moving new innovations through the phases of initiation, development, and implementation. While research attributes positive healthcare changes to the help of champions, little work provides details on the champion role.
Using a combination of immersion/crystallization and matrix techniques, we analyzed qualitative data from a sample of 8 practices which included field notes of team meetings, interviews, and transcripts of facilitator meetings.
Our analysis yielded insights into the value of having two discrete types of change champions: 1) those associated with a specific project (project champions) and 2) those leading change for entire organizations (organizational change champions). Relative to other practices under study, those that had both types of champions who complemented each other were best able to implement and sustain diabetes improvements. We provide insights into the emergence and development of these champion types, as well as key qualities necessary for effective championing.
Practice transformation requires a sustained improvement effort that is guided by a larger vision and commitment and assures that individual changes fit together into a meaningful whole. Change champions – both project and organizational change champions – are critical players in supporting both innovation-specific and transformative change efforts.
Surveys reveal limited screening and counseling for alcohol misuse by primary care physicians despite evidence-based recommendations. We developed and evaluated an alcohol screening and misuse counseling tool designed to assist clinicians at the point-of-care (POC).
Mixed methods, prospective cohort study conducted in a practice-based research network with licensed clinicians. A software tool was designed to guide clinicians through evidence-based alcohol misuse assessment and interventions.
Participants (N=12) used the tool an average of 3 sessions and 71% were satisfied with the tool. Participants increased their ability to differentiate between patients who are “at risk” drinkers vs. those with alcohol use disorders including dependence/abuse (21%; t=2.4, p=.04). Thematic analysis of interviews suggest that barriers to overall use included perceptions of alcohol use; clinical need to intervene; time; and issues with use of technology generally at the POC. However, the tool added confidence and a valuable framework for interventions and was valued as an educational tool. Users felt that increased training and practice could increase comfort and impact future POC use. Increased POC usability may also be achieved through tool simplification and additional flexibility in POC use options.
A computer-assisted counseling tool for alcohol misuse and abuse can be implemented in primary care settings and shows promise for improving physician screening and interventions for alcohol misuse. To enhance utility in daily clinical practice we recommend design enhancements and strategies to enhance usage as described in this research.
The recent emphasis on improving health literacy highlights the importance of building strong relationships between patients and healthcare providers. Patients perceiving good communication in healthcare settings report better health status. Having a usual source of care (USC) may play a key role in achieving optimal communication between patients and physicians.
To determine if having an identified place for usual care is more often associated with positive patient perceptions about their communication and relationships with healthcare providers.
Cross-sectional descriptive and multivariable analysis of the 2002 Medical Expenditure Panel Survey (MEPS), a nationally representative survey.
Civilian non-institutionalized US population aged ≥18 years who had visited a healthcare provider in the 12 months prior to the survey (N=approximately 16,700).
Respondents perceptions of their physicians’ communication skills, measured in six related survey questions. Responses along a four-point Likert scale were dichotomized into “always” and “not always.”
Approximately 78% of U.S. adults reported having a USC in 2002. Among those who visited a healthcare provider in the 12 months prior to the 2002 MEPS survey, positive patient perceptions about physician communication were significantly associated with having an identified USC. When compared with adults reporting no USC (reference group, OR=1.0), adults with a USC were more likely to report that their providers always listened to them (OR=1.31, 95% CI 1.16-1.48), always explained things so they can understand (OR=1.26, 95% CI 1.13-1.41), always showed respect (OR=1.24, 95% CI 1.10-1.40), and always spent enough time with them (OR=1.20, 95% CI 1.07-1.35). Among those with an identified USC, several demographic factors were associated with patient perceptions of autonomy in making healthcare decisions, including: non-Hispanic ethnicity, private health insurance coverage, having a rural residence, living in a Western census region, and having a higher income.
Patients who have a usual place to go for healthcare needs are more likely to report positive communication and interactions with their healthcare providers. This study suggests that one way to improve communication in healthcare settings is to develop policies and practices to ensure that all patients have consistent access to a usual source of care.
In 2001, community health center (CHC) leaders in Oregon established an organization to facilitate the integration of health information technology, including a shared electronic health record (EHR), into safety net clinics. The Oregon Community Health Information Network (shortened to OCHIN as other states joined) became a CHC information technology hub, supporting a network-wide EHR with one master patient index, now linked across >40 safety net organizations serving >900,000 patients with nearly 8,000,000 distinct CHC visits. Recognizing the potential of OCHIN’s multi-clinic network and comprehensive EHR database for conducting safety net-based research, OCHIN leaders and local researchers formed the Safety Net West practice-based research network (PBRN). The Safety Net West “community-based laboratory,” based at OCHIN, is positioned to become an important resource for many studies including: evaluation of the real-time impact of health care reform on uninsured populations; development of new models of primary care delivery; dissemination and translation of interventions from other EHR-based systems (e.g., Kaiser Permanente) into the community health setting; and analyses of factors influencing disparities in health and health care access. We describe the founding of Safety Net West, its infrastructure development, current projects, and the future goals of this community-based PBRN with a common EHR.
practice-based research; community health; primary care; electronic health records; health care safety net
To examine the prevalence of difficult psychiatrist-patient interactions of 20 psychiatrists in the South Texas Psychiatric PBRN, determine what characteristics were associated with “difficult” patients, and compare findings with previous studies in primary care.
During a 2-month observational study, psychiatrists collected patient information on setting, demographics, diagnoses, medications and rated the patients using a Difficult Doctor Patient Relationship Questionnaire (DDPRQ-10) which had previously been used and validated in the primary care setting.
A total of 905 valid data cards were collected. Difficult patients were identified in 15% of the sample. Diagnoses of schizophrenia, alcohol/substance abuse, and personality disorder were associated with difficulty. Psychiatrists least burdened by difficult patients were older, in solo practice, and worked 51-55 hours per week.
This cross-sectional study demonstrates that psychiatrists encounter difficult patients at a similar rate (15%) as do primary care physicians. Mentoring programs and structured treatment interventions for the most difficult patient groups may assist all physicians who treat psychiatric patients whether in specialty, family medicine, or other primary care settings.
Hot flashes (HFs) are a particularly common and distressing symptom in breast cancer survivors (BCS). Given its low rate of side effects, acupuncture shows promise as a therapeutic approach for HFs but little is known about BCS’s decision-making about use of acupuncture. This study seeks to identify attitudes and beliefs about using acupuncture for HFs by BCS.
Using the Theory of Planned Behavior (TPB) as a conceptual framework, we conducted semi-structured interviews among women with stage I–III breast cancer who had finished primary treatment and were currently experiencing HFs. Interviews were taped, transcribed, and coded. We used a modified grounded theory approach to analyze the data.
Twenty-five BCS (13 Caucasian/12 African American) participated in the study. Respondents stated that their intended use of acupuncture for HFs would be dependent on: 1) Expected therapeutic effects (e.g. pain relief, energy); 2) Practical concerns (e.g. fear of needles, practitioner experience, time commitment); and 3) Source of decision support/validation (e.g. family members, physicians, self). Although constructs in the TPB accounted for many decision factors, respondents identified two major themes outside of the TPB: 1) Viewing acupuncture as a natural alternative to medications, and 2) Assessing the degree of HFs as bothersome enough in the context of other medical co-morbidities to trigger the need for therapy.
BCS expressed varied expected therapeutic benefits, practical concerns, and decision support, emphasizing the “natural appeal” and symptom appraisal as key determinants in using acupuncture for HFs. Incorporating these factors in counseling BCS may promote patient-centered communication leading to improved hot flash management and quality of life.
There is little evidence to document patient satisfaction with follow up care provided by family physicians/general practitioners (FP/GP) to breast cancer patients. We aimed to identify determinants of satisfaction with such care in low-income medically underserved women with breast cancer.
Cross sectional study of 145 women who reported receiving follow up care from a FP/GP. Women were enrolled in California’s Breast and Cervical Cancer Treatment Program and were interviewed by phone 3 years after breast cancer diagnosis. Cleary and McNeil’s model, which states that patient satisfaction is a function of patient characteristics, structure of care, and processes of care, was used to understand the determinants of satisfaction. Stepwise logistic regression was used to identify significant predictors.
73.4% reported that they were extremely satisfied with their treatment by the family physician/general practitioner. Women who were able to ask their family physicians questions about their breast cancer had six times greater odds of being extremely satisfied compared to women who were not able to ask any questions. Women who scored the family physician higher on the ability to explain things in a way she could understand had a higher odds of being extremely satisfied compared to women who scored their family physicians lower.
FP/GPs providing follow up care for breast cancer patients should encourage patients to ask questions, and must communicate in a way that patients understand. These recommendations are congruent with the characteristics of patient centered communication for cancer patients enunciated in a recent NCI monograph.
family physician; breast cancer; satisfaction
Intimate partner violence (IPV) victims frequently seek medical treatment though rarely for IPV. Recommendations for health care providers (HCPs) include: IPV screening, counseling, and safety referral.
Report women’s experiences discussing IPV with HCPs.
Structured interviews with women reporting IPV HCP discussions; descriptive analyses; bivariate and multivariate analyses and association with patient demographics and substance abuse.
Women from family court, community-based, inner-city primary care practice, and tertiary care-based outpatient psychiatric practice.
A total 142 women participated: family court (N=44; 31%), primary care practice (N=62; 43.7%), and psychiatric practice (N=36; 25.4%) Fifty-one percent (n=72) reported HCPs knew of their IPV. Of those, 85% (n=61) told a primary care provider. Regarding IPV attitudes, 85% (n=61) found their HCP open, and 74% (n=53) knowledgeable. Regarding approaches, 71% (n= 51) believed their HCP advocated leaving the relationship. While 31% (n=22) received safety information, only 8% (n=6) received safety information and perceived their HCP as not advocating leaving the abusive relationship.
Half of participants disclosed IPV to their HCP’s but if they did, most perceived their provider advocated them leaving the relationship. Only 31% reported HCPs provided safety planning despite increased risks associated with leaving. We suggest healthcare providers improve safety planning with patients disclosing IPV.
domestic violence; patient-physician communication; women’s health
The patient-centered medical home (PCMH) concept has recently garnered national attention as a means of improving the quality of primary care. Preventive services are one area where the PCMH is hoped to achieve gains, though there has been limited exploration of PCMH characteristics that can assist with practice redesign.
To examine whether first-contact access characteristics of a medical home (e.g., availability of appointments or advice by telephone) confer additional benefit in the receipt of preventive services for individuals already in a longitudinal relationship with a usual primary care physician at a site of care.
Secondary analysis examining data from 5,507 insured adults with a usual physician who participated in the 2003–2006 round of the Wisconsin Longitudinal Survey. Using logistic regression, we calculated the odds of receiving each preventive service, comparing individuals who had first-contact access to those without first-contact access.
Eighteen percent of the sample received care with first-contact access. In multivariable analyses, after adjustment, individuals who had first-contact access had higher odds of having received a prostate exam (OR 1.62; 95% CI 1.20–2.18), a flu shot (OR 1.36; 95% CI 1.01–1.82) and a cholesterol test (OR 1.36; 95% CI 1.01–1.82) in the past year. There was no significant difference in receipt of mammograms (OR 1.23; 95% CI 0.94–1.61).
In the primary care home, first-contact accessibility adds benefit beyond continuity of care with a physician in improving receipt of preventive services. Amid increasing primary care demands and finite resources to translate the PCMH into clinic settings there is need for further studies of the interplay between specific PCMH principles and how they perform in practice.
patient-centered medical home; preventive medicine; access to care; continuity of care; primary care; quality improvement
Motivational Interviewing (MI) is used to help patients change their behaviors. We sought to determine if physician use of specific MI techniques increases patient satisfaction with the physician and perceived autonomy.
We audio-recorded preventive and chronic care encounters between 40 primary care physicians and 320 of their overweight or obese patients. We coded use of MI techniques (eg, empathy, reflective listening). We assessed patient satisfaction and how much the patient felt the physician supported him or her to change. Generalized estimating equation models with logit links were used to examine associations between MI techniques and patient perceived autonomy and satisfaction.
Patients whose physicians were rated as more empathic had higher rates of high satisfaction than patients whose physicians were less empathic (29% vs 11%; P = .004). Patients whose physicians made any reflective statements had higher rates of high autonomy support than those whose physicians did not (46% vs 30%; P = .006).
When physicians used reflective statements, patients were more likely to perceive high autonomy support. When physicians were empathic, patients were more likely to report high satisfaction with the physician. These results suggest that physician training in MI techniques could potentially improve patient perceptions and outcomes.
Counseling; Empathy; Patient Satisfaction; Reflective Listening
Quality improvement collaboratives (QICs) are used extensively to promote quality improvement in healthcare. Evidence of their effectiveness is limited, prompting calls to open up the ‘black box’ to better understand how and why such collaboratives work.
We selected a cohort of five primary care practices that participated in a six-month intervention study aimed at improving colorectal cancer screening rates. Using an immersion/crystallization technique, we analyzed qualitative data which included audio-recordings and fieldnotes of QICs and practice-based team meetings.
Three themes emerged from our analysis. 1) Practice staff became empowered through and drew on the QICs to advance change efforts in the face of leader/physician resistance. 2) A mix of content and media in a QIC program was important for reaching all participants. 3) Resources offered at the QIC did little to spur practice change efforts.
QICs offer a potentially powerful way of disseminating healthcare innovations through enhanced strategies for learning and change. Creating collaborative environments where diverse participants learn, listen, reflect, and share together can enable them to take key messages and change strategies back to their own organizations that benefit them the most.