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1.  Patient-Physician Colorectal Cancer Screening Discussion Content and Patients’ Use of Colorectal Cancer Screening 
Patient education and counseling  2013;94(1):10.1016/j.pec.2013.09.008.
Objective
The US Preventive Services Task Force recommends using the 5As (i.e., Assess, Advise, Agree, Assist and Arrange) when discussing preventive services. We evaluate the association of the 5As discussion during primary care office visits with patients’ subsequent colorectal cancer (CRC) screening use.
Methods
Audio-recordings of N=443 periodic health exams among insured patients aged 50-80 years and due for CRC screening were joined with pre-visit patient surveys and screening use data from an electronic medical record. Association of the 5As with CRC screening was assessed using generalized estimating equations.
Results
93% of patients received a recommendation for screening (Advise) and 53% were screened in the following year. The likelihood of screening increased as the number of 5A steps increased: compared to patients whose visit contained no 5A step, those whose visit contained 1-2 steps (OR=2.96 [95% CI 1.16, 7.53]) and 3 or more steps (4.98 [95% CI 1.84, 13.44]) were significantly more likely to use screening.
Conclusions
Physician CRC screening recommendations that include recommended 5A steps are associated with increased patient adherence.
Practice Implications
A CRC screening recommendation (Advise) that also describes patient eligibility (Assess) and provides help to obtain screening (Assist) may lead to improved adherence to CRC screening.
doi:10.1016/j.pec.2013.09.008
PMCID: PMC3865022  PMID: 24094919
2.  A Case Control Study of Bacterial Species and Colony Count in Milk of Breastfeeding Women with Chronic Pain 
Breastfeeding Medicine  2014;9(1):29-34.
Abstract
Background: An infectious etiology for chronic breast pain in breastfeeding women continues to be debated. Although recent data suggest that Staphylococcus aureus and coagulase-negative Staphylococcus (CNS) may cause chronic breast pain, no studies have used quantitative cultures to address this question. In this study we compared bacterial species and colony counts between breastfeeding women with (cases) and without (controls) chronic pain.
Subjects and Methods: We enrolled 114 breastfeeding women in a prospective cohort study. Cases (n=61), breastfeeding women with breast pain for >1 week and no signs of acute infection, were matched with controls (n=53) by weeks postpartum and parity.
Results: More cases had a history of mastitis (14% vs. 2%, p=0.036), cracked nipples (64% vs. 17%, p=0.001), and other breastfeeding difficulties. Enterobacter species growth was less likely in cases (0% vs. 7.5%, p=0.029). Cases had a significantly higher growth of S. aureus (19.7% vs. 1.9%, p=0.003). CNS frequency was similar between groups (75% vs. 79%, p=0.626), but median colony count growth was significantly lower in cases (900 colony-forming units/mL vs. 5,000 colony-forming units/ml, p=0.003). Growth of CNS and S. aureus was negatively correlated (r=–0.265, p=0.004).
Conclusions: Higher S. aureus growth in cases supports a pathogenic role for S. aureus and reinforces the need for future antibiotic treatment studies in breastfeeding women with chronic pain. In contrast, similar CNS frequency between groups, lower CNS colony counts in cases, and a negative correlation between S. aureus and CNS growth suggest that neither CNS, nor its overgrowth, causes chronic breast pain.
doi:10.1089/bfm.2013.0012
PMCID: PMC3903327  PMID: 23789831
3.  Initiation of health behavior discussions during primary care outpatient visits 
Patient education and counseling  2008;75(2):214-219.
Objective
Despite the importance of health promotion, rates of health behavior advice remain low and little is known about how advice is integrated into routine primary care. This study examines how health behavior topics of diet, physical activity and smoking are initiated during outpatient visits.
Methods
Audio recording of 187 adults visit to five purposefully selected physicians. An iterative analysis involved listening to and discussing cases to identify emergent patterns of initiation of health behavior talk and advice that followed.
Results
Physicians initiated 65% of discussions and used two overarching strategies (1) Structured: a routine to ask about health behavior and (2) Opportunistic: use of a trigger to make a transition to talk about health behavior. Opportunistic strategies identified a greater proportion of patients at risk (50% vs. 34%) and led to a greater rate of advice (100% vs. 75%). Patients initiated one-third of health behavior discussions and were more likely to receive advice if they explicitly indicated readiness to change.
Conclusions
Opportunistic strategies show promise for a higher yield of identifying patients at risk and leading to advice.
Practice Implications
Encouraging patients to be explicit about their readiness to change is likely to increase physician advice and assistance.
doi:10.1016/j.pec.2008.09.008
PMCID: PMC4166517  PMID: 19013742
Clinician–patient communication; Health behavior change; Primary care; Practice-based research
4.  Comparing Primary Care Physicians' Smoking Cessation Counseling Techniques to Motivational Interviewing 
Journal of addiction medicine  2013;7(2):139-142.
Objectives
This study examined the degree of similarity between Motivational Interviewing (MI) methods and smoking cessation techniques that are routinely used by primary care physicians. Its purpose was to inform the development of more effective MI-based health behavior change training programs for primary care physicians.
Methods
Visits to primary care physicians were audio-recorded in northeast Ohio from 2005-2008. Doctor-patient talk about smoking cessation (n=73) was analyzed for adherence to MI using the Motivational Interviewing Skills Code (MISC) version 2.1 behavioral coding system. Participating physicians were not provided with MI training as part of the study and were blinded as to the study's purpose.
Results
Physicians displayed MI adherent behaviors in 56% of discussions and MI non-adherent behaviors in 57%. The most common MI adherent statements involved affirming the patient; least common were requests for the patient's permission before raising concerns. The most frequent MI non-adherent behaviors were directing, confronting, and warning the patient. Physicians made simple reflections and complex reflections in 36% and 25% of visits, respectively.
Conclusions
Physicians used both MI adherent and MI non adherent behaviors in approximately equal proportions, suggesting a base of MI adherent smoking cessation counseling skills upon which additional MI skills can be built. Efforts to improve smoking cessation effectiveness may involve providing training in brief MI models and additional MI skills, while reinforcing physicians' current use of MI adherent methods.
doi:10.1097/ADM.0b013e3182879cc5
PMCID: PMC3638868  PMID: 23519048
5.  Factors Associated with Patient Reports of Positive Physician Relational Communication 
Patient education and counseling  2012;89(1):96-101.
Objective
To evaluate the patient, physician, and visit-related factors associated with patient ratings of positive physician relational communication.
Methods
Pre- and post-visit surveys were conducted with 485 patients attending a routine periodic health exam with one of 64 participating physicians. The audio-recorded visits were coded for elements of patient-physician communication including assertive responses, partnership building, question asking, supportive talk, and expressions of concern.
Results
Patient reports of positive physician relational communication were associated with patient perceptions of how well the physician understood the patient’s health care preferences and values, a patient-physician interaction outside of the exam room, and physician-prompted patient expressions of concern.
Conclusion
In addition to a patient’s perception of their relationship with their physician going into the visit, relatively simple acts like extending the interaction beyond the exam room and ensuring that patients feel invited to express concerns they may have during the visit may influence patient perceptions of physician relational communication.
Practice Implications
This study offers preliminary support for the idea that relational communication and its associated benefits may be fostered through simple physician-driven acts such as interacting with patients outside of the exam room and encouraging patients to express concerns within the visit.
doi:10.1016/j.pec.2012.04.003
PMCID: PMC3431455  PMID: 22554386
6.  Integrating Routine Lactation Consultant Support into a Pediatric Practice 
Breastfeeding Medicine  2012;7(1):38-42.
Abstract
Background
Although research shows that healthcare professionals' support improves breastfeeding duration, many physicians do not believe they have adequate time to address breastfeeding concerns during office visits. This study evaluated the impact of a pediatric practice's postnatal lactation consultant intervention. To improve breastfeeding support, the study practice changed policy and began using a lactation consultant overseen by a physician, to conduct the initial postpartum office visit for all breastfeeding infants.
Methods
A retrospective chart review was performed on consecutive newborns before (n = 166) and after (n = 184) implementation of the program. Feeding method was assessed at each well child visit during the infant's first 9 months. χ2 and logistic growth curve analyses were used to test the association between implementation status and non-formula feeding (NFF).
Results
Mothers and infants in 2007 and 2009 were similar with regard to type of insurance, parity, gestational age, multiple births, and cesarean sections. Overall, NFF improved after program implementation (odds ratio = 1.12, 95% confidence interval 1.02–1.23). In 2009, NFF rates at 2 months, 4 months, 6 months, and 9 months were greater than 2007 rates by 10%, 15%, 11%, and 9%, respectively. Logistic growth curve analysis indicated the difference across these time points was significant between 2007 and 2009.
Conclusion
A routine post-discharge outpatient lactation visit coordinated within a primary care practice improved breastfeeding initiation and intensity. This effect was sustained for 9 months.
doi:10.1089/bfm.2011.0003
PMCID: PMC3579324  PMID: 21657890
7.  PATIENT RATED IMPORTANCE AND RECEIPT OF INFORMATION FOR COLORECTAL CANCER SCREENING 
Background
Physician recommendation is one of the most important determinants of obtaining colorectal cancer (CRC) screening; however, little is known about the degree to which CRC screening discussions include information that patients report as important to guide screening decisions. This study examines and compares both patient rated importance and physician communication of key information elements about CRC screening during annual physical exams.
Methods
Design: Cross-sectional cohort. Setting: 26 ambulatory clinics of an integrated delivery system in the Midwest. Participants: 64 primary care physicians and 415 patients aged 50–80 due for CRC screening. Patients completed a pre-visit survey to assess importance of specific information when making a preventive screening decision. Visits were audio recorded to assess the content of screening discussions.
Results
Most patients rated test accuracy (85%), testing alternatives (83%), the pros and cons of testing (86%) and the testing process (78%) very important when making preventive screening decisions. Ninety-one percent of visits included a CRC screening discussion, however, CRC screening talk rarely included information that patients rated as important. Physicians infrequently asked if patients had questions pertaining to CRC screening (5%), however, 49% of patients asked a CRC screening question with the vast majority pertaining to screening logistics.
Conclusions
Audio recordings confirm that discussions of CRC screening are often lacking information that patients indicate is very important when making preventive health decisions and patient questions during the visit are not eliciting information to fill the gap.
Impact
These findings provide actionable information to improve CRC screening discussions.
doi:10.1158/1055-9965.EPI-11-0281
PMCID: PMC3189279  PMID: 21813727
colorectal cancer screening; colonoscopy; communication; primary care
8.  A teachable moment communication process for smoking cessation talk: description of a group randomized clinician-focused intervention 
Background
Effective clinician-patient communication about health behavior change is one of the most important and most overlooked strategies to promote health and prevent disease. Existing guidelines for specific health behavior counseling have been created and promulgated, but not successfully adopted in primary care practice. Building on work focused on creating effective clinician strategies for prompting health behavior change in the primary care setting, we developed an intervention intended to enhance clinician communication skills to create and act on teachable moments for smoking cessation. In this manuscript, we describe the development and implementation of the Teachable Moment Communication Process (TMCP) intervention and the baseline characteristics of a group randomized trial designed to evaluate its effectiveness.
Methods/Design
This group randomized trial includes thirty-one community-based primary care clinicians practicing in Northeast Ohio and 840 of their adult patients. Clinicians were randomly assigned to receive either the Teachable Moments Communication Process (TMCP) intervention for smoking cessation, or the delayed intervention. The TMCP intervention consisted of two, 3-hour educational training sessions including didactic presentation, skill demonstration through video examples, skills practices with standardized patients, and feedback from peers and the trainers. For each clinician enrolled, 12 patients were recruited for two time points. Pre- and post-intervention data from the clinicians, patients and audio-recorded clinician‒patient interactions were collected. At baseline, the two groups of clinicians and their patients were similar with regard to all demographic and practice characteristics examined. Both physician and patient recruitment goals were met, and retention was 96% and 94% respectively.
Discussion
Findings support the feasibility of training clinicians to use the Teachable Moments Communication Process. The next steps are to assess how well clinicians employ these skills within their practices and to assess the effect on patient outcomes.
Trial Registration
ClinicalTrials.gov Identifier: NCT01575886
doi:10.1186/1472-6963-12-109
PMCID: PMC3529679  PMID: 22554310
Smoking cessation; Health behavior change; Doctor-patient communication; Primary care; Study protocol; Teachable moments
9.  Interpreting the psychometric properties of the components of primary care instrument in an elderly population 
Objective:
To determine the psychometric properties of the Components of Primary Care Instrument (CPCI) in a patient population aged 65 or older.
Materials and Methods:
795 participants in the OKLAHOMA Studies, a longitudinal population-based study of predominantly Caucasian, elderly patients, completed the CPCI. Reliability analysis and confirmatory factor analysis were done to provide psychometric properties for this elderly sample. Models were constructed and tested to determine the best fit for the data including the addition of a method factor for negatively worded items.
Results:
Cronbach's alphas were comparable to values reported in prior studies. The confirmatory factor analysis with factor inter-correlations and a method factor each improved the fit of the factor model to the data. The combined model's fit approached the level conventionally recognized as adequate.
Conclusion:
CPCI appears to be a reliable tool for describing patient perceptions of the quality of primary care for patients over age 65.
doi:10.4103/2230-8229.98299
PMCID: PMC3410175  PMID: 22870416
Components of primary care instrument; elderly; older patients; primary care; reliability; validity
10.  Inconsistencies in Patient Perceptions and Observer Ratings of Shared Decision Making: The Case of Colorectal Cancer Screening 
Patient education and counseling  2010;80(3):358-363.
Objective
To compare patient-reported and observer-rated shared decision making (SDM) use for colorectal cancer (CRC) screening and evaluate patient, physician and patient-reported relational communication factors associated with patient-reported use of shared CRC screening decisions.
Methods
Study physicians are salaried primary care providers. Patients are insured, aged 50-80 and due for CRC screening. Audio-recordings from 363 primary care visits were observer-coded for elements of SDM. A post-visit patient survey assessed patient-reported decision-making processes and relational communication during visit. Association of patient-reported SDM with observer-rated elements of SDM, as well as patient, physician and relational communication factors were evaluated using generalized estimating equations.
Results
70% of patients preferred SDM for preventive health decisions, 47% of patients reported use of a SDM process, and only one of the screening discussions included all four elements of SDM per observer ratings. Patient report of SDM use was not associated with observer-rated elements of SDM, but was significantly associated with female physician gender and patient-reported relational communication.
Conclusion
Inconsistencies exist between patient reports and observer ratings of SDM for CRC screening.
Practice Implications
Future studies are needed to understand whether SDM that is patient-reported, observer-rated or both are associated with informed and value-concordant CRC screening decisions.
doi:10.1016/j.pec.2010.06.034
PMCID: PMC2971658  PMID: 20667678
11.  New Prescriptions: How Well Do Patients Remember Important Information? 
Family medicine  2011;43(4):254-259.
BACKGROUND AND OBJECTIVES
Patients receiving more information about a new prescription are more adherent to their medication regimens and have better treatment outcomes. Yet it is unclear how much information patients retain when they receive a new prescription. This study aims to describe patient recall of information about new medication prescriptions after an outpatient visit.
METHODS
We used a cross-sectional study of 117 adult outpatient visits to six family physicians. Direct observation of physician-patient encounters by medical students was used to document discussion of information about new prescriptions. Patient recall of specific prescription information was assessed by interviewing patients immediately after the visit.
RESULTS
When prescribing a new medication, physicians most frequently discussed the medication purpose (all visits), how often to take the medication (82%), and how much to take (76%). On average, patients recalled 86% (± 23%) of the information provided, and 64% recalled all information discussed during their visit. Of the 42 patients who failed to recall all of the information, 47% forgot how much to take and 42% forgot potential side effects, but only 24% forgot directions about when to take their medication. Complete recall of information about a new prescription was not associated with the amount of information provided, patient education, race, or duration of relationship with their physician.
CONCLUSIONS
Almost two thirds of patients remember all of the basic information they are given when a new medication is prescribed. Providers should work on improving patient education when prescribing new medications and should not be deterred by worries about poor patient recall.
PMCID: PMC3099139  PMID: 21499998
12.  Intraclass Correlation Estimates for Cancer Screening Outcomes: Estimates and Applications in the Design of Group-Randomized Cancer Screening Studies 
Background
Screening has become one of our best tools for early detection and prevention of cancer. The group-randomized trial is the most rigorous experimental design for evaluating multilevel interventions. However, identifying the proper sample size for a group-randomized trial requires reliable estimates of intraclass correlation (ICC) for screening outcomes, which are not available to researchers. We present crude and adjusted ICC estimates for cancer screening outcomes for various levels of aggregation (physician, clinic, and county) and provide an example of how these ICC estimates may be used in the design of a future trial.
Methods
Investigators working in the area of cancer screening were contacted and asked to provide crude and adjusted ICC estimates using the analysis of variance method estimator.
Results
Of the 29 investigators identified, estimates were obtained from 10 investigators who had relevant data. ICC estimates were calculated from 13 different studies, with more than half of the studies collecting information on colorectal screening. In the majority of cases, ICC estimates could be adjusted for age, education, and other demographic characteristics, leading to a reduction in the ICC. ICC estimates varied considerably by cancer site and level of aggregation of the groups.
Conclusions
Previously, only two articles had published ICCs for cancer screening outcomes. We have complied more than 130 crude and adjusted ICC estimates covering breast, cervical, colon, and prostate screening and have detailed them by level of aggregation, screening measure, and study characteristics. We have also demonstrated their use in planning a future trial and the need for the evaluation of the proposed interval estimator for binary outcomes under conditions typically seen in GRTs.
doi:10.1093/jncimonographs/lgq011
PMCID: PMC2924625  PMID: 20386058
13.  Intraclass Correlation Estimates for Cancer Screening Outcomes: Estimates and Applications in the Design of Group-Randomized Cancer Screening Studies 
Background
Screening has become one of our best tools for early detection and prevention of cancer. The group-randomized trial is the most rigorous experimental design for evaluating multilevel interventions. However, identifying the proper sample size for a group-randomized trial requires reliable estimates of intraclass correlation (ICC) for screening outcomes, which are not available to researchers. We present crude and adjusted ICC estimates for cancer screening outcomes for various levels of aggregation (physician, clinic, and county) and provide an example of how these ICC estimates may be used in the design of a future trial.
Methods
Investigators working in the area of cancer screening were contacted and asked to provide crude and adjusted ICC estimates using the analysis of variance method estimator.
Results
Of the 29 investigators identified, estimates were obtained from 10 investigators who had relevant data. ICC estimates were calculated from 13 different studies, with more than half of the studies collecting information on colorectal screening. In the majority of cases, ICC estimates could be adjusted for age, education, and other demographic characteristics, leading to a reduction in the ICC. ICC estimates varied considerably by cancer site and level of aggregation of the groups.
Conclusions
Previously, only two articles had published ICCs for cancer screening outcomes. We have complied more than 130 crude and adjusted ICC estimates covering breast, cervical, colon, and prostate screening and have detailed them by level of aggregation, screening measure, and study characteristics. We have also demonstrated their use in planning a future trial and the need for the evaluation of the proposed interval estimator for binary outcomes under conditions typically seen in GRTs.
doi:10.1093/jncimonographs/lgq011
PMCID: PMC2924625  PMID: 20386058
14.  Development of an Instrument to Document the 5A’s for Smoking Cessation 
Background
The widely recommended 5A’s strategy for brief smoking cessation includes five tasks: Ask, Advise, Assess, Assist, and Arrange. Assessments of the 5A’s have been limited to medical-record review and self-report. Using observational data, an instrument to assess the rate at which the 5A’s are accomplished was developed.
Methods
The 5A’s Direct Observation Coding scheme (5A-DOC) was developed using published 5A’s guidelines and was refined using observed clinician–patient interactions. The development sample consisted of 46 audio-recorded visits of smokers with their physician (n=5), collected in 2000. The 5A-DOC was next applied to a second sample of 739 visits with 28 physicians between 2005 and 2008. Inter-rater reliability was assessed and frequencies reported. Analyses were completed in 2008.
Results
Three observations shaped the development of the 5A-DOC: (1) patients accomplish 5A’s tasks; (2) some communication actions accomplish multiple 5A’s tasks simultaneously; and (3) sequence is important. Inter-rater agreement for identifying each task was moderate to excellent (kappa=0.58–1.0). When smoking status was established (Ask, n=78), 61% Assessed readiness, and 50% contained Assist. In all, 73% failed to complete the 5A’s adequately.
Conclusions
Accounting for patient activity in smoking-cessation discussions is essential to accurately capture the degree to which the 5A’s have been accomplished. The 5A-DOC can be applied to audio or transcript data to reliably assess which of the 5A’s tasks have been accomplished. Clinician performance of the 5A’s was modest, and findings suggest that clinician training should focus on Assess, the timing of this task, and its alignment with patients’ reported readiness.
doi:10.1016/j.amepre.2009.04.027
PMCID: PMC2735336  PMID: 19666161
15.  Teachable moments for health behavior change: a concept analysis 
Objective
“Teachable moments” have been proposed as events or circumstances which can lead individuals to positive behavior change. However, the essential elements of teachable moments have not been elucidated. Therefore, we undertook a comprehensive review of the literature to uncover common definitions and key elements of this phenomenon.
Methods
Using databases spanning social science and medical disciplines, all records containing the search term “teachable moment*” were collected. Identified literature was then systematically reviewed and patterns were derived.
Results
Across disciplines, ‘teachable moment’ has been poorly developed both conceptually and operationally. Usage of the term falls into three categories: 1) “teachable moment” is synonymous with “opportunity” (81%); 2) a context that leads to a higher than expected behavior change is retrospectively labeled a ‘teachable moment’ (17%); 3) a phenomenon that involves a cueing event that prompts specific cognitive and emotional responses (2%).
Conclusion
The findings suggest that the teachable moment is not necessarily unpredictable or simply a convergence of situational factors that prompt behavior change but suggest the possible creation of a teachable moment through clinician-patient interaction.
Practice Implications
Clinician-patient interaction may be central to the creation of teachable moments for health behavior change.
doi:10.1016/j.pec.2008.11.002
PMCID: PMC2733160  PMID: 19110395
teachable moment; health behavior; motivation; smoking cessation
16.  Defining and Measuring the Patient-Centered Medical Home 
The patient-centered medical home (PCMH) is four things: 1) the fundamental tenets of primary care: first contact access, comprehensiveness, integration/coordination, and relationships involving sustained partnership; 2) new ways of organizing practice; 3) development of practices’ internal capabilities, and 4) related health care system and reimbursement changes. All of these are focused on improving the health of whole people, families, communities and populations, and on increasing the value of healthcare.
The value of the fundamental tenets of primary care is well established. This value includes higher health care quality, better whole-person and population health, lower cost and reduced inequalities compared to healthcare systems not based on primary care.
The needed practice organizational and health care system change aspects of the PCMH are still evolving in highly related ways. The PCMH will continue to evolve as evidence comes in from hundreds of demonstrations and experiments ongoing around the country, and as the local and larger healthcare systems change. Measuring the PCMH involves the following:Giving primacy to the core tenets of primary careAssessing practice and system changes that are hypothesized to provide added valueAssessing development of practices’ core processes and adaptive reserveAssessing integration with more functional healthcare system and community resourcesEvaluating the potential for unintended negative consequences from valuing the more easily measured instrumental features of the PCMH over the fundamental relationship and whole system aspectsRecognizing that since a fundamental benefit of primary care is its adaptability to diverse people, populations and systems, functional PCMHs will look different in different settings.Efforts to transform practice to patient-centered medical homes must recognize, assess and value the fundamental features of primary care that provide personalized, equitable health care and foster individual and population health.
Electronic supplementary material
The online version of this article (doi:10.1007/s11606-010-1291-3) contains supplementary material, which is available to authorized users.
doi:10.1007/s11606-010-1291-3
PMCID: PMC2869425  PMID: 20467909
primary care; patient-centered medical home; measurement; quality improvement
17.  Clinician Reflections on Promotion of Healthy Behaviors in Primary Care Practice 
Objective
Recommendations to use integrated models for health behavior change abound, however, the translation to practice has been poor. We used stimulated reflections of primary care physicians and nurse practitioners to generate insights about current practices and opportunities for changing how health behavior advice is addressed.
Method
Twenty-one community practicing primary care clinicians invited to a nationally sponsored practice-based research network conference on promotion of healthy behaviors were asked to record aspects of health behaviors they addressed during a day of outpatient visits. In response to 8 questions, clinicians reflected insights which were then analyzed by a multidisciplinary team to identify over-arching themes.
Results
Health behavior discussions are initiated and carried out predominantly by the clinician. These discussions occur primarily during health care maintenance visits or visits in which presenting complaints or chronic illnesses can be linked to health behaviors. Clinicians' reflections on viable opportunities for change include different modes of patient education materials such as web-based materials. Suprisingly infrequent were solutions outside of the clinical encounter or strategies that engage other staff or other community partners.
Conclusion
Implementation of the integrated care model as an opportunity to enhance health promotion seems far from the current realities and future vision of even motivated network-based clinicians.
doi:10.1016/j.healthpol.2007.04.003
PMCID: PMC2728451  PMID: 17543414
health promotion; primary care practice; practice patterns; practice-based research
18.  Physician Practice Patterns and Variation in the Delivery of Preventive Services 
Background
Strategies to improve preventive services delivery (PSD) have yielded modest effects. A multidimensional approach that examines distinctive configurations of physician attributes, practice processes, and contextual factors may be informative in understanding delivery of this important form of care.
Objective
We identified naturally occurring configurations of physician practice characteristics (PPCs) and assessed their association with PSD, including variation within configurations.
Design
Cross-sectional study.
Participants
One hundred thirty-eight family physicians in 84 community practices and 4,046 outpatient visits.
Measurements
Physician knowledge, attitudes, use of tools and staff, and practice patterns were assessed by ethnographic and survey methods. PSD was assessed using direct observation of the visit and medical record review. Cluster analysis identified unique configurations of PPCs. A priori hypotheses of the configurations likely to perform the best on PSD were tested using a multilevel random effects model.
Results
Six distinct PPC configurations were identified. Although PSD significantly differed across configurations, mean differences between configurations with the lowest and highest PSD were small (i.e., 3.4, 7.7, and 10.8 points for health behavior counseling, screening, and immunizations, respectively, on a 100-point scale). Hypotheses were not confirmed. Considerable variation of PSD rates within configurations was observed.
Conclusions
Similar rates of PSD can be attained through diverse physician practice configurations. Significant within-configuration variation may reflect dynamic interactions between PPCs as well as between these characteristics and the contexts in which physicians function. Striving for a single ideal configuration may be less valuable for improving PSD than understanding and leveraging existing characteristics within primary care practices.
doi:10.1007/s11606-006-0042-y
PMCID: PMC1824741  PMID: 17356985
practice patterns; preventive service delivery; primary care
19.  The association of how time is spent during outpatient visits and patient satisfaction: are there racial differences? 
Both satisfaction with the physician and how time is spent in the patient-physician outpatient visit have been shown to differ between African-American and Caucasian patients. This study uses structural equation modeling to examine racial differences in the association between time use during the outpatient visit and patient satisfaction. This cross-sectional study employed direct observation of outpatient visits and surveys of 2,502 adult African-American and Caucasian outpatients visiting 138 primary care physicians in 84 family practices in Northeast Ohio. Patient satisfaction was measured using the Medical Outcome Study (MOS) nine-item Visit Rating Scale. Time use was assessed with the Davis Observation Code, which was used to classify every 20 seconds of a visit into 20 behavioral categories. No difference was found between African-American and Caucasian patients in the association between patient satisfaction with a physician and the time the physician spent chatting, planning treatment, providing health education, structuring the interaction, assessing health knowledge or answering patient questions. Patients were generally satisfied with their physicians, and no racial differences between Caucasians and African Americans were observed. Despite racial differences in how physicians spend time in the outpatient visit encounter, these differences are not associated with racial differences in patient satisfaction. Efforts to understand disparities in satisfaction should address areas other than how physicians allocate time in the physician-patient encounter.
PMCID: PMC2575872  PMID: 17913118
20.  Physician Practice Patterns and Variation in the Delivery of Preventive Services 
Background
Strategies to improve preventive services delivery (PSD) have yielded modest effects. A multidimensional approach that examines distinctive configurations of physician attributes, practice processes, and contextual factors may be informative in understanding delivery of this important form of care.
Objective
We identified naturally occurring configurations of physician practice characteristics (PPCs) and assessed their association with PSD, including variation within configurations.
Design
Cross-sectional study.
Participants
One hundred thirty-eight family physicians in 84 community practices and 4,046 outpatient visits.
Measurements
Physician knowledge, attitudes, use of tools and staff, and practice patterns were assessed by ethnographic and survey methods. PSD was assessed using direct observation of the visit and medical record review. Cluster analysis identified unique configurations of PPCs. A priori hypotheses of the configurations likely to perform the best on PSD were tested using a multilevel random effects model.
Results
Six distinct PPC configurations were identified. Although PSD significantly differed across configurations, mean differences between configurations with the lowest and highest PSD were small (i.e., 3.4, 7.7, and 10.8 points for health behavior counseling, screening, and immunizations, respectively, on a 100-point scale). Hypotheses were not confirmed. Considerable variation of PSD rates within configurations was observed.
Conclusions
Similar rates of PSD can be attained through diverse physician practice configurations. Significant within-configuration variation may reflect dynamic interactions between PPCs as well as between these characteristics and the contexts in which physicians function. Striving for a single ideal configuration may be less valuable for improving PSD than understanding and leveraging existing characteristics within primary care practices.
doi:10.1007/s11606-006-0042-y
PMCID: PMC1824741  PMID: 17356985
practice patterns; preventive service delivery; primary care

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