Behaviors and characteristics of African American and European American females that impact weight management.

PURPOSE: This report explores the extent to which sociodemographic and psychosocial factors could explain differences in obesity or dietary and exercise behaviors between middle-aged African American (AA) and European American (EA) women seen in primary care. We focus on "race × predictor" interactions that could explain how AA and EA women differ in ways that affect the prevalence of obesity. DESIGN: This comparative exploratory study uses data from the baseline examination of the Reasonable Eating and Activity to Change Health (REACH) trial, which included 173 AA women and 278 EA women. Inclusion criteria were membership in one of the study family medicine practices, an elevated body mass index (greater than 27 kg/m(2) ), age 40 to 69 years, and no contraindications to increased activity and dietary change. METHODS: Secondary data analyses were employed. FINDINGS: There was evidence of race differences in the level of multiple variables related to weight management but there were only three significant "race × predictor" interactions out of 48 comparisons: (a) race × physical health, with BMI as the dependent variable; (b) race × the percentage of dietary fat, with total dietary kilocalories as the dependent variable; and (c) race × median income, with exercise minutes per week as the dependent variable. CONCLUSIONS: The results support the proposition that the weight management experience of AA and EA primary care women is similar after different exposure levels are taken into account. The results contribute to the body of literature that addresses obesity management for AA and EA women in primary care settings. CLINICAL RELEVANCE: Findings illustrate the need for obesity prevention and management efforts from both multidisciplinary primary care providers and community-wide public health interventions. AA and EA women have different resources, but the same factors generally influence weight management, whether one is AA or EA. This suggests that clinical interventions and public health interventions for AA and EA women can be designed around the same principles while paying attention to relevant cultural issues.

Admission Data Predict High Hospital Readmission Risk.

PURPOSE: The purpose of this study was to identify data available at the time of hospital admission that predict readmission risk. METHODS: We performed a retrospective multiple regression analysis of 958 adult, nonpregnant patients admitted to the Family Medicine Service between June 2012 and October 2013. Data were abstracted from hospital administrative sources and electronic medical records. The outcome was 30-day hospital readmission. Candidate readmission predictors included polypharmacy (≥6 medicines), Charlson comorbidity index, age, sex, insurance status, emergency department use, smoking, nursing report of cognitive issues, patient report of social support or financial issues, and a history of heart failure, pneumonia, or chronic obstructive pulmonary disease. RESULTS: Patients at the Family Medicine Service had a 14% readmission risk. Bivariate analysis showed that high Charlson scores (≥5), polypharmacy, heart failure, pneumonia, or chronic obstructive pulmonary disease each increased readmission risk (P < .05). A logistic model showed an estimated odds ratio for readmission for high Charlson scores of 1.7 (95% confidence interval, 1.1-2.6) and of 2.1 for polypharmacy (95% confidence interval, 1.3-3.7). The model yielded a readmission risk estimate of 6% if neither a high Charlson score nor polypharmacy was present, 9% if only the Charlson score was high, 12% if only polypharmacy was present, and 19% if both were present. The receiver operating characteristics curve for the 2-factor model yielded an estimated area under the curve of 85%. Cross-validation supported this result. CONCLUSIONS: Polypharmacy and higher Charlson score at admission predict readmission risk as well as or better than published risk prediction models. The model could help to conserve limited resources and to target interventions for reducing readmission among the highest-risk patients.

Shoot, ready, aim: pneumonia care quality and costs in a community hospital.

Mandatory community-acquired pneumonia (CAP) protocol usage was proposed in our community-based teaching hospital because of senior medical staff perceptions that excessive variation in CAP care was adversely affecting clinical outcomes and costs. The purpose of our study was to examine CAP process of care variation, outcomes, and costs to ascertain whether the mandatory CAP protocol could be justified. The study consisted of an analysis of administrative and sampled chart data. We looked at pneumonia severity, orders for blood cultures or sputum staining, antibiotic usage, symptom resolution, length of stay, discharge status, readmission risk by follow-up time, and financial data. We found that process of care variation was low, clinical outcomes were generally good, and CAP care was profitable. Our data suggested that the proposed mandatory CAP protocol was not necessary. Our experience supports the management principle that fact finding should usually precede decision making, not the reverse.

Obesity treatment: broadening our perspective.

OBJECTIVE: To selectively review the dietary literature to broaden perspectives on energy restriction as the primary determinant of successful obesity treatment. METHODS: Forty-five articles describing novel dietary behaviors and nutrient intakes that may impact obesity treatment are examined. RESULTS: Two areas of promising research were identified: (a) Dietary behaviors and patterns--eating frequency, meal timing, specific dietary pattern and (b) Nutritional factors--fat, fiber, glycemic load, carbohydrate. CONCLUSIONS: Caloric restriction leads to weight loss. However, promotion of dietary behaviors that focus primarily on cutting calories needs evaluation. There may be many dietary behaviors and patterns that promote weight loss and maintenance, making it essential to consider new nutritional approaches for obesity treatment.

Sleep duration, quality, or stability and obesity in an urban family medicine center.

PURPOSE: Inadequate sleep has negative metabolic consequences that may contribute to obesity. A priori hypotheses posit relationships between sleep characteristics, carbohydrate and lipid metabolism, appetite, fatigue, and obesity in laboratory, clinical, and population settings. There are few reports from primary care; and none that address sleep duration, quality, and stability. This study examines the relationship between three sleep characteristics-duration, quality, or stability-and obesity in our urban hospital affiliated family medicine center in Akron, Ohio. METHODS: A systematic sampling process yielded 225 representative patients who completed the Pittsburgh Sleep Quality Index, the Berlin Apnea Questionnaire, and the Sleep Timing Questionnaire. Demographic, body mass, hypertension, and insurance data were obtained from the electronic medical record. Associations between self-reported sleep characteristics and obesity were examined via contingency tables and regression models. RESULTS: Seventy-eight percent (78%) reported poor quality sleep, 59% had elevated Berlin apnea-risk scores, 12% reported restless legs symptoms, and 9% reported a prior diagnosis of sleep apnea; 62% were obese. We found significant (p < 0.05) associations between sleep quality, duration or bedtime stability, and obesity. The association between sleep quality and obesity was negative and linear (69%, 72%, 56%, 43%), while the association between sleep duration and obesity was U-shaped (74%, 53%, 53%, 62%; linear term p = 0.02 and quadratic term p = 0.03). Less stable bedtimes during the week (OR = 2.3, p = 0.008) or on the weekend (OR = 1.8, p = 0.04) were also associated with obesity. The association between sleep quality and obesity was not explained by patient demographics or snoring (ORadj = 2.2; p = 0.008). CONCLUSION: This study adds to the sparse literature on the relationship between three self-reported sleep characteristics and obesity in urban primary care settings which typically differ from both general population and specialty outpatient settings.

The better weight-better sleep study: a pilot intervention in primary care.

OBJECTIVE: To explore the feasibility of integrating sleep management interventions with dietary and exercise interventions for obesity in a 12-week randomized trial. METHODS: We randomized 49 overweight or obese adult patients either to a better weight (BW) cognitive behavioral intervention, or to a combination of the BW intervention and a better sleep intervention, better weight-better sleep (BWBS). RESULTS: The BWBS group lost weight faster (P=.04), and coping self-efficacy accelerated (P=.01). CONCLUSIONS: These preliminary results merit replication in a larger primary care-based trial with a longer continuous intervention and follow-up period.

A method for obtaining an unbiased sample of family medicine patients for research purposes.

INTRODUCTION: Obtaining a representative patient sample for research purposes can be challenging. Classic probability sampling can be trusted, but these approaches are not always feasible; yet alternatives may introduce bias. We summarize relevant literature, the need for new approaches, and illustrate a practical hybrid approach that could consistently produce representative patient samples. METHODS: Valid approaches shift sampling decisions from fallible interviewers to less fallible reproducible processes. In lieu of the interviewer's inclination to select particular patients, we used the day of the week, the appointment time, and the sequence of the patient's last name in the alphabet to select a sample for a consent process and a survey. ILLUSTRATIVE USE: Characteristics of the study sample (n = 225) were compared with the characteristics of the population (N = 1964) that had an office visit during the recruiting period. The data suggested that the study sample was highly representative of the population in this illustrative case. DISCUSSION: A hybrid sampling approach, in the context of a brief consent process, and a nonthreatening interview produced a representative study sample, but formal evaluation via simulation is needed to validate the hybrid approach. Convenience samples of consecutive patients should be avoided to minimize bias.

An opt-out influenza vaccination policy improves immunization rates in primary care.

PURPOSE/OBJECTIVE: During the 2007-08 influenza season 36% of outpatients seen at our urban family medicine center received an influenza immunization. We explored the expected increase in vaccinations from an opt-out policy using standing orders in a lower-income population. METHODS: A comparison of vaccination rates during the periods 10/1/2007 to 3/31/2008 (P1) versus 10/1/2008 to 3/31/2009 (P2) with adjustments for cohort non-independence. RESULTS: The overall P2 vaccination rate increased to 49% [p<.000001]. P2 rates were significantly higher for those with diabetes, both genders, African American and European American patients from 3 to 64 years old, and in all insurance groups. The vaccination rates for patients with Medicaid insurance (37% and 54%) were higher than the rates for patients with commercial insurance (31% and 43%). CONCLUSIONS: The opt-out policy is associated with a moderate (1.4 fold) increase in the vaccination rate. Primary care resource constraints may limit further improvement.

Using the QIDS-SR16 to identify major depressive disorder in primary care medical patients.

Major depressive disorder (MDD) is a serious and prevalent mental health issue. As the majority of MDD cases are identified and treated by one's primary care physician, it is imperative that care providers utilize accurate and efficient methods for diagnosing MDD in primary care settings. The present study is the first to investigate the accuracy of the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR(16)) as a screen for MDD. A heterogeneous sample of 155 primary care patients completed the QIDS-SR(16) prior to attending a primary care appointment. Participants were then assessed for psychopathology using the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID) by clinicians who were blind to QIDS-SR(16) scores. Scores on the QIDS-SR(16) were compared to clinician-assessed current and lifetime diagnoses derived from the SCID, which represented the gold-standard criterion measure. Receiver operator characteristic analysis was utilized to determine the optimal QIDS-SR(16) cut score to correctly classify participants based on their MDD status as assessed by the SCID. The test revealed a robust area under the curve (.82, p<0.00001) and suggested that a cut score of 13 or 14 provided the best balance of sensitivity (76.5%) and specificity (81.8%) in this primary care sample. Over 80% of participants were correctly classified. Separate analyses by race were conducted to address the possibility that different cut scores may be more accurate for African American and Caucasians. Findings from the present study provide support for the use of the QIDS-SR(16) as a screening measure for identifying primary care patients who will meet diagnostic criteria for MDD based on clinician assessment.

Transtheoretical model-chronic disease care for obesity in primary care: a randomized trial.

OBJECTIVE: To compare health benefits achieved in a transtheoretical model-chronic disease (TM-CD) minimal intervention for obesity vs. augmented usual care (AUC). RESEARCH METHOD AND PROCEDURES: This was a 2-year, randomized clinical trial with overweight or obese men and women from 15 primary care sites. AUC (n = 336) included dietary and exercise advice, prescriptions, and three 24-hour dietary recalls every 6 months. TM-CD care (n = 329) included AUC elements plus "stage of change" (SOC) assessments for five target behaviors every other month, mailed SOC and target behavior-matched workbooks, and monthly telephone calls from a weight-loss advisor. Weight change was the primary outcome. RESULTS: Repeated measures models under the missing at random assumption yielded nonsignificant adjusted differences between the AUC and TM-CD groups for weight change, waist circumference, energy intake or expenditure, blood pressure, and blood lipids. The pattern of change over time suggested that TM-CD participants were trying harder to impact target behaviors during the first 6 to 12 months of the trial but relapsed afterward. Sixty percent of trial participants maintained their baseline weights for 18 to 24 months. DISCUSSION: A combination of mailed patient materials and monthly telephone calls based on the transtheoretical model and some elements of chronic disease care is not powerful enough, relative to AUC, to alter target behaviors among overweight primary care patients in an obesogenic environment. AUC may be sufficient to maintain weights among at-risk primary care patients.

Biopsychosocial characteristics of overweight and obese primary care patients: do psychosocial and behavior factors mediate sociodemographic effects?

BACKGROUND: The increasing prevalence of obesity and obesity-related conditions in primary care settings challenges the health care system. Thus, we used available baseline data from an on-going clinical trial to examine the biopsychosocial characteristics of overweight and obese primary care patients. The primary research objective was to ascertain whether theoretically important psychosocial and behavioral variables mediate the empirical relationships between sociodemographic factors and body mass index (BMI). METHODS: Overweight or obese primary care patients (n=665) enrolled in an on-going trial of a cognitive-behavioral obesity intervention provided baseline sociodemographic, psychosocial, nutritional, physical activity, and anthropometric data that were analyzed via multiple regression. RESULTS: Lower educational attainment was associated with a higher BMI after controlling for decisional balance, social support, self-efficacy, energy intake, and energy expenditure (P<0.05). In contrast, ethnicity was not associated with BMI after controlling for the psychosocial and behavioral variables. Decisional balance and social support variables were associated with BMI and energy intake, but the directions of some of the associations were not consistent with a priori expectations. CONCLUSIONS: Overall, we found some evidence of mediation by the psychosocial and behavioral variables of the relationship between ethnicity and BMI, but not for the relationship between education and BMI. In addition, some of the relationships between the psychosocial variables and BMI were opposite of our expectations.

Assessing dietary and exercise stage of change to optimize weight loss interventions.

OBJECTIVE: According to the Transtheoretical Model (TM), tailoring interventions to patients' readiness to change can enhance patient progress and help patients use therapeutic resources more effectively. However, tailoring an intervention depends on accurate assessment of patients' stage of change (SOC). This study describes a multi-item algorithm of SOC (M-SOC) for weight loss-related behaviors that attempts to overcome some of the conceptual and methodological difficulties encountered in previously SOC assessments. RESEARCH METHODS: Data were collected from participants randomly assigned to the treatment arm of a clinical trial comparing a TM-based, cognitive-behavioral intervention with enhanced usual care for weight loss. RESULTS: The stair-step relationships hypothesized by the TM between assessed SOC and key behavioral measures were found for all algorithms (p < 0.05), indicating that the M-SOC algorithm performs as well as single item algorithms. However, 50% fewer patients were classified in action or maintenance for dietary fat intake and portion control (p < 0.05) by the multiple-item algorithms, providing staging more consistent with the clinical presentation of obese individuals. In addition, logistic regression analyses indicated that the single-item algorithms were not sufficient predictors of these behavioral domains. DISCUSSION: To the extent that treatment is guided by assessed SOC, there is potential for a considerable variability in interventions with different approaches to staging. For weight-loss interventions that target portion control and decreased fat intake, the multi-item SOC algorithms seem to be better guides for matching treatments to SOC.

Longitudinal relationship between elapsed time in the action stages of change and weight loss.

OBJECTIVE: The objective of this study was to examine the longitudinal relationship between the elapsed time in the action and maintenance stages of change for multiple target behaviors and weight loss or gain. RESEARCH METHODS AND PROCEDURES: The research design was a prospective cohort study of overweight and obese primary care patients randomized to an obesity management intervention based on the Transtheoretical Model and a chronic disease paradigm. The target behaviors included increased planned exercise and usual physical activity, decreased dietary fat, increased fruit and vegetable consumption, and increased dietary portion control. The participants were 329 middle-aged men and women with elevated body mass indices recruited from 15 primary care practices in Northeastern Ohio; 28% of the participants were African Americans. The main outcomes were weight loss (5% or more) or weight gain (5% or more) after 18 or 24 months of follow-up. RESULTS: There were significant (p < 0.05) longitudinal relationships between the number of periods (0 to 4) in action or maintenance for each of the five target behaviors, or a composite score taken across the five target behaviors, and weight loss. In all cases, there was a significant (p < 0.05) stepped (graded) relationship between the time in action or maintenance and weight loss (or gain). DISCUSSION: The data support the concept of applying the Transtheoretical Model to the problem of managing obesity in primary care settings. The remaining challenge is to identify those factors that reliably move patients into the action and maintenance stages for long periods.