Practical Opportunities for Healthy Diet and Physical Activity: Relationship to Intentions, Behaviors, and Body Mass Index.

PURPOSE: Current strategies for improving diet and activity patterns focus on encouraging patients to make better choices, but they meet with limited success. Because the choices people make depend on the choices they have, we examined how practical opportunities for diet and physical activity shape behavioral intentions and achieved behaviors. METHODS: Participants included 746 adults who visited 8 large primary care practices in the Residency Research Network of Texas in 2012. We used structural equation models to confirm factor structures for a previously validated measure of practical opportunities, and then modeled achieved diet (Starting the Conversation - Diet questionnaire), physical activity (International Physical Activity Questionnaire), and BMI as a function of opportunities (classified as either resources or conversion factors that influence use of resources), behavioral intentions, and demographic covariates. RESULTS: In path models, resources (P <.001) and conversion factors (P = .005) predicted behavioral intentions for activity. Conversion factors (P <.001), but not resources, predicted diet intentions. Both activity resources (P = .01) and conversion factors (P <.001) were positively associated with weekly activity minutes. Diet conversion factors (P <.001), but not diet resources (P = .08), were positively associated with diet quality. The same patterns were observed for body mass index (BMI). Socioeconomic gradients in resources and conversion factors were evident. CONCLUSIONS: Individuals' feasible opportunities for healthy diet and activity have clinically meaningful associations with intentions, achieved behaviors, and BMI. Assessing opportunities as part of health behavior management could lead to more effective, efficient, and compassionate interventions.

Inpatient Hand-Offs in Family Medicine Residency Programs: A CERA Study.

BACKGROUND AND OBJECTIVES: Miscommunication during patient hand-off in the inpatient setting can lead to serious medical errors. Previous studies indicate heterogeneity in handoff practices among physicians in training. We sought to determine current practice patterns of patient hand-offs in family medicine residencies and training methods to reinforce effective transfer of care. METHODS: We developed 13 questions relating to patient hand-offs that were included in the Spring 2014 CERA Family Medicine Program Directors Survey. Descriptive statistics were generated for each survey item. RESULTS: We received 224 survey responses (response rate of 50%). The typical inpatient was subject to an average of seven transfers of care from a Thursday morning to a Monday morning. Use of two strategies consistent with best practices (face-to-face hand-off, use of a dedicated area) was very high. There was wide variation in training methods for patient transfer and infrequent use of national resources. Half of all residency programs relied on supervision as the primary method of instruction in patient hand-off. Estimated patient safety events in the last year attributed to a breakdown in hand-off procedure occurred "rarely/never" in 73% of programs. CONCLUSIONS: The vast majority of family medicine residencies use at least two of three best practices in patient hand-offs, though there was wider variation in the processes of hand-offs. Frequent hand-offs associated with a night float system is a potential cause of increased errors, though we were unable to measure actual patient safety events.

South Texas Residency Screening, Brief Intervention, and Referral to Treatment (SBIRT) Training: 12-Month Outcomes.

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT) is an efficacious and cost-effective skill set when implemented in primary care settings regarding hazardous alcohol use. This study assesses the impact of medical resident SBIRT training across 3 specialties and identifies predictors of change in trainee behavior, attitudes, and knowledge over 12 months. METHODS: This program's substance use SBIRT training was developed and tailored to fit diverse curricular objectives and settings across an array of medical residency programs in South Texas. The 329 residents training in pediatrics, family medicine, and internal medicine during 2009-2012 constituted the trainee group reported in this analysis. Surveys assessing SBIRT-related knowledge, current practice, confidence, role responsibility, attitudes, beliefs, and readiness to change were completed by 234 (71%) trainees at 3 time points: pre-training, then 30 days and 12 months post-initial training. RESULTS: SBIRT-related knowledge, confidence, and practice increased from pre-training to 12-month follow-up. Residents who reported the least amount of pre-training clinical and/or prior academic exposure to substance use reported the greatest SBIRT practice increases. When controlling for demographic and prior exposure variables, the largest contributor to variance in SBIRT practice was attributed to residents' confidence in their SBIRT skills. CONCLUSIONS: SBIRT training that employs diverse educational methodologies as part of customizing the training to residency specialties can similarly enhance SBIRT-related knowledge, confidence, and practice. Trainee report of limited prior clinical or academic exposure to substance use and/or low confidence regarding SBIRT skills and their professional role responsibilities related to substance use predicted trainee success and sustained SBIRT strategy application. When customizing SBIRT training, curriculum developers should consider leveraging and capacity building related to those factors predicting continued use of SBIRT practices.

SAFE TEENS: facilitators of and barriers to adolescent preventive care discussions.

BACKGROUND AND OBJECTIVES: This study's goal was to describe the topics discussed during adolescent preventive care visits and to identify facilitators and barriers of these discussions among physicians in family medicine residency programs. METHODS: Forty-six family physicians in five residency programs used SAFE TEENS study cards to record data during 321 visits with adolescents ages 11--21 years. The study cards included a checklist of 31 potential topics organized under 10 categories. Closed- and open-ended questions were used to explore facilitators and barriers. RESULTS: The topics most frequently discussed were under the categories of toxins (tobacco, alcohol, and drugs), environment (school, home, and friends), sexuality, and exercise. Physicians were more likely to conduct preventive care discussions in the clinical context of a physical examination and with a new patient. Parents being present for part of the visit, a reminder system, and the recognition of developmental stage were also significant facilitators. The presence of competing demands was the strongest barrier. CONCLUSIONS: To increase the number of adolescent preventive care discussions, family medicine educators should stress that visits with established patients and visits for reasons other than a physical examination are also opportunities to provide preventive care. The development of electronic reminder systems would also be useful.

Prevalence and 3-year incidence of abuse among postmenopausal women.

OBJECTIVES: We examined prevalence, 3-year incidence, and predictors of physical and verbal abuse among postmenopausal women. METHODS: We used a cohort of 91,749 women aged 50 to 79 years from the Women's Health Initiative. Outcomes included self-reported physical abuse and verbal abuse. RESULTS: At baseline, 11.1% reported abuse sometime during the prior year, with 2.1% reporting physical abuse only, 89.1% reporting verbal abuse only, and 8.8% reporting both physical and verbal abuse. Baseline prevalence was associated with service occupations, having lower incomes, and living alone. At 3-year follow-up, 5.0% of women reported new abuse, with 2.8% reporting physical abuse only, 92.6% reporting verbal abuse only, and 4.7% reporting both physical and verbal abuse. CONCLUSIONS: Postmenopausal women are exposed to abuse at similar rates to younger women; this abuse poses a serious threat to their health.

The patient-physician relationship, primary care attributes, and preventive services.

BACKGROUND: The importance of a sustained relationship between patients and physicians is a defining characteristic of family medicine. This study examined whether there is an association among the length of the patient-physician relationship, various attributes of primary care, and the delivery of clinical preventive services to Medicare beneficiaries. METHODS: The data source for this study was the 1993 Medicare Current Beneficiary Survey. Primary care attribute scales were developed by conducting a factor analysis of 17 survey questions. Three clinical preventive services were measured as outcomes: influenza vaccination, mammography, and an eye examination for diabetics. Path analyses were used to test the relationships between length of relationship, primary care attributes, and delivery of clinical preventive services. RESULTS: As the length of the relationship increased, scores on communication, accumulated knowledge of the patient by the physician, and trust all improved. Length of relationship and communication predicted accumulated knowledge of the patient by the physician, accumulated knowledge predicted trust, and trust predicted delivery of preventive services. CONCLUSIONS: Among elderly Medicare beneficiaries, the ability to develop a sustained relationship with a provider is related to the realization of other important attributes of primary care. Trust was associated with delivery of important clinical preventive services. Efforts should be made to protect the ability of patients and physicians to sustain a relationship over time.