Prescription of high-risk medications among patients with chronic kidney disease: a cross-sectional study from the Washington, Wyoming, Alaska, Montana and Idaho region Practice and Research Network.

Background: Patients with chronic kidney disease (CKD) are at high risk for adverse drug events related to medication dosing errors and prescriptions for relatively contraindicated medications, such as non-steroidal anti-inflammatory drugs (NSAIDs). Objectives: To examine the scope of and variation in prescribing relatively contraindicated medications and medications above the recommended dose levels among patients with stage III/IV CKD in primary care practice. Methods: This is a cross-sectional descriptive study that used structured electronic health record data. The study participants were patients aged 18 years and older from three primary care clinics in a practice-based research network. Number/proportion of adult patients with stage III/IV CKD; proportion of these patients with at least one NSAID or other relatively contraindicated medication prescribed over 2 years. Results: Of the 7586 eligible adult patients, 4.9% had stage III/IV CKD; 46.6% of these 373 patients with stage III/IV CKD were prescribed at least one relatively contraindicated drug (acarbose, chlorpropamide, glyburide, nitrofurantoin or any NSAID) during the 2-year study period; and 34.0% of patients with stage III/IV CKD were prescribed NSAIDs. Conclusions: Primary care patients with stage III/IV CKD were frequently prescribed or had documented use of relatively contraindicated drugs and thus were at risk of adverse drug events. Given the significant number of individuals with CKD in the USA, research that examines rates of adverse events related to these prescriptions and that tests primary care-based interventions to decrease inappropriate prescribing of relatively contraindicated medications to these patients is needed.

Exploring the barriers and facilitators to use of point of care tests in family medicine clinics in the United States.

BACKGROUND: Point-of-care tests (POCTs) are increasingly used in family medicine clinics in the United States. While the diagnostics industry predicts significant growth in the number and scope of POCTs deployed, little is known about clinic-level attitudes towards implementation of these tests. We aimed to explore attitudes of primary care providers, laboratory and clinic administrative/support staff to identify barriers and facilitators to use of POCTs in family medicine. METHODS: Seven focus groups and four semi-structured interviews were conducted with a total of 52 clinic staff from three family medicine clinics in two US states. Qualitative data from this exploratory study was analyzed using the constant comparison method. RESULTS: Five themes were identified which included the impact of POCTs on clinical decision-making; perceived inaccuracy of POCTs; impact of POCTs on staff and workflow; perceived patient experience and patient-provider relationship, and issues related to cost, regulation and quality control. Overall, there were mixed attitudes towards use of POCTs. Participants believed the added data provided by POCT may facilitate prompt clinical management, diagnostic certainty and patient-provider communication. Perceived barriers included inaccuracy of POCT, shortage of clinic staff to support more testing, and uncertainty about their cost-effectiveness. CONCLUSIONS: The potential benefits of using POCTs in family medicine clinics are countered by several barriers. Clinical utility of many POCTs will depend on the extent to which these barriers are addressed. Engagement between clinical researchers, industry, health insurers and the primary care community is important to ensure that POCTs align with clinic and patient needs.

Implementation Strategies Used by Facilitators to Improve Control of Cardiovascular Risk Factors in Primary Care.

BACKGROUND: Practice facilitation supports practice change in clinical settings. Despite its widespread use little is known about how facilitators enable change. OBJECTIVE: This study identifies which implementation strategies practice facilitators used and the frequency of their use in a study to improve the quality of cardiovascular care in primary care. DESIGN: Cross-sectional analysis of data collected by practice facilitators in the Healthy Hearts Northwest (H2N) study. PARTICIPANTS: Notes collected by facilitators in the H2N study. APPROACH: We coded these field notes for a purposeful sample of 44 practices to identify Expert Recommendations for Implementation Change (ERIC) strategies used with each practice and calculated the proportion of practices where each implementation strategy was coded at least once. Strategies were categorized as foundational (used in 80% to 100% of practices), moderately used (20%-<80% of practices), rarely used (1-[Formula: see text]% of practices), or absent (0%). KEY RESULTS: We identified 26 strategies used by facilitators. Five strategies were foundational: Develop and/or implement tools for quality monitoring, Assess barriers that may impede implementation, Assess for readiness or progress, Develop and support teams, and Conduct educational meetings. CONCLUSIONS: Commonly used strategies can help guide development of the core components of practice facilitation strategies.

Colonoscopy Outreach for Rural Communities (CORC): A study protocol of a pragmatic randomized controlled trial of a patient navigation program to improve colonoscopy completion for colorectal cancer screening.

BACKGROUND: Colonoscopy is one of the primary methods of screening for colorectal cancer (CRC), a leading cause of cancer mortality in the United States. However, up to half of patients referred to colonoscopy fail to complete the procedure, and rates of adherence are lower in rural areas. OBJECTIVES: Colonoscopy Outreach for Rural Communities (CORC) is a randomized controlled trial to test the effectiveness of a centralized patient navigation program provided remotely by a community-based organization to six geographically distant primary care organizations serving rural patients, to improve colonoscopy completion for CRC. METHODS: CORC is a type 1 hybrid implementation-effectiveness trial. Participants aged 45-76 from six primary care organizations serving rural populations in the northwestern United States are randomized 1:1 to patient navigation or standard of care control. The patient navigation is delivered remotely by a trained lay-person from a community-based organization. The primary effectiveness outcome is completion of colonoscopy within one year of referral to colonoscopy. Secondary outcomes are colonoscopy completion within 6 and 9 months, time to completion, adequacy of patient bowel preparation, and achievement of cecal intubation. Analyses will be stratified by primary care organization. DISCUSSION: Trial results will add to our understanding about the effectiveness of patient navigation programs to improve colonoscopy for CRC in rural communities. The protocol includes pragmatic adaptations to meet the needs of rural communities and findings may inform approaches for future studies and programs. TRIAL REGISTRATION: National Clinical Trial Identifier: NCT05453630. TRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT05453630. Registered July 6, 2022.

Early Response of Primary Care Practices to COVID-19 Pandemic.

INTRODUCTION: The emergence of the COVID-19 pandemic and subsequent public health mitigation strategies resulted in rapid and significant changes to delivery of primary care. The field of primary care faced an unprecedented dual challenge of providing routine care to patients while ensuring patient and staff safety and managing patients with a highly transmissible disease. This study describes how a diverse group of primary care practices addressed these challenges at the start of the COVID-19 pandemic, in Spring 2020. METHODS: A cross-sectional electronic survey of representatives from primary care practices in the WWAMI region Practice and Research Network (WPRN). Survey topics included clinical workforce, operations, and use of telemedicine in the first 3 months of the COVID-19 pandemic. RESULTS: To safely manage patients with COVID-19 symptoms all clinics modified operations; 81.3% diverted patients with respiratory symptoms to a telemedicine evaluation, 68.8% diverted these patients to be seen in-person at another location, and 75% made in-clinic changes to maintain safety. The set of operational changes employed by clinics was diverse. To continue to provide routine patient care, all clinics employed telemedicine. Over 80% of clinics had never used telemedicine prior to March 2020. CONCLUSIONS: A diverse group of primary care clinics all rapidly implemented a variety of operational adaptations to address patient needs and maintain patient and staff safety at the onset of the COVID- 19 pandemic. Telemedicine, together with other measures, provided critical pathways for maintaining delivery of care.

Complementary and Integrative Health Knowledge and Practice in Primary Care Settings: A Survey of Primary Care Providers in the Northwestern United States.

BACKGROUND: The demand for complementary and integrative health (CIH) is increasing by patients who want to receive more CIH referrals, in-clinic services, and overall care delivery. To promote CIH within the context of primary care, it is critical that providers have sufficient knowledge of CIH, access to CIH-trained providers for referral purposes, and are comfortable either providing services or co-managing patients who favor a CIH approach to their healthcare. OBJECTIVE: The main objective was to gather primary care providers' perspectives across the northwestern region of the United States on their CIH familiarity and knowledge, clinic barriers and opportunities, and education and training needs. METHODS: We conducted an online, quantitative survey through an email invitation to all primary care providers (n = 483) at 11 primary care organizations from the WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) region Practice and Research Network (WPRN). The survey questions covered talking about CIH with patients, co-managing care with CIH providers, familiarity with and training in CIH modalities, clinic barriers to CIH integration, and interest in learning more about CIH modalities. RESULTS: 218 primary care providers completed the survey (45% response rate). Familiarity with individual CIH methods ranged from 73% (chiropracty) to 8% (curanderismo). Most respondents discussed CIH with their patients (88%), and many thought that their patients could benefit from CIH (41%). The majority (89%) were willing to co-manage a patient with a CIH provider. Approximately one-third of respondents had some expertise in at least one CIH modality. Over 78% were interested in learning more about the safety and efficacy of at least one CIH modality. CONCLUSION: Primary care providers in the Northwestern United States are generally familiar with CIH modalities, are interested in referring and co-managing care with CIH providers, and would like to have more learning opportunities to increase knowledge of CIH.

Understanding infant feeding beliefs, practices and preferred nutrition education and health provider approaches: an exploratory study with Somali mothers in the USA.

The objective of this study was to explore Somali mothers' beliefs and practices around infant feeding and education, towards developing a culturally informed infant nutrition curriculum for health providers. Four focus groups were conducted to explore: (1) beliefs about infant feeding, hunger and ideal weight; (2) feeding practices; (3) nutrition education approaches; and (4) provider/mother interactions. Thirty-seven Somali mother participants identified the following themes within these topics: (1) strategies for assessing hunger, satiety and when to feed; shared beliefs that plump babies are healthy, leading to worry about infant weight; (2) context of breast milk adequacy, difficulties breastfeeding and environmental and cultural barriers to breastfeeding, leading to nearly universal early supplementation with formula; (3) preferred education approaches include provider visits with interpreters, Somali language educational materials and advice from older, experienced family members; and (4) desired health provider skills include: listening, explaining, empathy, addressing specific concerns, repeating important information, offering preventive advice and sufficient visit time. This study presents knowledge about Somali beliefs and practices that can directly guide discussions with these families. Given that these infants appear on a trajectory towards obesity, influencing infant feeding practices in the Somali community is a good upstream approach to preventing obesity. These findings will underpin a new infant nutrition curriculum for health providers.

Use of electronic health record data from diverse primary care practices to identify and characterize patients' prescribed common medications.

We use prescription of statin medications and prescription of warfarin to explore the capacity of electronic health record data to (1) describe cohorts of patients prescribed these medications and (2) identify cohorts of patients with evidence of adverse events related to prescription of these medications. This study was conducted in the WWAMI region Practice and Research Network (WPRN)., a network of primary care practices across Washington, Wyoming, Alaska, Montana and Idaho DataQUEST, an electronic data-sharing infrastructure. We used electronic health record data to describe cohorts of patients prescribed statin or warfarin medications and reported the proportions of patients with adverse events. Among the 35,445 active patients, 1745 received at least one statin prescription and 301 received at least one warfarin prescription. Only 3 percent of statin patients had evidence of myopathy; 51 patients (17% of those prescribed warfarin) had a bleeding complication. Primary-care electronic health record data can effectively be used to identify patients prescribed specific medications and patients potentially experiencing medication adverse events.

Prevalence of documented alcohol and opioid use disorder diagnoses and treatments in a regional primary care practice-based research network.

BACKGROUND: Most people with alcohol or opioid use disorders (AUD or OUD) are not diagnosed or treated for these conditions in primary care. This study takes a critical step toward quantifying service gaps and directing improvement efforts for AUD and OUD by using electronic health record (EHR) data from diverse primary care organizations to quantify the extent to which AUD and OUD are underdiagnosed and undertreated in primary care practices. METHODS: We extracted and integrated diagnosis, medication, and behavioral health visit data from the EHRs of 21 primary care clinics within four independent healthcare organizations representing community health centers and rural hospital-associated clinics in the Pacific Northwest United States. Rates of documented AUD and OUD diagnoses, pharmacological treatments, and behavioral health visits were evaluated over a two-year period (2015-2016). RESULTS: Out of 47,502 adult primary care patients, 1476 (3.1%) had documented AUD; of these, 115 (7.8%) had orders for AUD medications and 271 (18.4%) had at least one documented visit with a non-physician behavioral health specialist. Only 402 (0.8%) patients had documented OUD, and of these, 107 (26.6%) received OUD medications and 119 (29.6%) had at least one documented visit with a non-physician behavioral health specialist. Rates of AUD diagnosis and AUD and OUD medications were higher in clinics that had co-located non-physician behavioral health specialists. CONCLUSIONS: AUD and OUD are underdiagnosed and undertreated within a sample of independent primary care organizations serving mostly rural patients. Primary care organizations likely need service models, technologies, and workforces, including non-physician behavioral health specialists, to improve capacities to diagnose and treat AUD and OUD.

Examining the Needs of Patient Stakeholders as Research Partners in Health Data Networks for Translational Research.

Patient stakeholders are getting increasingly involved in research health data networks, particularly as research partners. However, tools do not exist to help effectively orient, educate, and engage patient stakeholders as they take on these roles. Using a human centered design approach, we conducted a patient stakeholder needs assessment qualitative study to identify key user needs to drive design recommendations for development of an online education and engagement tool for research health data networks. We found three key needs related to multiple role identities, motivations and expectations for participation on research teams, and patient journeys. Design recommendations derived from the needs assessment are discussed that can support future tool design and testing.

Room for Improvement: Rates of Birth Cohort Hepatitis C Screening in Primary Care Practices-A WWAMI Region Practice and Research Network Study.

Introduction: An estimated 2.4 million people in the United States live with hepatitis C. Though there are effective treatments for chronic hepatitis C, many infected individuals remain untreated because 40% to 50% of individuals with chronic hepatitis C are unaware of their hepatitis C status. In 2013, the United States Preventive Services Task Force (USPSTF) recommended that adults born between 1945 and 1965 should be offered one-time hepatitis C screening. The purpose of this study is to describe rates of birth cohort hepatitis C screening across primary care practices in the WWAMI region Practice and Research Network (WPRN). Methods: Cross-sectional observational study of adult patients born between 1945 and 1965 who also had a primary care visit at 1 of 9 participating health systems (22 primary care clinics) between July 31, 2013 and September 30, 2015. Data extracted from the electronic health record systems at each clinic were used to calculate the proportion of birth cohort eligible patients with evidence of hepatitis C screening as well as proportions of screened patients with positive hepatitis C screening test results. Results: Of the 32 139 eligible patients, only 10.9% had evidence of hepatitis C screening in the electronic health record data (range 1.2%-49.1% across organizations). Among the 4 WPRN sites that were able to report data by race and ethnicity, the rate of hepatitis C screening was higher among African Americans (39.9%) and American Indians/Alaska Natives (23.2%) compared with Caucasians (10.7%; P < .001). Discussion: Rates of birth cohort hepatitis C screening are low in primary care practices. Future research to develop and test interventions to increase rates of birth cohort hepatitis C screening in primary care settings are needed.

Use of an electronic health record data sharing system for identifying current contraceptive use within the WWAMI region Practice and Research Network.

OBJECTIVE: To evaluate the ability of electronic health record (EHR) data extracted into a data-sharing system to accurately identify contraceptive use. STUDY DESIGN: We compared rates of contraceptive use from electronic extraction of EHR data via a data-sharing system and manual abstraction of the EHR among 142 female patients ages 15-49 years from a family medicine clinic within a primary care practice-based research network (PBRN). Cohen's kappa coefficient measured agreement between electronic extraction and manual abstraction. RESULTS: Manual abstraction identified 62% of women as contraceptive users, whereas electronic extraction identified only 27%. Long acting reversible (LARC) methods had 96% agreement (Cohen's kappa 0.78; confidence interval, 0.57-0.99) between electronic extraction and manual abstraction. EHR data extracted via a data-sharing system was unable to identify barrier or over-the-counter contraceptives. CONCLUSIONS: Electronic extraction found substantially lower overall rates of contraceptive method use, but produced more comparable LARC method use rates when compared to manual abstraction among women in this study's primary care clinic. IMPLICATIONS: Quality metrics related to contraceptive use that rely on EHR data in this study's data-sharing system likely under-estimated true contraceptive use.

Which Point-of-Care Tests Would Be Most Beneficial to Add to Clinical Practice?: Findings From a Survey of 3 Family Medicine Clinics in the United States.

BACKGROUND: Point-of-care tests (POCTs) are increasingly used in family medicine to facilitate screening, diagnosis, monitoring, treatment, and referral decisions for a variety of conditions. Point-of-care tests that clinicians believe might be beneficial to add to clinical practice and the conditions for which they would be most useful in family medicine remain poorly understood in the United States. METHODS: Forty-two clinicians at 3 family medicine residency clinics completed a brief survey asking which POCTs they believed would be beneficial to add to their clinical practice and the conditions POCTs would be most useful for. We calculated frequencies of reported POCTs and conditions using descriptive statistics. RESULTS: Clinicians identified 34 POCTs that would be beneficial to add to family medicine, of which hemoglobin A1c, chemistry panels, and human immunodeficiency virus and gonococcal and/or chlamydia were most frequently reported and anticipated would be used weekly. Clinicians reported 30 conditions for which they considered POCTs would be useful. Diabetes mellitus, sexually transmitted infections, and respiratory tract infections were the most often reported and were identified as benefiting diagnosis, monitoring, and treatment decisions. CONCLUSIONS: Clinicians identified a number of POCTs they viewed as being beneficial to add to their routine clinical practice, mostly to inform diagnosis and treatment planning. Some POCTs identified are available in the United States; thus, understanding barriers to implementation of these POCTs in primary care settings is necessary to optimize adoption.

Conflicts of Interest and Distribution of Resources to Community Partners: An Organizational Ethics Dilemma.

BACKGROUND: Conflicts of interest can arise when faculty and staff administer programs that distribute research funds, training opportunities, and other resources across academic and community partners. We describe the ethical concerns encountered by a Clinical Translational Science Award (CTSA) program in administering its community-focused pilot grant program and how its Research Bioethics Consultation service helped to address them.Ethical Concerns: CTSA program faculty and staff identified ethical concerns in several areas, including appropriateness of including Regional Research Collaborations (RRC) faculty as principal or co-investigators on applications, determining how much help RRC faculty and staff should provide to prospective applicants, and creating a fair and effective application review process. DISCUSSION: The CTSA program identified common goals and values for its community-focused pilot grant program, and resolved the conflicts of interest with the new pilot grant policies. This approach could generalize to conflicts of interest that arise in other academic-community partnerships.

Patient-oriented health technologies: Patients' perspectives and use.

BACKGROUND: For patient-oriented mobile health tools to contribute meaningfully to improving healthcare delivery, widespread acceptance and use of such tools by patients are critical. However, little is known about patients' attitudes toward using health technology and their willingness to share health data with providers. AIMS: To investigate primary care patients' comfort sharing health information through mobile devices, and patients' awareness and use of patient portals. METHODS: Patients (n=918) who visited one of 6 primary care clinics in the Northwest US completed a survey about health technology use, medical conditions, and demographics. RESULTS: More patients were comfortable sharing mobile health information with providers than having third parties store their information (62% vs 30%, Somers D=.33, p<0.001). Patients older than 55 years were less likely to be comfortable sharing with providers (AORs 0.37-0.42, p<0.01). Only 39% of patients knew if their clinic offered a patient portal; however, of these, 67% used it. Health literacy limitations were associated with lower portal awareness (AOR=0.55, p=0.005) but not use. Portal use was higher among patients with a chronic condition (AOR= 3.18, p=0.004). CONCLUSION: Comfort, awareness, and use of health technologies were variable. Practices introducing patient-facing health technologies should promote awareness, address concerns about data security, and provide education and training, especially to older adults and those with health literacy limitations. Patient-facing health technologies provide an opportunity for delivering scalable health education and self-management support, particularly for patients with chronic conditions who are already using patient portals.

Qualitative study of primary care clinicians' views on point-of-care testing for C-reactive protein for acute respiratory tract infections in family medicine.

OBJECTIVE: To explore clinicians views of the barriers and facilitators to use of C-reactive protein (CRP) point-of-care tests (POCT) in US family medicine clinics for the management of acute respiratory tract infections (ARTIs) in adults. SETTING: Five family medicine clinics across two US states. PARTICIPANTS: 30 clinicians including 18 physicians, 9 physician residents, 2 physician assistants and 1 nurse practitioner, took part in the study. DESIGN: A qualitative study using a grounded theory approach to thematically analyse focus group interviews. RESULTS: These clinicians had limited access to diagnostic tests for patients with ARTI, and very little knowledge of CRP POCT. Three major themes were identified and included the potential clinical role of CRP POCT, concerns related to implementing CRP POCT and evidence needed prior to wider adoption in family medicine. Clinicians believed CRP POCT could support decision-making for some presentations of ARTIs and patient populations when used in conjunction with clinical criteria. Clinicians had concerns about possible overuse and inaccuracy of CRP POCT which they believed might increase antibiotic prescribing rates. Other concerns identified included integration of the test with clinic workflows and cost-effectiveness. CONCLUSIONS: Clinicians stand at the forefront of antibiotic stewardship efforts, but have few diagnostic tests to help them confidently manage ARTIs. CRP POCT may facilitate some aspects of clinical practice. Incorporating CRP POCT with clinical guidelines may strengthen utility of this test, when there is diagnostic uncertainty.

Patient Willingness to Have Tests to Guide Antibiotic Use for Respiratory Tract Infections: From the WWAMI Region Practice and Research Network (WPRN).

INTRODUCTION: The majority of consultations for acute respiratory tract infections (RTIs) lead to prescriptions for antibiotics, which have limited clinical benefit. We explored patients' willingness to have blood tests as part of the diagnostic work-up for RTIs, and patient knowledge about antibiotics. METHODS: Patients at 6 family medicine clinics were surveyed. Regression modeling was used to determine independent predictors of willingness to have venous and point-of-care (POC) blood tests, and knowledge of the value of antibiotics for RTIs. RESULTS: Data were collected from 737 respondents (response rate 83.8%), of whom 65.7% were women, 60.1% were white, and 25.1% were current smokers; patients' mean age was 46.9 years. Sex (female), race (white), and a preference to avoid antibiotics were independent predictors of greater level of antibiotic knowledge. A total of 63.1% were willing to have a venous draw and 79% a POC blood test, to help guide antibiotic decision-making. Non-American Indian/Alaskan Native race, current smoking, and greater knowledge of antibiotics were independent predictors of willingness to have a POC test. CONCLUSION: A large majority of patients seemed willing to have POC tests to facilitate antibiotic prescribing decisions for RTIs. Poor knowledge about antibiotics suggests better education regarding antibiotic use might influence patient attitudes towards use of antibiotics for RTIs.

Extracting Electronic Health Record Data in a Practice-Based Research Network: Processes to Support Translational Research across Diverse Practice Organizations.

CONTEXT: The widespread adoption of electronic health records (EHRs) offers significant opportunities to conduct research with clinical data from patients outside traditional academic research settings. Because EHRs are designed primarily for clinical care and billing, significant challenges are inherent in the use of EHR data for clinical and translational research. Efficient processes are needed for translational researchers to overcome these challenges. The Data QUEST Coordinating Center (DQCC), which oversees Data Query Extraction Standardization Translation (Data QUEST) - a primary-care, EHR data-sharing infrastructure - created processes that guide EHR data extraction for clinical and translational research across these diverse practices. We describe these processes and their application in a case example. CASE DESCRIPTION: The DQCC process for developing EHR data extractions not only supports researchers' access to EHR data, but supports this access for the purpose of answering scientific questions. This process requires complex coordination across multiple domains, including the following: (1) understanding the context of EHR data; (2) creating and maintaining a governance structure to support exchange of EHR data; and (3) defining data parameters that are used in order to extract data from the EHR. We use the Northwest-Alaska Pharmacogenomics Research Network (NWA-PGRN) as a case example that focuses on pharmacogenomic discovery and clinical applications to describe the DQCC process. The NWA-PGRN collaborates with Data QUEST to explore ways to leverage primary-care EHR data to support pharmacogenomics research. FINDINGS: Preliminary analysis on the case example shows that initial decisions about how researchers define the study population can influence study outcomes. MAJOR THEMES AND CONCLUSIONS: The experience of the DQCC demonstrates that coordinating centers provide expertise in helping researchers understand the context of EHR data, create and maintain governance structures, and guide the definition of parameters for data extractions. This expertise is critical to supporting research with EHR data. Replication of these strategies through coordinating centers may lead to more efficient translational research. Investigators must also consider the impact of initial decisions in defining study groups that may potentially affect outcomes.

Primary Care Patients' Willingness to Participate in Comprehensive Weight Loss Programs: From the WWAMI Region Practice and Research Network.

PURPOSE: In the United States, 69% of adults are overweight or obese, as defined by a body mass index (BMI) ≥25 kg/m(2). The US Preventive Services Task Force recommends screening all adult patients for obesity and referring obese patients to intensive, multicomponent behavioral weight loss programs comprising 12 to 26 yearly sessions. The objective of this study is to determine the degree to which overweight and obese primary care patients report willingness to participate in these intensive weight loss programs and to identify the patient factors associated with reported willingness to participate. METHODS: This 2013 cross-sectional survey was offered to all adult patients seen for an office visit at 1 of 12 primary care clinics in the Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) Region Practice and Research Network (WPRN). Patients self-reported both their health information and their willingness to participate in a comprehensive weight loss program. Respondents were characterized by descriptive statistics. We compared reported rates of willingness to participate by patient factors and assessed which patient factors were independently associated with reported willingness using bivariate analysis and logistic regression, respectively. RESULTS: Of overweight and obese respondents, 63% reported willingness to participate in comprehensive weight loss programs. Age, sex, race/ethnicity, insurance status, BMI, and reason for wanting to lose weight were all significantly and independently associated with reported willingness to participate. CONCLUSIONS: Reported willingness to participate in comprehensive weight loss programs suggests that additional resources are needed to understand strategies for disseminating and implementing effective comprehensive weight loss programs.

Using the diffusion of innovations theory to assess socio-technical factors in planning the implementation of an electronic health record alert across multiple primary care clinics.

BACKGROUND: Adverse drug events (ADEs) are a leading cause of death in the United States. Patients with stage 3 and 4 chronic kidney disease (CKD) are at particular risk because many medications are cleared by the kidneys. Alerts in the electronic health record (EHR) about drug appropriateness and dosing at the time of prescription have been shown to reduce ADEs for patients with stage 3 and 4 CKD in inpatient settings, but more research is needed about the implementation and effectiveness of such alerts in outpatient settings. OBJECTIVE: To explore factors that might inform the implementation of an electronic drug-disease alert for patients with CKD in primary care clinics, using Rogers' diffusion of innovations theory as an analytic framework. METHODS: Interviews were conducted with key informants in four diverse clinics using various EHR systems. Interviews were audio recorded and transcribed. results Although all clinics had a current method for calculating glomerular filtration rate (GFR), clinics were heterogeneous with regard to current electronic decision support practices, quality improvement resources, and organizational culture and structure. CONCLUSION: Understanding variation in organizational culture and infrastructure across primary care clinics is important in planning implementation of an intervention to reduce ADEs among patients with CKD.