Rural engagement in primary care for optimizing weight reduction (REPOWER): A mixed methods study of patient perceptions.

OBJECTIVE: To report on patients' satisfaction and experience of care across three different modes of weight loss counseling. METHODS: 1407 patients with obesity in the rural Midwest were enrolled to a 2-year weight management trial through their primary care practice and assigned to one of three treatment conditions: in-clinic individual, in-clinic group, phone group counseling. Patients completed surveys assessing seven domains of satisfaction and experience of care at 6 and 24-months. Post-treatment interviews were conducted to add context to survey responses. RESULTS: 1295 (92.0%) and 1230 (87.4%) completed surveys at 6 and 24-months, respectively. Patients in phone group counseling reported lower satisfaction than patients who received in-clinic group or in-clinic individual counseling across all domains at 6-months and five out of seven domains at 24-months. Interviews revealed that patients were more satisfied when they received face-to-face counseling and had meaningful interactions with their primary care provider (PCP) about their weight. CONCLUSION: Rural patients with obesity have higher satisfaction and experience of care when weight loss counseling is delivered in a face-to-face environment and when their PCP is involved with their treatment. PRACTICE IMPLICATIONS: Primary care practices looking to offer weight loss treatment should consider incorporating some level of face-to-face treatment plans that involves meaningful interaction with the PCP.

Implementation of cancer screening in rural primary care practices after joining an accountable care organisation: a multiple case study.

OBJECTIVE: To describe common strategies and practice-specific barriers, adaptations and determinants of cancer screening implementation in eight rural primary care practices in the Midwestern United States after joining an accountable care organisation (ACO). DESIGN: This study used a multiple case study design. Purposive sampling was used to identify a diverse group of practices within the ACO. Data were collected from focus group interviews and workflow mapping. The Consolidated Framework for Implementation Research (CFIR) was used to guide data collection and analysis. Data were cross-analysed by clinic and CFIR domains to identify common themes and practice-specific determinants of cancer screening implementation. SETTING: The study included eight rural primary care practices, defined as Rural-Urban Continuum Codes 5-9, in one ACO in the Midwestern United States. PARTICIPANTS: Providers, staff and administrators who worked in the primary care practices participated in focus groups. 28 individuals participated including 10 physicians; one doctor of osteopathic medicine; three advanced practice registered nurses; eight registered nurses, quality assurance and licensed practical nurses; one medical assistant; one care coordination manager; and four administrators. RESULTS: With integration into the ACO, practices adopted four new strategies to support cancer screening: care gap lists, huddle sheets, screening via annual wellness visits and information spread. Cross-case analysis revealed that all practices used both visit-based and population-based cancer screening strategies, although workflows varied widely across practices. Each of the four strategies was adapted for fit to the local context of the practice. Participants shared that joining the ACO provided a strong external incentive for increasing cancer screening rates. Two predominant determinants of cancer screening success at the clinic level were use of the electronic health record (EHR) and fully engaging nurses in the screening process. CONCLUSIONS: Joining an ACO can be a positive driver for increasing cancer screening practices in rural primary care practices. Characteristics of the practice can impact the success of ACO-related cancer screening efforts; engaging nurses to the fullest extent of their education and training and integrating cancer screening into the EHR can optimise the cancer screening workflow.

Rural Family Medicine Clinicians' Motivations to Participate in a Pragmatic Obesity Trial.

PURPOSE: To understand the motivations of rural-practicing primary care clinicians who participate in an intensive multiyear pragmatic randomized behavioral obesity intervention trial, Rural Engagement in Primary Care for Optimizing Weight Reduction (RE-POWER). METHODS: Structured interviews were conducted with 21 family medicine clinicians who were study leads at participating rural practices. Themes emerged through an analysis of transcripts and interview notes by using the constant comparative method. RESULTS: The analysis revealed 3 main themes. First, primary care clinicians participated in RE-POWER because it provided a concrete plan to address their recurring clinical care need for effective obesity treatment and management. Second, participation offered help to frustrated physicians who felt a deep professional duty to care for all their patients' problems but were dissatisfied with current obesity management. Third, participation was also attractive to rural primary care clinicians because it provided a visible and sustainable way to demonstrate their commitment to improving the health of patients and the broader community. CONCLUSIONS: Our findings show that clinicians are motivated to try solutions for a clinical problem-in this case obesity-when that clinical problem is also closely connected to a particularly frustrating area of clinical care that challenges their professional identity. Our data suggest that a motivation to close the gap between ideal and real practice can become such a high priority that clinicians are sometimes willing to try potential solutions, such as engagement in research, that they otherwise would not consider.