Inadequate Utilization of Diagnostic Colonoscopy Following Abnormal FIT Results in an Integrated Safety-Net System.

OBJECTIVES: The effectiveness of stool-based colorectal cancer (CRC) screening is contingent on colonoscopy completion in patients with an abnormal fecal immunochemical test (FIT). Understanding system and patient factors affecting follow-up of abnormal screening tests is essential to optimize care for high-risk cohorts. METHODS: This retrospective cohort study was conducted in an integrated safety-net system comprised of 11 primary-care clinics and one Gastroenterology referral unit and included patients 50-75 years, with a positive FIT between April 2012 and February 2015. RESULTS: Of the 2,238 patients identified, 1,245 (55.6%) completed their colonoscopy within 1-year of the positive FIT. The median time from positive FIT to colonoscopy was 184 days (interquartile range 140-232). Of the 13% of FIT positive patients not referred to gastroenterology, 49% lacked documentation addressing their abnormal result or counseling on the increased risk of CRC. Of the patients referred but who missed their appointments, 62% lacked documentation following up on the abnormal result in the absence of a completed colonoscopy. FIT positive patients never referred to gastroenterology or who missed their appointment after referrals were more likely to have comorbid conditions and documented illicit substance use compared with patients who completed a colonoscopy. CONCLUSIONS: Despite access to colonoscopy and a shared electronic health record system, colonoscopy completion after an abnormal FIT is inadequate within this safety-net system. Inadequate follow-up is in part explained by inappropriate screening, but there is an absence of clear documentation and systematic workflow within both primary care and GI specialty care addressing abnormal FIT results.

Health coaching by medical assistants improves patients' chronic care experience.

OBJECTIVES: We sought to test the hypothesis that training medical assistants to provide health coaching would improve patients' experience of care received and overall satisfaction with their clinic. STUDY DESIGN: Randomized controlled trial. METHODS: Low-income English- or Spanish-speaking patients aged 18 to 75 years with poorly controlled type 2 diabetes, hypertension, and/or hyperlipidemia were randomized to receive either a health coach or usual care for 12 months. Patient care experience was measured using the Patient Assessment of Chronic Illness Care (PACIC) scale at baseline and at 12 months. Patient overall satisfaction with the clinic was assessed with a single item asking if they would recommend the clinic to a friend or family member. PACIC and satisfaction scores were compared between study arms using generalized estimating equations to account for clustering at the clinician level. RESULTS: PACIC scores were available from baseline and at 12 months on 366 (76%) of the 441 patients randomized. At baseline, patients receiving health coaching were similar to those in the usual care group with respect to demographic and other characteristics, including mean PACIC scores (3.00 vs 3.06) and the percent who would "definitely recommend" their clinic (73% and 73%, respectively). At 12 months, coached patients had a significantly higher mean PACIC score (3.82 vs 3.13; P < .001) and were more likely to report they would definitely recommend their clinic (85% vs 73%; P = .002). CONCLUSIONS: Using medical assistants trained in health coaching significantly improved the quality of care that low-income patients with poorly controlled chronic disease reported receiving from their healthcare team.

Health coaching by medical assistants to improve control of diabetes, hypertension, and hyperlipidemia in low-income patients: a randomized controlled trial.

PURPOSE: Health coaching by medical assistants could be a financially viable model for providing self-management support in primary care if its effectiveness were demonstrated. We investigated whether in-clinic health coaching by medical assistants improves control of cardiovascular and metabolic risk factors when compared with usual care. METHODS: We conducted a 12-month randomized controlled trial of 441 patients at 2 safety net primary care clinics in San Francisco, California. The primary outcome was a composite measure of being at or below goal at 12 months for at least 1 of 3 uncontrolled conditions at baseline as defined by hemoglobin A1c, systolic blood pressure, and low-density lipoprotein (LDL) cholesterol. Secondary outcomes were meeting all 3 goals and meeting individual goals. Data were analyzed using χ(2) tests and linear regression models. RESULTS: Participants in the coaching arm were more likely to achieve both the primary composite measure of 1 of the clinical goals (46.4% vs 34.3%, P = .02) and the secondary composite measure of reaching all clinical goals (34.0% vs 24.7%, P = .05). Almost twice as many coached patients achieved the hemoglobin A1c goal (48.6% vs 27.6%, P = .01). At the larger study site, coached patients were more likely to achieve the LDL cholesterol goal (41.8% vs 25.4%, P = .04). The proportion of patients meeting the systolic blood pressure goal did not differ significantly. CONCLUSIONS: Medical assistants serving as in-clinic health coaches improved control of hemoglobin A1c and LDL levels, but not blood pressure, compared with usual care. Our results highlight the need to understand the relationship between patients' clinical conditions, interventions, and the contextual features of implementation.

Does health coaching change patients' trust in their primary care provider?

OBJECTIVE: To assess the impact of health coaching on patients' in their primary care provider. METHODS: Randomized controlled trial comparing health coaching with usual care. PARTICIPANTS: Low-income English or Spanish speaking patients age 18-75 with poorly controlled type 2 diabetes, hypertension and/or hyperlipidemia. MAIN OUTCOME MEASURE: Patient trust in their primary care provider measured by the 11-item Trust in Physician Scale, converted to a 0-100 scale. ANALYSIS: Linear mixed modeling. RESULTS: A total of 441 patients were randomized to receive 12 months of health coaching (n=224) vs. usual care (n=217). At baseline, the two groups were similar to those in the usual care group with respect to demographic characteristics and levels of trust in their provider. After 12 months, the mean trust level had increased more in patients receiving health coaching (3.9 vs. 1.5, p=0.47), this difference remained significant after adjustment for number of visits to primary care providers (adjusted p=.03). CONCLUSIONS: Health coaching appears to increase patients trust in their primary care providers. PRACTICE IMPLICATIONS: Primary care providers should consider adding health coaches to their team as a way to enhance their relationship with their patients.

The effectiveness of medical assistant health coaching for low-income patients with uncontrolled diabetes, hypertension, and hyperlipidemia: protocol for a randomized controlled trial and baseline characteristics of the study population.

BACKGROUND: Many patients with chronic disease do not reach goals for management of their conditions. Self-management support provided by medical assistant health coaches within the clinical setting may help to improve clinical outcomes, but most studies to date lack statistical power or methodological rigor. Barriers to large scale implementation of the medical assistant coach model include lack of clinician buy-in and the absence of a business model that will make medical assistant health coaching sustainable. This study will add to the evidence base by determining the effectiveness of health coaching by medical assistants on clinical outcomes and patient self-management, by assessing the impact of health coaching on the clinician experience, and by examining the costs and potential savings of health coaching. METHODS/DESIGN: This randomized controlled trial will evaluate the effectiveness of clinic-based medical assistant health coaches to improve clinical outcomes and self-management skills among low-income patients with uncontrolled type 2 diabetes, hypertension, or hyperlipidemia. A total of 441 patients from two San Francisco primary care clinics have been enrolled and randomized to receive a health coach (n = 224) or usual care (n = 217). Patients participating in the health coaching group will receive coaching for 12 months from medical assistants trained as health coaches. The primary outcome is a change in hemoglobin A1c, systolic blood pressure, or LDL cholesterol among patients with uncontrolled diabetes, hypertension and hyperlipidemia, respectively. Self-management behaviors, perceptions of the health care team and clinician, BMI, and chronic disease self-efficacy will be measured at baseline and after 12 months. Clinician experience is being assessed through surveys and qualitative interviews. Cost and utilization data will be analyzed through cost-predictive models. DISCUSSION: Medical assistants are an untapped resource to provide self-management support for patients with uncontrolled chronic disease. Having successfully completed recruitment, this study is uniquely poised to assess the effectiveness of the medical assistant health coaching model, to describe barriers and facilitators to implementation, and to develop a business case for sustainability. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT-01220336.

Building teams in primary care: what do nonlicensed allied health workers want?

INTRODUCTION: Nonlicensed allied health workers are becoming increasingly important in collaborative team care, yet we know little about their experiences while filling these roles. To explore their perceptions of working as health coaches in a chronic-disease collaborative team, the teamlet model, we conducted a qualitative study to understand the nature and dynamics of this emerging role. METHODS: During semistructured interviews, 11 health coaches reflected on their yearlong experience in the teamlet model at an urban underserved primary care clinic. Investigators conducted a thematic analysis of transcriptions of the interviews using a grounded theory process. RESULTS: Four themes emerged: 1) health-coach roles and responsibilities included acting as a patient liaison between visits, providing patient education and cultural brokering during medical visits, and helping patients navigate the health care system; 2) communication and relationships in the teamlet model of care were defined by a triad of the patient, health coach, and resident physician; 3) interest in the teamlet model was influenced by allied health workers' prior education and health care roles; and 4) factors influencing the effectiveness of the model were related to clinical and administrative time pressures and competing demands of other work responsibilities. CONCLUSION: Nonlicensed allied health workers participating in collaborative teams have an important role in liaising between patients and their primary care physicians, advocating for patients through cultural brokering, and helping patients navigate the health care system. To maximize their job satisfaction, their selection should involve strong consideration of motivation to participate in these expanded roles, and protected time must be provided for them to carry out their responsibilities and optimize their effectiveness.

Using the Teamlet Model to improve chronic care in an academic primary care practice.

BACKGROUND: Team care can improve management of chronic conditions, but implementing a team approach in an academic primary care clinic presents unique challenges. OBJECTIVES: To implement and evaluate the Teamlet Model, which uses health coaches working with primary care physicians to improve care for patients with diabetes and/or hypertension in an academic practice. DESIGN: Process and outcome measures were compared before and during the intervention in patients seen with the Teamlet Model and in a comparison patient group. PARTICIPANTS: First year family medicine residents, medical assistants, health workers, and adult patients with either type 2 diabetes or hypertension in a large public health clinic. INTERVENTION: Health coaches, in coordination with resident primary care physicians, met with patients before and after clinic visits and called patients between visits. MEASUREMENTS: Measurement of body mass index, assessment of smoking status, and formulation of a self-management plan prior to and during the intervention period for patients in the Teamlet Model group. Testing for LDL and HbA1C and the proportion of patients at goal for blood pressure, LDL, and HbA1C in the Teamlet Model and comparison groups in the year prior to and during implementation. RESULTS: Teamlet patients showed improvement in all measures, though improvement was significant only for smoking, BMI, and self-management plan documentation and testing for LDL (p = 0.02), with a trend towards significance for LDL at goal (p = 0.07). Teamlet patients showed a greater, but non-significant, increase in the proportion of patients tested for HbA1C and proportion reaching goal for blood pressure, HgbA1C, and LDL compared to the comparison group patients. The difference for blood pressure was marginally significant (p = 0.06). In contrast, patients in the comparison group were significantly more likely to have had testing for LDL (P = 0.001). CONCLUSIONS: The Teamlet Model may improve chronic care in academic primary care practices.

Is there an association between athletic amenorrhea and endothelial cell dysfunction?

PURPOSE: To test the hypothesis that young females with athletic amenorrhea and oligomenorrhea show signs of early cardiovascular disease manifested by decreased endothelium-dependent dilation of the brachial artery. METHODS: Ten women with athletic amenorrhea (mean +/- SE, age 21.9 +/- 1.2 yr), 11 with oligomenorrhea (age 20.8 +/- 1.1 yr), and 11 age-matched controls (age 20.2 +/- 1.1 yr) were studied. Study subjects were amenorrheic an average of 2.3 (range 0.6-5) yr and oligomenorrheic an average of 6.2 yr. All ran a minimum of 25 miles.wk. They were nonpregnant and free of metabolic disease. Brachial artery flow-mediated dilation (endothelium-dependent) was measured with a noninvasive ultrasound technique in each group. RESULTS: Endothelium-dependent brachial artery dilation was reduced in the amenorrheic group (1.08 +/- 0.91%) compared with oligomenorrheic (6.44 +/- 1.3%; P< 0.05) and eumenorrheic (6.38 +/- 1.4%; P< 0.05) groups. CONCLUSION: Athletic amenorrhea is associated with reduced endothelium-dependent dilation of the brachial artery. This may predispose to accelerated development of cardiovascular disease.