Decision Aid Use in Primary Care: An Overview and Theory-Based Framework.

BACKGROUND AND OBJECTIVES: Increasing patients' participation in health care is a commonly cited goal. While patient decision aids can promote participation, they remain underutilized. Theory-based models that assess barriers and facilitators to sustained decision aid use are needed. The ready, willing, and able model specifies three preconditions for behavioral change. We present a descriptive analysis of the uptake of patient decision aids in the primary care setting and show how the ready, willing, and able model can be used to identify potential barriers and facilitators. METHODS: An Ovid Medline literature search from January 2004 to November 2014 was used; additional sources were identified from reference lists and through peer consultations. Barriers and facilitators to decision aid use were identified and grouped into salient themes. RESULTS: The ready, willing, and able model provided a simple yet practical framework for identifying the mechanisms that facilitate (or work against) the adoption of patient decision aids within primary care. While time was a prominent barrier, additional barriers such as perceived legitimacy, clinic capacity, processes of care, and the overarching health care environment were also noted. CONCLUSIONS: The ready, willing, and able model posits that several preconditions must first be satisfied before sustained use of patient decision aids can take hold. By pinpointing bottlenecks, the model can inform policies and tailored interventions to target identified problems. Using the model to troubleshoot for bottlenecks prior to the implementation of a decision aid could help to improve uptake and sustained use within the primary care setting.

The cultural context of teaching and learning sexual health care examinations in Japan: a mixed methods case study assessing the use of standardized patient instructors among Japanese family physician trainees of the Shizuoka Family Medicine Program.

BACKGROUND: In contrast to many western nations where family medicine is a cornerstone of the primary care workforce, in Japan the specialty is still developing. A number of services within the bailiwick of family medicine have yet to be fully incorporated into Japanese family medicine training programs, especially those associated with sexual health. This gap constitutes a lost opportunity for addressing sexual health-related conditions, including cancer prevention, diagnosis, and treatment. In this mixed methods case study we investigated the perceived acceptability and impact of a standardized patient instructor (SPI) program that trained Japanese family medicine residents in female breast, pelvic, male genital, and prostate examinations. CASE DESCRIPTION: Building on an existing partnership between the University of Michigan, USA, and the Shizuoka Family Medicine Program, Japan, Japanese family medicine residents received SPI-based training in female breast, pelvic, male genital, and prostate examinations at the University of Michigan. A mixed methods case study targeting residents, trainers, and staff was employed using post-training feedback, semi-structured interviews, and web-based questionnaire. DISCUSSION AND EVALUATION: Residents' and SPIs' perceptions of the training were universally positive, with SPIs observing a positive effect on residents' knowledge, confidence, and skill. SPIs found specific instruction-related approaches to be particularly helpful, such as the positioning of the interpreter and the timing of interpreter use. SPIs provided an important opportunity for residents to learn about the patient's perspective and to practice newly learned skills. Respondents noted a general preference for gender concordance when providing gender-specific health care; also noted were too few opportunities to practice skills after returning to Japan. For cultural reasons, both residents and staff deemed it would be difficult to implement a similar SPI-based program within Japan. CONCLUSIONS: While the SPI program was perceived favorably, without sufficient practice and supervision the skills acquired by residents during the training may not be fully retained. Deep-rooted taboos surrounding gender-specific health care appear to be a significant barrier preventing experimentation with SPI-based sexual health training in Japan. The feasibility of implementing a similar training program within Japan remains uncertain. More research is needed to understand challenges and how they can be overcome.

A Systems Approach to Improving Tdap Immunization Within 5 Community-Based Family Practice Settings: Working Differently (and Better) by Transforming the Structure and Process of Care.

OBJECTIVES: We examined how family medicine clinic physicians and staff worked in collaborative teams to implement an automated clinical reminder to improve tetanus, diphtheria, and acellular pertussis (Tdap) booster vaccine administration and documentation. METHODS: A clinical reminder was developed at 5 University of Michigan family medicine clinics to identify patients 11 to 64 years old who were in need of the Tdap booster vaccine. Quality improvement cycles were used to improve clinic care processes. Immunization rates from 2008 to 2011 were compared with rates at 4 primary care control clinics. RESULTS: Vaccination rates among eligible patients increased from 15.5% to 47.3% within the family medicine clinics and from 14.1% to 30.2% within the control clinics. After adjustment for covariates, family medicine patients had a higher probability of vaccination than control patients during each measurement period (0.17 vs 0.15 at baseline, 0.53 vs 0.22 during year 1, and 0.50 vs 0.30 during year 2). CONCLUSIONS: Automated clinical reminders, when designed and implemented via a consensus-based framework that addresses the process of care, can dramatically improve provision of preventive health care.

The use of medical scribes in health care settings: a systematic review and future directions.

BACKGROUND: Electronic health records (EHRs) hold promise to improve productivity, quality, and outcomes; however, using EHRs can be cumbersome, disruptive to workflow, and off-putting to patients and clinicians. One proposed solution to this problem is the use of medical scribes. The purpose of this systematic review is to summarize the literature investigating the effect of medical scribes on health care productivity, quality, and outcomes. Implications for future research are discussed. METHODS: A keyword search of the Cochrane Library, OvidSP Medline database, and Embase database from January 2000 through September 2014 was performed using the terms scribe or scribes in the title or abstract. To ensure no potentially eligible articles were missed, a second search was done using Google Scholar. English-language, peer-reviewed studies assessing the effect of medical scribes on health care productivity, quality, and outcomes were retained. Identified studies were assessed and the findings reported. RESULTS: Five studies were identified. Three studies assessed scribe use in an emergency department, 1 in a cardiology clinic, and 1 in a urology clinic. Two of 3 studies reported scribes had no effect on patient satisfaction; 2 of 2 reported improved clinician satisfaction; 2 of 3 reported an increase in the number of patients; 2 of 2 reported an increase in the number of relative value units per hour; 1 of 1 reported increased revenue; 3 of 4 reported improved time-related efficiencies; and 1 of 1 reported improved patient-clinician interactions. CONCLUSIONS: Available evidence suggests medical scribes may improve clinician satisfaction, productivity, time-related efficiencies, revenue, and patient-clinician interactions. Because the number of studies is small, and because each study suffered important limitations, confidence in the reliability of the evidence is significantly constrained. Given the nascent state of the science, methodologically rigorous and sufficiently powered studies are greatly needed.

Diagnosis and management of generalized anxiety disorder and panic disorder in adults.

Generalized anxiety disorder (GAD) and panic disorder (PD) are among the most common mental disorders in the United States, and they can negatively impact a patient's quality of life and disrupt important activities of daily living. Evidence suggests that the rates of missed diagnoses and misdiagnosis of GAD and PD are high, with symptoms often ascribed to physical causes. Diagnosing GAD and PD requires a broad differential and caution to identify confounding variables and comorbid conditions. Screening and monitoring tools can be used to help make the diagnosis and monitor response to therapy. The GAD-7 and the Severity Measure for Panic Disorder are free diagnostic tools. Successful outcomes may require a combination of treatment modalities tailored to the individual patient. Treatment often includes medications such as selective serotonin reuptake inhibitors and/or psychotherapy, both of which are highly effective. Among psychotherapeutic treatments, cognitive behavior therapy has been studied widely and has an extensive evidence base. Benzodiazepines are effective in reducing anxiety symptoms, but their use is limited by risk of abuse and adverse effect profiles. Physical activity can reduce symptoms of GAD and PD. A number of complementary and alternative treatments are often used; however, evidence is limited for most. Several common botanicals and supplements can potentiate serotonin syndrome when used in combination with antidepressants. Medication should be continued for 12 months before tapering to prevent relapse.