Effect on cessation counseling of documenting smoking status as a routine vital sign: an ACORN study.

PURPOSE: Guidelines encourage primary care clinicians to document smoking status when obtaining patients' blood pressure, temperature, and pulse rate (vital signs), but whether this practice promotes cessation counseling is unclear. We examined whether the vital sign intervention influences patient-reported frequency and intensity of tobacco cessation counseling. METHODS: This study was a cluster-randomized, controlled trial conducted in the Virginia Ambulatory Care Outcomes Research Network (ACORN). At intervention practices, nurses and medical assistants were instructed to assess the tobacco use status of every adult patient and record it with the traditional vital signs. Control practices did not use any systematic tobacco screening or identification system. Outcomes were the proportion of smokers reporting clinician counseling of any kind and the frequency of 2 counseling subcomponents: simple quit advice and more intensive discussion. RESULTS: A total of 6,729 adult patients (1,149 smokers) at 18 primary care practices completed exit questionnaires during a 6-month comparison period. Among 561 smokers at intervention practices, 61.9% reported receiving any counseling, compared with 53.4% of the 588 smokers at control practices, for a difference of 8.6% (P = .04). The effect was largely restricted to simple advice, which was reported by 59.9% of intervention patients and 51.5% of control patients (P=.04). There was no significant increase in more extensive discussion, with 32.5% and 29.3% of patients at intervention and control practices, respectively, reporting this type of counseling (P=.18). CONCLUSIONS: The vital sign intervention promotes tobacco counseling at primary care practices through a modest increase in simple advice to quit. When implemented as a stand-alone intervention, it does not appear to increase intensive counseling.

Patient perceptions of how physicians communicate during prostate cancer screening discussions: a comparison of residents and faculty.

BACKGROUND: Residents are required to demonstrate competency in communication skills. Prostate cancer screening discussions are examples of complex physician-patient communication processes, requiring an objective presentation of the known risks, potential benefits, and scientific uncertainties surrounding screening. National organizations recommend shared decision making (SDM) in these discussions. METHODS: A stratified analysis to contrast resident and faculty outcomes was planned as part of a randomized controlled trial comparing decision aids for prostate cancer screening in a suburban Washington, DC, residency practice. All eligible men between the ages of 50 and 70 years scheduled for a wellness examination with either a resident or a faculty physician were randomly assigned to one of two intervention arms (Web- or paper-based decision aid) or to the control group (no pre-visit education). Patients were asked to complete exit surveys that evaluated their perceptions of key elements of SDM for prostate cancer screening (PCS). RESULTS: Patients seen by resident physicians were younger than patients seen by faculty, and a smaller proportion had undergone previous prostate-specific antigen (PSA) testing. Patients seen by residents and faculty reported similar levels of the elements of SDM (eg, knowledge about PCS, achieving their desired locus of control for the decision) and similar time spent discussing screening. Both groups also had nearly identical decisional conflict scores and PSA testing rates. Residents discussed more PCS topics (6.3 versus 5.3 topics), including more topics that might influence a patient to decide against screening, than did faculty physicians. CONCLUSIONS: According to patient perceptions, residents appeared to perform as well as faculty in SDM and other aspects of PCS discussions, although the topics that they covered with patients might have differed.

Using Health Information Technology to Reach Patients in Underserved Communities: A Pilot Study to Help Close the Gap With Health Disparities.

INTRODUCTION: In the current era of medical education and curriculum reform, medical schools across the United States are launching innovative approaches to teaching students in order to improve patient outcomes and increase patient safety. One such innovation is the use information technology (IT) that can be used to disseminate health information, especially for patients with limited access to care. Strategies for using health IT to enhance communication between providers and patients in low-income communities can be incorporated into undergraduate medical education (UME) curriculum. METHODS: A pilot study was conducted to determine if IT could serve as an effective means of communication with patients at a free clinic where 100% of the patients are uninsured; the clinic is located in an urban setting and primarily serves Latinos, the working poor, and the homeless. An anonymous survey was administered to patients to assess rates of IT ownership, general IT use, and IT use for health and medical information. RESULTS: The majority of study participants owned a cell phone (92%); one-third used their cell phone to access health or medical information (38%). Most study participants reported using the Internet (72%), and two-thirds had used the Internet to obtain health and medical information (64%). CONCLUSION: Given the difficulties faced by low income and medically underserved communities in accessing healthcare services, the use of IT tools may improve their' access to health information in ways that could enhance patient knowledge and self-management, and perhaps positively impact health outcomes. Therefore, it is essential to incorporate use of IT tools in training for medical students and residents to enhance communication with patients in underserved communities.

Residency faculty opinions about medical student advising: a national survey.

BACKGROUND AND OBJECTIVES: Medical student faculty advisors are charged with providing students the best possible information and advice regarding residency selection and how to increase their likelihood of matching into the program of their choice. Given the lack of clear and consistent processes for ranking residency applicants, medical student advisors will benefit from better insight into the perspectives of family medicine residency (FMR) faculty. METHODS: This study was designed to increase understanding of the perceptions of FMR faculty in evaluating and ranking medical student applicants. We surveyed all FMR programs in the United States and Puerto Rico. Program directors, or their designees, were asked to provide basic program characteristics and then to either agree or disagree with various advising statements medical school faculty might say to students applying to FMR programs. RESULTS: Of the 24 items in the survey, consensus among programs was reached for only seven. CONCLUSIONS: These results, especially given the current climate of an increasing number of applicants for a nearly stable number of residency training slots, clearly support the need for enhanced communication and collaboration between family medicine student advisors and residency educators.

Patient weight counseling choices and outcomes following a primary care and community collaborative intervention.

OBJECTIVE: Obesity has become a public health epidemic in adults and children. Clinician practices need new models to effectively address overweight in patients, yet, practices lack time and resources. We tested a clinician-delivered intervention that utilized community resources for in-depth counseling for unhealthy behaviors including overweight. METHODS: Eligible patients in nine primary care practices were identified using an electronic linkage system (eLinkS) which also automated patient referrals to group (Weight Watcher's), telephone counseling (TC), or usual care. Pre/post-survey data were used to assess factors related to counseling choices as well as changes in BMI (kg/m(2)) and weight-related behaviors using descriptive statistics, unadjusted, and adjusted statistical analyses. RESULTS: Study sample (n=146) was 70% female with a mean age of 57 years. More patients (57%) selected WW, followed by usual care (27%) or TC (16%). Age, gender, clinician recommendation, and counseling program characteristics were influential in counseling selections. Weight Watcher's participants and those in TC, reported statistically significant weight loss, WW participants also reported significant increases in fruit/vegetable intake; after 4 months compared with usual care. CONCLUSIONS: This practice-based intervention utilizing community counseling referrals was associated with positive health behavior change. PRACTICE IMPLICATIONS: Identifying influential factors related to patient weight counseling choices may help guide referrals to community programs.

Promoting primary care smoking-cessation support with quitlines: the QuitLink Randomized Controlled Trial.

BACKGROUND: Counseling by clinicians promotes smoking cessation, but in most U.S. primary care practices, it is difficult to provide more than brief advice to quit in the course of routine work. Telephone quitlines can deliver effective intensive counseling, but few collaborate closely with clinicians. PURPOSE: This study aimed to determine whether cessation support in practices is enhanced by a systems approach, in partnership with quitlines. DESIGN: A cluster RCT was used. SETTING/PARTICIPANTS: Participants included 1817 adult smokers from 16 primary care practices in the Virginia Ambulatory Care Outcomes Research Network. INTERVENTION: An expanded tobacco-use "vital sign" intervention (identify smokers, advise cessation, and assess readiness to quit) that was combined with fax referral of preparation-stage smokers to a quitline providing feedback to practices was compared to a traditional tobacco-use vital sign alone. MAIN OUTCOME MEASURES: The frequency of cessation support (in-office discussion of methods to quit or quitline referral) reported by patients in an exit survey (September 2005-July 2006, analyzed in 2008) was measured. RESULTS: The adjusted percentage of smokers who reported receiving cessation support differed by 12.5% in intervention and control practices (40.7% vs 28.2%, respectively; p<0.001). Both in-office discussion of methods to quit and quitline referral increased significantly with the intervention. Post hoc analysis revealed that the increase in cessation was stable for both patient gender and visit type and was more pronounced with patients aged 35-54 years and with male and more experienced clinicians. CONCLUSIONS: A systems approach to identifying smokers, advising and assessing readiness to quit, combined with a partnership with a quitline, increases delivery of cessation support for primary care patients beyond that accomplished by traditional tobacco-use vital sign screening alone. CLINICAL TRIAL REGISTRATION: NCT00112268.