Search

Background and Objectives: Fear of falling is a substantial barrier to walking and has been associated with increased fall risks. This study examines neighborhood environmental risk factors related to fear of outdoor falling in middle-aged and older adults., Research Design and Methods: A total of 394 participants aged 50 years or older living independently in the community were recruited between 2013 and 2014 from an integrated health care network serving Central Texas. Fear of outdoor falling and perceived neighborhood environmental variables were assessed using self-reported questionnaires. Logistic regression identified perceived neighborhood environmental variables associated with fear of outdoor falling., Results: Sixty-nine (17.9%) of 385 participants reported having a fear of outdoor falling. Compared to those who did not report a fear of outdoor falling, those who reported having a fear of outdoor falling were more likely to be adults aged 65 years or older (odds ratio [OR] = 2.974, 95% confidence interval [CI] = 1.247-7.094), be female (OR = 4.423, 95% CI = 1.830-10.689), have difficulty with walking for a quarter of a mile (OR = 2.761, 95% CI = 1.124-6.782), and have had a fall in the past year (OR = 4.720, 95% CI = 1.472-15.137). Among the neighborhood environmental characteristics examined, low traffic speed on streets (OR = 0.420, 95% CI = 0.188-0.935), drainage ditches (OR = 2.383, 95% CI = 1.136-5.000), and broken sidewalks (OR = 3.800, 95% CI = 1.742-8.288) were associated with the odds of having a fear of outdoor falling., Discussion and Implications: In addition to the individual factors, findings from this study suggest the importance of addressing the environmental risk factors in identifying and reducing fear of outdoor falling among middle-aged and older adults.

Background: Most older adults do not adhere to the US Centers for Disease Control physical activity guidelines; their physical inactivity contributes to overweight and multiple chronic conditions. An urgent need exists for effective physical activity-promotion programs for the large number of older adults in the United States., Objective: This study presents the development of the intervention and trial protocol of iCanFit 2.0, a multi-level, mobile-enabled, physical activity-promotion program developed for overweight older adults in primary care settings., Methods: The iCanFit 2.0 program was developed based on our prior mHealth intervention programs, qualitative interviews with older patients in a primary care clinic, and iterative discussions with key stakeholders. We will test the efficacy of iCanFit 2.0 through a cluster randomized controlled trial in six pairs of primary care clinics., Results: The proposed protocol received a high score in a National Institutes of Health review, but was not funded due to limited funding sources. We are seeking other funding sources to conduct the project., Conclusions: The iCanFit 2.0 program is one of the first multi-level, mobile-enabled, physical activity-promotion programs for older adults in a primary care setting. The development process has actively involved older patients and other key stakeholders. The patients, primary care providers, health coaches, and family and friends were engaged in the program using a low-cost, off-the-shelf mobile tool. Such low-cost, multi-level programs can potentially address the high prevalence of physical inactivity in older adults., (©Y Alicia Hong, Samuel N Forjuoh, Marcia G Ory, Michael D Reis, Huiyan Sang. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 12.09.2017.)

Introduction: Primary care providers (PCPs) are strategically positioned to communicate with their overweight/obese patients about positive behavioral changes to improve health and functioning. Demographic and behavioral correlates of receiving a recommendation for more physical activity (PA) from a PCP by overweight/obese patients were assessed., Methods: Community-dwelling adults aged ≥50 years from four Texas cities who were seen by a family physician in a primary care clinic were surveyed from October 2013 to June 2014. Multivariate logistic regression predicted the likelihood of receiving a PA recommendation from a PCP, controlling for sociodemographic factors, health conditions, and walking behaviors. The analysis was conducted in 2016., Results: Of the total 388 participants (survey response rate, 6.8%), 30.1% were obese, 55.4% were female, and most were non-Hispanic white (82.9%), married (75.6%), or reported an annual household income of ≥$50,000 (66.8%). Receipt of a PA recommendation from a PCP (n=151, 38.9%) was significantly correlated with reporting poor to fair health (OR=7.33, 95% CI=2.6, 20.32), obesity (OR=2.95, 95% CI=1.69, 5.14), having only a little or some difficulty walking for a quarter of a mile (OR=2.94, 95% CI=1.41, 5.88), not walking the recommended ≥150 minutes for any purpose (OR=2.60, 95% CI=1.25, 5.38), and being employed (OR=2.11, 95% CI=1.13. 3.94)., Conclusions: PCPs seem to be targeting obese, inactive individuals with poor to fair health, populations traditionally not encouraged to be more physically active. These findings are consistent with the current trend in medical care to recommend positive lifestyle changes to a broader range of the population., (Copyright © 2017 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: This study examined the association between selected sociodemographic, health, and built environmental factors and walking behaviors of middle-aged and older overweight/obese adults., Methods: Subjective data were obtained from surveys administered to community-dwelling overweight/obese adults aged ≥50 years residing in four Texas cities from October 2013 to June 2014, along with objective data on neighborhood walkability (Walk Score™). Multivariate logistic regression identified factors predicting the odds of walking the recommended ≥150 minutes per week for any purpose., Results: Of 253 participants, the majority were non-Hispanic white (81.8%), married (74.5%), and male (53.4%) and reported an annual income of ≥$50,000 (65.5%). Approximately, half were employed (49.6%) or had at least a college degree (51.6%). Walking the recommended ≥150 minutes per week for any purpose ( n = 57, 22.5%) was significantly associated with having at least a college degree (OR = 5.55, 95% CI = 1.79-17.25), having no difficulty walking a quarter of a mile (OR = 5.18, 95% CI = 1.30-20.83), and being unemployed (OR = 3.25, 95% CI = 1.18-8.93) as well as perceived presence of sidewalks/protected walkways (OR = 3.56, 95% CI = 1.10-11.50) and perceived absence of distracted drivers in the neighborhood (OR = 4.08, 95% CI = 1.47-11.36)., Conclusion: Addressing neighborhood conditions related to distracted drivers and pedestrian infrastructure may promote walking among middle-aged and older overweight/obese individuals.

We aimed to determine the relationship between neighborhood characteristics (walkability, cohesion/safety) and recommended activity levels among community-dwelling middle-aged and older adults. Subjective and objective data on 394 individuals aged ≥50 years were used to assess the likelihood of walking ≥150 min/week. Environmental factors associated with a greater likelihood of any walking ≥150 min/week included living in a neighborhood with high perception of cohesion/safety versus low, living in walkable areas versus car-dependent, and living in an area with a low-moderate median income versus the lowest. Middle-aged and older adults were more likely to walk ≥150 min/week in a walkable, perceived safe/cohesive neighborhood. Identifying neighborhood factors associated with promoting walking among this population can enable stakeholders (e.g., researchers, planners, and policy makers) to direct interventions focusing on the built environment.

Rationale: Neighborhood safety is important for older adults' health and wellbeing, but there has not been a synthesis in the literature of what is currently known about this construct., Objectives: This systematic literature review, following the PRISMA guidelines, focuses on identifying neighborhood safety factors associated with health-related outcomes and behaviors of older adults in the U.S., Methods: A search was conducted in 2014 via Academic Search Complete, CINAHL, Embase, MEDLINE, SportDis, and Transportation Databases. Based on our inclusion and exclusion criteria, we identified thirty-two articles for review., Results: Sixteen studies examined health outcomes such as health status, mental health, physical function, morbidity/mortality, and obesity; the other sixteen studies focused on health behaviors, such as physical activity and walking. Four domains of neighborhood safety were identified: overall/general neighborhood safety; crime-related safety; traffic-related safety; and proxies for safety (e.g., vandalism, graffiti). Overall/general neighborhood safety appeared most relevant to mental health and physical function. Traffic-related safety was most pertinent to physical activity, while crime-related safety was more consistently associated with mental health and walking. While all safety variables were significantly associated with mental health, no significant associations were found for obesity. We also found that specific measures or constructs of safety were not applied consistently across the examined studies, making it difficult to compare the results., Conclusion: This review identified several important gaps in the existing studies dealing with neighborhood safety-health relationships among older adults. Further studies are needed that examine the different roles of multidimensional neighborhood safety in promoting the community health, not only in the U.S., but globally., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Regular physical activity (PA) is a major factor in maintaining health in aging populations. This study examines the influences of sociodemographic, health, and environmental characteristics on older adults' walking behaviors, and the role physicians can play in promoting physical activity., Methods: Online and paper surveys (n = 272) were distributed to community-dwelling older (age ≥ 60) adults from a large integrated healthcare system in two counties in Central Texas. Descriptive statistics were utilized to characterize participant's walking behaviors and places. Multivariate logistic regression was employed to predict being: 1) a frequent walker (i.e., walking at least three times a week); and 2) meeting the Centers for Disease Control and Prevention (CDC) PA recommendation through walking (i.e., walking ≥150 min per week), while considering sociodemographic, health, and environmental factors., Results: Individuals had a median age of 69 years, were of both genders (50.37 % female), and were primarily non-Hispanic White (84.87 %). While the majority (59.55 %) walked at least three times a week, only 27.86 % walked ≥150 min a week. Factors associated with a lower likelihood of being frequent walkers included experiencing poor mental health in the past month (OR = 0.345, 95 % CI = 0.185-0.645) and residing in areas with low or moderate (versus high) perceived neighborhood cohesion (OR = 0.471, 95 % CI = 0.228-0.974), while those in Census Tracts reflecting populations with a lower median age were more likely to report frequent walking behavior (OR = 1.799, 95 % CI = 1.034-3.131). Factors associated with a lower likelihood of meeting the CDC PA recommendation included being 60-69 years (versus 70 years or older) (OR = 0.538, 95 % CI = 0.290-0.997), experiencing poor mental health in the past month (OR = 0.432, 95 % CI = 0.198-0.944), and lacking social support for walking (OR = 0.383, 95 % CI = 0.154-0.957)., Conclusion: Given the health benefits, PA promotion must be seen as a national responsibility. In particular, physicians have a major role to play in communicating the importance of PA to their older patients and making discussions about strategies for overcoming barriers to walking an integral part of their clinical encounter with these patients.

The authors examined the responses of 63 primary care physicians to diabetes clinical protocols (DCPs) for the management of type II diabetes (T2DM). We measured physician demographics, current diabetes patient loads, and responses to DCPs (physician attitudes, physician familiarity, and physician recommendation of DCPs) using a 20-question electronic survey. Results of the survey indicate that primary care physicians may be unfamiliar with the benefits of diabetes clinical protocols for the self-management of T2DM. Given the importance of diabetes self-management education in controlling T2DM, those interested in implementing DCPs should address the beliefs and attitudes of primary care physicians.

Purpose: We tested whether prospective use of electronic health record-based trigger algorithms to identify patients at risk of diagnostic delays could prevent delays in diagnostic evaluation for cancer., Methods: We performed a cluster randomized controlled trial of primary care providers (PCPs) at two sites to test whether triggers that prospectively identify patients with potential delays in diagnostic evaluation for lung, colorectal, or prostate cancer can reduce time to follow-up diagnostic evaluation. Intervention steps included queries of the electronic health record repository for patients with abnormal findings and lack of associated follow-up actions, manual review of triggered records, and communication of this information to PCPs via secure e-mail and, if needed, phone calls to ensure message receipt. We compared times to diagnostic evaluation and proportions of patients followed up between intervention and control cohorts based on final review at 7 months., Results: We recruited 72 PCPs (36 in the intervention group and 36 in the control group) and applied the trigger to all patients under their care from April 20, 2011, to July 19, 2012. Of 10,673 patients with abnormal findings, the trigger flagged 1,256 patients (11.8%) as high risk for delayed diagnostic evaluation. Times to diagnostic evaluation were significantly lower in intervention patients compared with control patients flagged by the colorectal trigger (median, 104 v 200 days, respectively; n = 557; P < .001) and prostate trigger (40% received evaluation at 144 v 192 days, respectively; n = 157; P < .001) but not the lung trigger (median, 65 v 93 days, respectively; n = 19; P = .59). More intervention patients than control patients received diagnostic evaluation by final review (73.4% v 52.2%, respectively; relative risk, 1.41; 95% CI, 1.25 to 1.58)., Conclusion: Electronic trigger-based interventions seem to be effective in reducing time to diagnostic evaluation of colorectal and prostate cancer as well as improving the proportion of patients who receive follow-up. Similar interventions could improve timeliness of diagnosis of other serious conditions., (© 2015 by American Society of Clinical Oncology.)

Background: The benefits of physical activity for cancer survivors are well documented. However, few older cancer survivors are engaged in regular physical activity. Mobile technologies may be an effective method to deliver physical activity promotion programs for older cancer survivors. iCanFit, a mobile-enabled Web-based app, was developed based on formative research and usability testing. This app includes interactive features of physical activity, goal setting and tracking, and receiving personalized visual feedback., Objective: The aim of this study is to pilot test the initial efficacy of iCanFit., Methods: Older cancer survivors (N=30) were recruited online through our collaborative partnership with a cancer survivor's organization. After the participants completed an online baseline survey, they were asked to use the iCanFit website. Instructional videos on how to use the web app were available on the website. Participants were asked to complete a follow-up survey 2-3 months later. Participants' physical activity, quality of life, and their experience with iCanFit were measured., Results: A total of 30 participants completed the baseline survey, and 26 of them (87%, 26/30) also completed a follow-up survey 2-3 months later. The median age of participants was 69 years (range 60-78). Participants' quality of life and engagement in regular physical activity improved significantly after the use of iCanFit. Participants indicated a general affinity towards the key function "Goals" in iCanFit, which motivated continued activity. They also provided suggestions to further improve the app (eg, adding a reminder functionality, easier or alternative ways of entering activities)., Conclusion: The interactive Web-based app iCanFit has demonstrated initial efficacy. Even though our study was limited by a small sample size, convenience sampling, and a short follow-up period, results suggest that using mobile tools to promote physical activity and healthy living among older cancer survivors holds promise. Next steps include refining iCanFit based on users' feedback and developing versatile functionality to allow easier physical activity goal setting and tracking. We also call for more studies on developing and evaluating mobile and web apps for older cancer survivors., (©Yan Alicia Hong, Daniel Goldberg, Marcia G Ory, Samuel D Towne Jr, Samuel N Forjuoh, Debra Kellstedt, Suojin Wang. , 26.06.2015.)

Objective: To determine physician perspectives about direct notification of normal and abnormal test results., Methods: We conducted a cross-sectional survey at five clinical sites in the US and Australia. The US-based study was conducted via web-based survey of primary care physicians and specialists between July and October 2012. An identical paper-based survey was self-administered between June and September 2012 with specialists in Australia., Results: Of 1417 physicians invited, 315 (22.2%) completed the survey. Two-thirds (65.3%) believed that patients should be directly notified of normal results, but only 21.3% were comfortable with direct notification of clinically significant abnormal results. Physicians were more likely to endorse direct notification of abnormal results if they believed it would reduce the number of patients lost to follow-up (OR=4.98, 95%CI=2.21-1.21) or if they had personally missed an abnormal test result (OR=2.95, 95%CI=1.44-6.02). Conversely, physicians were less likely to endorse if they believed that direct notification interfered with the practice of medicine (OR=0.39, 95%CI=0.20-0.74)., Conclusion: Physicians we surveyed generally favor direct notification of normal results but appear to have substantial concerns about direct notification of abnormal results., Practice Implications: Widespread use of direct notification should be accompanied by strategies to help patients manage test result abnormalities they receive., (Published by Elsevier Ireland Ltd.)

Aim: To assess the effectiveness of the Chronic Disease Self-Management Program (CDSMP) on glycated hemoglobin A1c (HbA1c) and selected self-reported measures., Methods: We compared patients who received a diabetes self-care behavioral intervention, the CDSMP developed at the Stanford University, with controls who received usual care on their HbA1c and selected self-reported measures, including diabetes self-care activities, health-related quality of life (HRQOL), pain and fatigue. The subjects were a subset of participants enrolled in a randomized controlled trial that took place at seven regional clinics of a university-affiliated integrated healthcare system of a multi-specialty group practice between January 2009 and June 2011. The primary outcome was change in HbA1c from randomization to 12 mo. Data were analyzed using multilevel statistical models and linear mixed models to provide unbiased estimates of intervention effects., Results: Demographic and baseline clinical characteristics were generally comparable between the two groups. The average baseline HbA1c values in the CDSMP and control groups were 9.4% and 9.2%, respectively. Significant reductions in HbA1c were seen at 12 mo for the two groups, with adjusted changes around 0.6% (P < 0.0001), but the reductions did not differ significantly between the two groups (P = 0.885). Few significant differences were observed in participants' diabetes self-care activities. No significant differences were observed in the participants' HRQOL, pain, or fatigue measures., Conclusion: The CDSMP intervention may not lower HbA1c any better than good routine care in an integrated healthcare system. More research is needed to understand the benefits of self-management programs in primary care in different settings and populations.

Objective: This study compared time-to-hospitalization among subjects enrolled in different diabetes self-management programs (DSMP). We sought to determine whether the interventions delayed the occurrence of any acute event necessitating hospitalization., Methods: Electronic medical records (EMR) were obtained for 376 adults enrolled in a randomized controlled trial (RCT) of Type 2 diabetes (T2DM) self-management programs. All study participants had uncontrolled diabetes and were randomized into either: personal digital assistant (PDA), Chronic Disease Self-Management Program (CDSMP), combined PDA and CDSMP (COM), or usual care (UC) groups. Subjects were followed for a maximum of two years. Time-to-hospitalization was measured as the interval between study enrollment and the occurrence of a diabetes-related hospitalization., Results: Subjects enrolled in the CDSMP-only arm had significantly prolonged time-to-hospitalization (Hazard ratio: 0.10; p=0.002) when compared to subjects in the control arm. Subjects in the PDA-only and combined PDA and CDSMP arms showed no improvements in comparison to the control arm., Conclusion: CDSMP can be effective in delaying time-to-hospitalization among patients with T2DM., Practice Implications: Reducing unnecessary healthcare utilization, particularly inpatient hospitalization is a key strategy to improving the quality of health care and lowering associated health care costs. The CDSMP offers the potential to reduce time-to-hospitalization among T2DM patients., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

The objective was to assess the impacts of diabetes self-management programs on productivity-related indirect costs of the disease. Using an employer's perspective, this study estimated the productivity losses associated with: (1) employee absence on the job, (2) diabetes-related disability, (3) employee presence on the job, and (4) early mortality. Data were obtained from electronic medical records and survey responses of 376 adults aged ≥18 years who were enrolled in a randomized controlled trial of type 2 diabetes self-management programs. All study participants had uncontrolled diabetes and were randomized into one of 4 study arms: personal digital assistant (PDA), chronic disease self-management program (CDSMP), combined PDA and CDSMP, and usual care (UC). The human-capital approach was used to estimate lost productivity resulting from 1, 2, 3, and 4 above, which are summed to obtain total productivity loss. Using robust regression, total productivity loss was modeled as a function of the diabetes self-management programs and other identified demographic and clinical characteristics. Compared to subjects in the UC arm, there were no statistically significant differences in productivity losses among persons undergoing any of the 3 diabetes management interventions. Males were associated with higher productivity losses (+$708/year; P<0.001) and persons with greater than high school education were associated with additional productivity losses (+$758/year; P<0.001). Persons with more than 1 comorbid condition were marginally associated with lower productivity losses (-$326/year; P=0.055). No evidence was found that the chronic disease management programs examined in this trial affect indirect productivity losses.

Background: There is a growing recognition of the importance of lifestyle behavior change for health promotion and disease prevention, as well as the concomitant influence of patient-physician communication on effective behavior change. Mobile technology is increasingly being recognized as an important and efficient tool to collect patients' health behavior data and facilitate patient-physician communication., Objective: The aim of this study was to assess the feasibility of an iPod touch-based health behavior assessment (HBA) tool in enhancing patient-physician collaborative goal-setting for health promotion in primary care., Methods: A total of 109 patients from three primary care clinics in central Texas completed a brief HBA, which was programmed on an iPod touch device. An instant feedback report was generated for the patient and their physician simultaneously to facilitate collaborative goal-setting. Within approximately 7 days of the HBA, the patients were phoned for a follow-up survey for their feedback on the iPod touch-based HBA and resultant patient-physician communication., Results: Patients were able to complete an HBA on the iPod touch with ease. Among those who completed the follow-up survey (n=83), 30% (25/83) reported that their physicians discussed the HBA report with them, while 29% (24/83) established behavior change goals with them. More than 90% (75/83) of the patients reported positive experiences with the iPod touch-based HBA., Conclusions: It is feasible to use mobile tools for HBA in the primary care setting. The HBA also facilitated patient-physician communication on behavior change. However, more research is needed on the effectiveness of large scale dissemination of mobile-based HBA technology on health communication and behavior change for preventing or managing lifestyle-related chronic conditions, such as obesity, diabetes, cancer, or heart diseases.

Background: Diabetes self-care by patients has been shown to assist in the reduction of disease severity and associated medical costs. We compared the effectiveness of two different diabetes self-care interventions on glycemic control in a racially/ethnically diverse population. We also explored whether reductions in glycated hemoglobin (HbA1c) will be more marked in minority persons., Methods: We conducted an open-label randomized controlled trial of 376 patients with type 2 diabetes aged ≥18 years and whose last measured HbA1c was ≥7.5% (≥58 mmol/mol). Participants were randomized to: 1) a Chronic Disease Self-Management Program (CDSMP; n = 101); 2) a diabetes self-care software on a personal digital assistant (PDA; n = 81); 3) a combination of interventions (CDSMP + PDA; n = 99); or 4) usual care (control; n = 95). Enrollment occurred January 2009-June 2011 at seven regional clinics of a university-affiliated multi-specialty group practice. The primary outcome was change in HbA1c from randomization to 12 months. Data were analyzed using a multilevel statistical model., Results: Average baseline HbA1c in the CDSMP, PDA, CDSMP + PDA, and control arms were 9.4%, 9.3%, 9.2%, and 9.2%, respectively. HbA1c reductions at 12 months for the groups averaged 1.1%, 0.7%, 1.1%, and 0.7%, respectively and did not differ significantly from baseline based on the model (P = .771). Besides the participants in the PDA group reporting eating more high-fat foods compared to their counterparts (P < .004), no other significant differences were observed in participants' diabetes self-care activities. Exploratory sub-analysis did not reveal any marked reductions in HbA1c for minority persons but rather modest reductions for all racial/ethnic groups., Conclusions: Although behavioral and technological interventions can result in some modest improvements in glycemic control, these interventions did not fare significantly better than usual care in achieving glycemic control. More research is needed to understand how these interventions can be most effective in clinical practice. The reduction in HbA1c levels found in our control group that received usual care also suggests that good routine care in an integrated healthcare system can lead to better glycemic control., Trial Registration: Clinicaltrials.gov Identifier: NCT01221090.

Primary care physicians' perceptions of diabetes treatment protocols (DTPs) in the management of type 2 diabetes mellitus (T2DM) were examined at the individual and organizational levels. A 27-item electronic survey was administered to primary care physicians from an integrated multispecialty health care system in Texas. Information was collected on various aspects of DTPs, including attitudes toward these protocols, perceived barriers, and knowledge, as well as utilization of diabetes self-management programs. Besides quality of care, the primary care physicians surveyed generally had mixed feelings regarding DTPs' ability to contribute positively to other aspects of health care; in addition, only a small percentage were familiar with some currently available self-management programs. Given that implementation of DTPs depends on primary care physicians, we should address physicians' attitudes and perceptions toward DTPs so as to increase utilization of these helpful protocols.

Background: Delayed diagnosis of cancer can lead to patient harm, and strategies are needed to proactively and efficiently detect such delays in care. We aimed to develop and evaluate 'trigger' algorithms to electronically flag medical records of patients with potential delays in prostate and colorectal cancer (CRC) diagnosis., Methods: We mined retrospective data from two large integrated health systems with comprehensive electronic health records (EHR) to iteratively develop triggers. Data mining algorithms identified all patient records with specific demographics and a lack of appropriate and timely follow-up actions on four diagnostic clues that were newly documented in the EHR: abnormal prostate-specific antigen (PSA), positive faecal occult blood test (FOBT), iron-deficiency anaemia (IDA), and haematochezia. Triggers subsequently excluded patients not needing follow-up (eg, terminal illness) or who had already received appropriate and timely care. Each of the four final triggers was applied to a test cohort, and chart reviews of randomly selected records identified by the triggers were used to calculate positive predictive values (PPV)., Results: The PSA trigger was applied to records of 292 587 patients seen between 1 January 2009 and 31 December 2009, and the CRC triggers were applied to 291 773 patients seen between 1 March 2009 and 28 February 2010. Overall, 1564 trigger positive patients were identified (426 PSA, 355 FOBT, 610 IDA and 173 haematochezia). Record reviews revealed PPVs of 70.2%, 66.7%, 67.5%, and 58.3% for the PSA, FOBT, IDA and haematochezia triggers, respectively. Use of all four triggers at the study sites could detect an estimated 1048 instances of delayed or missed follow-up of abnormal findings annually and 47 high-grade cancers., Conclusions: EHR-based triggers can be used successfully to flag patient records lacking follow-up of abnormal clinical findings suspicious for cancer.

This study examines factors associated with completion (attendance ≥4 of 6 sessions) of the Chronic Disease Self-Management Program (CDSMP) by adults with type 2 diabetes. Patients with glycated hemoglobin ≥ 7.5 within 6 months were enrolled and completed self-report measures on demographics, health status, and self-care (n = 146). Significant differences in completion status were found for several self-care factors including healthful eating plan, spacing carbohydrates, frequent exercise, and general health. Completion was not influenced by race/ethnicity or socioeconomics. Results suggest better attention to exercise and nutrition at the start of CDSMP may be associated with completion, regardless of demographic subgroup.

Importance: Diagnostic errors are an understudied aspect of ambulatory patient safety., Objectives: To determine the types of diseases missed and the diagnostic processes involved in cases of confirmed diagnostic errors in primary care settings and to determine whether record reviews could shed light on potential contributory factors to inform future interventions., Design: We reviewed medical records of diagnostic errors detected at 2 sites through electronic health record-based triggers. Triggers were based on patterns of patients' unexpected return visits after an initial primary care index visit., Setting: A large urban Veterans Affairs facility and a large integrated private health care system., Participants: Our study focused on 190 unique instances of diagnostic errors detected in primary care visits between October 1, 2006, and September 30, 2007., Main Outcome Measures: Through medical record reviews, we collected data on presenting symptoms at the index visit, types of diagnoses missed, process breakdowns, potential contributory factors, and potential for harm from errors., Results: In 190 cases, a total of 68 unique diagnoses were missed. Most missed diagnoses were common conditions in primary care, with pneumonia (6.7%), decompensated congestive heart failure (5.7%), acute renal failure (5.3%), cancer (primary) (5.3%), and urinary tract infection or pyelonephritis (4.8%) being most common. Process breakdowns most frequently involved the patient-practitioner clinical encounter (78.9%) but were also related to referrals (19.5%), patient-related factors (16.3%), follow-up and tracking of diagnostic information (14.7%), and performance and interpretation of diagnostic tests (13.7%). A total of 43.7% of cases involved more than one of these processes. Patient-practitioner encounter breakdowns were primarily related to problems with history-taking (56.3%), examination (47.4%), and/or ordering diagnostic tests for further workup (57.4%). Most errors were associated with potential for moderate to severe harm., Conclusions and Relevance: Diagnostic errors identified in our study involved a large variety of common diseases and had significant potential for harm. Most errors were related to process breakdowns in the patient-practitioner clinical encounter. Preventive interventions should target common contributory factors across diagnoses, especially those that involve data gathering and synthesis in the patient-practitioner encounter.

Walking is a popular form of physical activity that can bring many public health benefits. It can be even more beneficial to those who are currently obese or overweight. However, many barriers discourage people from walking, ranging from lack of motivation to unsafe neighborhood environments, and such barriers vary with age. This study addresses barriers and motivators to walking among overweight and obese adults, and examines their age variations. Particular emphasis was given to modifiable environmental factors as the priority intervention targets. A survey of 161 overweight and obese adults recruited from a large integrated healthcare system in central Texas provided data on walking, demographics, motivators and barriers. Descriptive statistics and correlation analysis were conducted. The respondents had a mean age of 48.4 (20-86), and were predominantly female (80.8%), non-Hispanic White (86.0%), and obese (mean BMI = 32.5). Popular environmental barriers to walking were: bad weather, inadequate lighting, no shade, unattended dogs, disconnected sidewalks, poor walking surfaces, no interesting places to walk nearby, and no benches (74.5-38.5%). Even and smooth walking surfaces and benches were more frequently reported by older adults as motivators. Proximity to recreational facilities was a stronger motivator for younger adults. Two safety related barriers, fear of injury (older adults) and traffic safety concerns (younger adults), also showed significant age differences. Overweight and obese adults experience substantial environmental barriers to walking, but many of them are modifiable. Observed age variations suggest that future interventions may be more effective if tailored to address age-specific barriers.

Purpose: The purpose of this article was to examine primary care providers' perceived challenges when implementing evidence-based diabetes self-management guidelines and opportunities for promoting the use of such guidelines in practice., Methods: We engaged 3 group discussions with 43 key stakeholders representing family physicians, medical directors, and quality assurance leaders in a large, university-affiliated, integrated health care organization in Central Texas. Transcripts from group discussions were summarized using thematic content analysis., Results: Key themes that emerged as challenges of implementing evidence-based diabetes self-management guidelines included lack of easily retrievable electronic patient health information, inadequate coordination with other health care providers when implementing guidelines, conflict between information in the guidelines and physicians' knowledge, and physician compensation by patient load rather than by quality of care. Two main opportunities identified were the use of health coaches or nurses trained in diabetes self-management and active collaboration between practicing providers and key stakeholders in the development and dissemination of guidelines., Conclusion: Our study shows a need for involving front-line family physicians and other primary care providers as well as patients in the design and development of best practice guidelines to enhance implementation of diabetes self-management guidelines in primary care settings.

Purpose: This study explored the impact of personal digital assistant (PDA) features, users' perceptions, and other factors that may have hindered PDA acceptability and usability as technology advances in e-health diabetes self-management., Study Design and Results: An ongoing study on PDA usage is set within the context of the advancements of Web 2.0 for type 2 diabetes mellitus (T2DM) self-management e-interventions. Advancements in technology as it relates to the future of T2DM mobile applications are discussed as possible deterrents of PDA acceptability and usability., Conclusions: This case study illustrates the importance of addressing factors that may impede the adoption of electronic devices intended for sustained health behavior change. Recognizing the importance of individual perception within the context of rapid technological advancements is imperative for designing future health interventions. Incorporating electronic devices that individuals are more inclined to utilize, such as smartphones, as the platform for health interventions is a promising strategy to improve acceptability and usability, allowing researchers to more accurately assess the health benefits of self-management programs.

Background and Objectives: Primary care practitioners can play a significant role in helping patients adopt healthy behaviors such as physical activity (PA). The aim of this qualitative study was to assess family physicians' understanding and perception of the personal and environmental factors influencing PA, especially walking, and factors affecting their counseling of obese patients about environmental motivators and barriers to PA., Methods: We conducted five focus groups with 35 family physicians and 14 family medicine residents in four clinics and a residency program affiliated with CenTexNet, a primary care practice-based research network in central Texas. Data were transcribed and analyzed using thematic content analysis., Results: Physicians were aware of the PA guidelines, but not many actually brought up PA during their counseling of patients. Physicians agreed that neighborhood environments are important for walking and reported that their patients often brought up environmental barriers. Physicians recommended walking as an ideal type of PA for obese patients and sidewalks, parks, and trails/tracks with smooth and soft surfaces as ideal places to engage in walking. However, they rarely talked about these factors with their patients due to a perceived ineffectiveness in counseling, an inability to address environmental factors, and time constraints in the medical encounter., Conclusions: While physicians believe neighborhood environments often present many barriers to PA, they still believe that environmental factors are secondary to personal motivation in promoting PA among obese patients. Physicians, if better informed of the growing evidence on the environment-PA links, may be able to facilitate patients' behavior change more effectively.

Background: Diagnostic errors in primary care are harmful but difficult to detect. The authors tested an electronic health record (EHR)-based method to detect diagnostic errors in routine primary care practice., Methods: The authors conducted a retrospective study of primary care visit records 'triggered' through electronic queries for possible evidence of diagnostic errors: Trigger 1: A primary care index visit followed by unplanned hospitalisation within 14 days and Trigger 2: A primary care index visit followed by ≥1 unscheduled visit(s) within 14 days. Control visits met neither criterion. Electronic trigger queries were applied to EHR repositories at two large healthcare systems between 1 October 2006 and 30 September 2007. Blinded physician-reviewers independently determined presence or absence of diagnostic errors in selected triggered and control visits. An error was defined as a missed opportunity to make or pursue the correct diagnosis when adequate data were available at the index visit. Disagreements were resolved by an independent third reviewer., Results: Queries were applied to 212 165 visits. On record review, the authors found diagnostic errors in 141 of 674 Trigger 1-positive records (positive predictive value (PPV)=20.9%, 95% CI 17.9% to 24.0%) and 36 of 669 Trigger 2-positive records (PPV=5.4%, 95% CI 3.7% to 7.1%). The control PPV of 2.1% (95% CI 0.1% to 3.3%) was significantly lower than that of both triggers (p≤0.002). Inter-reviewer reliability was modest, though higher than in comparable previous studies (к=0.37 (95% CI 0.31 to 0.44))., Conclusions: While physician agreement on diagnostic error remains low, an EHR-facilitated surveillance methodology could be useful for gaining insight into the origin of these errors.

Background: Integrating online weight-loss programs into the primary care setting could yield substantial public health benefit. Little is known about primary care providers' perspectives on online weight-loss programs., Objective: To assess primary care providers' perspectives on online weight-loss programs., Methods: We conducted focus group discussions with providers in family medicine, internal medicine, and combined internal medicine/pediatrics in Texas and Pennsylvania, USA. Open-ended questions addressed their experience with and attitudes toward online weight-loss programs; useful characteristics of existing online weight-loss programs; barriers to referring patients to online weight-loss programs; and preferred characteristics of an ideal online weight-loss program. Transcripts were analyzed with the grounded theory approach to identify major themes., Results: A total of 44 primary care providers participated in 9 focus groups. The mean age was 45 (SD 9) years. Providers had limited experience with structured online weight-loss programs and were uncertain about their safety and efficacy. They thought motivated, younger patients would be more likely than others to respond to an online weight-loss program. According to primary care providers, an ideal online weight-loss program would provide-at no cost to the patient-a structured curriculum addressing motivation, psychological issues, and problem solving; tools for tracking diet, exercise, and weight loss; and peer support monitored by experts. Primary care providers were interested in receiving reports about patients from the online weight-loss programs, but were concerned about the time required to review and act on the reports., Conclusions: Primary care providers have high expectations for how online weight-loss programs should deliver services to patients and fit into the clinical workflow. Efforts to integrate online weight-loss programs into the primary care setting should address efficacy and safety of online weight-loss programs in clinic-based populations; acceptable methods of sending reports to primary care providers about their patients' progress; and elimination or reduction of costs to patients.

Objective: To determine whether there are any age-related disparities in the frequency of provision of counseling and education for diabetes care in a large HMO in Central Texas., Methods: EMR search from 13 primary care clinics on patients aged ≥18 years (n=1300) who had been diagnosed with type 2 diabetes., Results: There were no significant age differences in the frequency of provision of counseling about HBGM, diet, smoking or diabetes education. However, there were significant age differences in the provision of exercise counseling. Patients aged ≥75 were significantly less likely to have been provided exercise counseling than those aged <65 (adjusted OR=0.60; 95% CI=0.37-0.98). The mean HbA1c for patients aged ≥75 and 65-74 were significantly lower than that of patients aged <65 (8.9 vs. 9.0 vs. 9.7; P<0.001)., Conclusion: While age-related variations in self-management protocols were not found, the provision of formal diabetes education was low (29.4%). The persistence of key risk factors in later life (e.g., obesity) underscores the need for better self-management protocols for older adults., Practice Implications: Additional efforts on strategies to increase counseling about lifestyle habits and diabetes self-management care by appropriate health care providers is needed. Diabetes counseling should be individually tailored in older population., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)