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Background Weight regain after intentional loss is common. Most evidence-based weight management programs focus on short-term loss rather than long-term maintenance. Objective To evaluate the benefit of coaching in an electronic health record (EHR)-based weight maintenance intervention. Design Randomized controlled trial. (ClinicalTrials.gov: NCT01946191). Setting Practices affiliated with an academic medical center. Participants Adult outpatients with body mass index (BMI) of 25 kg/m2 or higher, intentional weight loss of at least 5% in the previous 2 years, and no bariatric procedures in the previous 5 years. Intervention Participants were randomly assigned to EHR tools (tracking group) versus EHR tools plus coaching (coaching group). The EHR tools included weight, diet, and physical activity tracking flow sheets; standardized surveys; and reminders. The coaching group received 24 months of personalized coaching through the EHR patient portal, with 24 scheduled contacts. Measurements The primary outcome was weight change at 24 months. Secondary outcomes included 5% weight loss maintenance and changes in BMI, waist circumference, number of steps per day, health-related quality of life, physical function, blood pressure, and satisfaction. Results Among 194 randomly assigned participants (mean age, 53.4 years [SD, 12.2]; 143 [74%] women; 171 [88%] white), 157 (81%) completed the trial. Mean baseline weight and BMI were 85.8 kg (SD, 19.1) and 30.4 kg/m2 (SD, 5.9). At 24 months, mean weight regain (± SE) was 2.1 ± 0.62 kg and 4.9 ± 0.63 kg in the coaching and tracking groups, respectively. The between-group difference in weight change at 24 months was significant (-2.86 kg [95% CI, -4.60 to -1.11 kg]) in the linear mixed model. At 24 months, 65% of participants in the coaching group and 50% in the tracking group maintained weight loss of at least 5%. Limitation Single-site trial, which limits generalizability. Conclusion Among adults with intentional weight loss of at least 5%, use of EHR tools plus coaching resulted in less weight regain than EHR tools alone. Primary funding source Agency for Healthcare Research and Quality and National Institutes of Health.

Physicians report outpatient quality measures from data in electronic health records to facilitate care improvement and qualify for incentive payments.To determine the frequency and validity of exceptions to quality measures and to test a system for classifying the reasons for these exceptions.Cross-sectional observational study.5 internal medicine or cardiology practices.47,075 patients with coronary artery disease between 2006 and 2007.Counts of adherence with and exceptions to 4 quality measures, on the basis of automatic reports of recommended drug therapy by computer software and separate manual reviews of electronic health records.3.5% of patients who had a drug recommended had an exception to the drug and were not prescribed it (95% CI, 3.4% to 3.7%). Clinicians did prescribe the recommended drug for many other patients with exceptions. In 538 randomly selected records, 92.6% (CI, 90.3% to 94.9%) of the exceptions reported automatically by computer software were also exceptions during manual review. Most medical exceptions were clinical contraindications, drug allergies, or drug intolerances. In 592 randomly selected records, an unreported exception or a drug prescription was found during manual review for 74.6% (CI, 71.1% to 78.1%) of patients for whom automatic reporting recorded a quality failure.The study used a convenience sample of practices, nonstandardized data extraction methods, only drug-related quality measures, and no financial incentives.Exceptions to recommended therapy occur infrequently and are usually valid. Physicians frequently prescribed drugs even when exceptions were present. Automated reports of quality failure often miss critical information.Agency for Healthcare Research and Quality.

The quality of communication that leads to the completion of written advance directives may influence the usefulness of these documents, but the nature of that communication remains relatively unexplored.To describe how physicians discuss advance directives with patients.Prospective study.Five outpatient primary care medicine practices in Durham, North Carolina, and Pittsburgh, Pennsylvania.56 attending internists and 56 of their established patients. Eligible patients were at least 65 years of age or had a serious medical illness.Two raters coded transcripts of audiotaped discussions about advance directives to document how physicians introduced the topic of advance directives, discussed scenarios and treatments, provided information, elicited patient values, and identified surrogate decision makers.Conversations about advance directives averaged 5.6 minutes; physicians spoke for two thirds of this time. In 91% of cases, physicians discussed dire scenarios in which most patients would not want to be treated, and 48% asked patients about their preferences in reversible scenarios. Fifty-five percent of physicians discussed scenarios involving uncertainty, typically using vague language. Patients' values were rarely explored in detail. In 88% of cases, physicians discussed surrogate decision making and documents to aid in advance care planning.Although they accomplished the goal of introducing patients to advance directives, discussions infrequently dealt with patients' values and attitudes toward uncertainty. Physicians may not have addressed the topic in a way that would be of substantial use in future decision making, and these discussions did not meet the standards proposed in the literature.