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Patient education is a critical component of the patient-centered medical home and is a powerful and effective tool in chronic disease management. However, little is known about the effect of practice payment on rates of patient education during office encounters.For this study we took data from the 2009 National Ambulatory Medical Care Survey. This was a cross-sectional analysis of patient visits to primary care providers to determine whether practice payment in the form of capitated payments is associated within patient education being included more frequently during office visits compared with other payment methods.In a sample size of 9863 visits in which capitation status was available and the provider was the patient's primary care provider, the weighted percentages of visits including patient education were measured as a percentages of education (95% confidence intervals):25% capitation, 42.7% (38.3-47.3); 26% to 50% capitation, 37.6% (23.5-54.2); 51% to 75% capitation, 38.4% (28.1-49.8);75% capitation, 74.0% (52.2-88.1). In an adjusted logistic model controlling for new patients (yes/no), number of chronic conditions, number of medications managed, number of previous visits within the year, and age and sex of the patients, the odds of receiving education were reported as odds ratios (95% confidence intervals):25% capitation, 1.00 (1.00-1.00); 26% to 50% capitation, 0.77 (0.38-1.58); 51% to 75% capitation, 0.81 (0.53-1.25); and75% capitation, 3.38 (1.23-9.30).Patients are more likely to receive education if their primary care providers receive primarily capitated payment. This association is generally important for health policymakers constructing payment strategies for patient populations who would most benefit from interventions that incorporate or depend on patient education, such as populations requiring management of chronic diseases.

Background: Though the benefits of healthy lifestyle choices are well-established among the general population, less is known about how developing and adhering to healthy lifestyle habits benefits obese versus normal weight or overweight individuals. The purpose of this study was to determine the association between healthy lifestyle habits (eating 5 or more fruits and vegetables daily, exercising regularly, consuming alcohol in moderation, and not smoking) and mortality in a large, population-based sample stratified by body mass index (BMI). Methods: We examined the association between healthy lifestyle habits and mortality in a sample of 11,761 men and women from the National Health and Nutrition Examination Survey III; subjects were ages 21 and older and fell at various points along the BMI scale, from normal weight to obese. Subjects were enrolled between October 1988 and October 1994 and were followed for an average of 170 months. Results: After multivariable adjustment for age, sex, race, education, and marital status, the hazard ratios (95% CIs) for all-cause mortality for individuals who adhered to 0, 1, 2, or 3 healthy habits were 3.27 (2.36–4.54), 2.59 (2.06–3.25), 1.74 (1.51–2.02), and 1.29 (1.09–1.53), respectively, relative to individuals who adhered to all 4 healthy habits. When stratified into normal weight, overweight, and obese groups, all groups benefited from the adoption of healthy habits, with the greatest benefit seen within the obese group. Conclusions: Healthy lifestyle habits are associated with a significant decrease in mortality regardless of baseline body mass index.

Objective: The aim of this study was to examine the relationship of hepatitis antibodies and liver enzymes with impaired fasting glucose and undiagnosed diabetes in adults. Methods: We analyzed the National Health and Nutrition Examination Survey, 1999 to 2004, a nationally representative sample of the noninstitutionalized US population. Among adults (aged >20 years of age) who were not problem drinkers, we examined hepatitis B and C antibodies and the liver enzymes aspartate aminotransferase (AST), alanine aminotransferase (ALT), and glutamyl transaminase (GGT) with impaired fasting glucose and undiagnosed diabetes (unweighted, n 5234; weighted, n 172,626,805). Logistic regression models were computed controlling for major risk factors that drive diabetes screening, including age, gender, race, diagnosed hypertension, diagnosed hypercholesterolemia, and obesity. Results: In unadjusted analyses 51% of individuals with undiagnosed diabetes have elevated GGT versus 20% of individuals without diabetes or impaired fasting glucose (P .01). Similarly, 43% of individuals with undiagnosed diabetes have elevated ALT versus 23% of individuals without diabetes or impaired fasting glucose (P .01). AST and Hepatitis C antibodies were not associated with undiagnosed diabetes. In adjusted analyses, elevated GGT (odds ratio, 2.15; 95% CI, 1.44 –3.20) and ALT (odds ratio, 1.84; 95% CI, 1.06 –3.20) are associated with undiagnosed diabetes. Similarly, in adjusted analyses, elevated GGT (odds ratio, 1.23; 95% CI, 1.00 –1.53) and ALT (odds ratio, 1.44; 95% CI, 1.15– 1.79) are associated with impaired fasting glucose. Hepatitis antibodies, reporting a current liver problem, or AST were associated with having undiagnosed diabetes in adjusted analyses. Conclusions: Liver function is associated with undiagnosed diabetes and impaired fasting glucose and may justify further investigation as a risk stratification variable for undiagnosed diabetes or impaired fasting glucose. (J Am Board Fam Med 2008;21:497–503.)

Objective: Although many coronary heart disease (CHD) risk factors are known, the role of an individual’s changing personal health history is unclear. We implemented this study to evaluate whether accounting for previous Framingham Risk Scores (FRSs) improves the predictive ability of a current FRS for future CHD in middle-aged adults. Methods: We analyzed data from the Atherosclerosis Risk in Communities Study (ARIC), a longitudinal cohort of people 45 to 64 years old at entry (1986 to 1989 through 2001). FRSs were calculated for participants in the ARIC cohort (3901 men, 5406 women) at baseline (visit 3) and 3 and 6 years before. Using Cox regressions we evaluated the risk of CHD development for the FRS 6 years from baseline and then evaluated whether the addition of the change in FRS assessments from 3 and 6 years before the baseline improved the predictive ability of the FRS. Areas under the receiver operating characteristic (AUROC) curves were compared. Results: The addition of the difference between the baseline FRS (eg, in 1995) and the FRS from 6 years earlier (eg, in 1989) to predict CHD development by 2001 for the entire cohort yielded an AUROC of 0.730, which was a significant improvement over just using the baseline FRS (P < .05). The effect was located primarily among women, with the AUROC curve improving from 0.667 to 0.709 (P < .05). There was no improvement for CHD risk prediction in men when the earlier FRS assessments were taken into account. Men seem to have less change in some risk factors over time. Conclusions: Accounting for an individual’s history improves risk assessments based on current measures. (J Am Board Fam Med 2008;21:408 – 413.)

Background: Asthma has been linked to stroke, but it is unknown if hay fever is related to stroke. This study was designed to investigate if there is an association between a reported history of hay fever and stroke during a 4.4-year study period. Methods: Analysis was performed of the Atherosclerosis Risk in Communities study, a cohort of middle aged and elderly adults. We examined the association of a reported history of hay fever to the development of stroke. Results: There were 9272 participants meeting our criteria, of which 125 had strokes. Of those with a history of hay fever, 2.2% had a stroke. Of those without a history of hay fever, 1.25% had a stroke. Participants with a history of hay fever had an unadjusted hazard ratio of 1.72 (95% CI, 1.08–2.27) for stroke versus participants without hay fever. Risk of stroke remained significant (hazard ratio, 1.87 [95% CI, 1.17–2.99]) after controlling for age, sex, race, smoking status, body mass index, diabetes, hypertension, alcohol use, and hyperlipidemia. Conclusion: A history of hay fever seems to be a risk factor for stroke, and this association may be an area for future research and intervention.