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Context Preventive medicine physicians work at the intersection of clinical medicine and public health. A previous report on the state of the preventive medicine workforce in 2000 revealed an ongoing decline in preventive medicine physicians and residents, but there have been few updates since. Objective The purpose of this study was to describe trends in both the number of board-certified preventive medicine physicians and those physicians who self-designate preventive medicine as a primary or secondary specialty and examine the age, gender distribution, and geographic distribution of this workforce. Design Analysis of the supply of preventive medicine physicians using data derived from board certification files of the American Board of Preventive Medicine and self-designation data from the American Medical Association Masterfile. Setting The 50 US states and District of Columbia. Participants Board-certified and self-designated preventive medicine physicians in the United States. Main outcome measures Number, demographics, and location of preventive medicine physicians in United States. Results From 1999 to 2018, the total number of physicians board certified in preventive medicine increased from 6091 to 9270; the number of self-identified preventive medicine physicians has generally decreased since 2000, with a leveling off in the past 4 years matching the trend of preventive medicine physicians per 100 000 population; there is a recent increase in women in the specialty; the practice locations of preventive medicine physicians do not match the US population in rural or micropolitan areas; and the average age of preventive medicine physicians is increasing. Conclusions The number of preventive medicine physicians is not likely to match population needs in the United States in the near term and beyond. Assessing the preventive medicine physician workforce in the United States is complicated by difficulties in defining the specialty and because less than half of self-designated preventive medicine physicians hold a board certification in the specialty.

Background. In the United States, patients referred to as high-need, high-cost (HNHC) constitute a very small percentage of the patient population but account for a disproportionally high level of healthcare use and cost. Payers, health systems, and providers would like to improve the quality of care and health outcomes for HNHC patients and reduce their costly use of potentially preventable or modifiable healthcare services, including emergency department (ED) and hospital visits. Methods. We assessed evidence of criteria that identify HNHC patients (best fit framework synthesis); developed program theories on the relationship among contexts, mechanisms, and outcomes of interventions intended to change HNHC patient behaviors (realist review); and assessed the effectiveness of interventions (systematic review). We searched databases, gray literature, and other sources for evidence available from January 1, 2000, to March 4, 2021. We included quantitative and qualitative studies of HNHC patients (high healthcare use or cost) age 18 and over who received intervention services in a variety of settings. Results. We included 110 studies (117 articles). Consistent with our best fit framework, characteristics associated with HNHC include patient chronic clinical conditions, behavioral health factors including depression and substance use disorder, and social risk factors including homelessness and poverty. We also identified prior healthcare use and race as important predictors. We found limited evidence of approaches for distinguishing potentially preventable or modifiable high use from all high use. To understand how and why interventions work, we developed three program theories in our realist review that explain (1) targeting HNHC patients, (2) engaging HNHC patients, and (3) engaging care providers in these interventions. Theories identify the need for individualizing and tailoring services for HNHC patients and the importance of building trusting relationships. For our systematic review, we categorized evidence based on primary setting. We found that ED-, primary care–, and home-based care models result in reduced use of healthcare services (moderate to low strength of evidence [SOE]); ED, ambulatory intensive caring unit, and primary care-based models result in reduced costs (low SOE); and system-level transformation and telephonic/mail models do not result in changes in use or costs (low SOE). Conclusions. Patient characteristics can be used to identify patients who are potentially HNHC. Evidence focusing specifically on potentially preventable or modifiable high use was limited. Based on our program theories, we conclude that individualized and tailored patient engagement and resources to support care providers are critical to the success of interventions. Although we found evidence of intervention effectiveness in relation to cost and use, the studies identified in this review reported little information for determining why individual programs work, for whom, and when.

Background The National Diabetes Prevention Program (National DPP) is rapidly expanding in an effort to help those at high risk of type 2 diabetes prevent or delay the disease. In 2012, the Centers for Disease Control and Prevention funded six national organizations to scale and sustain multistate delivery of the National DPP lifestyle change intervention (LCI). This study aims to describe reach, adoption, and maintenance during the 4-year funding period and to assess associations between site-level factors and program effectiveness regarding participant attendance and participation duration. Methods The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to guide the evaluation from October 2012 to September 2016. Multilevel linear regressions were used to examine associations between participant-level demographics and site-level strategies and number of sessions attended, attendance in months 7–12, and duration of participation. Results The six funded national organizations increased the number of participating sites from 68 in 2012 to 164 by 2016 across 38 states and enrolled 14,876 eligible participants. By September 2016, coverage for the National DPP LCI was secured for 42 private insurers and 7 public payers. Nearly 200 employers were recruited to offer the LCI on site to their employees. Site-level strategies significantly associated with higher overall attendance, attendance in months 7–12, and longer participation duration included using self-referral or word of mouth as a recruitment strategy, providing non-monetary incentives for participation, and using cultural adaptations to address participants’ needs. Sites receiving referrals from healthcare providers or health systems also had higher attendance in months 7–12 and longer participation duration. At the participant level, better outcomes were achieved among those aged 65+ (vs. 18–44 or 45–64), those who were overweight (vs. obesity), those who were non-Hispanic white (vs. non-Hispanic black or multiracial/other races), and those eligible based on a blood test or history of gestational diabetes mellitus (vs. screening positive on a risk test). Conclusions In a time of rapid dissemination of the National DPP LCI the findings of this evaluation can be used to enhance program implementation and translate lessons learned to similar organizations and settings. Electronic supplementary material The online version of this article (10.1186/s13012-019-0928-9) contains supplementary material, which is available to authorized users.

The Centers for Disease Control and Prevention (CDC)’s National Diabetes Prevention Program (National DPP) lifestyle change program (LCP) is effective in preventing or delaying type 2 diabetes among people with prediabetes. Increasing enrollment in the National DPP LCP remains a priority. Some LCPs attempt to increase enrollment by offering introductory sessions, pre-enrollment sessions that aim to recruit, engage, and enroll participants based on emerging evidence linking introductory sessions with increased enrollment. As part of a national survey of CDC-recognized organizations offering the National DPP LCP, we examined the content and characteristics of introductory sessions currently offered. Of the 544 organizations who reported offering introductory sessions, the majority provide essential information by overviewing the organization’s LCP (98%) and providing information about type 2 diabetes prevention (79%) during the session. Most provide social support by offering an opportunity to meet the coach (86%) and for program staff and participants to mingle (69%), but only 36% offer light refreshments. Most assess eligibility and readiness to change by offering participants an opportunity to take a risk test to determine eligibility (74%), assess their readiness to join (63%), and to enroll in the program, if interested (71%). Only 34% provide resources for participants not eligible for the program. Session characteristics intended to overcome behavioral barriers to enrollment as identified in prior studies are less common: 39% conduct activities to help participants feel that they can be successful, 38% include testimonials from successful program participants, and 26% assess how soon a participant plans to enroll. There is room for improvement in incorporating behavioral science principles in introductory sessions. Future work will examine associations between specific introductory session characteristics and enrollment. Disclosure P. Williams: None. W. Elkins: None. K. Proia: None. Z. Tayebali: None. K. Axelrod: None. N. S. Esquivel: None. A. Smith: None. D. Porterfield: None.

Context The Institute for Healthcare Improvement's Triple Aim is rooted in improving population health and therefore requires a focus on prevention as well as management of disease. Preventive medicine (PM) physicians are uniquely trained in clinical medicine as well as health care delivery and systems-based practice, thus potentially positioning them to lead population health and contribute to the Triple Aim. Objective The objectives of this study were to (1) describe PM physicians' contributions related to the Triple Aim and (2) describe PM physician satisfaction with these activities. Design A survey was administered to physicians graduating from a single Preventive Medicine Residency program between 1975 and 2015. Physicians were asked about work in 3 specific emerging areas that relate to the Triple Aim's focus on population health improvement: population health; health system transformation; and integration between primary care and public health. PM physicians were also asked about their job, career, and specialty satisfaction. Results Most respondents (74%) practiced population health, with the majority (63%) defining this as improving the health of the population at large versus for a defined clinical population (37%). Approximately half (59%) of PM physicians are involved in health system transformation leadership. Most respondents practice both public health and primary care, but only 32% report having had positions that involve integration of these activities. PM physicians reported high specialty satisfaction levels, particularly among those involved in population health and health care transformation. Conclusion PM physicians already make substantial contributions to population health and lead work related to the Triple Aim. High satisfaction among PM physicians suggests that they can contribute to a stable and sustainable population health workforce.

Background and Objectives: The growing prevalence of obesity in the United States and globally highlights the need for innovative strategies to provide obesity treatment in primary care settings. This report describes and evaluates the Weight Management Program (WMP), an interprofessional program in an academic family medicine clinic delivering intensive behavioral therapy (IBT) following evidenced-based guidelines. Methods: We extracted WMP participant health data from the electronic health record and evaluated retrospectively. Eligible participants completed at least four WMP visits and had a baseline weight, blood pressure, and hemoglobin A1c (HbA1c) recorded within 1 year prior to their first visit. Paired t tests were used to assess changes in, weight, HbA1c and systolic and diastolic blood pressures from baseline. Results: WMP counseled 673 patients over 3,895 visits from September 2015 to June 2019. Of these, 186 met eligibility criteria (at least four visits), with a median of eight visits (mean=11.3, SD=8.1). Participants saw an average weight decrease during program participation of 9.7 lbs (P5%) at 18 months. The program has become financially sustainable through billing for preventive counseling services and a $125 out-of-pocket enrollment fee. Conclusions: WMP provides one model for primary care practices to develop a financially sustainable and evidence-based behavioral therapy weight management program for their patients with obesity. Future work will include assessment of longer-term program benefits, quality metrics, and health care costs.

Introduction Healthcare organizations are transitioning from fee-for-service, volume-based care toward value-based care and the Triple Aim. Physicians have critical roles as leaders and practitioners in this emerging field of population health management; however, the competencies required of these physicians are not well described. The purpose of this study is to explore the approaches of healthcare systems to population health–related functions, the competencies needed, and the characteristics of physicians who lead or staff these functions. Methods Investigators conducted semistructured interviews with a convenience sample of 14 healthcare executives and 15 Preventive Medicine physicians and a focus group with 9 healthcare executives. Interviews and the focus group were recorded, transcribed, and coded. Themes and notable quotes were identified. Data were collected and analyzed in 2019. Results Population health was variously defined by the healthcare executives, often naming specific components or activities. The typical population health activities described by healthcare executives (e.g., quality measurement and process improvement) were reported along with the skills of physicians performing these functions (e.g., data analysis, informatics, leadership, business acumen). A total of 2 types of population health physicians were described: the clinician leader and the population health specialist. Conclusions This exploratory study identified several useful competencies for population health physicians in healthcare systems. Findings point to opportunities to promote a more systematic approach to population health and to prepare Preventive Medicine and other physicians for population health management positions.

Background: Sex differences are known to exist in the management of older patients presenting with acute myocardial infarction (AMI). Few studies have examined the incidence and risk factors of AMI among young patients, or whether clinical management differs by sex. Methods: The Atherosclerosis Risk in Communities (ARIC) Surveillance study conducts hospital surveillance of AMI in 4 US communities (MD, MN, MS, and NC). AMI was classified by physician review, using a validated algorithm. Medications and procedures were abstracted from the medical record. Our study population was limited to young patients aged 35 to 54 years. Results: From 1995 to 2014, 28 732 weighted hospitalizations for AMI were sampled among patients aged 35 to 74 years. Of these, 8737 (30%) were young. The annual incidence of AMI hospitalizations increased for young women but decreased for young men. The overall proportion of AMI admissions attributable to young patients steadily increased, from 27% in 1995 to 1999 to 32% in 2010 to 2014 ( P for trend=0.002), with the largest increase observed in young women. History of hypertension (59% to 73%, P for trendP for trend Conclusions: The proportion of AMI hospitalizations attributable to young patients increased from 1995 to 2014 and was especially pronounced among women. History of hypertension and diabetes among young patients admitted with AMI increased over time as well. Compared with young men, young women presenting with AMI had a lower likelihood of receiving guideline-based AMI therapies. A better understanding of factors underlying these changes is needed to improve care of young patients with AMI.

Objectives: Quality improvement is a critical mechanism to manage public health agency performance and to strengthen accountability for public funds. The objective of this study was to evaluate a relatively new quality improvement resource, the Public Health Quality Improvement Exchange (PHQIX), a free online communication platform dedicated to making public health quality improvement information accessible to practitioners. Methods: We conducted an internet-based survey of registered PHQIX users (n = 536 respondents) in 2013 and key informant interviews with PHQIX frequent users (n = 21) in 2014, in the United States. We assessed use of the PHQIX website, user engagement and satisfaction, communication and knowledge exchange, use of information, and impact on quality improvement capacity and accreditation readiness. Results: Of 462 respondents, 369 (79.9%) browsed quality improvement initiatives, making it the most commonly used site feature, and respondents described PHQIX as a near-unique source for real-world quality improvement examples. Respondents were satisfied with the quality and breadth of topics and relevance to their settings (average satisfaction scores, 3.9-4.1 [where 5 was the most satisfied]). Of 407 respondents, 237 (58.2%) said that they had put into practice information learned on PHQIX, and 209 of 405 (51.6%) said that PHQIX had helped to improve quality improvement capacity. Fewer than half of respondents used the commenting function, the Community Forum, and the Ask an Expert feature. Conclusions: Findings suggest that PHQIX, particularly descriptions of the quality improvement initiatives, is a valued resource for public health practitioners. Users reported sharing information with colleagues and applying what they learned to their own work. These findings may relate to other efforts to disseminate quality improvement knowledge.

Mind-body therapies (MBTs), a subset of complementary and alternative medicine (CAM), are used by cancer survivors to manage symptoms related to their cancer experience. MBT use may differ by cancer survivorship stage (i.e., acute, short-term, long-term) because each stage presents varying intensities of medical activities, associated emotions, and treatment effects. We examined the relationship between MBT use and survivorship stage (acute1 year; short-term 1 to 5 years; long-term5 years since diagnosis) using the CAM supplement of the 2012 National Health Interview Survey. We also examined reported reasons for and outcomes of MBT use and frequency of MBT types.The sample included cancer survivors (N = 3076) and non-cancer controls (N = 31,387). Logistic regression tested the relationship of MBT use and survivorship stage. Weighted percentages were calculated by survivorship stage for reported reasons and outcomes of use and frequency of MBT types.MBT use varied by cancer survivorship stage (p = 0.02): acute (8.3 %), short-term (15.4 %), long-term (11.7 %) survivorship and non-cancer controls (13.2 %). In the adjusted model, short-term survivors had 35 % greater odds of MBT use than did controls (95 % CI 1.00, 1.83). Reasons for and outcomes of MBT use varied among the survivorship stages, with more acute survivors reporting medical-related reasons and more short-term survivors reporting to manage symptoms.MBT may fulfill different symptom management needs at varying stages of survivorship. These findings can help inform supportive care services of survivors' use of MBT for symptom burden at each stage and the allocation of these services.

A strategic opportunity exists to coordinate public health systems and services researchers’ efforts to develop local health department service delivery measures and the efforts of divisions within the Centers for Disease Control and Prevention’s National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) to establish outcome indicators for public health practice in chronic disease. Several sets of outcome indicators developed by divisions within NCCDPHP and intended for use by state programs can be tailored to assess outcomes of interventions within smaller geographic areas or intervention settings. Coordination of measurement efforts could potentially allow information to flow from the local to the state to the federal level, enhancing program planning, accountability, and even subsequent funding for public health practice.

Introduction Diabetes Prevention Programs (DPPs) have shown that healthy eating and moderate physical activity are effective ways of delaying and preventing type 2 diabetes in people with impaired glucose tolerance. We assessed willingness to pay for DPPs from the perspective of potential recipients and the cost of providing these programs from the perspective of community health centers and local health departments in North Carolina. Methods We used contingent valuation to determine how much potential recipients would be willing to pay to participate in DPPs under 3 different models: delivered by registered professionals (traditional model), by community health workers, or online. By using information on the minimum reimbursement rate at which public health agencies would be prepared to provide the 3 models, we estimated the marginal costs per person of supplying the programs. Matching supply and demand, we estimated the degree of cost sharing between recipients and providers. Results Potential program recipients (n = 99) were willing to pay more for programs led by registered professionals than by community health workers, and they preferred face-to-face contact to an online format. Socioeconomic status (measured by education and employment) and age played the biggest roles in determining willingness to pay. Leaders of public health agencies (n = 27) reported up to a 40% difference in the cost of providing the DPP, depending on the delivery model. Conclusion By using willingness to pay to understand demand for DPPs and computing the provider’s marginal cost of providing these services, we can estimate cost sharing and market coverage of these services and thus compare the viability of alternate approaches to scaling up and sustaining DPPs with available resources.

Objectives. We conducted a literature review and environmental scan to develop a framework for interventions that utilize linkages between clinical practices and community organizations for the delivery of preventive services, and to identify and characterize these efforts. Methods. We searched 4 major health services and social science electronic databases and conducted an Internet search to identify examples of linkage interventions in the areas of tobacco cessation, obesity, nutrition, and physical activity. Results. We identified 49 interventions, of which 18 examples described their evaluation methods or reported any intervention outcomes. Few conducted evaluations that were rigorous enough to capture changes in intermediate or long-term health outcomes. Outcomes in these evaluations were primarily patient-focused and did not include organizational or linkage characteristics. Conclusions. An attractive option to increase the delivery of preventive services is to link primary care practices to community organizations; evidence is not yet conclusive, however, that such linkage interventions are effective. Findings provide recommendations to researchers and organizations that fund research, and call for a framework and metrics to study linkage interventions.

Context A literature review and environmental scan were conducted to develop a framework for interventions that utilize linkages between clinical practices and community organizations for the delivery of preventive services, and to identify and characterize these efforts. Evidence acquistion A search was made of four major health services and social science electronic databases and an Internet search was conducted to identify examples of linkage interventions in the areas of tobacco cessation, obesity, nutrition, and physical activity. Evidence synthesis In all, 49 interventions were identified, of which 18 examples described their evaluation methods or reported any intervention outcomes. Few conducted evaluations that were rigorous enough to capture changes in intermediate or long-term health outcomes. Outcomes in these evaluations were primarily patient-focused and did not include organizational or linkage characteristics. Conclusions An attractive option to increase the delivery of preventive services is to link primary care practices to community organizations; evidence is not yet conclusive, however, that such linkage interventions are effective. Findings provide recommendations to researchers and organizations that fund research, and call for a framework and metrics to study linkage interventions.

Background In 2006, we conducted case studies of 4 North Carolina local health departments (LHDs) that scored highly on an index of diabetes prevention and control performance, to explore characteristics that may serve as barriers or facilitators of diabetes prevention and control services. Methods Case studies involving in-depth interviews were conducted at 4 LHDs. Sites were selected on the basis of 2 variables, known external funding for diabetes services and population size, that were associated with performance in diabetes prevention and control in a 2005 survey of all North Carolina LHDs. Fourteen interviews (individual and group) were conducted among 17 participants from the 4 LHDs. The main outcome measures were LHD characteristics that facilitate or hinder the performance of diabetes programs and services. Results Interviews revealed that all 4 high-performing LHDs had received some sort of funding from a source external to the LHD. Case study participants indicated that barriers to additional service delivery included low socioeconomic status of the population and lack of financial resources. Having a diabetes self-management education program that was recognized by the American Diabetes Association appeared to be a facilitator of diabetes services provision. Other facilitators were leadership and staff commitment, which appeared to facilitate the leveraging of partnerships and funding opportunities, leading to enhanced service delivery. Limitations The small number of LHDs participating in the study and the cross-sectional study design were limitations. Conclusion Leadership, staff commitment, partnership leveraging, and funding appear to be associated with LHD performance in diabetes prevention and control services. These factors should be further studied in future public health systems and services research.

Background In 2005, CDC began the Diabetes Primary Prevention Initiative Interventions Focus Area (DPPI-IFA), which funded five state Diabetes Prevention and Control Programs (DPCPs) to translate diabetes primary prevention trials into real-world settings by developing and implementing a framework for state-level diabetes primary prevention. Purpose The purpose of this case study, conducted in 2007, was to describe DPPI-IFA implementation, including facilitators and challenges to the initiative. Methods Case studies of the five DPCPs in the DPPI-IFA involving site visits with key informant interviews of state staff and partners and archival record collection. Results Partners recruited for DPPI-IFA activities included local or state public health agencies (three of five DPCPs); regional or state nonprofit organizations (five DPCPs); businesses or employers (three DPCPs); and healthcare organizations (four DPCPs). The DPCPs implemented a variety of interventions in three main domains: diabetes primary prevention and prediabetes awareness, screening activities and lifestyle interventions, and prediabetes-related health policy efforts. Preliminary outcomes are described at the individual and organization/partnership levels. Results suggest the importance of utilizing preexisting partnerships to extend work into diabetes prevention, providing even small amounts of funding to partners, and prior program planning for diabetes prevention. Challenges for the DPPI-IFA included recruiting participants, establishing links with providers to obtain diagnostic testing for people screened for prediabetes, and offering a lifestyle intervention. Conclusions The DPPI-IFA represents a unique effort by state public health programs in the translation of diabetes primary prevention trials into real-world settings. The experiences of the DPPI-IFA programs offer valuable lessons for future community-based diabetes prevention initiatives, especially regarding the need to strengthen clinical–community partnerships for referral of people with prediabetes to evidence-based lifestyle programs.

Integration among health care professionals, health care systems, and public health organizations to improve population health has recently emerged as a policy priority for federal health and public health agencies. A large gap exists, however, between current policy and program implementation efforts and the existing evidence for integration interventions. The challenges of research into integration effectiveness include lack of a standardized definition of integration and lack of a taxonomy to allow grouping of similar interventions that helps to facilitate an understanding of their effectiveness. We address these challenges and advance research into integration. Drawing from prior evidence syntheses of integration interventions, we provide a recommended definition and a classification scheme for describing and grouping like interventions. Our work can benefit researchers engaged in generating evidence for integration interventions and policy makers; it will help to ensure that the integration policy promoted by health and public health agencies is supported by science.

The objective of this study was to examine the number and characteristics of National Health Service Corps (NHSC) alumni who currently practice with an underserved population. The study design was a cross-sectional survey mailed in 1998 to a sample of 2,160 alumni. The response rate was 58.9 percent; overall, 52.5 percent of respondents reported currently working with the underserved. In bivariate analyses, retention in practice with the underserved was associated with several clinician and service experience variables. In a logistic regression model, higher initial desire to work with the underserved, older age, job satisfaction, and higher salary were associated with current service. The authors conclude that more than half of the NHSC alumni responding to the survey reported working with an underserved population in 1998. Associations between clinician and service experience characteristics and retention in practice with the underserved can inform policy and research to improve retention.

Cervical cancer is the leading cause of cancer mortality in India, accounting for 17% of all cancer deaths among women aged 30 to 69 years. At current incidence rates, the annual burden of new cases in India is projected to increase to 225,000 by 2025, but there are few large-scale, organized cervical cancer prevention programs in the country. We conducted a review of the cervical cancer prevention research literature and programmatic experiences in India to summarize the current state of knowledge and practices and recommend research priorities to address the gap in services. We found that research and programs in India have demonstrated the feasibility and acceptability of cervical cancer prevention efforts and that screening strategies requiring minimal additional human resources and laboratory infrastructure can reduce morbidity and mortality. However, additional evidence generated through implementation science research is needed to ensure that cervical cancer prevention efforts have the desired impact and are cost-effective. Specifically, implementation science research is needed to understand individual- and community-level barriers to screening and diagnostic and treatment services; to improve health care worker performance; to strengthen links among screening, diagnosis, and treatment; and to determine optimal program design, outcomes, and costs. With a quarter of the global burden of cervical cancer in India, there is no better time than now to translate research findings to practice. Implementation science can help ensure that investments in cervical cancer prevention and control result in the greatest impact.

National guideline groups recommend screening and discussion of screening options for persons at average risk for colorectal cancer (CRC). However, emerging evidence suggests that CRC screening is simultaneously underused, overused, and misused and that adequate patient-provider discussions about screening are infrequent.To summarize evidence on factors that influence CRC screening and strategies that increase the appropriate use and quality of CRC screening and CRC screening discussions.MEDLINE, the Cochrane Library, and the Cochrane Central Register of Controlled Trials were searched for English-language publications describing studies conducted in the United States from January 1998 through September 2009.Two reviewers independently selected studies that addressed the study questions and met eligibility criteria.Information on study design, setting, intervention, outcomes, and quality were extracted by one reviewer and double-checked by another. Reviewers assigned a strength-of-evidence grade for intervention categories by using criteria plus a consensus process.Reviewers found evidence of simultaneous underuse, overuse, and misuse of CRC screening as well as inadequate clinical discussions about CRC screening. Several patient-level factors were independently associated with lower screening rates, including having low income or less education, being uninsured, being Hispanic or Asian, being less acculturated into the United States, or having limited access to care. Evidence that interventions that included patient reminders or one-on-one interactions (that is, between patients and nonphysician clinic staff), eliminated structural barriers (for example, simplifying access to fecal occult blood test cards), or made system-level changes (for example, using systematic screening as opposed to opportunistic screening) were effective in enhancing use of CRC screening was strong. Evidence on how best to enhance discussions about CRC screening options is limited. No studies focused on reducing overuse, and very few focused on misuse.Reporting and publication bias may have affected our findings. The independent effect of individual elements of multicomponent interventions was often uncertain.Although CRC screening is underused overall, important problems of overuse and misuse also exist. System- and policy-level interventions that target vulnerable populations are needed to reduce underuse. Interventions aimed at reducing barriers by making the screening process easier are likely to be effective. Studies aimed at reducing overuse and misuse and at enhancing the quality and frequency of discussions about CRC screening options are needed.Agency for Healthcare Research and Quality.

Undertreatment of cancer pain remains a major health-care problem. We utilized focus groups of hospice and home-health nurses and patients to elucidate factors contributing to inadequate pain management and to generate solutions for closing the gap between the current reality and optimal pain management. Focus groups were conducted among hospice and home-health-care nurses (two groups; n=22) and patients (six groups; n=54) using a standardized question guide. Audiotapes were transcribed and analyzed using NUD*IST software. Themes discovered among patients and nurses were analyzed for similarities and differences. Of 22 participants in the two home-health and hospice nurses focus groups, all were white women, the average age was 43 (range 29–64) years, and the average number of years in nursing was 21 (range 8–47) years. Of 54 participants in the six cancer patient focus groups, 80% were women, the average age was 54 (range 25–76) years, and 76% were white. Fifty-four percent of patients reported a history of pain associated with their cancer, and almost 30% had pain that they rated as 8 or higher on the pain scale. Barriers to adequate pain management fell into four categories: fears; attitudes, beliefs, and values; patient and provider behaviors; and structural barriers. Patients and nurses reported similar barriers to pain management; however, patients identified more barriers related to provider behavior and structure of the health care system. This study identified several barriers to cancer pain control not previously identified in the literature. Strategies to improve cancer pain control are suggested.

OBJECTIVE This study examined factors associated with dentists continuing to provide care to the underserved populations beyond their National Health Service Corps (NHSC) obligation period. METHODS Self-administered questionnaires were mailed in 1998 to 404 dentists who had completed their service obligation between 1980 and 1997. The outcome variable was dentist self-report of continuing to work with the underserved population past NHSC obligation. RESULTS Among 249 respondents (62% response rate), 46 percent of alumni dentists continued to work with an underserved population. Multivariate analyses found that being an African American (odds ratio [OR] = 3.2), higher final salary during the NHSC assignment (OR = 1.2), and higher altruistic motivation to work with the underserved populations prior to entering NHSC (OR = 1.1) were significantly associated with continued service to the underserved populations. CONCLUSIONS A small number of factors were associated with alumni NHSC dentists' decisions to continue to provide care for the underserved populations. Targeting African-American students and students interested in caring for the underserved may improve the long-term commitment of dentists to provide care for the underserved populations. Attention will also need to be given to increased salary as a potential intervention to increase the numbers of dentists who continue to serve the underserved populations.