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Purpose: In this study, we developed and field tested the Medication Error and Adverse Drug Event Reporting System (MEADERS)-an easy-to-use, Web-based reporting system designed for busy office practices.Methods: We conducted a 10-week field test of MEADERS in which 220 physicians and office staff from 24 practices reported medication errors and adverse drug events they observed during usual clinical care. The main outcomes were (1) use and acceptability of MEADERS measured with a postreporting survey and interviews with office managers and lead physicians, and (2) distributions of characteristics of the medication event reports.Results: A total of 507 anonymous event reports were submitted. The mean reporting time was 4.3 minutes. Of these reports, 357 (70%) included medication errors only, 138 (27%) involved adverse drug events only, and 12 (2.4%) included both. Medication errors were roughly equally divided among ordering medications, implementing prescription orders, errors by patients receiving the medications, and documentation errors. The most frequent contributors to the medication errors and adverse drug events were communication problems (41%) and knowledge deficits (22%). Eight (1.6%) of the reported events led to hospitalization. Reporting raised staff and physician awareness of the kinds of errors that occur in office medication management; however, 36% agreed or strongly agreed that the event reporting "has increased the fear of repercussion in the practice." Time pressure was the main barrier to reporting.Conclusions: It is feasible for primary care clinicians and office staff to report medication errors and adverse drug events to a Web-based reporting system. Time pressures and a punitive culture are barriers to event reporting that must be overcome. Further testing of MEADERS as a quality improvement tool is warranted. [ABSTRACT FROM AUTHOR]

Although diabetes management remains an important problem, little is known about the effectiveness of employing emerging information technologies to enhance self-management strategies in order to improve diabetes care and patient outcomes. This report reviews the use of a community-based participatory research (CBPR) approach with user feedback to understand the feasibility of introducing the personal digital assistant (PDA) as a self-management tool for diabetes management. We focused on problem identification, intervention selection, and methodological issues. Both physician and patient perspectives are addressed. A search of electronic medical records helped to identify diabetes as a major clinical issue for primary care physicians in an integrated group practice. Physicians subsequently identified technological innovations as a promising tool to enhance patient outcomes. User feedback data confirmed the usefulness of using PDAs to assist patients to keep track of their appointments, physical activity, dietary intake, medication use, and daily blood glucose readings. While those with more computer experience caught on quicker, even some of those with limited computer experience were able to draw some benefit. Needed adaptations for greater success with this technological innovation in a wider range of patients were identified. Implementation of new technological approaches in disease management can benefit from a CBPR framework that addresses factors affecting both physician and patient acceptance and uptake. [ABSTRACT FROM AUTHOR]

A 72-year-old woman with a prior history of stage IIIa lung adenocarcinoma was seen with complaints of knee pain, swelling, and difficulty sleeping at night for 1 month. Although mimicking osteoarthritis, patellofemoral syndrome, and iliotibial band syndrome, radiographs showed a lytic lesion suspicious for metastatic disease. The right tibial lesion was excised, saphenous neurolysis was performed, and radiation treatment and four cycles of chemotherapy were administered. This case shows the importance of early imaging in patients with knee pain of prolonged duration seen in the primary care setting. [ABSTRACT FROM AUTHOR]

Rationale and objectives: The purpose of ordering an imaging test for headache, which is one of the most common reasons for patient consultation with a primary care physician (PCP), include medical indications as well as patient anxiety and medico-legal concerns. The impact of nonclinical factors on PCPs’ ordering patterns of magnetic resonance imaging/computed tomography for patients presenting with a headache was examined.Materials and methods: A retrospective record review of all patients treated for headache as their primary complaint by a PCP from a multispecialty group practice associated with an 180,000-member Health Maintenance Organization during calendar year 2000 was examined. The practice included 18 clinics. Logistic regression was used to estimate the association between physician ordering patterns of imaging tests and patient, physician, and clinic setting characteristics.Results: Of the total study subjects (n = 4,372), a magnetic resonance imaging/computed tomography imaging test was ordered for 5.3%. At their first encounter, patient’s gender, site of care, and insurance status under the health care system’s Health Maintenance Organization had statistically significant associations with the likelihood of imaging test orders. Female physicians were less likely to order an imaging test (OR = 0.65; 95% confidence interval, 0.39–1.08). For subsequent encounters, however, site of care was the only nonclinical factor that had a consistent association with the likelihood of having a magnetic resonance imaging/computed tomography ordered.Conclusion: These data show that a number of nonclinical factors may have been associated with having an imaging test ordered by a PCP when patients presented with a headache. These factors were more significant when the patient was being seen for the first time with this complaint. [Copyright &y& Elsevier]

The authors determined the incidence of concussion as well as correlates of grade II and grade III concussion among high school varsity football athletes. School team physicians completed an Internet-based incident card on their athletes who sustained a concussion on the field of play over three football seasons. Reported information included demographic data, school size, play position, game quarter of injury, and grade of concussion. A total of 70 concussions were reported on 981 eligible athletes for a cumulative incidence of 2.4 per 100 eligible players. The majority was grade II (52.9%). Most concussions occurred during the second (41.4%) and fourth (28.6%) quarters. The risk of concussion increased with increasing school size. After controlling for grade, weight, play position, and school size, playing during the fourth quarter was the only significant correlate of grade II and grade III concussion. Compared to playing during the first quarter, the risk of grade II and grade III concussion occurring during the fourth quarter was 8.7 (95% confidence interval, 1.2-64.2). Although the authors found a lower incidence of concussion than reported by others, they recommend that football coaches and team physicians be extra vigilant during the fourth quarter. [ABSTRACT FROM AUTHOR]

Injuries have now become a recognizable public health problem in developing Countries. However, no definite policies regarding their surveillance and control are yet available in most of these countries. This paper, using Ghana as a prototype, examines the need for policy and action which has been accentuated in recent times by public outcry. The paper also provides some recommendations to solve this problem: the urgent need to initiate programs such as needs assessment, the establishment of a surveillance system for injuries at various levels of health services, creation of public awareness and provision of health education, and the institution of simple first-aid measures. Specific policies regarding injuries from motor vehicle accidents and fires are also given. [ABSTRACT FROM AUTHOR]

Objectives-This study examined determinants of modern health care use by families after their child aged 0-5 years sustained a burn injury in the Ashanti Region of Ghana. Methods-A community based survey of children aged 0-5 years was conducted in 50 enumeration areas in the region. Mothers of all children with scars as evidence of a burn were selected for a follow up interview using a standard questionnaire two to three months later. Determinants of health care use were investigated through a multivariate logistic regression using interview responses from mothers of 617 children for whom report on some treatment was given. Results-Overall, 48% of the burned children were taken to a modern health facility for treatment. Of those taken to a modern health facility, 68% were sent within 24 hours of the burn event. Factors with large adjusted odds ratios for modern health care use included wound infection, burns covering 6% or more of the body surface, and third degree burns. Compared with scalds, children with contact and flame burns were less likely to be taken to a health facility, as were burns to rural children, and those given first aid treatment at home. Conclusions-It is concluded that families, particularly rural residents, should be educated about appropriate health care seeking practices after a burn. [ABSTRACT FROM AUTHOR]

Editorial. Addresses injury prevention for people with disabilities. How risks can be minimized without unduly restricting activities; Mechanics behind why the risk of injury for people with impairments, disabilities or other special healthcare needs is multiplied exponentially; Details of injury prevention, a multidisciplinary science of averting damage to body tissues by identifying the host, agent, and environmental factors that interact to create the risk of injury.

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. [ABSTRACT FROM AUTHOR]

Presents a team approach to reducing the financial deficit of a multispecialty medical group in the United States. Request to physicians to help find solutions; Plans to cut their salaries; Need to raise productivity; Development of an action plan.

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Abstract: 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 &y& Elsevier]

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.

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.)

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.

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.

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.

We determined the nature and magnitude of extant health disparities in patients with type 2 diabetes (T2DM) by race and ethnicity. Data were abstracted from the electronic medical records and charts of all patients 18 years or older who had been diagnosed with T2DM and seen over a 1-year period in one primary care clinic. Data abstracted included patient demographics; provision of counseling on smoking cessation, diet, exercise, and home blood glucose monitoring (HBGM); health care utilization; laboratory measures; and clinical outcomes. No significant racial or ethnic differences were found in the rate of provision of counseling on smoking cessation, diet, exercise, and HBGM, which were all suboptimal according to American Diabetes Association recommendations. In addition, no significant differences were found in the mean number of hospital admissions, emergency room visits, and referrals for specialty care. However, the mean HbA1c levels for African Americans (9.9%) and Hispanics (9.0%) were significantly higher than that of whites (8.7%; P<.0001), even after controlling for body mass index and age. Explanation of the significant racial and ethnic differences found in HbA1c levels, despite similar diabetes self-management treatment protocols or health care utilization, calls for further research.

Use of information technology in diabetes management has been shown to improve self-care. We determined whether enhancing type 2 diabetes (T2DM) self-care with a personal digital assistant (PDA) by patients in the ambulatory setting would improve glycemic control. A pretest/posttest intervention study was conducted in four family practice clinics in a large multispecialty group practice associated with an 186,000-member Health Maintenance Organization. Adults with T2DM and last measured glycosylated hemoglobin (HbA1c) of > or = 8.00% received one-on-one training on the use of a loaned PDA pre-installed with "Diabetes Pilot." Changes in HbA1c and other outcomes were assessed at 6 months from baseline for all participants and by participant-reported PDA use patterns, dichotomized into high PDA users (> or =3 days in past 7) and low PDA users (< 3 days). Of 43 subjects enrolled, 18 (41.90%) completed the 6-month intervention. Their mean HbA1c decreased 17.50% from 9.70% at baseline to 8.00%, a significant mean HbA1c change of -1.7% (95% CI = -2.60 to -0.90). The mean HbA1c change was higher among reported high PDA users (n = 9, mean difference = -1.90, 95% CI = -3.20 to -0.50) than among reported low PDA users (n = 9, mean difference = -1.50, 95% CI = -2.80 to -0.30). Significant increases were reported for the foot care and general diet subscales of the Summary of Diabetes Self-Care Activities from 3 to 6 months. Enhancing T2DM self-care by adults with a PDA was associated with significant reductions in HbA1c; the reductions were greater among reported high PDA users.

Context: Although physician influence can be especially powerful with older adults, relatively little is known about how primary care physicians (PCPs) interact with their patients regarding lifestyle issues., Objective: To document the length of time that PCPs discuss lifestyle issues with their older patients and to examine patient, physician, and contextual correlates., Design: Descriptive and multivariate analysis of videotapes of physician-patient encounters., Setting: Medical encounters from 3 primary care ambulatory settings., Patients: There were 116 ongoing medical encounters with patients aged 65 years or older., Main Outcome Measures: Total time spent in physical activity (PA) discussions and total time spent discussing PA, nutrition, and smoking during the medical encounter., Results: Very little time was spent in lifestyle discussions. On average, PA was discussed for less than a minute (58.28 seconds) and nutrition for slightly less than 90 seconds (83.11 seconds). Only about 10% of the average 17-minute, 22-second encounter was spent on physical activity, nutrition, or smoking topics. Physician supportiveness score (beta = 8.92, P