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Patients with comorbid medical needs and challenging psychosocial concerns often experience barriers navigating the healthcare system, and may utilize the ED inappropriately or be re-hospitalized within 30 days of discharge. Two concurrent QI projects began by using EMR data to create registries of (a) patients with high ED utilization and (b) patients in need of post-hospitalization follow-up. Both population-based and person-centered interventions, created in partnership with patients, were implemented to better manage the complex nature of the healthcare issues and to stimulate team learning. The interventions included embedding a patient-centered Urgent Plan of Care template into the RN triage system to identify patient concerns beyond symptoms, and creating a new team-based model of hospital follow-up to help discharged patients transition to home, identifying and addressing complex healthcare and social needs. These resulted in significant reductions in ED utilization, increased patient activation and team cohesiveness, and a better understanding of the complexity of the discharged patients’ needs.

Primary care reform proponents advocate for patient-centered medical homes built on interdisciplinary teamwork. Recent efforts document the difficulty achieving reform, which requires personal transformation by doctors. Currently no widely accepted curriculum to teach team membership in Family Medicine residencies exists. Organizational Development (OD) has 40 years of experience assessing and teaching the skills underlying teamwork. We present a curriculum that adapts OD insights to articulate a framework describing effective teamwork; define and teach specific team membership skills; reframe residents' perception of medicine to make relationships relevant; and transform training experiences to provide practice in interdisciplinary teamwork. Curriculum details include a rotation to introduce the new framework, six workshops, experiential learning in the practice, and coaching as a teaching method. We review program evaluations. We discuss challenges, including institutional resources and support, incorporation of a new language and culture into residency training, recruitment "for fit," and faculty/staff development. We conclude that teaching the relationship skills of effective team membership is feasible, but hard. Succeeding has transformative implications for patient relationships, residency training and the practice of family medicine.

Background: The Chronic Care Model (CCM) was developed to improve chronic disease care, but it may also inform delivery of other types of preventive care. Using hierarchical analyses of service delivery to patients, we explored associations of CCM implementation with diabetes care and counseling for diet or weight loss and physical activity in community-based primary care offices. Methods: Secondary analysis focused on baseline data from 25 practices (with an average of 4 physicians per practice) participating in an intervention trial targeting improved colorectal cancer screening rates. This intervention made no reference to the CCM. CCM implementation was measured through staff and clinical management surveys and was associated with patient care indicators (chart audits and patient questionnaires). Results: Overall, practices had low levels of CCM implementation. However, higher levels of CCM implementation were associated with better diabetes assessment and treatment of patients (P = .009 and .015, respectively), particularly among practices open to “innovation.” Physical activity counseling for obese and, particularly, overweight patients was strongly associated with CCM implementation (P = .0017), particularly among practices open to “innovation”; however, this association did not hold for overweight and obese patients with diabetes. Conclusions: Very modest levels of CCM implementation in unsupported primary care practices are associated with improved care for patients with diabetes and higher rates of behavioral counseling. Incremental incorporation of CCM components is an option, especially for community practices with stretched resources and with cultures of “innovativeness.”

Background: Central to the "medical home" concept is the premise that the delivery of effective primary care requires a fundamental shift in relationships among practice members and between practice members and patients. Primary care practices can potentially increase their capacity to deliver effective care through knowledge management (KM), a process of sharing and making existing knowledge available or by developing new knowledge among practice members and patients. KM affects performance by influencing work relationships to enhance learning, decision making, and task execution. Purpose: We extend our previous work to further characterize, describe, and contrast how primary care practices exhibit KM and explain why KM deserves attention in medical home redesign initiatives. Methodology: Case studies were conducted, drawn from two higher and lower performing practices, which were purposely selected based on disease management, prevention, and productivity measures from an improvement trial. Observations of operations, clinical encounters, meetings, and interviews with office members and patients were transcribed and coded independently using a KM template developed from a previous secondary analysis. Face-to-face discussions resolved coding differences among research team members. Confirmation of findings was sought from practice participants. Findings: Practices manifested varying degrees of KM effectiveness through six interdependent processes and multiple overlapping tools. Social tools, such as face-to-face-communication for sharing and developing knowledge, were often more effective than were expensive technical tools such as an electronic medical record. Tool use was tailored for specific outcomes, interacted with each other, and leveraged by other organizational capacities. Practices with effective KM were more open to adopting and sustaining new ways of functioning, ways reflecting attributes of a medical home. Practice Implications: Knowledge management differences occur within and between practices and can explain differences in performance. By relying more on social tools rather than costly, high-tech investment, KM leverages primary care's relationship-centered strength, facilitating practice redesign as a medical home.

Background: Controversy surrounds prostate-specific antigen (PSA) testing for prostate cancer screening, especially among elderly men aged 75 and older. This study examines whether patient age results in differential use of PSA testing and if organizational attributes such as communication, stress, decision making, and practice history of change predict PSA testing among men aged 75 and older. Methods: Data came from chart audits of 1149 men ≥50 years old who were patients of 46 family medicine practices participating in 2 northeastern practice-based research networks. Surveys administered to clinicians and staff in each practice provide practice-level data. A stratified Cochran-Mantel-Haenszel test was applied to examine whether PSA testing decreased with age. Hierarchical logistic regression analyses determined characteristics associated with PSA testing for men ≥75 years old. Results: Comparable rates for annual PSA testing of 77.2% for men aged 50 to 74 years and 74.6% for men ≥75 years old were reported. The Cochran-Mantel-Haenszel test indicated no significant change in trend. Hierarchical models suggest that practice communication is the only organizational attribute that influences PSA testing for men 75 years of age or older (odds ratio, 5.04; P = .022). Practices with higher communication scores (eg, promoted constructive work relationships and a team atmosphere between staff and clinicians) screened men aged 75 and older at lower rates than others. Conclusions: Elderly men in community settings receive PSA testing at rates comparable to their younger counterparts even though major clinical practice guidelines discourage the practice for this population. Intraoffice practice interventions that target PSA testing to the most appropriate populations and focus on communication (both within the office and with patients) are needed.

Background: Closing the gap between evidence and practice demands interventions targeting the whole practice. These system level interventions require more complex designs and require greater practice involvement. Current descriptions of trials use research designs that either limit practice involvement or make use of large health system resources. Objective: To share insights on retention of practices in a complex clinical trial aimed at improving care of multiple chronic conditions in 60 diverse community primary care practices not supported by large health system resources. Research Design: Qualitative cross case analysis of field notes from meetings of a diverse research team. Results: Five interrelated factors were found to be important to the success of the study implementation process: (1) developing structure and activities for relationship building; (2) attention to consistent communication; (3) timely information sharing; (4) evolution of a cross-functional research team; (5) provision of technical assistance. Specific strategies were identified to overcome challenges to study implementation. Conclusions: Diverse community primary care practices without support from health system resources will complete participation in complex trials. Researchers need not avoid answering questions requiring complex study designs; however, successful implementation requires an individualized approach tailored to the needs and characteristics of each practice.

PURPOSE Care of patients with diabetes requires management of complex clini- cal information, which may be improved by the use of an electronic medical record (EMR); however, the actual relationship between EMR usage and diabetes care quality in primary care settings is not well understood. We assessed the relationship between EMR usage and diabetes care quality in a sample of family medicine practices. METHODS We conducted cross-sectional analyses of baseline data from 50 prac- tices participating in a practice improvement study. Between April 2003 and December 2004 chart auditors reviewed a random sample of medical records from patients with diabetes in each practice for adherence to guidelines for diabe- tes processes of care, treatment, and achievement of intermediate outcomes. Prac- tice leaders provided medical record system information. We conducted multivari- ate analyses of the relationship between EMR usage and diabetes care adjusting for potential practice- and patient-level confounders and practice-level clustering. RESULTS Diabetes care quality in all practices showed room for improvement; however, after adjustment, patient care in the 37 practices not using an EMR was more likely to meet guidelines for process (odds ratio (OR), 2.25; 95% confi dence interval (CI), 1.42-3.57) treatment (OR, 1.67; 95% CI, 1.07-2.60), and intermediate outcomes (OR, 2.68; 95% CI, 1.49-4.82) than in the 13 practices using an EMR . CONCLUSIONS The use of an EMR in primary care practices is insuffi cient for insuring high-quality diabetes care. Efforts to expand EMR use should focus not only on improving technology but also on developing methods for implementing and integrating this technology into practice reality.

Background: Diabetes care requires management of complex clinical information. We examine the relationship between diabetic outcomes and practices’ use of information. Methods: We performed a cross-sectional, secondary analysis of baseline data from 50 community primary care practices participating in a practice improvement project. Medical record review assessed clinical targets for diabetes (HbA 1c

Background A potentially fruitful strategy for increasing enrollment of minority patients in research is to engage minority clinicians. However, little attention has been paid to unique challenges and effective strategies for engaging practices with minority physicians. Objective The objective of this study was to provide a model for recruiting community-based primary care practices with minority physicians into research studies. Research design Practices were recruited using a 3-step process that included telephone contact, on-site meetings, and follow-up discussions. Strategies used to recruit 18 New Jersey community-based primary care practices with minority physicians for a quality improvement intervention study were assessed. Results Twelve of 18 practices (67%) were successfully recruited into the study. Effective recruitment strategies included building rapport using a multiethnic/multidisciplinary team led by a minority physician recruiter and stressing study benefits for the practice. We attempted to match recruiters and key practice members by race, underrepresented minority status of the lead recruiter, gender, career stage, experience in urban practice, and experience in clinical instruction. Practices that were successfully recruited had more characteristics in common between recruiters and key practice members than unsuccessfully recruited practices (mean number of characteristic matches = 3.75 vs. 1.83, P = 0.020). Study benefits cited by participants as motivators for participation included a general desire to provide good patient care by understanding their practices' strengths and challenges (92%) and improving their practice (85%). Conclusions Our experience suggests that a staged, tailored, and iterative recruitment process emphasizing communication and relationship building can be successful in recruiting community-based primary care minority physicians into practice-based research.

PURPOSE Social network analysis (SNA) provides a way of quantitatively analyzing relationships among people or other information-processing agents. Using 2 practices as illustrations, we describe how SNA can be used to characterize and compare communication patterns in primary care practices. METHODS Based on data from ethnographic field notes, we constructed matrices identifying how practice members interact when practice-level decisions are made. SNA software (UCINet and KrackPlot) calculates quantitative measures of network structure including density, centralization, hierarchy and clustering coefficient. The software also generates a visual representation of networks through network diagrams. RESULTS The 2 examples show clear distinctions between practices for all the SNA measures. Potential uses of these measures for analysis of primary care practices are described. CONCLUSIONS SNA can be useful for quantitative analysis of interaction patterns that can distinguish differences among primary care practices.

The U.S. health care system serves a diverse population, often resulting in significant disparities in delivery and quality of care. Nevertheless, most quality improvement efforts fail to systematically assess diversity and associated disparities. This article describes application of the multimethod assessment process (MAP) for understanding disparities in relation to diversity, cultural competence, and quality improvement in clinical practice. MAP is an innovative quality improvement methodology that integrates quantitative and qualitative techniques and produces a system level understanding of organizations to guide quality improvement interventions. A demonstration project in a primary care practice illustrates the utility of MAP for assessing diversity.

The patient-centered medical home model incorporates patient-centered care as a central tenet and espouses the health care team partnering with an engaged patient. The tools to accomplish this type of care have not evolved along with these values. This report describes how the adoption and use of a patient-centered care plan (PCCP) document enhanced care for complex patients and changed the relationships with health team members. The PCCP was used in a residency-affiliated community hospital, group family medicine site and provided patient-centered, goal-directed care for complex patients. Use of the PCCP changed the patient-team relationship, showing that this care plan document can support the practice of the patient-centered medical home model by enhancing patient-centered, coordinated, comprehensive care. (PsycINFO Database Record (c) 2012 APA, all rights reserved).

PURPOSE The Using Learning Teams for Reflective Adaptation (ULTRA) study used facilitated reflective adaptive process (RAP) teams to enhance communication and decision making in hopes of improving adherence to multiple clinical guidelines; however, the study failed to show significant clinical improvements. The purpose of this study was to examine qualitative data from 25 intervention practices to understand how they engaged in a team-based collaborative change management strategy and the types of issues they addressed. METHODS We analyzed field notes and interviews from a multimethod practice assessment, as well as field notes and audio-taped recordings from RAP meetings, using an iterative group process and an immersion-crystallization approach. RESULTS Despite a history of not meeting regularly, 18 of 25 practices successfully convened improvement teams. There was evidence of improved practice-wide communication in 12 of these practices. At follow-up, 8 practices continued RAP meetings and found the process valuable in problem solving and decision making. Seven practices failed to engage in RAP primarily because of key leaders dominating the meeting agenda or staff members hesitating to speak up in meetings. Although the number of improvement targets varied considerably, most RAP teams targeted patient care-related issues or practice-level organizational improvement issues. Not a single practice focused on adherence to clinical care guidelines. CONCLUSION Primary care practices can successfully engage in facilitated team meetings; however, leaders must be engaged in the process. Additional strategies are needed to engage practice leaders, particularly physicians, and to target issues related to guideline adherence.

This paper focuses on knowledge sharing as an important area in the study of knowledge management (KM). The paper's primary goal is to examine how health-care practices employ knowledge sharing tools and processes to the benefit of their daily work processes. In addition, the study seeks to understand how knowledge sharing would contribute to practices' performance. Adopting a qualitative approach, four health care practices were selected from within a research network to represent larger and smaller practice with different performance levels, two highperforming practices (HP) and two low-performing practices (LP), using standard clinical and health care practice measures. Data collection and analysis involved several iterative steps including interviews, field notes of observations. Four case studies were developed reflecting how each practice implemented knowledge sharing tools and processes and how this implementation influenced performance. The study found that all of the four practices manifested and implemented knowledge sharing tools including knowledge artifacts; sharing social tools-meetings and communication channels; and processes including training and apprenticeship and communities of practices; however, the level of implementation varied among the four practices. A comparison of the high-performing and low-performing practices showed that even though the high-performing practices implemented and invested more in knowledge sharing, knowledge sharing processes and tools were not completely integrated throughout the practices including the high performing ones. Moreover, in all practices there was little evidence of encouragement to efficiently use knowledge sharing tools either among staff members or between patients and the practice.

BACKGROUND Family medicine practices face increasing demands to enhance efficiency and quality of care. Current solutions propose major practice redesign and investment in sophisticated technology. Knowledge management (KM) is a process that increases the capacity of a practice to deliver effective care by finding and sharing information and knowledge among practice members or by developing new knowledge for use by the practice. Our preliminary research in family medicine practices has suggested improved patient outcomes with greater and more effective KM. Research in other organizational settings has suggested that KM can be facilitated by certain organizational characteristics. PURPOSE To identify those organizational characteristics within a family medicine practice that management can effect to enhance KM. METHODOLOGY/APPROACH We performed a cross-sectional secondary analysis of second-year data from 13 community family medicine practices participating in a practice improvement project. Practice KM, leaderships' promotion of participatory decision making, existence of activities supportive of human resource processes, and effective communication were derived from clinician's, nurses', and staff's responses to a survey eliciting responses on practice organizational characteristics. Hierarchical linear modeling examined relationships between individual practice members' perception of KM and organizational characteristics of the practice, controlling for practice covariates (solo-group, electronic medical record use, and perception of a chaotic practice environment) and staff-level covariates (gender, age, and role). FINDINGS Practices with greater participatory decision making and human resources' processes and effective communication significantly (p < .019, p < .0001, and p < .004) increased odds of reporting satisfactory KM (odds ratio = 2.48, 95% confidence interval = 1.32-4.65; odds ratio = 10.84, 95% confidence interval = 4.04-29.12; and odds ratio = 4.95, 95% confidence interval = 2.02-12.16). The sizes of these effects were not substantially changed even when practice members perceived their practice environment as more chaotic. PRACTICE IMPLICATIONS Steps to facilitate KM should be considered when evaluating more intensive and costly organizational solutions for enhancing family medicine practice performance.

PURPOSE The aim of this study was to assess whether the quality of diabetes care differs among practices employing nurse-practitioners (NPs), physician’s assistants (PAs), or neither, and which practice attributes contribute to any differences in care. METHODS This cross-sectional study of 46 family medicine practices from New Jersey and Pennsylvania measured adherence to American Diabetes Association diabetes guidelines via chart audits of 846 patients with diabetes. Practice characteristics were identified by staff surveys. Hierarchical models determined differences between practices with and without NPs or PAs. RESULTS Compared with practices employing PAs, practices employing NPs were more likely to measure hemoglobin A1c levels (66% vs 33%), lipid levels (80% vs 58%), and urinary microalbumin levels (32% vs 6%); to have treated for high lipid levels (77% vs 56%); and to have patients attain lipid targets (54% vs 37%) (P ≤ .005 for each). Practices with NPs were more likely than physician-only practices to assess hemoglobin A1c levels (66% vs 49%) and lipid levels (80% vs 68%) (P≤.007 for each). These effects could not be attributed to use of diabetes registries, health risk assessments, nurses for counseling, or patient reminder systems. Practices with either PAs or NPs were perceived as busier (P=.03) and had larger total staff (P

BACKGROUND Knowledge management (KM) is the process by which people in organizations find, share, and develop knowledge for action. KM affects performance by influencing work relationships to enhance learning and decision making. PURPOSE To identify how family medicine practices exhibit KM. METHODOLOGY A model and a template of KM concepts were derived from a comprehensive organizational literature review. Two higher and two lower performing family medicine practices were purposefully selected from existing comparative case studies based on prevention delivery rates and innovation. Interviews, fieldnotes of operations, and clinical encounters were coded independently using the template. Face-to-face discussions resolved coding differences. FINDINGS All practices had processes and tools for finding, sharing, and developing knowledge; however, KM overall was limited despite implementation of expensive technologies like an electronic medical record. Where present, KM processes and tools were used by individuals but not integrated throughout the organization. Loss of information was prominent, and finding knowledge was underdeveloped. The use of technical tools and developing knowledge by reconfiguration and measurement were particularly limited. Socially related tools, such as face-to-face-communication for sharing and developing knowledge, were more developed. As in other organizations, tool use was tailored for specific outcomes and leveraged by other organizational capacities. PRACTICE IMPLICATIONS Differences in KM occur within family practices and between family practices and other organizations and may have implications for improving practice performance. Understanding interaction patterns of work relationships and KM may explain why costly technical or externally imposed "one size fits all" practice organizational interventions have had mixed results and limited sustainability.

The impact of the work environment on clinical performance and outcomes is receiving renewed interest by health systems researchers, health care administrators, and policy makers (IOM Committee on Quality of Health Care in America 2001; Shortell 2002; Shortell and Selberg 2002). A growing body of literature derived from research in large health care settings, such as hospitals and large multispecialty group practices, suggests that better health outcomes are associated with particular organizational attributes (Shortell and LoGerfo 1981; Shortell 1985, 1990, 2002; Davies and Ware 1988; Shortell, O'Brien et al. 1994; Shortell, Zimmerman et al. 1994; Shortell et al. 1998; Mitchell and Shortell 1997; Davies and Nutley 2000; Donaldson et al. 2000; Ferlie and Shortell 2001). Similar studies within primary care have the potential to impact a broader spectrum of the American population. In a given year most Americans visit a primary care physician (Benson and Marano 1994), with more than a quarter of these visits to family medicine practices (Woodwell 1999). Primary care practices, including family medicine, general internal medicine, and pediatric practices, are unique among health providers in that they must serve as the front line for large variety of health care needs, from prevention to identification of disease and illness to the treatment of ailments or referral to specialists. To understand the impact of organizational attributes of primary care practices on delivery of patient care, one first needs to understand the attributes of these typically small medical providers and develop a method for measuring these attributes. A key element of a practice's ability to maintain and improve quality of care for their patients is their ability to adapt to the evolving understanding of medicine, to demands for enhanced clinical performance, and to changes in the larger health care management system. While general models of change have been proposed (Senge 1990, 1994; Rogers 1995), these models have typically not incorporated the features unique to primary care practices. One exception is the primary care change model recently described by Cohen et al. (2004) that includes four interdependent elements that determine a practice's capacity for sustainable change. This model emerged from three federally funded studies, two descriptive studies, the Direct Observation of Primary Care (DOPC) study (Crabtree et al. 1998; Miller et al. 1998) and Prevention & Competing Demands in Primary Care (PC Miller et al. 1998; Tallia et al. 2003), and one intervention study, the Study to Enhance Prevention by Understanding Practice (STEP-UP) (Goodwin et al. 2001; Cohen et al. 2004). The model identifies clinician and staff characteristics, particularly their interrelationships, as important in distinguishing the between practices' abilities to improve their rates of delivery of prevention services. Of the four elements described by Cohen et al. (motivation of key stakeholders, resources for change, outside motivators, and opportunities for change), resources for change best describes organizational characteristics that a practice must have to modify not only its technical aspects, but also its values and beliefs regarding itself as an organization. The resources for change element includes internal resources such as relationships among practice members, leadership and decision-making approaches, communication and perception of competing demands. Information management and management infrastructure, are also facets of the internal resources for change element. Measurement tools exist for assessing important organizational attributes of larger health systems, such as hospitals (Shortell 1985; Shortell et al.1991, 2000; Jennings and Westfall 1994; Nabitz et al. 2000; Weeks et al. 2000; Meyer and Collier 2001; Nordhaus-Bike 2001; Goldstein and Schweikhart 2002). These attributes include: (1) leadership that engages a diversity of perspectives and shares critical information in order to enhance problem solving processes; (2) a culture that fosters openness, connectedness, and learning; (3) relationships that foster communication and collaboration; (4) management functions that describe presence of diverse structural components and processes such as fiscal, material, clinical, recognition, and feedback, and strategic planning; and (5) information mastery that includes the access and use of information that supports learning and problem solving activities (Shortell et al. 1998; Davies and Nutley 2000; Donaldson et al. 2000; Ferlie and Shortell 2001). The first three of these attributes, in particular, were also identified by Cohen et al. (2004) as internal resources that are needed to create and sustain change (Cohen et al. 2004) in the primary care practice. However, a systematic tool to measure these attributes in primary care practices has not been developed. Because these practices are much smaller and have much more limited resources than hospitals and other larger health systems, instruments for measuring attributes of larger health systems are not expected to describe and differentiate between primary care practices well. As such, an instrument must be created specifically for use in the primary care practice. This study aims to develop an instrument to measure organizational attributes of primary care practices and to evaluate the measurement properties of this newly developed instrument. The instrument, intended to be a survey of clinicians, nurses and staff within the practice, seeks to measure some facets of resources for change, including relationships among practice members, leadership and decision-making approaches, communication, and perception of competing demands. The other facets, specifically information management and management infrastructure, are thought to be better addressed at the practice level by one or two key members of the practice, for example the office manager or medical director. This instrument is developed based on the experience of investigators in family medicine, internal medicine, and pediatric practices; however, its use will be evaluated within family medicine practices. It was hypothesized that this instrument's items would measure internal resources for change and be able to sort practices according to the strength of their available internal resources.

A transformation in the way in which primary care is delivered is underway in the US. Across the country primary care practices are grappling with how to change from the traditional physician-directed model to a more patient-centred collaborative style as part of the effort to curb the rise of chronic disease. To date, few tools or techniques exist to help the individual primary care provider make this difficult and complex transformation. One such tool that has arisen is the shared care plan (SCP). As defined in the Taking Action for Learning and Knowledge Management to improve Diabetes Mellitus (TALK/DM) study (a NIDDK funded pilot project to implement SCPs in primary care), the SCP of primary care becomes the product of collaboration between the practice and the patients. The SCP is created by combining knowledge management (KM) techniques and motivational interviewing (MI) health counselling methods to form a new knowledge object. This paper focuses on this aspect of the TALK/DM study and takes a case study approach to explore how one primary care practice is implementing the SCP as knowledge object (both a paper document and an electronic record in the EMR system) in its organisation. This study adds nuance and insight into how knowledge objects such as the SCP can serve as a tool for collaboration in primary care.

Background: Obesity is epidemic and leads to substantial morbidity/mortality. Effective strategies exist for managing obesity yet are rarely used by physicians. This applied evidence-based review provides a rationale for the diagnosis and treatment of obesity in adults by providing test characteristics for the body mass index (BMI) and number needed to treat (NNT) for relevant treatments. Methods: We integrated evidence supporting recommendations from scientific bodies addressing obesity in adults, including: the National Heart, Lung, and Blood Institute, the World Health Organization, the Canadian Task Force on Preventive Health Care, and the US Preventive Task Force. In addition, pertinent studies were identified from MEDLINE, Database of Abstracts of Reviews of Effectiveness, and the Cochrane Database. Results: (1) manage obesity as a chronic relapsing disease; (2) use BMI as a vital sign to screen for overweight/obese patients and to decide treatment (positive predictive value of 97%); (3) modest weight loss (10%) positively affects prevention/treatment of hypertension (NNT = 3), diabetes (NNT = 9), and hyperlipidemia; (4) effective treatments exist for overweight/obese patients and a combination of diet and exercise provides the best results (NNT = 7); (5) counsel patients to achieve a goal of 10% reduction in weight (500 to 800 kcal/day decrease to affect 1- to 2-pound loss/week); (6) counsel patients to exercise to achieve a goal of any increased energy expenditure. Conclusions: Weight loss has an impact on important disease states and risk factors. Effective strategies exist for the management of obesity when viewed as a chronic relapsing disease.

Background. Obesity is epidemic in the US and other industrialized countries and contributes significantly to population morbidity and mortality. Primary care physicians see a substantial portion of the obese population, yet rarely counsel patients to lose weight. Methods. Descriptive field notes of outpatient visits collected as part of a multimethod comparative case study were used to study patterns of physician–patient communication around weight control in 633 encounters in family practices in a Midwestern state. Results. Sixty-eight percent of adults and 35% of children were overweight. Excess weight was mentioned in 17% of encounters with overweight patients, while weight loss counseling occurred with 11% of overweight adults and 8% of overweight children. In weight loss counseling encounters, patients formulated weight as a problem by making it a reason for visit or explicitly or implicitly asking for help with weight loss. Clinicians did so by framing weight as a medical problem in itself or as an exacerbating factor for another medical problem. Conclusions. Strategies that increase the likelihood of patients identifying weight as a problem, or that provide clinicians with a way to “medicalize” the patient's obesity, are likely to increase the frequency of weight loss counseling in primary care visits.

Objective. To describe how clinicians create opportunities to deliver preventive care in illness visits and assess the impact this has on preventive service delivery. Method. Detailed and descriptive fieldnotes were collected from 18 purposefully selected family practices, including direct observations of 53 primary care clinicians and 1620 patient encounters. Conversation analysis was used to examine the conversational techniques employed to deliver four preventive services (smoking counseling, immunization delivery, mammography, and cervical cancer screening) in illness visits. Qualitative data was coded and analyzed to assess impact on preventive service delivery rates. Results. Two methods for opportunistic preventive service delivery were observed. In the first, clinicians used the close of the medical encounter to make arrangement for follow-up preventive care. In the second approach, clinicians use a stepwise conversational device to exit talk about the patient's presenting problem and enter into relevant health habit advice. Quantitative analyses show that opportunistic methods are rarely used to deliver preventive services in illness visits. The stepwise technique was the most frequently used method. Patients treated by clinicians who used opportunistic techniques to deliver preventive care in illness visits were more likely to be up-to-date on smoking counseling and cervical cancer screening than those patients who were treated by clinicians who did not use opportunistic approaches. Conclusions. Opportunistic preventive service delivery in illness visits can be an efficient and effective way to deliver preventive care. Although infrequently used, quantitative data suggest that the use of opportunistic approaches to deliver preventive services during illness visits can enhance preventive care rates. Interventions aimed at helping clinicians develop effective strategies for offering preventive care during illness visits may be an important complement to existing mechanical interventions that might, by themselves, be insufficient to improve preventive care.